The shoulder is one of the most movable joints in your body, and it’s a complex one that depends on the rest of your body to work properly— which is why shoulder problems can affect people of all ages.
Shoulder replacement surgery (arthroplasty), one of the most successful orthopedic surgical procedures, is evolving. Advances include much improved replacement implants, individualized planning and execution, and a more comfortable recovery. These advances are similar to those that have changed the way doctors perform knee replacement surgery.
In this Q&A, Dave Shukla, MD, explains some of the most common problems that might require surgery, the different options available to patients, and some of the latest advances, including the use of mixed reality technology to plan and execute shoulder replacement surgery at Mount Sinai Brooklyn, the first of its kind in New York City.
What are the most common job and sports-related injuries and lifestyle conditions that can cause shoulder pain?
Dave Shukla, MD
Osteoarthritis is an example of a condition that can cause shoulder pain. Anyone whose job requires repeated lifting or pushing, such as a construction worker, is prone, to shoulder injuries. Athletes in sports that involve repetitive shoulder motion, such as a baseball or tennis, are also prone to injuries. About 30 percent of people over the age of 60 develop arthritis in the shoulder joint, with most of the cases affecting women.
Your biological makeup can also predispose you to loss of cartilage. There are some genetic factors that might make some people prone to having less durable cartilage, or some people’s cartilage doesn’t stick to the bone as well. These individuals tend to have their cartilage wear away more easily. Some people develop shoulder arthritis even though they do not subject their shoulder to much stress and participate in low-impact sports, such as swimming. Also, a history of trauma to a joint, such as a dislocation after a fall or skiing accident or having a broken bone in the past that causes some malalignment in the joint, will predispose someone to arthritis.
What types of traumatic injuries require shoulder surgery?
A visit to an orthopedic surgeon is essential to repair a broad array of injuries, including rotator cuff tear, a tendon tear, shoulder trauma, or fractures of the humerus, clavicle, and scapula. The type and extent of the surgery depends on the severity of the injury. The surgeon will recommend if reconstruction or full joint replacement is needed. The surgeon will try to spare the patient’s native anatomy whenever possible. In the case of soft tissue injury, surgeons try to repair rotator cuff tendons that are destabilizing the shoulder. There are situations when there is a rotator cuff tear that’s so severe, or has been there for so long, that even if the tendons are repaired, they may not heal. Once the rotator cuff has been damaged for a long time, the shoulder can start to develop arthritis, which is called rotator cuff tear arthropathy. Once the joint and the bones start remodeling and lose their shape and the cartilage wears away, we then move to recommendations on joint replacement options.
How are shoulder injuries or conditions diagnosed?
A visit to an orthopedic surgeon begins with taking a patient’s history: When did the pain start? How did it start? Was there any previous trauma or injury? The doctor will perform a physical exam to determine the extent of functional impairment, range of motion, and the extent of pain. Typically, X-rays will be the first screening test. If there is any concern for soft tissue injury that you can’t see on an X-ray, a magnetic resonance imaging (MRI) scan may be needed. The MRI would be able to help diagnose rotator cuff or labrum tears, biceps tendon injuries, the onset of arthritis, and wear and tear of the cartilage causing bone changes. The surgeon may also use computed axial tomography (CAT) scans before performing any operation involving bone work, such as a shoulder replacement, or sometimes before repairing a broken bone.
What are the most common non-surgical treatments for shoulder pain?
The majority of shoulder problems are usually initially treated with conservative management consisting of rest, activity modification (especially with rotator cuff tears), and physical therapy. That can be coupled with oral anti-inflammatory medication or possibly a steroid injection, which can be very helpful in controlling inflammation and pain.
What is arthroscopy?
Arthroscopy is a minimally invasive procedure for diagnosing and treating joint problems. During an arthroscopic procedure, the surgeon inserts a narrow video camera about the thickness of a pencil through a very small incision to view the joint. The doctor can diagnose problems as well as repair a range of injuries by inserting instruments through an additional small incision to repair. Surgeons can remove bone spurs or cleanout scar tissue that might be the cause of pain and impingement, potentially resulting in loss of motion.
What are the different types of shoulder surgery and when is each needed?
There are four types of shoulder surgery, which offer patients options for their specific condition:
- Shoulder reconstruction surgery: This is for patients with moderate symptoms and conditions that don’t require total joint replacement. The surgeon repairs torn or stretched ligaments and other soft tissues to stabilize the shoulder joint and to prevent future dislocations. Minimally invasive techniques are used whenever possible, but some patients need open surgery. Reconstructive surgical options include arthroscopy and open surgery.
- Partial shoulder replacement surgery (shoulder hemiarthroplasty): This procedure replaces the upper bone in the arm with a prosthetic metal implant, leaving the other half of the shoulder joint, the socket, intact.
- Total shoulder replacement surgery (shoulder arthroplasty): Patients who have severe arthritis in the shoulder but whose rotator cuff tendons are intact (not torn) can benefit from an “anatomic” total shoulder replacement surgery. The shoulder replacement surgery replaces both the ball and socket of the shoulder joint with an artificial joint (made of metal, ceramic, or plastic).
- Reverse shoulder replacement surgery: If you have severe shoulder arthritis and rotator cuff tears or deformity with bone loss, your surgeon may also recommend a different type of surgery called “reverse” shoulder replacement surgery. This surgery involves replacing both the ball and socket of the shoulder joint but switches their positions. In this technique, surgeons attach a metal ball to the shoulder socket and a plastic socket to the upper end of the humerus. A reverse shoulder replacement allows the patient to use an upper arm muscle (the deltoid) rather than the rotator cuff to raise and move the arm.
What are the risks for each procedure?
Complications can happen with any surgery. The range of complications can include infections and possible nerve injury. Overall, the risk for shoulder arthroplasty is relatively low. Risks for shoulder implants are related to implant instability or the implants’ failure to incorporate into the patient’s bone. If the surgery is for a fracture, the risk might be related to the joint not functioning exactly how you want it to function.
Is shoulder arthroplasty an outpatient procedure?
There is a national trend to performing shoulder arthroplasty as a same-day procedure. Most shoulder replacement surgeries at Mount Sinai Brooklyn are same-day surgeries. An assessment of each patient is made pre- and post-surgery to ensure they can be safely allowed to go home the same day, though if pain control is challenging or other medical issues arise, then the patient would stay overnight.
What will a successful surgery and recovery look like?
It usually takes about three months for a near-full recovery, though patient function continues to improve up to one year after surgery. Patients wear a sling for the first four to six weeks. Once out of the sling, the patient can start active range of motion followed by strengthening, often with the assistance of a physical therapist. By the end of three months, most patients feel like they have an 80 percent recovery.
Will there be activity restrictions post surgery?
Once you are fully recovered, we recommend no lifting overhead of more than 25 pounds for reverse shoulder replacement. As a rule, the more strenuous activity you place on the new joint, the less life it might have in the long term. Patients are able to resume most leisure athletic activities such as golf, swimming, and light weight lifting.
How long will the shoulder replacement last?
In general, 95 percent of shoulder replacements last about 10 years, and 85 percent of them last more than 20 years. If you live long enough and you have had replacement surgery, you can plan on having another at some point in your life. Considering the advances in surgical techniques and the materials used for the replacements, there’s a possibility that the replacement might last 30 years or longer.
What innovations or advancements are being used to improve the surgical outcomes?
There are a number of innovations and advancements in shoulder surgery, including advances in the use of CAT scan technology, the use of mixed reality to plan and execute the surgeries, and the expected use of robot-assisted surgery, similar to what is being done in total knee replacement.
- CAT scan technology: A significant advancement has been the increased use of CAT scan technology for shoulder arthroplasty, which can provide what is called “patient-matched implants.” This is where a CAT scan of the patient is used to manufacture an implant that fits the shape of the patient’s anatomy perfectly. The surgeon can now use an individualized, custom-made implant for each patient. Creating an individualized implant used to cost tens of thousands of dollars and could have taken several months to manufacture. The length of time to produce these implants is now about five weeks. The goal is to try to reduce the wait time to two weeks.
- Robot-assisted surgery: Over the next few years, shoulder surgeons will be able to use robot-assisted surgical technology. Currently used by some for total knee replacements, robot-assisted surgery will bring an increased level of precision. This can lead to the use of a less-invasive approach to shoulder replacement.
- Mixed reality: This uses holographic technology combined with a surgeon’s pre-operative plan to more precisely execute each shoulder surgery.
What is mixed reality and how does it work?
One of the newest technologies available, mixed reality uses 3D holographic technology to allow surgeons to plan the operation using perfect images of your shoulder’s anatomy. This planning will allow for a greater level of precision in placing implants. Based on years of experience, the latest research informs us that if a shoulder implant is put in even two or three millimeters too high or slightly in the wrong rotation or alignment, it will drastically affect not only the range of motion and the outcome, but also how long the implant can last.
During the pre-surgical planning, CT scan images are loaded onto a database using a new software that allows the surgeon to plan a patient’s surgery in a 3D space. This creates a precise holographic image of the patient’s shoulder. The surgeon creates a detailed map of the patient’s anatomy that is brought into the operating room to provide precise guidance. The mixed reality technology is yet another major advancement in shoulder replacement surgery that provides individualized care based on each patient’s anatomy. The technology works with special goggles that project the 3D image and, through voice and hand control commands, allows surgeons to position and manipulate the hologram during the procedure. Surgeons can rotate and zoom in or out of the hologram model while comparing it in real time to the patient’s own anatomy. This technology allows the surgeon to minimize the risks of improper placement, reducing the risk of early joint loosening, and also to protect the soft tissues around the shoulder.
Will Artificial Intelligence (AI) play a role in shoulder arthroplasty in the future?
AI is currently being used for hip, knee, and spine surgeries to predict which patients will do well and which might have complications. In the near future, AI will play a larger role in shoulder arthroplasty. This will enable surgeons to advise patients about potential risks based on the AI algorithm of their medical chart and risk factors. This will allow for a greater understanding between the surgeon and patient about risk factors before going into the surgery.