Shoulder Pain Management

Joint Replacement

Shoulder Resurfacing

In patients who have mild to moderate humeral head wear, joint resurfacing, a newer alternative to joint replacement, may be considered. This procedure removes the diseased cartilage tissue from the shoulder joint while retaining much of the patient’s natural bone. By eliminating the need for a full head resection, shoulder resurfacing provides another possible solution for active patients who are concerned with bone preservation. In cases of extensive humeral head wear, a traditional hemiarthroplasty (replacement of the head of the humerus), may be a more appropriate option.

Figure 1: A shoulder resurfacing component in place.

Partial Shoulder Arthroplasty

Two types of shoulder replacement are performed by orthopaedic surgeons: hemiarthroplasty (humeral head replacement) or a total shoulder arthroplasty. A hemiarthroplasty is where the glenoid socket is not replaced. In this procedure, the patient receives only humeral components. Hemiarthroplasty may be the procedure of choice for active patients with reasonable glenoid anatomy and a balanced joint. In some patients, conversion of the hemiarthroplasty to a total shoulder arthroplasty might be necessary.

Figure 2: A hemiarthroplasty (humeral head replacement).

Total Shoulder Arthroplasty

When the patient’s arthritis remains painful following hemiarthroplasty and reduces implant performance, the total shoulder arthroplasty may restore comfort and function to the joint. In the total shoulder arthroplasty, the patient receives both humeral components and the glenoid implant. A recent review of various studies on the subject by R. John Naranja, MD and Joseph P. Iannotti, MD, PhD, found that shoulder replacement surgery reduced pain in the shoulder joint in most people.¹ They also noted an improved range of motion in those who underwent shoulder replacement. The studies they looked at found that the use of modular implants had a favorable impact on the results of shoulder replacement surgery.¹

Figure 3: A total shoulder arthroplasty.

Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty (reverse Delta), has been found to lessen shoulder pain and improve function in end-stage rotator cuff arthropathy (shoulders with failed surgery or combined arthritis, rotator cuff tears and instability). In this surgical procedure, the shoulder structure is reversed, with the ball portion of the implant attached to the scapula and the socket placed at the upper end of the humerus. The design of the implant enables the deltoid muscle to power the shoulder to restore range of motion and reduce pain.

Figure 4: A reverse shoulder arthroplasty.

Conditions That May Require Shoulder Replacement

Acromioclavicular Arthritis

When conservative treatment of acromioclavicular joint arthritis does not provide pain relief, or in cases where acromioclavicular joint arthritis is impeding daily activity, your patient’s orthopaedic shoulder specialist may recommend surgical intervention.²

Glenohumeral Arthritis

The surgical option for patients whose pain continues after conservative treatment is shoulder replacement. The primary goal of shoulder replacement in cases of glenohumeral arthritis is pain relief, though some patients will also experience improved function with increased range-of-motion. Keeping in mind variables such as the degree of degeneration of the humeral head, the condition of the rotator cuff and the age of the patient, options include hemiarthroplasty (humeral head replacement) or a total shoulder arthroplasty.

Rotator Cuff Tear Arthropathy

Rotator cuff tear arthropathy is when the rotator cuff muscles degenerate or become unstable to where they can no longer hold the shoulder joint intact. This condition may be caused by a rotator cuff tear or failed previous shoulder surgery or a combination of the two. Rotator cuff tear arthropathy results in pain and loss of mobility. It may be exacerbated by arthritis. Specialized humeral head implants that provide increased surface area of articulation are used in shoulder replacement for rotator cuff tear arthropathy. They may reduce pain, improve range of motion and improve joint stability.

A reverse shoulder replacement may be selected in advanced cases of rotator cuff tear arthropathy, when the rotator cuff can no longer provide adequate range-of-motion. This procedure may be considered in patients with stiffness due to failed surgery or combined glenohumeral arthritis, rotator cuff tears and instability. Fracture, shoulder replacement revision and tumor surgery are other indications.

Fracture

Shoulder arthroplasty is considered when the humerus has been fractured in three or more places, or when the humeral head has been fractured or crushed. The goal of shoulder arthroplasty in these cases is to restore range of motion and reduce pain.

While non-displaced fractures may only require a sling to keep the shoulder joint immobilized during healing, approximately 20% of shoulder fractures are displaced and may require surgical repositioning, thus shoulder arthroplasty might be recommended. Shoulder arthroplasty might also be considered in older patients (>65 years) in whom the bone may heal more slowly or incompletely following a fracture.

Contraindications

For patients with active infection, absent deltoid function, Charcot or neuropathic arthropathy, and intractable shoulder instability, shoulder replacement is contraindicated. For these patients and those with prior unsuccessful surgery, arthrodesis or surgical fusion may be a good option.

References