Total Shoulder Replacement or Arthroplasty

The shoulder is the most mobile and most complex joint in the human body, which also makes it vulnerable to injury and arthritis. Each year, nearly 60,000 Americans undergo shoulder replacement surgery, also known as total shoulder arthroplasty (TSA).

In this episode of MedStar Health DocTalk, host Debra Schindler sits down with orthopedic surgeon Dr. Ryan Hoffman, a shoulder and elbow specialist at MedStar Health, to explore:

·       What shoulder arthroplasty is and when it’s needed

·       The difference between total vs. reverse shoulder replacements

·       How advances like robotic planning, 3D templating, and stemless implants are changing outcomes

·       What recovery looks like and how patients regain mobility

·       What to ask when choosing a shoulder surgeon

If you’ve ever wondered about shoulder pain, rotator cuff tears, or when it’s time to consider replacement surgery, this conversation breaks it all down.

Watch and learn how modern shoulder surgery is helping patients get back to the life they love.

For an appointment with Dr. Hoffman call 410-554-2272. If you would like to share feedback on this podcast or suggest a topic for another episode of MedStar Health Doc talk, send an email: debra.schindler@medstar.net.

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

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Comprehensive, relevant and insightful conversations about health and medicine happen here. When MedStar Health Doc talk, these are real conversations with physician experts from around the largest healthcare system in the Maryland DC region. It's well established and medical communities that the large ball and socket joint of the shoulder has a wider range of motion than any joint in the human body. It's a complicated joint. It's not as stable as a hip or a knee, which makes it prone to injury requiring that ball and socket be replaced. This year, nearly 60,000 Americans will need a shoulder replacement surgery known as shoulder arthroplasty. The good news is that placing the shoulder joint has advanced by strides in recent years with improved implants, robotic planning, minimally invasive techniques, and even outpatient procedures that have you going home the same day. We're going to get all the details on them and more with orthopedic surgeon, Dr. Ryan Hoffman, a shoulder and elbow specialist at MedStar Health. I'm your host, Deborah Schindler. Thanks for being with us today on doc talk Dr. Hoffman. Thanks for having me. I'm happy to be here. So sometimes I hear this surgery referred to as a total shoulder replacement or a total shoulder arthroplasty and then TSA for short, it's all the same thing, right? Can you explain exactly what shoulder arthroplasty is? Sure. That's a great question. So shoulder arthroplasty is replacing the opponents of your joint, so it is a ball and socket joint. It is putting implants in for the ball and the socket. Now the interesting thing is that we can actually do these conventionally where we replace the ball with another ball and the socket with something that looks like a little piece of plastic and it goes right in the socket and it looks just like your normal shoulder just with implants in. Alternatively, we can reverse that. So the other version of a shoulder arthroplasty is a reverse shoulder arthroplasty where instead of the ball being on the humerus side, the ball is actually on the socket side and the socket is on the humerus side. And typically that was initially adapted for patients that had rotator cuff tears and injuries that we couldn't fix and they had trouble with motion. However, the uses of that have been expanding significantly over the years. Correct. I think most of us are familiar with the bow and socket joint in the shoulder that I mentioned earlier, but there is a much more complex network of bones, muscles, tendons. Can you give us a little bit of background or understanding of the anatomy of the shoulder and what happens that requires the joint to be replaced? Sure. The two largest conditions that end up resulting in shoulder replacements are one glenohumeral osteoarthritis or just standard shoulder arthritis. In that condition, what we have is we have a layer of cartilage, which is just a really smooth layer that lines the joints and allows them to move freely without pain. Now in some individuals over years and over time the cartilage kind of begins to deteriorate and then eventually it becomes bone grinding on bone and that can be quite painful. It can be debilitating. We can have significant decreases in range of motion and for those, that's where the traditional standard anatomic total shoulder arthroplasty came into play because we can't really replace cartilage, but we can replace the joints with kind of plastic and metal depending on where you are and that can give us a freely gliding joint that allows us to have more motion. The second type is considered with rotator cuff tear arthropathy or if patients have really big rotator cuff tears in the past, a standard shoulder replacement would not work because the rotator cuff is what allows us to function. It's what allows us to really move our shoulders. However, by reversing the implants, it allows your deltoid muscle, which is not your rotator cuff, to take over and restore function to patients where it might not have been the case decades ago. What exactly is the rotator cuff? I really don't even understand what it is. It's a great question. I get that literally every it's essentially a sleeve of muscles that turn into tendons and they attach to the top of the shoulder bone and what they do is they allow you to move your shoulder freely in different directions. Now the problem comes when you have rotator cuff tears in how we can actually raise and move our arms. So a lot of times there are tons of people that live their lives with big rotator cuff tears or if they fall and they sustain one and they can't lift their arm up and they end up having these terrible injuries that hopefully we get to them inside. There's always things that we can do for them. But the rotator cuff is a very important structure that we have to take seriously because it allows us to really move our arms how we'd like to do. Apart from a fall or a sudden injury, what's usually the first indication a person has that they need to see a shoulder surgeon? So I would say pain and weakness are the two most common things I happen to see. Typically, pain is the biggest driving force without an injury. Now oftentimes patients will see their primary care physicians and they'll try physical therapy. Sometimes they will try injections and really when we have pain that doesn't respond to physical therapy or injections, then that is a time where I think it's very important to see a shoulder specialist because a lot of the times we live our lives with pain that we don't necessarily have to. There are a lot of people that don't know that shoulder replacements or specific shoulder surgeries exist and they end up just living their lives with what they call their bad shoulder. And the things we pride ourselves in is taking away the term of bad shoulder. We can always do something for, we can almost always fix it. We can always do things to make it improve and we can try to restore quality of life to individuals who didn't know that that was an option in the past. Well, shoulder pain can mean a lot of things though it doesn't necessarily mean that the person needs a shoulder replacement. So what's your advice to listeners who are trying to figure out what the source of their pain is? How is that diagnosed? So that's a great question. Typically, if it's not associated with a fall or an injury, a lot of times simple shoulder pain from overuse injuries will go away with time. If you rest, you take it easy ice. These are things that often can be very helpful with physical therapy too. Rotator cuff tendonitis or anything that you have in there, a lot of the times can be treated. It's that pain that really just doesn't go away with time kind of gets worse over time when it starts turning into weakness. These are other things we can look for. If you have persistent grinding in the shoulder, that's another thing that is something that we can look into, but it's really pain that doesn't get better. With physical therapy, I have a lot of patients that will come in and they have mixed opinions on physical therapy and I'll tell you as a former shoulder surgery patient myself, I think physical therapy is phenomenal. I think it works great for the shoulder and when it stops working, I think those are times when we need to really start looking at what the bigger picture is and why we're still having these issues. What do you mean by that? They don't agree with getting physical therapy as a means of trying to eliminate the pain or they just don't want to do it because it hurts? Just say that there's some individuals who they have preconceived notions about physical therapy. Sometimes people will tell individuals to go to physical therapy and patients will sometimes view that as a, I don't have anything else more for you to do, but in actuality, physical therapy is a really phenomenal thing. The shoulder is such a unique joint, there's so many different areas that we need to balance. There's force couples in the shoulder and by strengthening one, you decrease the force on another. And physical therapy itself is a phenomenal thing that shoulder. The other thing is I think some patients don't always want to go to physical therapy. It's time consuming. It is hard to get off of work. Sometimes the hours are tricky, but in all the patients that I've had go and they've been very happy with it because they have been able to see the gains that they can make and the strides the physical therapy can actually provide in a lot of these general shoulder conditions. At what point would you order up imaging and what kind of imaging would be necessary for you to say to a patient that they need arthroplasty? So I always start with x-rays. I think when you have shoulder pain, it's always important to have x-rays because you never find and there are a lot of different variants that you can see that can lead to different types of shoulder issues. What I typically do, I base a lot of these off x-rays and if we're looking at shoulder arthritis in general, an MRI is really helpful and it shows us if the rotator cuff is of good quality. As we mentioned, the rotator cuff's important to move the shoulder. If we're going to do a standard shoulder replacement, you need to have a really good rotator cuff. So in general, I look at advanced imaging when we have no longer responded to conservative management like physical therapy or injections and we're looking to see if we want to go down a surgical route. So really I use MRIs for patients with standard arthritis just so I can see the quality of the rotator cuff and make sure there's no surprises. What are you exactly looking for? So that's great. So I look for tears. I look to see if the quality of the rotator cuff tendon especially over certain ages, can have underlying tears that they never knew about just from the wear and terror of life. So those are things that I look for to make sure that we don't have an increased risk of the implant failing at a sooner period of time. Other things I look for is I look for little fluid collections that you can see in the bone called cysts and look to see how good of a quality the bone is because these are also things that we want to look for whenever we do a surgery. We want to maximize the chances of this being the last surgery anyone's going to ever have. And I think the more information we have, the better so that we improve the rates of having the most successful outcome possible. Do. You ever get in and you look at the imaging and find shoulder at all, that they have shoulder pain, but it is not even the shoulder that is causing the pain? I see that every day. It's. Usually the culprit. What is. So that is an excellent question. Oftentimes what can happen is patients can have pinched nerves in their neck and when you have a pinched nerve in your neck, a lot of times it gives you pain that comes down your arm into your shoulder and it makes it feel like you're having shoulder pain, but it's actually coming from your neck. Ways that we can kind of help identify that is a lot of shooting pain that kind of goes up into your neck, numbness and tingling that shoots down your arm, pain that comes down past the elbow. These are all indicators a lot of the time that patients have a pinched nerve in their neck. And that would probably really benefit from physical therapy. Absolutely. So physical therapy, we have a lot of great spine doctors here at MedStar and I have a lot of colleagues that I'll refer some of these patients to so that we can maximize their outcome. Okay. So you see that the rotator cuff is in fair condition, but there's minimal cartilage and that the patient has a lot of pain and you know that they need an arthroplasty. How long do they wait? What's the right time for that surgery? There's a lot of things that we kind of factor in there. One is how bad the arthritis is. I have a lot of patients that come in and their arthritis is not that bad. It just gives them a little bit of pain here and there and they're not ready for a surgery. And in patients that aren't ready for a surgery, I don't force it on them. My job is to give the risks and benefits of all options and to help the patient make the best decision that they feel is they can make. So one of the other things we kind of look for sometimes age. I do have a lot of young patients with pretty bad arthritis, which is a little rare, but the thing is implants are not meant to last a hundred years, so we have to factor in lifetime when or basically number of years when we look and see what implants we're going to use or when we're going to do an arthroplasty. But it is something that we take into consideration. That being said, I do have a lot of young patients that have had great outcomes from shoulder replacements. Isn't that interesting because you would think that by the time the joint wears out, the patient would be maybe in their seventies, but I have read that they're getting younger. Is that because maybe of sports or playing year-round sports or I don't know. Athletics? That's a really good question. There's a number of conditions. I will tell you that with more and more high contact sports, their rates of dislocations in shoulders has increased. Sometimes when you have shoulder instability where out, it can increase your risk of developing arthritis and sometimes, sometimes certain procedures that are intended to stabilize the shoulder can result in patients getting arthritis at an earlier age than normal at a sacrifice of having a more stable shoulder at a younger period of time. In addition to that, some people just have a higher predisposition for it. Some people have very tough manual labor positions that put you at a higher risk and some people just have genetic conditions that risk of needing a shoulder replacement. I mean, there's just a lot of things that can drive it. I mentioned that the technology has just advanced strides in shoulder replacement. I know it has in the past 20 years that I've been here working at MedStar Health. Let's talk about that. Let's talk about the advancements and you mentioned the reverse shoulder replacement, which is an amazing kind of reconfiguration of what nature created, taking the ball and make it into a socket and taking the socket and making it into a ball. Who exactly would benefit from that kind of change in the anatomy and what is the end result for that? Do the patients still have the same kind of motion? So historically, the best patients for the reverse replacement were tear. They could not be repaired or those who had such bad rotator cuff tears that they started to have different changes to their joint that couldn't be treated with a standard shoulder replacement. That is still the case. Patients that have rotator cuff tears that we can't fix a lot of times can benefit very much from a reverse shoulder replacement. However, there have been more and more studies recently that show that you can do a reverse shoulder replacement for conventional arthritis too, and patients still have excellent range of motion and they have excellent pain control. So it really kind of varies. Now you can actually utilize a reverse shoulder replacement for a number of things. I am very selective in when I use an anatomic versus a reverse shoulder replacement, but the indications for them have been increasing significantly. Why might you use that if the person's rotator cuff was fine, why might you opt for a reverse shoulder replacement? So one of the things that you look for with a standard shoulder replacement is you want to make sure that the socket can sit well or the piece or the material we use to recreate the socket can sit well in the bone. Now in some of the patients, they have different types of wear or erosion of the socket, which makes it challenging to get good coverage of the new socket. And if you don't have good seeding of it, it can result in early failure or if you have different degrees that the socket is tilted, that can also make it challenging and result in early failure. So in patients like that, we typically tend to go to a more constrained device such as the reverse shoulder replacement is it's more predictable, you have better coverage, lesser chance of there being failure from essentially the piece of plastic that is not seated very well in the bone. So we really look at the glenoid side or the socket side when we're making these decisions and make sure that we can put everything in the best way possible. Is it different in terms of the length of the surgery or how big the incision is or the recovery? So the length of surgery is about the same for both of them. I would say the incision is the exact same incision for both of them. Which is about how many inches would you say? It's about four to five inches. Four to five inches front of the patient's shoulder, front of the shoulder, kind of coming from just kind of inside of the shoulder up top down to the mid level of the arm bone. Okay. And then after the surgery and the recovery processes be different? And getting back to that question, do they have the same motion? So the recovery period is pretty similar. We typically start patients with range of motion early on, but there is a period of time where they're in a sling. For my patients, I have them in a sling for about six weeks. I start assistive range of motion early on for about six weeks. After six weeks we start doing active range of motion, removing the arm on its own at three months we start doing strengthening at six months. There's kind of fewer restrictions in terms of range of motion in general, both surgeries, the range of motion is great. Patients do very well. It has been my experience. I think that patients with anatomic shoulder replacements get a little bit better internal rotation, so reaching up their back. But in terms of forward elevation and external rotation, if the rotator cuff is intact, there are great studies that show that both types of replacements can result in similar outcomes. It kind of just varies on how much of the rotator cuff is intact. Okay. Let's get to the next advancement. And that's stemless shoulder replacement. Can you explain what that is? Sure. So shoulder replacements, they conventionally have had a stem, which is just a long, it's a long part of the metal that goes down the center of the tube, which is the canal of the humerus. And in the past all implants have had that, but more recently we've developed stemless, which is a smaller component that actually is bone preserving. So it actually results, if you ever need another surgery, it makes it for a much easier procedure. There's less bone that needs to be removed and it's really quite fascinating. It was mostly used in anatomic total shoulder replacements, but we're currently in a few government studies now looking at its use in reverse. How does that benefit the patient and why would they want that? I think one of the ways that it benefits them is that it's bone preserving. If you ever need another surgery in the future, it makes for a significantly easier procedure or a less complex procedure. One of the issues is sometimes when we do these procedures, it can result in significant bone loss if they need to be revised. The other thing is that sometimes patients have a lot of deformity from prior fractures and that can make it really challenging to put a stem down, a not straight bone. But with a stemless procedure or stemless implant, you can really tailor that to the patient's anatomy you can do with what you have. How does it hold onto the bone if it's not hammered into that implant and that stem get hammered into that bone? So I'm wondering how the STEM was would even hold on. How secure is it in your body? I'll tell you, it is very secure. There's different types of metal material that we use. They can be porous, they can have little grip blasting, but essentially the bone can form on and inside of it and it kind of forms around it and kind of incorporates it into it. And it is quite strong. I tell you, they get such great fixation. And there's nothing that would be different in putting what the patient needs to know and managing their expectations about the surgery, the length of the surgery or the recovery. Getting a STEMIs doesn't change anything for them? No, it does not. I've actually found the surgeries are a little bit faster, but it's not significant. And in terms of their recovery, it does not have any impact. Oh, okay. Alright. What about 3D templating? I think 3D templating is fantastic. It is that we utilize to help tailor the procedure so that it is the most specific for each patient. And what that is is when we do shoulder replacements, we have patients get CAT scans. And what that does is it allows us to look at the bones and what worth two dimensional views and we can convert them into a three-dimensional view on the computer and we can then plan the surgery specific to the patient's anatomy so we can really tailor this as much as possible so that each patient gets the most specific accurate surgery possible directly related to their own anatomy. So it's for planning? Absolutely. Planning. You're not looking at a 3D template during this actual surgery or just using. For planning? So what we use it for here is that we use it for planning. There are some companies that do have mixed reality glasses that you can use them in the operating room and that's a really interesting area that we have been looking into moving forward, but that is one area of advancement, but currently we're using them for planning. I know we used 3D printing on a tus bone that was replaced. Very cool technology. It is pretty cool. And I'll tell you, so we actually do a lot of custom shoulder replacements. Patients where there's so much bone loss that conventional implants don't work and we actually work with certain companies that 3D create certain implants that will fit into those defects. And apart from just 3D templating on the computer, we can actually design implants that we've used in individuals and we can also design different models so we can see how our implants will fit in the patient. And that's another unique thing that we do here. That is very cool. The implants that we've been talking about used in shoulder arthroplasty are all different. What do patients need to know about them? What makes them different? What makes them better? Should they ask their doctor for anything specific? How would they know what to ask for? I think ultimately when you're looking at a shoulder replacement, the biggest thing is that you want to have trust in the person who's doing it and you want them to use the implants that they are going to do the best job for you. However, there are very interesting technologies that are out. One of the things are we have highly cross-linked polyethylene, which is a specifically manufactured type of plastic that we use. And then when it's also coated with vitamin E, it is something that myself and the shoulder division here we are very interested in using because we believe that it has lower rates of wear and creating issues for patients down the road. That's one thing that we typically use. The use of pyro carb or use of hydrocarbon in shoulder arthroplasty is of another in interesting feature that we utilize here as well. It's a different type of material than the conventional metals that are used in standard shoulder arthroplasty. It's kind of a material on bone and our goal is that it decreases the risk and the rate that you have where and needing another shoulder surgery in the future and that is something that we certainly utilize here at MedStar. I think ultimately though, when you're looking at these, I think it's always important to ask what implants the surgeon uses if they use anything new or innovative and if they have experience with 3D templating. I think 3D templating is fantastic and I think everyone should use it. What should patients consider when deciding on a shoulder surgeon? Maybe they don't have one already or they haven't been referred to one and the shoulder program. I think one thing is that you certainly, and there have been studies looking at this, but you certainly want to go to somebody who does a lot of shoulder arthroplasty if you have individuals who do maybe five or 10 a year. I think that the experience is not quite there as much and I think that there are certain differences that you can see in outcomes. So I think volume is certainly a significant thing that you need to ask. I think duration of time, number of cases are all important features. And then I think philosophy too. I think it's always really important to understand what everybody's postoperative procedures are, how they take you through the postoperative period, what the hospital stay is like. There's a lot of really unique things that we do here that I think really show in our patient satisfaction, but I definitely think you need to be pretty selective when you're deciding who you finally go to have your shoulder replaced. Well, to that point, Helio published the results of a study that showed total shoulder arthroplasty performed by a high volume surgeon may decrease medical and surgical complications compared with those who performed lower volumes. Should patients ask how many total shoulder replacements a surgeon has done during a consult, would you be offended by that question? As a surgeon, I. Would tell you I don't think I'm offended by any question I get asked. You never know what you're going to get asked. Good to know. I'm an open book. I answer all questions that are asked. So I personally am not offended by anything that is asked, especially when you're making such an important decision as to having a part of your body replaced. It's very personal decision and I don't think that anybody should be offended when somebody's doing their due diligence and trying to do their homework and make sure they make the best decision possible. I mean, especially when there's so many people that dabble in different areas, you want to make sure that you go to somebody who's really comfortable, who does a lot of them and who can give you the outcome that you're looking for. What would be a lot of them, what would be a good number to make you feel safe? I would say you want somebody who does at least 50 to a hundred a year. Okay. With all the changes we've already seen in the advancement of shoulder arthroplasty, what do you think the future holds? So I think that's a really great question. I think one of the things that the future holds is robotics and shoulder surgery. We've already seen great success with that in total hip and knee surgery, and we have more and more areas where we can use robotics and shoulder surgery, especially with shoulder replacements Here at MedStar, we actually have the technology for these and this is definitely an area that we are working towards implementing in our regular practice. How would that work? Actually, to tell you what angle to put the implant in or to put a screw in, I am thinking in terms of how it works for other orthopedic surgeries. I think one of the ways that people have utilized or one of the ways that people have utilized it are making sure that we make perfect cuts when we make our cuts for the humerus or putting the implants into the socket. Sometimes the deformity that you can see in the socket can be a little tricky and unless you do a lot of them, getting certain trajectories can be a little bit challenging for some. And what robotics allows us to do is to be extremely accurate to make sure that we don't have any issues to make sure that the implants are placed and all of the cuts are made in the most perfect way possible. They kind of take out a lot of the guess and check aspect of it. We've been talking with MedStar Health Shoulder and elbow surgeon, Dr. Ryan Hoffman. Thank you for sharing your expertise with us here on Doc talk for an appointment with Dr. Hoffman off 4 1 0 5 5 4 2 2 7 2. If you would like to share feedback on this podcast or suggest a topic for another episode of MedStar Health Doc talk, send me an email Deborah schindler@medstar.net.