What is the problem with your shoulder?
Does your shoulder hurt and have shoulder arthrosis (rheumatism)?
Normally, cartilage (an elastic layer that covers the articular surfaces of bones) protects the bone ends and dampens shocks between them; it facilitates movement providing a smooth sliding in the joint. Arthrosis is characterized by the progressive wear of the joint cartilage. The disappearance of cartilage leaves bone uncovered; friction between bone ends is the root of shoulder pain.
This wear is accompanied by an inflammation of the joint capsule and surrounding region.
What are the symptoms most common in the arthrosis of the shoulder?
Arthrosis usually affects patients after 50 years of age; it is more common in patients with a history of shoulder fractures; there are primary arthroses of genetic origin.
The symptoms most common are pain, limited mobility, shoulder stiffness, painful swelling of the joint. These symptoms tend to progress, but what is interesting is that they do not always progress steadily with time. Sometimes patients describe periods of months when the shoulder is less painful; symptoms are influenced by changes in the weather.
Examinations to be carried out as quickly as possible
They begin with an X-ray of the shoulder. The orthopaedic surgeon will assess the need for additional examinations (arthrogram, scanner, MRI, shoulder ultrasound).
By X-rays, we can see the disappearance of joint interlining at first (emptyareathatis found normally between the humeral head and shoulder blade). This space is normally filled by a cartilage that gradually diminishes after wear. Of course, other joint changes will be seen according to the injury (e.g. ascension of the humeral head).
What is the surgical option?
When other treatments do not give results, surgical treatment is required:
Shoulder arthroscopy: a mini invasive surgical act. This intra-articular surgical act leads to improvement on the long term. By arthroscopy, we remove the existing joint debris, clean tendon damage or fix tendons that, by their inflammation, are at the root of pain. Bone fragments can be removed to improve joint mobility; we can remove inflamed bursitis or extend the subacromial space.
Shoulder arthroplasty or installing shoulder prosthesis
When all these treatments have failed or if the joint is so damaged that there is no other solution, we recommend arthroplasty with shoulder prosthesis.
The best-known indication for shoulder prosthesis remains arthrosis. There are several types of prostheses in the market and shoulder prosthesis is currently indicated for other pathologies (fracture of the shoulder, irreducible sub-dislocation of the shoulder, major instability of the shoulder, the humeral head necrosis…).
The prosthesis of the shoulder comprises a metal stem (often based on chromium, cobalt, titanium alloys), which has a metal sphere in its proximal or upper side. This is the humeral head. Of course, the humeral head with bone destruction is removed.
In the scapula, polyethylene implant will replace the damaged cartilage of the scapular glenoid cavity. This polyethylene implant is cemented in the shoulder blade bone or is fixed to a metal support, which in turn is attached to the shoulder blade. Before fixing, the articular surface of the glenoid cavity will be polished to obtain a flat surface, suitable for prosthesis implantation.
Humeral implants can also be cemented into the bone or left cementless (the surface of the prosthesis is provided with a product that acts as “biological glue” inducingbone growth on the prosthesis).
Reverse shoulder prosthesis
This is a shoulder joint replacement with a special prosthesis.
The indications for this prosthesis are different from anatomic prosthesis. It is composed of a “half-sphere”, which is attached to the scapula; a hollowed stem at the top will be placed at the top of the humerus. The upper hollow part of this stem, which has a plastic coating (polyethylene) will be articulated with the half-sphere that was implemented at the shoulder blade level. A new joint is thus obtained. The space between the two metal components is completed with a polyethylene insert. We call this a reversed prosthesis, because the metallic half-sphere, which would represent the humeral head, does not appear in the humerus,like in case of anatomic prosthesis, but in the humeral head. This type of prosthesis has rather limited indications and is provided mainly for elderly patients with large tendon tears, which usually stabilize the shoulder, or in the case of complex fractures. Recovery after installing this type of prosthesis is often comparable to that related to anatomic prostheses. Shoulder movements will be limited, patients will rarely be able to lift their arms overhead and there is also a limitation of external rotation of the arm.
Sometimes, in the elderly, complete recovery of joint amplitudes is not mandatory, the most important is that shoulder is not painful.
In short, prosthetic shoulder replacement surgery makes progress. Shoulder prostheses remain an excellent solution for different pathologies.
Anatomic prosthesis is therefore indicated for patients suffering from shoulder arthrosis but the quality of muscle tissue remains correct, allowing patients to recover their normal mobility after surgery. Simple anatomical humeral prostheses (humeral stems without replacement of the glenoid part) are indicated for certain types of fractures where osteosynthesis is not possible.
Reverse prosthesis is indicated for older people with tendon tears around the shoulder (rotator cuff), and in the case of complex fractures.
The outcome of these prostheses depends on surgical indications, pre-operative condition of the shoulder, surgeons’ experience and especially a tailored rehabilitation of the shoulder.
Complications occur rarely but patients must be informed:
- Humeral head sub-dislocation
This represents 5% of complications. Patients feel major pain and do not manage to move the armoperated on; a reduction of this dislocation is performed generally under anaesthesia.
It occurs in 1-2% of patients, and antibiotics are sometimes necessary. If the infection covered the entire prosthesis, it will be replaced.
- Nerve injury
It represents 1% of complications. These injuries are rare and recovery is often progressive.
- Prosthesis detachment
It is a complication that occurs many years after fitting a prosthesis. The prosthesis is no longer attached to the bone, and there is a movement of the prosthesis. It is necessary to change it and install a new prosthesis. Most often, these detachments occur after a major injury or after many years of wearing the prosthesis.
- Postoperative stiffness
It is often the result of an incomplete recovery; rehabilitation and balneotherapy sessions can help. Each patient recovers at his/her own pace; some patients need a year before regaining normal mobility of the operated shoulder.
This type of intervention is most often performed under general anaesthesia. Seeing an anaesthetist before intervention is required. As usual, the anaesthetist will be informed about the medicines you usually take and additional examinations may be required (cardiac examination, ECG, opinion a pulmonologist, respiratory function test…).
A shoulder prosthesis is mounted in about 1 to 2 hours depending on the type of prosthesis implemented (total, unipolar, inverted prosthesis). Most often, intervention is performed under general anaesthesia; an incision of approx. 15 cm is made on the front or side of the shoulder. After surgery, patients are taken to their rooms with the arm operated on maintained held by a sling. The first night after surgery can be a bit difficult, even if post-operative pain is largely alleviated by strong painkillers.
How long does the hospital stay last?
Patients come to the hospital on the eve of intervention and will remain hospitalized normally about 5 to 7 days
Patients will receive prophylactic antibiotics for about 48 hoursto prevent a possible infection.
Dressings will be changed regularly
An X-ray of the shoulder operated on will be performed in the first days after surgery.
Post-operative rehabilitation, functional respiratory test….).
Rehabilitation of the shoulder operated on usually begins 48 hours after surgery. Kinesiotherapy will be prescribed, 3 to 5 sessions per week. The physical therapist must achieve a slight mobilization of the shoulder operated on with rotary movements in the anterior-posterior plane. A rehabilitation protocol is provided for this type of intervention. The physical therapist will have to teach patients the exercises they will have to perform themselves when returning home, especially tilting movements to be performed 2 to 3 times a day by the patient. Patients are allowed to actively use the arm after approximately four weeks: In a first phase, with the help of a physical therapist (assisted active mobilization) and from the sixth week, the patient is encouraged to do these movements alone, actively. As soon as the active mobilization is allowed, supportive sling can be abandoned progressively. Work resumption will be taken into account in approximately three months after the surgery. Six months after surgery, recovery is largely achieved. Patients can drive the car about six weeks after the intervention, avoiding brutal gestures at the beginning, and external rotation especially.
Indications at hospital discharge
At hospital discharge, a prescription will be given for painkillers, which should be taken 3 to 4 times a day if necessary. The arm remains immobilized in sling, and stitches shall be removed on the 14th day after surgery. At hospital discharge, a return for check-up will be established after a week, with an X-rays of the operated shoulder. Periodic consultations will be provided at one month, three months, six months and twelve months after surgery.
You can use your fingers, fist and elbow immediately after surgery. Walking is authorized, with a nurse, immediately after recovery from anaesthesia. Shower or bath is permitted 48 to 72 hours after surgery. Do not try to lift heavy loads with the operated arm nor use it to push a chair or a bed. Lifting heavy objects and overhead use of arm usually requires 6 to 8 months. There is no fixed rule to return to work, but usually the patient resumes work about 3 to 4 months after surgery. Walking outdoors is advised a week after surgery, resuming sports with jogging or bicycle 4 to 6 months after the intervention.