Shoulder and Elbow Surgery for Arthritis

If your shoulder or elbow joints are stiff and sore, you may find it hard to get a good night’s sleep. It may be difficult to reach high objects and get dressed, and you’ll likely have trouble brushing your teeth, combing your hair, and eating. In short, your ability to carry out tasks of daily living can be significantly reduced. There are many ways to treat shoulder and elbow pain, but in the most serious cases, surgery may be the best option. This article looks at some common problems in the shoulder and elbow joints and the surgeries used to repair them.

The shoulder

Three bones connect at the shoulder: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). There are actually two joints at this intersection, one where the scapula connects to the clavicle and one where the humerus connects with a part of the scapula known as the glenoid cavity. When people say “shoulder joint,” it is this second joint — the glenohumeral joint — that they usually mean. (See a diagram of the shoulder.)

The glenohumeral joint is a ball-and-socket joint. The rounded end of the humerus — the “ball” — fits into the concave glenoid — the “socket.” Both the ball and the socket are covered by a smooth layer of cartilage, allowing the two surfaces to glide easily against each other. A complex system of muscles, tendons, and ligaments gives the shoulder strength and stability. Of especial importance is the rotator cuff, a group of muscles and tendons that form a cuff over the ball to hold it in place in the shallow socket and enable the arm to rotate. The combination of the ball-and-socket design and the supporting system of muscles, tendons, and ligaments lets you twist your arm and move it up and down, out to the side, and backward and forward.

Among the most common causes of shoulder problems are osteoarthritis (OA), rheumatoid arthritis (RA), and posttraumatic arthritis (a type of OA that develops after injury). All of these can damage cartilage, bone, and surrounding structures so that it is difficult to use the joint normally. Other common causes of serious shoulder problems include rotator cuff tears, avascular necrosis (when the bone of the humeral ball dies, leading to degeneration of the joint), and fractures.

If the doctor diagnoses a traumatic injury (such as a complete rotator cuff tear or fracture), you may require immediate surgery. But most shoulder problems progress gradually and will respond well to rest, heat and ice, oral medicines, gentle stretching and strengthening exercises, and physical therapy. (Physical therapy can also help you avoid a condition called frozen shoulder, in which the shoulder becomes “stuck,” unable to move freely.) Some physicians will recommend the supplements glucosamine and chondroitin, corticosteroid injections, or viscosupplementation (hyaluronic acid injections).

Because shoulder surgery in most instances is elective, whether to move on to surgery is an individual decision. You and your doctor need to look at the positive outcomes you can expect from nonsurgical and surgical treatments, as well as possible downsides from surgery and problems you might face if you don’t have surgery. While many people need a strong and functioning joint for work, sports, or everyday living activities, for others, not having a perfectly functioning joint may be less of a problem. Some people adjust to living with a certain amount of pain and mobility limitations. Some are afraid of the risks of surgery, such as infection and other complications. Some may not be able or willing to commit the time needed for rehabilitation. Some may have other health conditions or problems that make surgery unwise, such as heart disease or bone that is in very poor shape. These are the kinds of factors you need to think about when you’re evaluating whether shoulder surgery (or elbow surgery, discussed below) is the right choice for you.
Two common surgeries performed on shoulder joints are rotator cuff repair and total shoulder joint replacement.

Shoulder surgery: rotator cuff repair

The four muscles of the rotator cuff (one in the front of the shoulder, two on top, and one in the back) attach to tendons that in turn attach to the head (the “ball”) of the humerus. In a rotator cuff tear, it is usually the tendons that are torn. Rotator cuff tears occur most often in individuals over the age of 40. Some tears occur gradually over a period of weeks or even months, perhaps because of aging, or chronic inflammation from RA or lupus. Others are immediate, caused by a trauma or injury. The most common symptoms of a rotator cuff tear are weakness and pain in the front of the shoulder (the pain is often most acute when you are lifting your arm over your head). The doctor will diagnose a tear based on the symptoms, a physical exam, and the results of an x-ray or MRI.

Some rotator cuff tears are relatively small and can be treated with rest, physical therapy, or other nonsurgical methods. Others are more extensive, involving more than one tendon and/or bigger tears. These in particular may require surgical repair. Younger individuals, those desiring to compete aggressively in sports, or those in need of excellent motion and strength for their jobs are more likely to feel the need for surgery. However, even a large tear may be treated without surgery. People who have recently torn their rotator cuff and whose tears are the result of traumatic injury are most likely to have success with surgery because their shoulder muscles have not had time to degenerate.

How the surgeon fixes a torn rotator cuff depends on the tear. For a partial tear the surgeon may only need to trim or smooth the cuff (a procedure known as debridement). In most other cases, rotator cuff repair involves reattaching the torn tendons to the head of the humerus. To perform the surgery, the surgeon will choose one of the following surgical techniques: arthroscopy (using tiny incisions, specially-sized surgical tools, and an arthroscope that sends images of the joint to a TV monitor); mini-open surgery (using one larger incision); or open surgery (using a traditional-size incision).

Which technique the surgeon chooses depends on the patient’s preference, the surgeon’s experience, the size of the tear, the anatomy of the patient, and the quality of the bone and tendons. Either general anesthesia (in which the whole body is put to sleep) or regional anesthesia (in which only the area of the body being worked upon is put to sleep) is used. Pain after rotator cuff surgery is controlled with pain-killing drugs. Most people can leave the hospital the day of their surgery, though surgeons will occasionally recommend hospitalization for one night.

After surgery, careful rehabilitation is crucial if you are to regain strength in your shoulder and improve its functioning. Most physicians request that the shoulder be immobilized in a sling for a while after surgery to protect it. Your rehabilitation may at first be limited to “passive movement,” in which a physical therapist moves the shoulder joint gently and stretches your arm. The therapist may teach you how to do this for yourself. This passive movement is needed to stop the development of scar tissue, which can reduce the shoulder’s mobility.

It usually takes 4–6 weeks for the repair to heal, pain to decrease, and motion in the joint to return, at which point you can begin stretching and strengthening exercises to regain range of motion and strength. The doctor or physical therapist will teach you how to do them. Six months after surgery, most individuals have 80% of their normal strength back again. They won’t be able to return to sports or aggressive physical activity and work until the physician is satisfied that the rotator cuff is strong enough. From 80% to 95% of those who have rotator cuff repairs report satisfactory results, with relief of pain and improvement in function and range of motion.

Since this is a common surgery, many orthopedic surgeons routinely do it. Ask your family doctor or rheumatologist to recommend a doctor who does many of these surgeries. You can also investigate sports medicine clinics, or check with your medical society or hospital referral list.

Rotator cuff repair may help save the shoulder from developing future problems, such as OA. A person with a stable, strong joint that works properly will hopefully avoid wear and tear of the shoulder joint that could lead to a need for total shoulder replacement surgery.

Shoulder surgery: replacements

Shoulder replacements are much less common than hip and knee replacements. The American Academy of Orthopaedic Surgeons estimates that in 2002, around 23,000 total shoulder replacements were done in the United States, compared with over 700,000 total hip and knee replacement surgeries. Although shoulder replacements are relatively rare, they are generally successful.

Most shoulder replacements are done on people who have OA, RA, or posttraumatic arthritis. Signs that suggest you need a shoulder replacement include loss of strength and mobility in your shoulder and a reduced ability to function. Initially, the shoulder joint may feel more painful with movement and less painful with rest. Later it may also feel painful at rest. The pain is often described as a deep ache. Some damaged shoulder joints grind and make grating sounds with movement. A shoulder joint may also catch when it is moved and may even lock up. X-rays will show changes in the joint — loss of joint space because of cartilage loss, flattening or change of the head of the humerus (which should look like a ball), and perhaps bone spurs and loose pieces of cartilage or even bone in the joint space. Some fractures and avascular necrosis can also lead to the need for replacements.

Because a limited number of total shoulder joint surgeries are done each year, you may need to do a little doctor shopping to find a surgeon who is very experienced and practices at a medical center familiar with shoulder replacements. Surgeons who specialize may practice at university schools of medicine, or you may find their names through the county medical societies or orthopedic societies in your state. Ask your family doctor or rheumatologist who in the area does most of the shoulder replacement surgeries, or check with American Shoulder and Elbow Surgeons. Be prepared to travel, as you may not find a doctor close to you.

Conventional replacements. The conventional shoulder replacement prosthesis, or implant, has two parts: a metal stem and ball and a plastic socket. The surgeon cuts off the damaged humeral head, then places the stem in a hole drilled into the humerus, with the ball taking the place of the humeral head. The plastic socket, called the glenoid component, fits into the glenoid cavity of the shoulder blade. (See the diagram on this page.) If the glenoid cavity is in good condition, or if the rotator cuff or glenoid cavity is in very poor condition, the surgeon may only replace the ball. (A rotator cuff in poor condition raises the risk that the glenoid component will loosen; a glen­oid cavity in poor condition won’t have enough healthy bone to support the component.) The surgeon can choose to cement or not to cement the replacement ball — cementing is usually done if the humerus is not of good quality. The glenoid component, if used, is usually cemented.

Reverse replacements. If you have a completely torn rotator cuff or cuff tears related to severe OA or to a previous shoulder replacement, the surgeon may opt for a reverse total shoulder replacement. The reverse shoulder replacement has been used for many years in Europe and was approved by the US Food and Drug Administration in 2004. In this type of replacement, the metal ball and the plastic socket switch places. That is, the ball is attached to the glenoid cavity and the socket to the humerus. This allows a person to use muscles other than those of the rotator cuff to move the shoulder.

Resurfacing. Another possible replacement procedure is shoulder resurfacing. The implant used in this procedure is designed to cover the head of the humerus but not fully replace it. This option may be appealing because less bone and cartilage are removed. Because it preserves much of the humeral bone, it means that if a total replacement is needed later in life, the procedure will be less complicated than it would be if you’d already had a total replacement.

Pain after shoulder replacement surgery is controlled with painkilling drugs. The usual hospital stay is two or three days. You will probably work with a physical therapist and start with gentle range-of-motion exercises the first day after the procedure. The physical therapist will also teach you exercises to do on your own when you get home. After two weeks, you may be able to eat and dress yourself. To protect your new joint, however, don’t use your arm to push yourself up from bed or a chair, place your arm behind your back, or drive a car until your doctor says it is OK. An easy-to-remember guideline is that you shouldn’t lift anything heavier than a cup of coffee for six weeks following the surgery. Ask your doctor for a list of activities you can and cannot do after surgery. Most doctors will not allow any contact sports or repetitive heavy lifting at all after total shoulder replacement surgery. Also, remember to increase your activities little by little, and don’t be afraid to ask for help.

The long-term prognosis of shoulder replacements is generally good. So is patient satisfaction with the surgery. In one study, researchers from Columbia University in New York interviewed people with OA who had undergone total shoulder replacement between 1982 and 1992. In total, 73% reported excellent results, 20% reported satisfactory results, and only 7% reported their results as unsatisfactory.

The elbow

The elbow is a hinge joint situated where the humerus meets the two forearm bones called the ulna and the radius. The surfaces where the three bones come together are protected by cartilage. Additionally, the joint is surrounded by muscles, tendons, and ligaments that support it and allow it to move. (See a diagram of the elbow.) As with the shoulder, arthritis — such as RA, OA, or posttraumatic arthritis — can damage the elbow enough to make it both painful and difficult to move. The elbow may also “grate” or lock up. Sometimes, nonsurgical treatments bring relief, but some individuals eventually elect to have surgery. The most common type of elbow surgery is total joint replacement.

Elbow replacements. Although only a few thousand total elbow joint replacements are done every year, they usually produce good results. Success is related to the type of health problem the individual has, the individual’s motivation, and, of course, the quality of the care received. People with RA tend to benefit the most from the surgery.

It may take a little research to find doctors who specialize in total elbow surgery. Use the avenues described in the section on shoulder replacements, above. Once you locate a surgeon, this doctor can tell you if the surgery is appropriate for you and if and how it will benefit you.

The prosthesis developed for total elbow replacement surgery is similar to a door hinge. The stem of the upper component is placed in the lower part of the humerus. The stem of the lower component is placed in the upper part of the ulna. The components are cemented in place. Next the surgeon inserts a hinge pin to hold the components together (see illustration of elbow implant). The surgery is performed under general or regional anesthesia. During the surgery the ulnar nerve, which runs the length of the arm, is pulled aside so it is not damaged. This precaution often causes temporary numbness in the pinky finger after the surgery. You can expect the surgery to take approximately two hours, and you will be given pain medicine for several days afterward. Your hospital stay will be somewhere between two and four days. Usually, the doctor will recommend range-of-motion exercises that you do soon after surgery with the help of a physical therapist. You will continue to do the exercises for several weeks at home after you leave the hospital. The therapist will also teach you strengthening exercises to add to your program when you’re ready for them.

It is important that the elbow have a chance to heal. Even if your new joint feels great, you must not put much strain on it in the weeks following surgery. As with shoulder joint replacements, you shouldn’t lift anything heavier than a cup of coffee for at least six weeks after surgery. Expect to continue regaining strength and mobility in the elbow for up to a year. Most doctors recommend that you avoid forever impact activities such as sports, hammering, lifting of heavy objects or weights, and heavy resistance exercises. Remember, you want this joint to last your lifetime.

Other elbow surgeries

Occasionally, instead of total elbow replacement, the surgeon will choose another procedure. Arthroscopy, for instance, is used to “clean” bits of cartilage from the joint. Fusion is sometimes used to reduce pain when a total joint replacement cannot be done. (Previous infection, for example, might limit the doctor’s willingness or ability to do a total elbow replacement.) In fusion, the ends of the humerus and ulna are joined together. Fusion can stabilize the joint, but you lose the ability to move it. Another procedure replaces the head of the radius if it is damaged by arthritis or fracture. This reduces pain and stabilizes the elbow and preserves its range of motion.

The final word

Whether you are getting shoulder or elbow replacement surgeries or are having your rotator cuff fixed, your long-term prognosis is good as long as you carefully follow your doctor’s and physical therapist’s instructions. A program of therapy and exercise after your surgery is essential for regaining the function of your joint, and care is needed afterward to protect the repaired joint from unnecessary strain.

Keep in mind that in most cases, these surgeries are elective and are not done until exercise, drugs, and other conservative measures have been tried. Often a program of physical therapy can increase strength and reduce pain enough that surgery is unnecessary. Talk to your doctor and take time to weigh the pros and cons so you can make an informed decision about shoulder or elbow surgery.

Wendy McBrair spent 30 years as a health-care professional in the fields of rheumatology and orthopedics, where she specialized in patient and community service, patient education, and advocacy.

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