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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Shoulder arthritis: medications and joint replacement

Patients with arthritis are often on medications to control the condition and its symptoms. Certain of these medications can substantially affect the safety of and recovery from joint replacement for shoulder arthritis.


My colleague Greg Gardner has put together a very nice summary of these concerns in this article published in the AAOS journal. Quoting from this article "Managing the perioperative drug regimen of the patient with RA can be challenging, but it is essential in order to optimize surgical outcome.

Perioperative consultation and collaboration with the patient’s rheumatologist or internist is recommended. In patients with RA, correct timing of discontinuation of NSAIDs in preparation for surgery may avoid patient discomfort without risking complications resulting from cyclooxygenase inhibition. Corticosteroid management depends on the type of orthopaedic procedure and must be part of perioperative planning. The goal of perioperative management of DMARDs is to reduce the risk of infection and optimize wound healing while minimizing the chance of a disease flare that could compromise recovery. Currently,methotrexate is the only medication with evidencebased data supporting continuing treatment through surgery.Without data to the contrary, we recommend that the more powerful biologic agents should be used as described in Table 1. These recommendations may change as experience and data accumulate"

The tables from this article are shown below

See also Medicines to Avoid Before Surgery

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Shoulder arthritis: antibiotics after joint replacement

A common question after a shoulder joint replacement surgery regards taking antibiotics for future procedures. Obviously the goal is to minimize the risk of bacteria in the bloodstream that may result in an infection of the joint replacement.

Our usual recommendations are that (1) any elective dental (cleaning, root canals, gum surgery, etc) or other surgical procedure should be done at least six weeks before the joint replacement and the wounds should have healed completely, (2) no elective surgery be done within three months after the joint replacement and (3) prophylactic antibiotics be used for life after a shoulder joint replacement for arthritis. Of course, individual treatment plans need to be developed for individuals - these are only general guidelines based on the 2009 recommendations of the American Academy of Orthopaedic Surgeons. I recommend that you take a moment to read their information statement on antibiotics.

Often our recommendations are:

Dental work: 2 grams of cephalexin 1 hour prior to the procedure for individuals without penicillin allergy, 600mg of clindamycin 1 hour prior to the dental procedure for individuals with penicillin allergy.

The AAOS recommendations for other procedures are shown below.

Again, these are only general guidelines. The specifics for an individual patient must be established by the treating physician/surgeon.

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Shoulder arthroplasty for arthritis: rehabilitation: the traction three

Our patients have taught us that three additional exercises are useful in the recovery from a shoulder arthroplasty after the first six weeks. Each of these involves applying a gentle pull or traction on the joint, thus we've called them the 'traction three'.  Again, it is important to avoid any exercise that causes pain or that does not feel right. Each exercises is done smoothly and gently.

The first is the gravity swing in which a light weight is held in the hand. The shoulder is relaxed while the arm swings gently back and forth and around in smooth circles.

The second is the gentle row, where the legs and back provide the push while the hands hold onto the bar.

The third is the lat pull with a light weight. Allow the weight to pull up on the arms and relax. Then pull smoothly down so that the bar passes in front of the face.

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Shoulder arthroplasty for arthritis: rehabilitation: early strengthening

Post surgical rehabilitation is essential to achieving a good result from a total shoulder or a ream and run procedure for shoulder arthritis.

The muscles of an arthritic shoulder are often weak after years of disuse. Shoulder joint replacement does not improve the strength of the muscles, but it does provide smooth joint surfaces that allow for progressive muscle rehabilitation. However, strengthening cannot be started until an excellent and comfortable assisted range of motion is in place.

Once at least 150 degrees of assisted flexion is comfortably achieved

and provided the shoulder does not become painful when doing them, gentle progressive strengthening exercises are often started at week 6 after a total shoulder or a ream and run procedure for shoulder arthritis. These Phase II exercises include the progressive tilting supine press series shown below. The shoulder should be able to perform each exercise comfortably 20 times before advancing to the next step.

In step A, the two hands are held together grasping a washcloth. The hands are pressed upwards as in a bench press action. In step B, one hand presses a light weight (one pound) upwards while lying flat. In step C, the light weight is pressed upwards while lying in a slightly elevated position. The angle of elevation is progressively increased as long as 20 repetitions can be performed at one elevation before increasing it. In step D the light weight is elevated in a standing position.

When step B is achieved, the shoulder blade is elevated at the top of the press as shown below (the press plus).

This helps strengthen the muscles supporting the shoulder blade as does the shoulder shrug shown below.

The final Phase II exercise is external rotation isometrics where the elbow is flexed to a right angle and held at the side while the wrist is pressed against a stable object.

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Shoulder replacement for arthritis: rehabilitation: maintaining range of motion: the videos

Thanks to the kindness of some of our star patients, we can show you videos of the key exercises that we use after total shoulder replacement arthroplasty or the ream and run procedure for shoulder arthritis.

The first is continuous passive motion. This video shows one of our shoulder arthroplasty patients in the recovery room immediately after his procedure. The CPM machine gently moves his arm through a comfortable arc, even though he is still asleep. This is the first step for preventing unwanted scar tissue formation.

The next three videos show a man one week out from his right shoulder ream and run procedure doing the three basic range of motion exercises:

The forward lean.

Note the slow and smooth motion of the hand gliding forward on the table as he leans forward.

The supine stretch

Note the slow and smooth motion of the operated right shoulder as the left assists it. Note also the nice slow breathing.

The pulley

Note the patient has his back to the door with the pulley securely fixed overhead. Note the slow and smooth upward motion of the operated right shoulder as it is assisted by the left pulling down.

Here are some tips about the art of stretching.

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Shoulder arthroplasty for arthritis: rehabilitation: maintaining range of motion

Post surgical rehabilitation is essential to obtaining the desired result from a total shoulder joint replacement arthroplasty or a ream and run for arthritis of the shoulder.

Yesterday we emphasized the importance of protecting the repaired subscapularis during the 6 to 12 weeks required for it to regain its secure attachment to the humerus.

During this time, it is also critical to maintain the passive range of motion achieved at surgery in a manner that does not threaten the subscapularis repair. This is usually accomplished by the use of continuous passive motion (CPM) immediately after surgery in which a carefully controlled machine gently moves the operated arm through a range of motion while the patient relaxes. CPM is usually continued during the period of hospitalization while the patient is in bed so that restricting adhesions do not have a chance to form.

On the day of surgery, assisted range of motion exercises are also learned by the patient. This are simple exercises that can be done anywhere with no special equipment.  These include assisted elevation, as shown below

and the forward lean, as shown below

These exercises must be mastered by the patient and a range of 150 degrees of elevation consistently attained by the patient before leaving the medical center. 

We use a chart on the wall of the hospital room to track their forward elevation so the patient can see their progress towards the 150 degree target for hospital discharge.

We usually prescribe visits to a qualified physical therapist to monitor the patient's recovery. It is essential, however, that the patient and the therapist adhere to the details of our post surgical rehabilitation program.

Here are some tips about the art of stretching.

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Shoulder arthroplasty for arthritis: rehabilitation: care for the subscapularis.

A key to success after shoulder replacement for arthritis is the post operative exercise program. Click on this link: rehabilitation program to see our usual approach, although this may be modified in certain circumstances.

One of the key facts to keep in mind during the first 6 weeks after shoulder joint replacement is that the subscapularis muscle is cut off the front of the humerus early in the surgical operation to gain access to the joint. In the figure below, the subscapularis has been retracted to the right with two sutures.

Near the end of the case, repair sutures are placed through the bone.

Once the humeral implant is in position, the subcapularis is repaired to the previously placed sutures.

Although this repair is usually strong enough for Phase I of the early motion program, advanced healing of the repair is necessary before the shoulder can be stretched in passive external rotation or strengthened in active internal rotation. For this reason the two sets of exercises shown below are AVOIDED. 

EXTERNAL ROTATION STRETCHING  

INTERNAL ROTATION STRENGTHENING

 Our resident Zlomislic demonstrated that the tension is not evenly distributed across the repair sutures and that the superior suture takes the preponderance of the load in the activities shown above - activities that put it at risk of pulling through the tendon.

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Total shoulder for arthritis: the results

In considering the value of a procedure, it is important to measure its effect on the overall health of the patient. Our shoulder fellow Boorman did such a study for total shoulder replacement and found that the effect of total shoulder arthroplasty on self-assessed health status is comparable to that of total hip arthroplasty and coronary artery bypass grafting.

As the reader will recall from previous posts regarding the Simple Shoulder Test (SST), we consider the patient's own assessment of shoulder comfort and function to be the 'gold standard' for evaluating the result of the treatment of a shoulder condition. Over fifteen years ago, we published a study on the Early Effectiveness of Shoulder Arthroplasty for Patients Who Have Primary Glenohumeral Degenerative Joint Disease, using the SST. Subsequently, our shoulder fellows Fehringer , Boorman, and Churchill used this tool in Characterizing the Functional Improvement After Total Shoulder Arthroplasty for Osteoarthritis. They found that total shoulder arthroplasty substantially improved the Simple Shoulder Test self-assessments of comfort and function in individuals with shoulder arthritis. On average, shoulders achieved approximately two-thirds of the maximum possible improvement, regardless of the preoperative level of function. A similar study, The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint disease, was published by our shoulder fellow Goldberg. The key data from this study are shown in the figure below.

Our fellows Antoniou and Rozencwaig studied the Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease. They found that male gender, preoperative physical function, social function, mental health and shoulder function before surgery were the strongest predictors of the quality of the result from total shoulder replacement. These same authors had previously investigated the correlation of comorbidity with function of the shoulder and health status of patients who have glenohumeral degenerative joint disease.

Our shoulder fellows Saltzman and Mercer published an important study entitled, Comparison of patients undergoing primary shoulder arthroplasty before and after the age of fifty. They found that younger patients having shoulder joint replacement were more likely to have complex forms of shoulder arthritis,  such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic athritis. Only 21% of the younger patients had primary degenerative joint disease, whereas 66% of the older patients had that diagnosis. These more complex forms of arthritis may complicate the surgery, the rehabilitation and the outcome of shoulder joint replacement.

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Total shoulder: the glenoid component, Part III

We have spent a substantial amount of effort in identifying causes of failed total shoulder arthroplasty; examples are the investigations of our shoulder fellows Hasan and Franta. One of the most common causes of total shoulder failure is failure of the glenoid component. In our research on this issue we have identified a number of factors, very important among which is the technique of insertion of the glenoid component. Our shoulder fellow Lazarus conducted a multicenter study in which radiographic evaluation of glenoid components demonstrated that many components inserted around the country were not well seated and or not well fixed. This may be due in part to the observation by our shoulder fellow Hasan that many surgeons doing shoulder joint replacement have less experience than those doing hip or knee surgery.

When the glenoid bone surface is not properly contoured to fit the back of the glenoid component, bone cement can be used to fill in the gaps as shown in the left hand diagram below. However, loading of the glenoid component can lead to fracture and loosening of this thin layer of cement, leading to its displacement and loss of support for the glenoid component as shown on the right hand diagram below.

In the investigation by Lazarus, glenoid component designs with pegs outperformed glenoid component designs with keels. This article also pointed out the importance of the experience of the surgeon: 80% of the glenoid components inserted by the most experienced surgeon had better cementing in comparison to 50% for the remaining surgeons. There are some other important articles relating to the effect of surgeon experience to the outcome of shoulder arthroplasty. An article by Hasan shows that 75% of shoulder arthroplasties are done by surgeons performing only one or two per year. Articles by Hammon and Jain show that surgeons performing higher numbers of shoulder arthroplasties have a lower rate of complications.

At present, the optimal approach to glenoid fixation combines (a) reaming the glenoid bone to precisely fit the back of the glenoid component

(b) drying the bone with a carbon dioxide jet to remove blood, fluid and debris before cement is inserted (as the divers among you will recognize, we use CO2 because of its solubility in water and blood, so that nitrogen bubbles (the bends) are avoided).

(c) pressurizing the cement in to the holes

(d) removing the excess cement so that none remains on the surface of the bone

(e) inserting the component so that the precise geometry of the pegs and back surface of the component meet the precise geometry of the holes and reamed surface of the glenoid bone

and (f) vigorously impacting the component into the prepared bone

This technique minimizes the amount of cement used, so that excessive heat is not generated by the curing of the methylmethacrylate, a risk pointed out by our shoulder fellow Churchill.
A detailed view of the postoperative film shown in yesterday's post reveals excellent seating of the glenoid component on the prepared bone surface with penetration of the pressurized cement into the bone (arrow) - note the absence of radiolucent lines.

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Total shoulder: the glenoid component, Part II

As per the last post, the glenoid component looks like this.

The use of a prosthetic glenoid component as a part of a total shoulder arthroplasty enables the restoration of the shape of the glenoid socket in a shoulder with arthritis where the joint space as been destroyed as shown on the preoperative x-rays below.

While the glenoid component cannot be seen directly on the postoperative x-ray, the space between the metal ball and the bone of the glenoid occupied by the glenoid compnent is evident on the post operative films from a patient we treated last week. The staples used to closed the skin are shown at left. The careful observer will also note that the humerus has been moved away from the scapula, re-tensioning the muscles around the shoulder. Also, faintly visible within the bone of the scapula to the right, one can see a thin white line representing a metal marker within the plastic socket component.

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Total shoulder: the glenoid component, Part I

After some initial work by Stillbrink and Kenmore, the late Charles Neer introduced the concept of prosthetic replacement of the glenoid joint surface in 1974. His insight was that restoring the concave shape of the glenoid surface could help improve centering of the humeral head. He wrote, "Because of the excessive excursion of the head of the prosthesis noted during this study when the glenoid was flattened and enlarged, it was thought logical to resurface the glenoid in a limited series to determine if the fulcrum could be improved." The combination of a humeral prosthesis and a polyethylene glenoid component is known as a total shoulder joint replacement arthroplasty.
A major challenge, as Neer recognized, was securing the polyethylene to the bone of the glenoid. He sculpted the bone surface by hand and used acrylic bone cement to hold the glenoid prosthesis in place.
One element of this securing is good carpentry, as pointed out by our shoulder fellow, David Collins, who showed that spherical reaming around a normalized axis is key for providing a good fit for the polyethlene prosthesis on the glenoid bone. In 1992, he showed that careful bone preparation minimized the wobble and warp of the polyethylene.

This led to our development of a hand-powered spherical reamer that enabled us to contour the bone around a drill hole placed in the center of the glenoid bone. This first glenoid reamer is shown below.

Now, the concept of reaming around the normal centerline of the glenoid is in common use. A modern reamer is shown below.

This reaming assures a precise fit of the polyethylene component (shown below) on the bone.

Our shoulder fellow Clinton has shown that care needs to be exercised during reaming to make sure the bone surface does not become overheated.

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