In this episode of PodMD, Orthopaedic Surgeon Dr Amin Masoumi will be discussing the topic of shoulder replacement. We discuss what shoulder replacement surgery is, different types of prostheses available, when to refer, realistic expectations after shoulder replacement surgery, and more.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
I’d like to welcome to the PodMD studio Dr Amin Masoumi
Amin is an Australian-trained orthopaedic surgeon and he has sub-specialty interests in shoulders and special interest in shoulder replacement and sports injury surgeries as well. So it’s lovely to talk to you today, Amin.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Amin, welcome to the studio once again, and thank you for joining us.
Amin: Hi Caroline, thank you for having me.
So today the topic of interest is shoulder replacement. What is shoulder replacement surgery?
Amin: Shoulder replacement surgery is a very successful procedure for treating severe pain and stiffness because of severe degeneration of the cartilage and tendons of the shoulder joint.
When you say deterioration, are you talking mainly about arthritis and what joints in particular are you referring to?
Amin: It’s mainly the ball and socket joint in our shoulder, which we call it gonohumeral joint. It’s the main functioning joint in your shoulder area, which gives you a very mobile range of movement. As you mentioned, that could be because of arthritis.
Yes, that’s right. We have many types of arthritis. For example, could be just osteoarthritis or could be a type of inflammatory arthritis that affecting the shoulder. Sometimes could be as a result of injury, we get arthritis, such as we call it post-traumatic arthritis. But especially in shoulder, we have… special type of arthritis, which is just specific to this joint, and we call it rotator cuff arthropathy, which basically happens as a result of injury to the rotator cuff muscles.
So in relation to the injury, are you talking about an injury that happened last week or an injury that happened many years ago? How does it usually present?
Amin: Usually injury happened many years ago. Either we have patients that they had, for example, motorbike, motor vehicle accident in early there when they were younger and they had the fractures of the shoulder joint. And over time, because it changes the dynamics of the shoulder joint, they get arthritis earlier than the others.
The other one is the rotator cuff muscles is a common, people get rotator cuff injury or by aging, they get rotator cuff tears. And over time, because this rotator cuff muscles is not functioning anymore, their job is basically to keep the shoulder joint all in the socket. And over time, when they’re damaged, this shoulder joint is not functioning as it’s supposed to do. And this results in shoulder, basically, some sort of arthritis as well.
When we’re talking about arthritis, often it’s attributed to older people. Is that always the case? What sort of patient demographic are you seeing with these injuries?
Amin: Yes, shoulder replacement mainly we do in older people, but I mean, older is, you know, we have, like you’re talking about age, also physiological age. Most of the, I would say, shoulder replacement happens in people over the age of 60.
But we have certain, like actually big number of patients that they come and they have arthritis or injuries to their shoulder before the age of 60. And sometimes even younger than 50 years old.
So the patient often presents to the GP with what sort of symptoms?
Amin: When they get to us, usually they can’t sleep. They have so much pain that they can’t sleep and they want something done. Usually with shoulder replacement, because people when they have hip and knee pain, they can’t walk, they present a bit earlier.
But with shoulder, people put up a bit longer. They put up longer, they get pain relief, they get injections, they do physio, and when they get referred to us, usually it’s the time that they can’t sleep because of pain.
Is there any benefit in the patient having the surgery earlier? So if they say, for example, they started having the niggles in their 40s, maybe early 50s, would they be better off coming and getting referred from the GP earlier before the arthritis really sets in?
Amin: I mean, that’s a good question, but it’s very… It depends on the type of the patient and type of the injury they have. Usually, you know, this over the last 20 years, the shoulder replacement, like any other part of orthopedics, has been evolved a lot.
Now our prosthesis we have, the type of implants we have, they last longer. But still we prefer to delay it as long as possible to do it in the patients in an older age, if possible. Obviously, this is most of the time when we do this operation is about quality of life. It’s about improving patient’s quality of life, improving their pain, and also help them to do things in their life that they like to do.
But also we have in every operation, there’s risks involved and also there is a risk of wearing of the implants. So we don’t like to do this too early. Always we weigh and risk and benefits send to that specific patient.
What do you recommend that interventions that a GP can discuss with a patient to ease the pain before considering surgery?
Amin: I think there are a few simple things that people can do, and it’s always useful. One thing is to, for example, if it’s a very young patient and they’re doing, they have certain interests, change their lifestyle. If they’re doing, for example, overhead gym activities, if they can stop that, and instead of that, doing other type of activities to, you know, not wear off their shoulder, if they have shoulder problem, that’s something easily they can do.
Doing physiotherapy is always useful. I think the simple steps goes a long way if they can do it at the start and helps with them to ease off their symptoms before they need anything done.
So you’re saying that you don’t want to overuse the joint either?
Amin: This is more, what I mentioned is more for younger patients. You know, if you have someone in their 40s, they have, they’ve been involved in you know, extreme sports or they and they have really they had injuries to their shoulder. They coming in early age with arthritis.
We usually try everything to buy time for them. And that’s obviously different from 70 year old coming with advanced shoulder arthritis. Then that’s completely different. In that case, we want them to be referred early and we can do advanced imaging and make a plan.
So in relation to shoulder replacement surgery, what does the modern technology offer?
Amin: It’s a good question. In the last 20 years, it’s been evolved A lot. Just a little bit back history about this. Shoulder replacement, you know, as you see the shoulder joint, it’s a very shallow joint. You’ve got a very shallow, like, if you look at your hip joint, you’ve got a very deep socket and ball sits in the socket. That creates natural stability.
With your shoulder joint, the socket is narrow and the ball is big. That’s why we have such a good range of movement. but this also caused problems because more instability and also coming doing joint replacement is a bit challenging and early days we had trouble finding the best possible prosthesis for this shoulder replacement. What changed which initiated by surgeon in France they come up with this idea because in shoulder as I mentioned where we have a very special type of arthritis which results from the wearing of rotator cuffs.
Most of all, people don’t have good rotator cuff muscles, which their job is to keep the shoulder joint in place and basically having a balance of forces in the shoulder joint as a ball and socket joint to be able to function.
So basically more muscles surrounding the area, stronger muscles to support it.
Amin: That’s right, but also you have a lot more stronger muscle outside, which they move your shoulder around. But these rotator cuff muscles mainly keep the ball in the socket to let the other muscles to function. And because we lose these muscles over time, and most people like…In a big percentage of people, these muscles are not good over time. We can’t rely on these muscles all the time to just do anatomical shoulder replacement. Anatomical meaning just replace the ball and socket as it is.
Yeah, I was mentioning that one French surgeon came up with this idea that revising the where ball and socket sits. So putting the prosthesis ball on the basically body side and putting the socket on the humerus side. And this initially looked stupid, but then we realized that actually functioning very well and this basically compromises for losing rotator cuff muscles. And over the years, we come up with very complex, basically, things that engineered and resulted in this type of prosthesis we have today, which we can see in Australian joint registry, other joint registries around the world, that this type of prosthesis is the best functioning prosthesis in most circumstances, and they can last up more than 15 years.
How long do they last? And are there different types of prostheses on the market, or is it just the one type?
Amin: No, there’s different types. We still have anatomical types. We still have the types that we more do if anatomical, as I said, like as it is, and we need a certain group of people that they have still good rotator cuff, we can do that. And also we can do sometimes partial joint replacement, which is a special type pyrocarbon type of arthroplasty which also has its own indications and in most small, especially younger people with intact rotator cuff is an option and the reverse shoulder arthroplasty as I mentioned.
And one other thing that’s been evolved a lot over the last few years is the type of plastic that we use between bone implants and that’s become a lot more stronger, and a lot more long-lasting prosthesis.
When you talk about that type of prosthesis and it’s lasting longer, how much longer are you talking?
Amin: I mean, it depends. It can depends on the patient, but we see that, you know, in like this modern prosthesis lasts over 10 years. And that’s been a big change. And it’s pretty much the results of joint replacement in shoulder surgery is as good as hip and knee replacement these days.
What about for our GPs? When do they refer? Is the timing of referral crucial?
Amin: I think it’s… It’s important that, as I said, like doing physio and modification of lifestyle is good. But what we see, especially in elderly people, that they really come, they’ve been dealing with the shoulder arthritis for a long time, they’ve been having trouble for five, 10 years, and most of the time they’ve been told that their shoulder replacement is not good surgery, they don’t have an option, they put up with that, they get older, they get more medical problems.
And they come and also their joint is wear off more, which kind of causes problems like the harder surgery. And they come in a later age with more medical problems and more advanced arthritis. I think these days, considering that we have good option, referring these patients early probably will be useful to improve their lifestyle and also have a less eventful like a surgery from an aesthetic point of view, from their other medical basically perspective.
What’s your advice for a GP then? What are the red flags? What are they looking for when the patient comes into the office? Is it just that they’re not sleeping well because of their shoulder? What are the triggers that they need to then contact you or another orthopedic surgeon about that?
Amin: I think getting simple x-ray is a good way to start, and usually x-ray shows they have arthritis, and also patients’ symptoms. They’re two easy things. If they have pain, pain that rest, affecting their sleep, affecting activity of daily living, I think that’s very important.
I always ask patients, like, I’m treating you, I’m not treating the x-ray. How much this condition is affecting you? What do you want to do that you can’t do? You know, obviously I tell them that surgery comes with these risks, but we have to make sure that you have, this is going to help you. You’re going to put yourself in the risk of surgery, yes, but all is about improving your lifestyle.
Yeah, I think that’s the same for GPs. If they have a patient that’s been their lifestyle has been affected by this condition, they can, you know, I think it’s, we have good option, good option to consider, which is this surgery.
What are the realistic expectations after shoulder surgery for the patient? You know, are they going to be back on the tennis court, back on the golf course?
Amin: So usually I tell them that every, basically after operation, they’re usually, they’re just in a sling. We keep them one night, and most people go home next day. And they’re going to be in a sling for four to six weeks.
They will have limited exercises, which mainly involves hand and wrist and elbow exercises and some shoulder exercises, which we teach them to do. And after six weeks, they take their sling off and they use their shoulder, and they’ll follow the physiotherapy protocol.
Getting back to sports, swimming, going back to golf, doing swings, and usually they can go back eight to nine weeks doing those kind of activities. Like by nine weeks, those people that they really were into golf, they were back to the golf course doing swings and putting and by three months they were playing golf. So they were, yeah, a big number, like lots of people can go back to usual activities such as swimming and playing golf and cycling.
What would be the three top tips for the GPs, the take-home messages from today?
Amin: Take home messages would be one is to listen to the patients if they have pain and the shoulder pain and arthritis is affecting their lifestyle. There is a good option and with the new technology, it’s a long lasting possibility of having long lasting arthroplasty is available these days. And secondly, to have basic imaging done and refer early. This will help us to provide better care. And thirdly, the other things that maybe would be useful for the patients to know is that they can go back to most of activities that elderly people do, most of like playing golf or swimming, and they can, their recovery is, yeah, that’s it.
Amin, thank you for coming in and talking about shoulder replacement surgery today. It’s been a delight to have you. I hope you’ll come back and record a few more for PodMD.
Amin: Yes, absolutely. Thank you for today.
