What's the right time to have a shoulder joint replacement arthroplasty? When is it "indicated"?

The “tipping point” for 931 elective shoulder arthroplasties

A patient with arthritis usually experiences the progression of symptoms over time. At some stage, the patient may decide that the symptoms have reached a level of severity that leads him or her to elect to proceed with joint replacement; the authors refer to this degree of symptom severity as the “tipping point.” The patient-reported severity of the shoulder condition can be characterized by the preoperative Simple Shoulder Test.

Their goal was to study the factors that influenced the tipping point for 931 patients undergoing elective shoulder arthroplasty.

The preoperative Simple Shoulder Test (SST) score for all patients averaged 3.6 ± 2.7, but varied over a wide range.

The average tipping points were different for the ream-and-run procedure (mean SST score, 5.0 ± 2.5), hemiarthroplasty(mean SST score, 3.1 ± 3.3), total shoulder arthroplasty (mean SST score, 3.0 ± 2.4), cuff tear arthropathy arthroplasty (mean SST score, 2.8 ± 2.5), and reverse total shoulder arthroplasty (mean SST score, 1.5 ± 1.8). 

Differences were also noted for different diagnoses.

A number of other factors were significantly associated with a higher tipping point: younger age, better health, male sex, commercial insurance, married, nonuse of narcotics, use of alcohol, and shoulder problem not related to work.

The authors concluded that analysis of the tipping point—the patients’ self-assessed comfort and function at the point they decide to undergo shoulder joint replacement—provides a means by which we can better understand the factors influencing the indications for these procedures.

Comment: It is often stated that a shoulder arthroplasty is "indicated" for certain diagnoses. However, this study demonstrates that it is not the diagnosis that indicates the need for surgery, but rather the degree of functional loss perceived by the patient. Most patients proceeding with elective shoulder arthroplasty have lost more that half of the 12 functions of the Simple Shoulder Test, but the typical tipping point varies for different diagnoses and different procedures.  Consideration of these data on the tipping points for a large number of patients is helpful in answering the question patients often as, "how will I know when it is time for me to have a shoulder replacement?"

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How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Rotator cuff surgery in workers - effect of timing

The effect of expedited rotator cuff surgery in injured workers: a case-control study

These authors examined the effect of ‘expedited’ surgery on recovery and work status in injured workers.

Injured workers who had undergone an 'expedited' rotator cuff surgery funded by parallel-pay insurance (study group) were compared with workers who had used the public health insurance (control group) while adjusting for sex, age, severity of pathology, and follow-up period.

The patients in the ‘expedited’ group waited less time to have surgery than the control group, reported less disability after surgery, had a higher number of patients whose improvement exceeded the minimal clinically important improvement in the ASES score, and were more likely to be working at the time of the final follow-up.

Comment: The duration of symptoms was <18 months in 77% of the ‘expedited’ group and in 41% of the control group. In the ‘expedited’ group symptoms had been present for 16±18 months and for 38±51 months in the control group. It is not clear whether the workers were off work for the duration of symptoms. It well known that the longer a worker is off work the more difficulty it is to get them back to work. Thus it is not surprising that only 36% of the ‘expedited’ group was back to regular work at followup and only 19% of the control group was back to regular work at followup.

While the title of this study indicates that it is about ‘rotator cuff surgery’, only 45% of the cases in either group had rotator cuff repairs. Other surgeries included acromioplasty, distal clavicle resection, and biceps surgery. This is not a study of the value of acute repairs of traumatic cuff tears.

It is noted that patients in the ‘expedited’ group had an orthopedic evaluation at a specialty shoulder and elbow clinic and an expedited arthroscopic rotator cuff decompression or repair, or both. In contrast, patients in the control group had an active compensable injury that had undergone a publicly funded operation for rotator cuff decompression or repairs. Who winds up being covered by ‘parallel-pay insurance’ and who winds up being covered by public health insurance? We are not informed if these surgeries were performed at a ‘specialty shoulder and elbow clinic’ or not. Thus it is unclear whether selection bias may have tipped the results in favor of the ‘expedited’ group.

The management of injured workers is complex. Our approach is to do our best at the initial visit to determine whether the patient is likely to return to work without or with surgery. If return to work is likely, we expedite non-operative or operative treatment to minimize the detrimental off work time.

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Consultation for those who live a distance away from Seattle.

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Click here to see the new Rotator Cuff Book

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In bilateral arthritis, how long after the first TSA should the contralateral TSA be done?

Staged bilateral total shoulder arthroplasty: improved outcomes with less than 6 months between surgeries

These authors analyzed 82 total shoulders  (41 patients, 70 ± 9 years old) comparing 4 “interval groups” based on timing between surgeries: <6 months, 6 to 12 months, 12 to 24 months, and >24 months.

Mean postoperative UCLA, Constant, and SST scores were 29, 72, and 9 points, respectively; 83% of patients reported satisfaction with both shoulders.

Patients with <6 months between surgeries (Group 1) demonstrated significantly better UCLA scores than 6- to 12-month interval patients (P = .04), greater Constant scores compared with all other groups (P < .001), and greater SST scores compared with 6- to 12-month and 12- to 24-month interval patients (P = .002), with no differences in length of follow-up between groups.

Thirty-four patients (83%) reported that they were satisfied with both shoulders and 3 patients (7%) were satisfied with 1 shoulder. Twenty-six patients (63%) reported that 1 side endured a more difficult recovery. Of these 26 patients, 17 (65%) reported that their first side was the more difficult side to recover from, whereas 13 (50%) reported their dominant side as the most difficult side to recover from.

The authors concluded that patients may be advised that having the second arthroplasty within 6 months of the first might optimize their postoperative functional outcomes and satisfaction compared with waiting a longer interval between surgeries.

Comment: The reasons that the < 6 month group seemed to have better outcomes than the longer interval groups are not clear. In that patients were not randomly assigned to different intervals between surgeries, one wonders what factors explained the different the timing selected by the patient and the surgeons.  It could be that the patients electing to have shorter intervals between surgery were more healthy or more optimistic.

In our practice we often consider the second side at about 6 months after the first so that the patient has time to regain their strength and to get far along with the rehabilitation of the first shoulder. As often is the case (as pointed out by these authors) external factors often influence the timing of the second side, for example patients may want to have both surgeries in the same calendar year so that they can avoid paying the insurance deductible for the the second side.

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Consultation for those who live a distance away from Seattle.

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Shoulder joint replacement for arthritis - when is the right time to have surgery? FAQ

We received this message on FaceBook today:

"Thank you for your blog,and the information you post here on Facebook.

I am 52 and can't play catch or shoot a basketball with my 14 year old son. I have to support my arm with my other arm in order to lift it over my head, or grab something from the back of the refrigerator.

I have bone on bone Arthritis, 1/2 inch bone spurs, and loose debris in my shoulder.

That being said, my Dr. has recommended Ream and Run for me. I like that it is not restrictive.

My fear is that although I can't through a ball or lift my arm over my head, I am still able to work good down low. I just baled and stacked 56'000 pounds of hay this week by hand. I need to be able to work and work hard.

I am worried about the what ifs... The information you have provided is great, and I am getting more jazzed about the surgery. But not totally sure yet if it is right thing to do.

If I wait to do the surgery, is there a chance of damaging my shoulder to the point, that I may not have the option to do ream and run?

Thanks again for your time,

K."

The answer is that there is never a perfect time to have an elective surgery, such as a shoulder joint replacement for arthritis. The surgery and recovery from it will interfere with work and activities of daily living for a substantial period of time. The time necessary for recovery will be determined by the severity of the arthritis, the excellence of the surgery, the commitment of the patient to the rehabilitation effort, and the activities the patient desires to resume after the surgery. See this post.

The other factor is that arthritis is a progressive process - it can lead to progressive bone loss that makes the surgery and recovery from it more difficult. See for example this post on the Bad Arthritic Triad. It is easy to see that once put in motion, the process of posterior glenoid destruction is likely to continue.

So what advice can be offered to K, who can work but can't play with his son and who needs to be able to 'work and work hard'. 

The most important thing is to assure that the shoulder and the patient are assessed by someone experienced with the ream and run. This assessment needs to include the condition of the shoulder by standardized x-rays as well as the needs of the patient with respect to work and the ability to take time off to dedicate to post surgical rehabilitation. If it is not clear that 'now' is the time for surgery,  we will often re-evaluate the shoulder at 6 month intervals to determine the rate of progression of the arthritis. During this period of monitoring we will suggest gentle range of motion exercises to preserve the flexibility of the joint along with activity modifications that might lessen the impact of the arthritis.

The choice to proceed with surgery needs to be one shared between the surgeon and the patient.  And, as we say, "the decision is often more difficult than the incision" . 

Be sure to click on this link to the Shoulder Arthritis Book.

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Is surgery the right treatment now? The right question to ask.

USA Today recently pointed out that many surgeries that are performed are 'unnecessary'.

A quote from the article: "unnecessary surgeries might account for 10% to 20% of all operations in some specialties, including a wide range of cardiac procedures — not only stents, but also angioplasty and pacemaker implants — as well as many spinal surgeries. Knee replacements, hysterectomies, and cesarean sections are among the other surgical procedures performed more often than needed, according to a review of in-depth studies and data generated by both government and academic sources.

Since 2005, more than 1,000 doctors have made payments to settle or close malpractice claims in surgical cases that involved allegations of unnecessary or inappropriate procedures, according to a USA TODAY analysis of the U.S. government's National Practitioner Data Bank public use file, which tracks the suits. About half the doctors' payments involved allegations of serious permanent injury or death, and many of the cases involved multiple plaintiffs, suggesting many hundreds, if not thousands, of victims."

The article is appropriately unsettling. 

The challenge is that while in some cases, for example a fracture with bone protruding from the skin, the need for surgery is clear. In other cases the indications for surgery are relative: back pain, knee pain, and early arthritis, for example. The situation is made more complex when MRI's are obtained of a bothersome shoulder and show findings that may be present in most adults, such as 'partial cuff tear' or labral fraying'. 

To help patients consider the timing of surgery for a progressive condition, such as arthritis, we have provided a relevant post.

While surgeons are dedicated to helping their patients, there is no question that surgeons have a conflict of interest: surgeons get paid more for doing a surgery than for referring the patient to someone more qualified to perform it or for putting the patient on an exercise program. Conflicts of interest are substantially more concerning when the surgeon is a paid by a company to advocate the use of their products or if they receive royalties for the use of the product.

We suggest that patients considering surgery ask the following questions of their surgeon:

1 What is my diagnosis?
2 What is the name of the surgery you propose?

3 Do you have any financial relationships with the companies making the products that will be used?

4 Is their any rush in doing this surgery, or is it elective?

5 What are the alternatives to this surgery?

6 How many of these surgeries have you personally performed?
7 Are you fellowship trained to perform this operation?
8 What complications have you and others experienced with this procedure?
9 What are the usual results of this operation in your hands?
10 What is the likelihood that I will have lingering pain, limitations or disability?
11 What special care, rehabilitation will I require for the period after surgery?
12 How long is it likely to be before I can return home, return to work, return to my recreational activities?
13 Do you consider me a good candidate for this surgery in your hands?

14 If I wanted to get a second opinion, will you provide me with all my records to take to another surgeon?

We suggest patients take this 'check list' to their surgeon for the preoperative discussion. 

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


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Key steps in total shoulder replacement

Here we present some of the key elements of total shoulder arthroplasty. Click on each topic to link to the content.

When is the right time for a shoulder replacement
Medications and shoulder joint replacement
Taking proper x-rays
Important considerations of the glenoid 
The glenoid component Part 1
The glenoid component Part 2
The glenoid component Part 3
Minimizing risk of loosening
The humeral component
The subscapularis
Maintaining range of motion
Range of motion videos
Early strengthening
The traction three
More rehabilitation
Antibiotics after joint replacement
Activities recommended after surgery

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

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When is it the right time for a shoulder replacement for arthritis?

The question of 'When is the time right for a shoulder replacement?' comes up often. We discuss this in this link.

 The answer depends on many things, including the degree to which the quality of life of the individual is impaired by the shoulder condition, the condition of the muscles, tendons, bone and nerves around the shoulder, the expectations of the patient, the overall health of the individual, the individual's willingness to accept the risks of surgery, and the degree of comfort the individual has with the surgeon.

As the reader knows from earlier posts, we use the Simple Shoulder Test (SST) to enable the individual to characterize the comfort and function of the shoulder.  I recently summarized the SST scores of over 2800 of our patients at the point where they had decided to have a shoulder joint replacement for their arthritis. The average preoperative SST score was 3.9. The numbers of patients with each of the 12 possible SST scores is shown below. Basically, this graph shows that 62% of patients having joint replacement had preoperative SST scores of 4 or below; 30% had SST scores from 5-8; and 8% had scores from 9-12.

Importantly, shoulder joint replacement for arthritis is an elective procedure. Each individual considering joint replacement should seek a surgeon with substantial experience with that procedure and work with that surgeon in discussing the surgical options, the timing of the procedure, and how the risks of the procedure can be minimized.

Here are some important considerations before proceeding.

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You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

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