Arthritis is a loss of cartilage on the articular surface of any joint. It is associated with chronic pain and loss of motion leading to decreased function and increasing impairment of the shoulder. There are many types of arthritis affecting the shoulder. These include:
- Rheumatoid and Inflammatory Arthritis
- Post-traumatic arthritis
- Avascular necrosis causing shoulder arthritis
- Arthritis caused by exposure (Prolonged exposure to anesthetics like lidocaine)
- Arthritis associated with a rotator cuff tear (aka cuff tear arthropathy)
Symptoms of arthritis are often described as a deep and achy type pain associated with the shoulder.
Treatment of shoulder arthritis with non-surgical measures is the mainstay of management. This typically involves anti-inflammatory medications. Therapeutic exercises can help to slow the loss of motion but will not change the fact that the cartilage is lost. When these measures are no longer helpful surgical intervention is indicated.
The end stage of treatment for shoulder arthritis is a shoulder replacement. Depending on the type of shoulder arthritis, this may be a standard total shoulder arthroplasty (replacement) or a reverse total shoulder arthroplasty. There have been many advances in the treatment of shoulder arthritis as well as shoulder replacement implants and techniques.
Arthroscopic Treatment of Shoulder Arthritis can be done in patients with mild to moderate shoulder arthritis with success. This procedure typically involves removal of the osteophytes (bone spurs), release of the contractures of the capsule and removal of any loose cartilage fragments. Often, the biceps is damaged with arthritis as well and this damaged tendon causes a significant amount of the pain experienced. Dr. Lenarz will also often also perform a biceps tenodesis to remove the damaged segment of the tendon and re-attach the tendon to the bone. This is also done arthroscopically.
Additionally, Dr. Lenarz performs an Arthroscopic Biologic Resurfacing of the joint using osteochondral allografts. This procedure was first performed by Dr. Lenarz and his mentor during fellowship. This procedure offers a biologic solution to arthritis as a majority of the damaged cartilage is replaced with new donor cartilage. The advantages of this procedure are that it is done all arthroscopically and there is no significant bone loss associated with performing this surgery. This is especially important in the young active patient where a standard total shoulder arthroplasty is at high risk of early failure. This is secondary to the increased stresses and use that a “younger” patient normally places on their shoulder and can lead to early loosening of the implants and failure.
Shoulder replacement surgery has become increasingly common. Unfortunately, the techniques for adequately exposing the shoulder joint and appropriately placing the shoulder implants have not gotten any easier. Unfortunately, many of these replacements are performed by surgeons who often do less than 10 or even 1 to 2 per year. Similar to total knees and total hips, shoulder replacements performed by lower volume surgeons have been shown in nationally publicized peer reviewed literature (Journal of Bone and Joint Surgery) to have prolonged hospital stays and higher rates of complication and mortality. Dr. Lenarz spent an additional year in Cleveland after completion of his residency training in a Shoulder and Elbow Fellowship to learn and master the techniques of both simple and complicated arthroscopic shoulder surgery and shoulder reconstruction/replacement. He is skilled and educated in contemporary arthroscopic techniques as well as primary and revision open shoulder surgery. Revisions of a failed total shoulder can be quite complicated and require special expertise and training. An important way to avoid a failed shoulder replacement is to ensure that it is done well during the primary surgery. This is why Dr. Lenarz focuses his practice on shoulder and elbow care. By doing so, it is Dr. Lenarz’s belief, that he can provide the patient with the optimal care by staying up to date on the latest surgical techniques and therapeutic interventions (injections/physical therapy) as well as their outcomes to provide his patients with the very best of care.
Shoulder implants have also been evolving in shoulder surgery. Recent developments have included a “stemless” shoulder implant. The use of this implant minimizes the amount of bone that is removed from the humerus (ball side of the joint) during the procedure. This becomes important in that it decreases the amount of tissue removed and likely the amount of bleeding and pain. In addition, if the shoulder replacement were ever to fail, it allows for an easier revision of the shoulder as these implants are easier to remove and there is less bone loss in doing so.
Shoulder implants also include a reverse total shoulder arthroplasty. This is a specialized implant that was developed initially in the 80’s in France. It was approved by the FDA for use in the United States in 2003. Since that time, surgeons in the US have be using this implant with increasing frequency. The design of this implant is such that the “ball” of the joint is placed on the cup side and the “cup” of the joint is placed on the ball side. Thus, it is called a reverse shoulder arthroplasty. Initial indication for a reverse shoulder arthroplasty was primarily for shoulder arthritis with a poorly functioning or torn rotator cuff. When this occurs the rotator cuff can not be adequately repaired and a standard total shoulder replacement will often fail in a short period of time. Indications for the use of reverse shoulder replacements have expanded to include revisions shoulder replacements, comminuted proximal humerus fractures in the appropriate patient and large irreparable rotator cuff tears without arthritis in the appropriate patient. Just like a standard total shoulder replacement, a reverse shoulder replacement requires expertise in the use and indications for the surgery to ensure an optimal outcome for the patient and their shoulder. Dr. Lenarz offers this expertise.
Evaluation of a shoulder with shoulder arthritis often requires x-rays as well as an MRI and occasionally a CT scan. The information provided with these studies helps to determine the degree of damage to the joint as well as the surrounding tissues. This in turn will ensure the selection of the appropriate procedure to improve the function of the shoulder.