CHICAGO – Total shoulder arthroplasty is increasingly providing patients who experience arthritis-related shoulder pain and disability with a viable and successful treatment option.
Replacement of the joint is particularly effective in those who have an intact rotator cuff but who have severe shoulder pain related to osteoarthritis (OA) causing difficulty with activities of daily living. The surgery can also be of benefit in those with rheumatoid arthritis (RA), Dr. Matthew Saltzman said at the symposium.
In those with advanced OA of the shoulder, total shoulder arthroplasty is probably the most effective treatment for relieving pain and restoring motion in the long term, said Dr. Saltzman, an orthopedic surgeon specializing in shoulder and elbow surgery at Northwestern University, Chicago.
He described a case involving a 67-year-old woman – an avid skier – who presented with progressive pain and decreased range of motion over several years despite corticosteroid injection therapy. Routine imaging studies showed straightforward advanced OA. This is “far and away the most common thing I treat as an orthopedic surgeon,” according to Dr. Saltzman.
The decision to perform a shoulder replacement was made.
At 6-month follow-up, the woman demonstrated remarkable restoration of range of motion and internal rotation, he said.
“The key with this operation … is that the patient has to have to an intact rotator cuff. I assess cuff integrity usually just by physical examination, but I won't hesitate to get an ultrasound or MRI if necessary,” he said, noting that most patients with OA will have an intact rotator cuff.
“The main problem is just that the joint is irregular and the cartilage is just completely gone,” he said. RA patients can benefit from this operation as well.
A recent study comparing total shoulder arthroplasty outcomes in 24,212 patients without RA and 1,186 patients with RA showed that the complication rate in both groups was less than 1%, and that length of stay was actually shorter in the RA patients at 3.7 days vs. 4.2 days (J. Shoulder Elbow Surg. 2011;20:77–85).
In patients who are not candidates for total shoulder replacement, another option is a hemi-arthroplasty procedure in which half of the joint is replaced. This procedure is common, and although data show that it is not nearly as effective in terms of pain relief and patient satisfaction as is complete joint replacement, it still can provide relief and improved range of motion.
In his presentation, Dr. Saltzman described a case involving a 69-year-old woman with RA who had severe medial erosion and loss of joint space.
Total shoulder arthroplasty was not an option because of the lack of glenoid bone to support it, but hemi-arthroplasty was successful for pain reduction (she rated her pain 0 out of 10 on a visual analogue scale following the surgery), and her function was substantially improved.
These outcomes are not unusual, he said.
In one study, for example, 102 patients who underwent total shoulder replacement surgery experienced significant improvements in their ability to perform prespecified shoulder functions. Patients successfully performed 4 of 12 functions (lifting a gallon jug of milk onto a shelf, etc.) before the operation, and were able to complete 9 of 12 postoperatively, he said (J. Bone Joint Surg. Am. 2002;84:1349–53). That study also showed that women present as candidates for surgery about a decade later than do men (at an average age of 73 years vs. 62 years).
Other data have demonstrated that shoulder replacement surgery is associated with lower mortality, lower complication rates, shorter hospital stays, and lower costs, compared with knee and hip replacements. A 2007 study showed that in 994 shoulder, 34,471 knee, and 15,414 hip replacement patients, respectively, mortality was 0%, 0.16%, and 0.18% (Clin. Orthop. Relat. Res. 2007;455:183–9). Complication rates were 7.55% (shoulder), 14.7% (knee), and 15.5% (hip). Lengths of stay were 2.42 days for the shoulder replacement patients, compared with just over 4 days for the knee and hip replacement patients. Mean hospital charges were ,351, ,674, and ,442 (for shoulder, knee, and hip procedures, respectively).
Most patients and physicians aren't very familiar with it. That will change soon, Dr. Saltzman said.“It's definitely coming with the baby boomers and we're really going to be seeing more and more of this.”
Data from 2002 show that about 23,000 shoulder replacements were performed, compared with about 400,000 knee replacements, but more recent data suggest the number of shoulder replacements will increase by about 250% by 2015.
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