Restoring Shoulder Functionality with Cutting Edge Procedures

With an aging Baby Boomer population that prizes staying active, the prospect of not being able to raise their arms due to a shoulder problem — whether to play golf, swim or even comb their hair — is simply unacceptable. That's why University of Maryland orthopaedic surgeons are on the leading edge of ever-evolving surgical procedures that can restore these patients' prior function and offer years more of pain-free living.

The duo of Mohit Gilotra, M.D., an assistant professor of orthopaedics at the University of Maryland School of Medicine, and S. Ashfaq Hasan, M.D., an associate professor of orthopaedics at the UM School of Medicine and chief of the shoulder and elbow service at UMMC, perform around 200 total shoulder replacement procedures each year. About 60% are comprised of so-called reverse total shoulder arthroplasty — so dubbed because the artificial joint reverses the normal anatomy of the shoulder — while the remainder is total shoulder replacements using anatomically standard artificial joints.

The University of Maryland, a designated tertiary referral center for complex shoulder problems because of its expertise in the field, is attracting greater numbers of patients each year for these two procedures. Some of these patients experienced failed prior surgeries at other institutions, while others come to UMMC specifically because of its stellar reputation and want the job done right the first time.

"The complication rate is now under 5%, so this has become one of the most important, highly satisfying parts of our practice," says Dr. Gilotra, "mostly because these patients are so badly affected and get so much better in a short amount of time."

Traditional vs. Reverse Shoulder Replacement

The shoulder joint is termed a "ball and socket" joint because it's formed by joining the dome-shaped head of the upper arm's humerus bone (the "ball") with the glenoid cavity of the shoulder (the "socket"). Many older adults begin experiencing shoulder pain and dysfunction as a normal course of aging, but deciding which of those severely affected should undergo traditional vs. reverse total shoulder replacements is fairly cut-and-dried: What really matters is whether their rotator cuff is intact.

Many shoulder patients suffer from osteoarthritis in the joint, causing stiffness and pain so extreme it can awaken them from sleep. But if their rotator cuff is intact, they are selected for traditional total shoulder replacement, in which their damaged joint is removed and replaced with a prosthesis. In contrast, reverse total shoulder replacement is offered to patients whose rotator cuff is so badly damaged or torn that it cannot support the movement of the shoulder joint. The rotator cuff may initially tear as the result of a fall or accident, but degenerative changes can also occur. Other reverse total shoulder replacement patients may have suffered complex fractures of the shoulder joint or have undergone failed rotator cuff surgery or failed traditional shoulder replacement surgery, Dr. Hasan explains.

Approved by the U.S. Food and Drug Administration in 2004, the reverse total shoulder procedure replaces the socket side of the joint with a ball and the ball side with a socket, unlike traditional shoulder replacement surgery. Before the surgery, most of these patients have exhausted options for restoring movement — including anti-inflammatory medications, steroid injections or physical therapy — and suffer from so-called "pseudo-paralysis" of the shoulder, rendering it all but useless in its normal capacity to rotate a full 360 degrees.

Reversing the position of the ball and socket in this type of surgery compensates for the loss of the normal rotator cuff, with the deltoid muscle in the shoulder filling in to once again raise the arm.

"It's called pseudo-paralysis because while the arm isn't paralyzed," Dr. Hasan says, "and the nerves and muscles still work, the person still can't raise his or her arm even to shoulder height because a massive tear of the rotator cuff results in loss of intrinsic stability to the joint."

Risks Minimal, Reward Great

Both surgeries are done at the front of the shoulder using a six-inch incision to insert the new artificial joint in a procedure that typically requires a two-night hospital stay afterward. Physical therapy is initiated during hospitalization — and for traditional shoulder replacement patients, continues on an outpatient basis — when they're taught a simple set of exercises they can continue on their own.

The risks of either procedure are minimal, though still higher than comparable joint replacements of the hip or knee. Infection, always a concern, can be particularly problematic for shoulder surgery patients because the positioning and depth of the joint can enable "smoldering" infections that are hard to pinpoint but necessitate another artificial joint be implanted.

For most patients, the rewards greatly outweigh the risks.

"Very predictably we can alleviate pain and offer them a functional extremity again," Dr. Hasan says. "People with bad hip and knee arthritis typically get their joint replacement surgeries much sooner, whereas someone with shoulder arthritis tends to put it off. When they finally do it, their reaction is 'wow,' and they say they wish they'd done it sooner."

Research Focuses on Improving Outcomes

Despite their current successes, UM orthopaedic surgeons are determined to reduce the need for total shoulder replacement or improve the safety, function and longevity of both traditional and reverse total shoulder surgeries. To this end, Drs. Gilotra and Hasan are pursuing numerous research projects exploring issues ranging from tissue engineering to infection prevention to biomechanics.

Research has indicated that bacteria populating the shoulder area are the same type that causes acne on the face, raising hopes of developing specific antibacterial products that can be used before and after surgery to protect the area from infection.

"We've figured out in the last 15 years that all skin types are primed for different bacteria," Dr. Gilotra explains, "and we're working on some basic skin ointments we know work well for acne to use as preps for surgery."

One of Dr. Hasan’s special areas of interest is using cutting-edge optic-based intraoperative tools to help surgically perfect the tension level of the deltoid muscle, which essentially must work overtime after reverse total shoulder replacement to help patients raise their arm.

"The issue is that, if the deltoid is over-tensioned, it could cause the patient to have some increased pain or cause it to be overworked, and five years later you may see results start to decrease," he says. "Right now, achieving the proper deltoid tension in reverse shoulder arthroplasty relies heavily on the individual surgeon's experience. In most cases, this works well, but a more objective technique would be ideal. So, we're looking at ways to actually measure individual muscle fiber tension intraoperatively."

The University of Maryland has several orthopaedic practice locations around the state. Appointments can be easily scheduled at 410-448-6400.