Amanda Wilde (Host): Shoulder Replacement surgery sounds complex and it is. It is also usually highly successful. We'll talk about what to expect from total shoulder replacement surgery with Orthopedic Surgeon, Dr. Jonathan D. Chappell. Dr. Chappell is a Sports Medicine Specialist with Wake Orthopedics, a WakeMed physician practice.

 This is WakeMed Voices, a podcast brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. I'm Amanda Wilde. Dr. Chappell, good to have you here to talk about total shoulder replacement. There are so many moving parts and range to the shoulder joint, so please tell us how does it work? What is involved in total shoulder replacement?

Jonathan D. Chappell, MD: Well, a total shoulder replacement is similar to a hip or a knee replacement in that what we're doing is trying to resurface the two ends of the bone that make up the shoulder joint to alleviate pain and to improve range of motion. So to do that, we do a surgery where we remove the diseased part of the bone and instead place a metal stem and a piece of plastic with a metal ball that will allow that patient to have near full range of motion and most of all, no pain after the surgery.

Host: So who is a candidate for this kind of surgery? When do you recommend a total shoulder replacement?

Jonathan D. Chappell, MD: We see patients who get shoulder replacements for a variety of reasons. The most common reason is additional shoulder arthritis where the actual ball and socket joint just wears out. The surfaces of the bone have become damaged to the point where it starts to limit motion and they have increasing pain.

We can manage it for a while with conservative measures like injections or physical therapy, but ultimately, when those fail, the next step is to do what's called a replacement. And what's unusual with the shoulder compared to a hip replacement or knee replacement is that they're actually two types of shoulder replacements.

The traditional shoulder replacement maintains the normal anatomy that you would see in a native shoulder. Reverse total shoulder arthroplasty actually flips the components around, which sounds a little unusual, but what it does is it bypasses the rotator cuff so it changes the mechanics of the shoulder. It's for patients who don't have a really functional rotator cuff, it's a way to have a very successful surgery with great motion and no pain in someone who doesn't have a functional rotator cuff.

Host: So when we say reverse, it doesn't mean in the end you'll be reaching behind you instead of in front of you or something like that?

Jonathan D. Chappell, MD: It just means that what we do in those cases is we actually place the ball on the normal socket side and then we remove the ball from the normal ball side and make that into a socket so it changes the mechanics to bypass the rotator cuff and use the other muscles around the shoulder to give you the same range of motion in a patient who doesn't normally have much motion at all and doesn't have a normal cuff.

Host: So what dictates whether you use the traditional or reverse surgical method?

Jonathan D. Chappell, MD: In general, patients prefer the traditional, if you had to compare them head to head with a reverse versus the traditional. But most importantly, we want to have a successful surgery, and in some situations it's best to do the reverse, which by the way, has great outcomes. So the first most common situation where we do the reverse is in a patient that has bad arthritis and their rotator cuff may not be a hundred percent.

Either they've had prior tears that they never had addressed, or they had previous surgeries, which may or may not have been successful. But we're also doing shoulder replacements, including reverse shoulder replacements for situations where patients have very large rotator cuff tears where we can't repair them.

So instead of trying to do a repair, which will likely be unsuccessful, we can just go straight to the reverse shoulder replacement and predictably have a very good outcome. We're also now doing reverse total shoulder arthroplasty for a variety of fractures. Both acute fractures and then sometimes when bones don't heal properly, to go back and reconstruct them to give the patients more motion and limited pain.

So while we began by doing reverse total shoulder arthroplasties for a very small percentage of patients who just didn't have a functional rotator cuff and had bad arthritis, we're now using them in a variety of situations and they're all showing great success.

Host: Now it sounds like the people who get the surgery, you mentioned arthritis and rotator cuff injuries, so it sounds like they're either athletes or older people who have worn out parts of the body. Is that right?

Jonathan D. Chappell, MD: In general, shoulder replacements are in older patients and we typically will see patients in their sixties and seventies and occasionally in their eighties, and those, that's our typical patient profile. But as we've seen so much success with these procedures, we're now performing them in younger and younger patients who just need them. We don't recommend them for patients under 50, but every year that number keeps going down.

Host: So what are the risks for total shoulder replacement for the population you work on?

Jonathan D. Chappell, MD: So in general, our outcomes are very good and patients are very happy. In fact, it's probably one of the best operations we do. Some of my happiest patients are patients who've had shoulder replacements or reverse shoulder replacements. But there are some potential complications. In general, the normal complications of infections, which are very rare, or sometimes prosthesis can dislocate, which is also extremely rare.

So in general, the success rate is probably over 95%. But when they do have complications, we sometimes have to do additional surgery to correct them. With the traditional shoulder replacement, we always have to worry about the rotator cuff because with the traditional shoulder replacement, we don't change the mechanics of the shoulders, so we still need to have a functional rotator cuff.

So when those patients who later have a problem, like a fall or an injury and the rotator cuff is damaged, we often have to then convert them from a traditional shoulder replacement to a reverse shoulder replacement. Both of which can be very successfully done. But sometimes you don't want to put a patient through a second surgery.

Host: Well, it's very individual, but that is still an amazing success rate, 95%. How long does a shoulder replacement last?

Jonathan D. Chappell, MD: Shoulder replacements are a little different than knees and hip replacements because the amount of bone that we have to work with is actually a lot smaller. So that creates some challenges about longevity. Particularly worried about the socket side of the shoulder replacement. Sometimes those can only last 10 to 15 years, but we know that some patients can go up to 20 years with their shoulder replacement. The reverses are interesting because they're still relatively new. We have studies now out to about 10 years, which show great results, and we think they're going to last longer.

We just haven't completed those studies yet, but we're all hopeful that we're going to see patients going 20 to 25 years longevity with these prostheses.

Host: And maybe that'll increase even as things get even more specialized.

Jonathan D. Chappell, MD: Technology's changing and the improvements we've seen over the last five to 10 years with reverses have definitely shown improvement in longevity, and we'll see how it plays out over the next 10 to 15 years, but I don't, I expect more advances over time.

Host: Well, Dr. Chappell, thank you for filling us in on what to expect from surgery and your insights into the wonderful world of total shoulder replacement.

Jonathan D. Chappell, MD: Thanks for having me.

Host: That was Dr. Jonathan D. Chappell, Orthopedic Surgeon, Sports Medicine Specialist with Wake Orthopedics, a WakeMed physician practice. To learn more about Wake Orthopedic Services, please visit wakemed.org/wakeortho. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you.

I'm Amanda Wilde with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina,