Shoulder Arthritis and Shoulder Replacement Surgery

Shoulder arthritis is much less common than that for other large joints in the body, which likely stems from the fact that it is a more mobile, flexible joint that does not bear the weight and stresses that the hips, knees and feet do. For those suffering from it however, it is a particularly troublesome area to lose mobility in, and a part of the body where pain can be quite difficult to manage. In shoulder arthritis, there is loss of the smooth cartilage in the gleno-humeral joints – the glenoid being the cup component (part of your shoulder blade), and the humeral head being the ball component (top part of your humerus or upper arm). As with all arthritic joints, rubbing of rough cartilage or exposed bone causes pain, swelling, stiffness and loss of motion.

• How do I know if I have arthritis in my shoulder?
  A reliable of feature of all those with arthritic conditions of the shoulder is a loss of range of motion in the joint, and in particular the ability to externally rotate the arm. If you bend your elbow to 90 degrees and keep your elbow against your body, try and rotate your arms out to the side. You should have symmetric movement, with most people able to rotate outwards ~45 degrees or more. If you are unable to do this, or one side moves more than the other, there is something restricting your shoulder movement and it may be arthritis. Other symptoms include pain and swelling, both of which are worse with activity and relieved with rest. If you have any concerns about your shoulder, seek review with your local doctor.
• How can shoulder arthritis be diagnosed?
  Your local doctor will take a thorough history and perform a focused physical examination. If you meet the criteria, you will be referred for a plain Xray of the shoulder joint. A plain xray will show moderate to advance arthritic changes, but can be negative in those with mild disease or focal areas of cartilage wear. If suspicion, remains, an MRI can be used to give more detailed information about the joint cartilage integrity. An MRI is also required to establish the integrity of the surrounding soft tissues, in particular the rotator cuff tendons. If you do have arthritis, you will be referred to an orthopaedic surgeon for opinion re management.
• I have had an Xray and it is normal, but my shoulder still hurts. What could be the problem?
  The difficulty with all shoulder conditions is that they all present with similar symptoms, and differentiating the cause can be a challenge. There are many conditions that affect the soft tissue components of the shoulder girdle that can present with pain, stiffness and reduced range of motion. If your xray was inconclusive or normal, there may be pathology involving the sub-acromial space (between your shoulder and your collar bone/acromion), biceps tendon, joint capsule, labrum or rotator cuff. Discuss the issue with your local doctor and seek review with an orthopaedic surgeon or sports medicine physician.
• What non-surgical treatment options are available for shoulder arthritis?
  Maintenance of joint range of motion (ROM) is essential in shoulder arthritis as in all arthritic conditions, and your physiotherapist should be consulted to design an appropriate rehab program to maintain shoulder girdle strength and ROM, without causing unnecessary pain or disease progression.
  Simple analgesics and anti-inflammatories can be used for symptom control, and when pain is severe, short courses of stronger prescribed analgesic may be indicated. Always discuss these with your local doctor before starting any medications.
  Dietary supplements such as chondroitin, glucosamine, calcium, vit D and fish oil have not been shown in studies to have substantial benefit in all patients, however, some people do have a great response. I would suggest you trial these supplement for 1-2 months, then cease. If your symptoms worsen when you stop, restart and continue taking the supplement – you are one of the lucky ones. If you cease the supplements and feel no different, save your money and look at other options.
• Are there any injections that can help my shoulder?
  A corticosteroid injection such as celestone can be of use in those where inflammation is a key part of the disease process. These injections are not without their own risks, and this must always be considered – there is a risk of introducing infection, and with frequent use, risks of humeral head osteonecrosis and weakening/tearing of the rotator cuff tendons. In general, only 3 injections can be given in a 12 month period, and spaced at least 4 months apart. Dr Host will discuss with you the pros and cons of these injections, and if it is applicable in your case.
• What surgical options are available for shoulder arthritis?
  Arthroscopic surgery on the shoulder in the setting of arthritis is unlikely to result in improved symptoms, and can lead to more rapid progression of the arthritis. There are circumstances where this will be performed, and that is when there are multiple problems in the same shoulder. Much like a hip, the definitive solution to advanced arthritis that is limiting your quality of life is a shoulder replacement. These come in a number of forms, ranging from a hemi-arthroplasty (only the ball is replaced), to a total shoulder replacement (both the cup and ball are replaced). The decision on which implant to use relates to your functional requirements and the integrity of the muscles around the shoulder. If you have an associated rotator cuff that cannot be easily repaired, a reverse total shoulder replacement (the ball and cup are reversed) is indicated. The difficulty, as with all joint replacements, is the longevity of the implants. Though shoulder implant survival has improved to match the hip and knee, the options in revision surgery are much more limited. This is mainly due to the smaller bones of the area, and the tendency for the rotator cuff to deteriorate as we age. The results of revision surgery are much poorer in comparison to a hip or knee replacement, and so it is best to wait until you are of an age that you will require only one shoulder replacement. There are those where this is not possible, and surgery is performed at a younger age. Dr Host will discuss with you in detail the pros and cons of all options, and how they apply to your situation in detail when he reviews you.
• Will my shoulder replacement function like a normal shoulder joint?
  In short, no. The aim of shoulder replacement surgery is foremost to reduce or remove the amount of pain that you are experiencing, and to restore functional ROM. It is common to lose permanently some rotation in the shoulder, and uncommon to restore the ability to raise the arm above the head (forward flexion is usually only 110-130 – head level). The operation will allow you to perform the tasks of daily living such as washing and dressing yourself, reaching the top shelf or the clothes line, and carrying light objects. It will not allow you to return to contact sports, repetitive overhead activity, and heavy lifting activities.
• How long will the shoulder replacement last?
  Current literature supports ~90% of implants will still be functioning at 10 years, though at 20 years it drops to ~80%. These figures are for a conventional total shoulder replacement. For a reverse shoulder replacement, the survival is lower and revision options reduced.
• Do I need to attend a pre-admission clinic review?
  Yes, all patients are to attend a pre-admission clinic review to ensure you are as well as you can be prior to surgery, as well as to ensure you have all the information you need.
• What should I do after my surgery?
  You will be given detailed instructions on all that is required of you prior to being discharged from hospital. To obtain a good or excellent result, you need to be diligent with your physical therapy and any restrictions placed on you.
• What should I look out for following surgery?
  If you develop any increasing redness or heat in your wound, or have ongoing wound discharge, you should seek review with Dr Host or your local doctor.
  If you develop any symptoms such as chest pain or tightness, shortness of breath, or lower limb/calf swelling and pain, you should seek emergency review at your nearest hospital.
• What rehabilitation must I do after the procedure?
  A detailed rehabilitation plan will be tailored for you to ensure that you achieve and maintain a functional ROM and mobility. You will be required to adhere closely to the plan and attend regular physiotherapy sessions.
• When can I drive after my procedure?
  You are not allowed to drive until you can safely control a vehicle with both hands. This will be at least a period of 6 weeks, and often closer to 3 months.
• When can I return to work or sports?
  You will need to remain in a sling for the first 6 weeks after surgery, and it will be at least another 6 weeks of physiotherapy before you can perform your daily duties comfortably. Depending on your occupational duties, you may require 3 or more months off. Dr Host will discuss this with you in detail during your review. With regards to sports, you will not be able to do any activities that involve heavy contact, heavy lifting, and prolonged or repetitive over head actions.