When is the right time to take the plunge for a shoulder arthroplasty?

Patients come to my office with shoulder pain for many reasons. One of the more common conditions in my shoulder practice is osteoarthritis.

The smooth articular cartilage of the ball and socket wear out, and your body tries to grow bone spurs to help distribute the force. It tries to help itself, but in the end, it hurts itself. The spurs that form turn your shoulder socket into a square peg in a round hole, resulting in lost motion and experience pain (all the time). It’s a miserable situation.

Generally, we begin treatment of shoulder osteoarthritis with activity modification, rest, and anti-inflammatory medications. Then, we try to avoid surgery for as long as possible through the use of steroid injections, as frequently as every three months–forever.

We do injections until they no longer work. Why? Because joint replacements don’t last forever, so we want people to be later on in life before they take the plunge and get a shoulder replacement.

We like to see people in their 70s for a total shoulder replacement. Will we do it for someone in there 50s or 60s? Potentially, but it’s important to work through the algorithm of treatment first.

As a side note, there are actually two types of shoulder arthroplasty procedures: total shoulder replacement and reverse total shoulder replacement.

A reverse procedure is where the ball and socket are flipped around because the rotator cuff is just simply not there anymore, often due to a traumatic fracture where the rotator cuff is destroyed (beyond repair), and a total replacement procedure maintains the same anatomical structure.

Currently, there are about 53,000 shoulder replacement procedures performed each year in the US.

The shoulder, It’s complicated…

Many people assume that joint replacements last forever, but they don’t. That perception probably comes from the longevity of hip and knee replacements, which can last 30-40 years, but the shoulder is less conducive to a joint replacement than the hip or knee.

Shoulders rely on a small, thin, glenoid/socket, and there’s a tremendous amount of force on that, which is where implant failure usually occurs. The implant works its way loose and it fails. Some studies show 94% of shoulder implants were in and doing great at 10 years; 87% at 15 years. For newer generation systems, we lack the numbers to accurately predict the replacement’s longevity.

Let’s look at an example: a man in his 50s comes in complaining of severe shoulder pain. He wants a replacement, but at his job, he often lifts heavy objects overhead. If he has a total shoulder replacement, it will last about one year–tops, and then he’ll need it removed and a new one put in.

There are just certain things we don’t want people to do after a shoulder replacement.

Lifting a suitcase from down low is not a big deal. It’s a one-time thing, close to your body. But lifting more than 10-15 pounds away from your body with an extended arm puts a great deal of strain on your shoulder socket, strain we want people to avoid.

Really, I feel like I’m convincing people to live smarter when they come in asking for shoulder replacements.

The people with whom we talk about arthroplasty are those people who have exhausted their options or those who experienced a catastrophic injury. They’ve exhausted everything, they’re miserable, on narcautics, and are not functioning well. That’s straightforward.

Shoulder Arthroplasty gets rid of pain

It’s important to know and remember that the number one reason you do a shoulder replacement is for pain relief, not function.

We can’t tell people they’ll have normal range of motion after a shoulder replacement procedure. Remember what I said: as you become more and more arthritic, you lose range of motion. The bones are getting bigger (sometimes smaller and they dissolve), but what routinely happens is that the entire shoulder collapses the soft tissues.

When we do a joint replacement, we can reconstruct the ball and the socket, but you have to tension things properly. If it’s too tight, the shoulder won’t move and will be painful. If it’s too loose, it could dislocate.

Pain medication abuse is a real concern

A patient may come in and say, “I need more pain meds,” and then I find out they’re riding motocross on the weekends. No…people have to accept that their joints are checking out. When the shoulders begin to go, you have to adjust. It’s a major lifestyle change for anyone, and there’s only so much we can do. We can get rid of the pain, but behaviors must change in order to support that pain-free solution.

If you’re taking more and more narcotics, that will always trigger a discussion for joint replacement because that affects not only your shoulder, but also your entire well-being. There are so many concerns about addiction and abuse with narcotics. Narcotics can affect your productivity and mental acuity.

It’s a valid conversation, and it happens because it’s so important to me that my patients are healthy in all respects.

Don’t misunderstand me. I want you to stay active, but I don’t want you doing explosive activities that will destroy the replacement.

So then, when should you get a shoulder replacement? When you absolutely cannot bear the pain anymore (and all other treatments have failed, including steroid injections). As mentioned previously, emergent situations where an accident or traumatic injury occurs may necessitate a replacement at a younger age without pursuing the traditional algorithm.