Dr. Rania Habib (Host): Did you know that 53,000 people in the U.S. will need shoulder replacement surgery each year, and that number is expected to possibly double by 2025? In this episode of Memorial Health Radio, we will learn all about shoulder replacement surgery.

This is Memorial Health Radio with Memorial Health System Ohio. I'm your host, Dr. Rania Habib. Joining me today is orthopedic surgeon, Dr. John Henry, and he is here to discuss everything you need to know about shoulder replacement surgery. Welcome and thank you for joining us here today, Dr. Henry. We're really excited to have you.

Dr. John Henry: Thank you, Dr. Habib, for having me. It's a pleasure to be here.

Host: Now, we know that your volume for shoulder surgery is fantastic. So, you are the perfect expert to be on our podcast today. So, let's begin. When a patient presents to you with shoulder pain, what is the workup?

Dr. John Henry: Well, it's all going to start with talking to the patient first, making sure it's their shoulder. There's a lot of overlap between cervical spine issues and shoulder issues. But just talk to them, find out where they're hurting, how long it's been going on, what do their symptoms entail, when does it hurt, how bad does it hurt, do they have any other symptoms? Clicking, catching, popping, grinding, things like that. How does it affect their rest? What other treatments have they had? Have they had any injections? Have they had physical therapy? Then, always a physical exam. You want to look at the shoulder, see what the shoulder looks like. What's their muscle mass? Any atrophy? Any deformities? Is it swollen? What's their range of motion? What's their strength? Make sure all the nerves are working. Usually, it's followed by an x-ray. Oftentimes, that will lead usually to an MRI at some point, maybe not, but that's generally how we go about it.

Host: And are you able to make that diagnosis directly off of the MRI then if they need that?

Dr. John Henry: Yeah. Generally through exam, history, x-ray and MRI, we're going to come up with a pretty clear diagnosis as to what the source of the shoulder pain is. And, you know, once you define the source of the pain, we will be able to come up with some sort of plan to fix that problem for them and get rid of the pain and hopefully improve the range of motion and their strength also.

Host: That's exactly what they want, right? To get out of pain and fix the problem. So, how do you decide as an orthopedic surgeon, Dr. Henry, if a patient needs surgery versus conservative therapies such as physical therapy?

Dr. John Henry: Well, again, it goes back to what's the problem. A lot of things, tendonitis, bursitis, a lot of those are going to resolve non-surgically through injections, patient's physical therapy. But when you start getting into the arthritis and/or torn rotator cuff or torn labrum or torn biceps tendon, then oftentimes the non-surgical options just aren't going to provide the patient what they need and you end up discussing surgery with them.

Host: So, when you have decided that surgery is definitely the option for a specific patient, what are the common surgical interventions for shoulder pain?

Dr. John Henry: Depending on the source of the pain, one option is to have arthroscopy or a shoulder scope. You can clean a lot of things up that way, torn cartilage, bursitis, trim up some partially torn tendons. Sometimes you end up having to repair their rotator cuff, repair their labrum. Sometimes the biceps tend to be the source of the pain and sometimes you cut those and sometimes you repair those. But arthroscopy is an option. And then, past that when you start getting into other issues, your arthritis, as your irreparable rotator cuff tears, then you're starting to head towards the realm of shoulder replacement or shoulder arthroplasty, same thing.

Host: So, let's really get into shoulder replacement surgery. That's the heart of this episode and, you know, our listeners are probably very interested to hear about that. What is shoulder replacement surgery?

Dr. John Henry: So, you've probably heard of knee replacements and hip replacements. Those have been around, for a very long time and are done much more commonly. And those are always done or primarily always done for end-stage arthritis, either osteoarthritis or rheumatoid arthritis. And that's when you're actually replacing the worn out joint surfaces and giving them a new one.

Same thing in shoulder replacement. There are two different types of shoulder replacements. There's what people would call the regular shoulder replacement, or it's also called an anatomic shoulder replacement, and there's also the reverse shoulder replacement, which is becoming much more common and widespread these days for various reasons. But it basically involves opening the joint up, removing a little bit of worn out bone cartilage, and then replacing that with a new joint made of metal and plastic.

Host: Now, I know a lot of people get nervous about metal in their body, and this is probably a common question you get all the time, but will they beep when they go through the airport?

Dr. John Henry: They could. Not everyone every time, but it is possible, and we do provide them with documentation they've got metal implants. Obviously, they'll have a scar. Fairly common thing between all the hips and knees and shoulders being done, so, it could set off the metal detector, but we do provide them with documentation showing they've got metal implants.

Host: Perfect. Now, when you are discussing with a patient arthroscopy versus total shoulder joint replacement or the partial or the reverse, like you had mentioned, who is a good candidate for the shoulder replacement surgery?

Dr. John Henry: So, the patient's problem is arthritis, if they have a worn out shoulder joint, bone on bone, and they can't live life anymore with corticosteroid injections or medications, the pain is just too significant, and they have an intact and healthy rotator cuff, they would get a regular or an anatomic shoulder replacement, on the viability of the rotator cuff muscles and tendons. So, it's for the treatment of primarily osteoarthritis only.

The reverse shoulder replacement came into being for a group of people, mostly older folks who had a combination of really, really bad arthritis and a really badly torn rotator cuff. And that's why it came around, and that's what its initial purpose was to treat what's called rotator cuff arthropathy, which is a combination of severe arthritis and a massive cuff tear, the primary reasons of having shoulder replacements. There's various other reasons. I do them commonly for fractures that are not really fixable. If they're busted in so many pieces that you can't piece it back together again, then replacing the upper end of the shoulder is a good way to get them pain-free and function again. And much more rarely, older folks who have shoulder dislocations and they keep dislocating, it's another good way to solve that problem too.

Host: Now, I'm sure our audience is really interested to hear how you do the surgery. So Dr. Henry, could you just briefly describe the surgical procedure for us?

Dr. John Henry: So, obviously, it's done in the operating room with anesthesia. Typically, these Involve both a regional anesthetic, which is a block with an injection that the anesthesiologist provides them in the upper shoulder, neck area. And that generally numbs the arm up pretty good for 18 to 20 hours. And then, they will be placed completely asleep under general anesthesia.

Once that's accomplished, we position them most of the time sitting up slightly in what we call a beach chair position. They will then get an incision on the front of the shoulder. We then kind of move the shoulder muscles to one side, chest muscles to the other side, that exposes the front of the shoulder. We open up the front of the shoulder joint, we actually dislocate the joint, and then we can remove a little bit of bone and start placing the new implants.

Host: Now, when a patient has a shoulder replacement surgery, any of the varieties that you said, what is the success rate?

Dr. John Henry: It's very high. The overwhelming majority of people who have shoulder replacement surgery are very happy. I tend to use a figure of about 95% of my patients, once they're done and through rehab, they're very glad they had it done. It might be a little higher than that, but that's a number that seems to have, over my years of doing these, kind of settled on, and that seems to be pretty accurate.

Host: That is amazing. There are very few surgeries that have a 95% patient success rate and satisfaction rate. So, that's amazing. What are the main risks and complications of shoulder replacement surgery?

Dr. John Henry: Well, basically, they're the same as most surgeries from the anesthesia and that comes with its own risks. And then, there's the basic risks of bleeding and infection. Anytime we do any surgery, we always run that risks, although they're very minimal. Those generally fall into a category of about 1%. When it comes to shoulders, particularly the reverse shoulders have a little risk of shoulder dislocation occurring afterwards. And that can happen very quickly or sometimes it can happen further down the road. It's about 3% of the time that can happen, even if everything is done correctly.

Host: So, it's still very, very low. And if a patient suffers a complication of a dislocation, what's the treatment for that?

Dr. John Henry: Again, it depends on kind of when it happened. But usually, the first thing we're going to try to do is what's called do a reduction, or basically put the shoulder back into place. And then, you begin having a discussion with the patient whether you need to modify the implants a little bit. Sometimes it just involves thickening up the plastic piece to increase the tension of the soft tissues around it to keep it in socket.

Infections come with their own unfortunate risks and worries. Most severe cases, sometimes you have to remove the entire shoulder implants and have them on antibiotics for an extended period of time. And the goal is to go back and put a new shoulder in for them at some point in time. But again, that's rare, but it does happen.

Host: Now, Dr. Henry, we know that with hips and with knees, sometimes they have to be replaced more than once in a person's lifetime. What's the expected length of time that a shoulder replacement should last?

Dr. John Henry: So, the rule of thumb we use when it comes to shoulder and knee replacements these days is about 15 to 20 years they should last. Same figures for the shoulders. I think that the reverse shoulders, being a bit of a newer procedure and I mean they've become really successful in use in the last 10 years. So, we don't have 20 years of data on that, but it's the same materials as basically as we use in hips and shoulders. And it's not a weight-bearing joint. So, the wear characteristics might be a little different. But I generally use the same figures as about 15 to 20 years.

Host: That's fantastic. Dr. Henry, how long does a typical recovery take and what should a patient expect?

Dr. John Henry: These are done both as an inpatient and outpatient procedure. The older folks, maybe a few more health issues. They'll generally have it done in the hospital and they'll be looking at an overnight stay. Folks, minimal health issues, they can be done as an outpatient so they can go home and be in their bed that night.

And again, it varies a little bit from surgeon to surgeon, the rehab protocols. But generally, you're going to start in the sling. At least in my hands, you come out of the sling the day after surgery. You can start doing some gentle dangling exercises for about seven to 10 days. I actually have them start actively moving the shoulder about 10 days after surgery, and do that independently for about 2 weeks. We start a little bit of physical therapy around the three-week mark.

So, every patient has a different path to recovery. Everybody's going to move at a different pace. I generally tell my patients that they can be pretty functional day to day, normal activity of daily life within two months, three months. I tell everybody, even the knee replacements that I do, that, you know, it really takes a year before you can look at that joint and say, "That's as good as I'm going to get from this." I do start them pretty quick into a rehab program, and they do start to get their function back pretty quickly

Host: Now, the patients that you're doing, let's say are very athletic or very active and they're doing weight lifting and all that kind of stuff, what are their initial restrictions and when do they come off those restrictions?

Dr. John Henry: When they get to about the three-week mark and they're starting into physical therapy, I basically let them progress at their own pace. I don't ultimately place any restrictions on the patients. I ask them to use a little bit of common sense and ease their way back into their normal activities. But you're back to working out, maybe not the shoulder per se, but you can be back in the gym doing lower body and aerobic conditioning. And you can ease yourself back into a strengthening program, probably around the six to eight-week mark. And I would hope by three months in, doing pretty much what you want to be doing again. But again, that's a smaller fraction of the folks. Most of them are older, a little less high demand. They want pain relief and everyday function.

Host: Now, is the surgery painful?

Dr. John Henry: I would definitely say that knee replacements are up there higher on the pain level, and up there higher on the patient demand in terms of how much rehab they have to do. Shoulders seem to go a bit easier than knee replacements. Hip replacements are pretty straightforward too, and they tend to move along a little quicker. But knees are the worst. And actually, rotator cuff repair surgeries are pretty painful and pretty long recoveries.

Host: So, not that bad is the bottom line that we're getting at, which is great for the patient.

Dr. John Henry: Not that bad for a joint replacement surgery.

Host: Well, Dr. Henry, you have provided us with a wealth of information about shoulder replacement surgery and shoulder pain. What is your final take-home message for our audience today?

Dr. John Henry: when it comes to shoulder pain, I just want to let the patients know that pretty much no matter what it is, we're going to be able to fix it for them. We're going to have to define the problem. Once we've defined the problem, we can generally make it better. And it may not be a shoulder replacement, it may not even be surgery. But shoulder pain, we can do a pretty good job of getting it better at least and getting them back to where they want to be again.

Host: Wonderful. Well, thank you so much for spending this time with us and we appreciate your expertise.

Dr. John Henry: Thank you very much for having me.

Host: That wraps up this episode of Memorial Health Radio with Memorial Health System. Once again, that was Dr. John Henry, an orthopedic surgeon, and he told you all you need to know about shoulder replacement surgery. I'm your host, Dr. Rania Habib, wishing you well. Head on over to our website at mhsystem.org for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all other Memorial Health System podcasts.