Q & A with Dr. Bryan Wall, M.D on shoulders

Bryan Wall, M.D., an orthopedic surgeon at the Core Institute in Phoenix, Ariz., explains how a new surgery that reverses the anatomy of the shoulder is easing pain for patients with rotator cuff tears with arthritis.

Are there limits to the types of patients who can have shoulder
replacement surgery?

Dr. Bryan Wall: The problem that we have in shoulder replacement surgery is that there is a certain segment of the population that has problems that are just too great to deal with traditional shoulder replacements. We have a certain subset of the population that has arthritis, but they also have large tears of their rotator cuff mechanism. What we've found in those patients is that a traditional shoulder replacement does not work particularly well because the mechanics of
the shoulder are dramatically altered, and that the shoulder replacement fails at a fairly rapid rate.

What has happened to these patients' shoulders that they aren't working correctly?

Dr. Wall: Typically, the entity is referred to as a cuff tear arthropathy. That's a massive rotator cuff tear, and then they eventually develop arthritis of the shoulder joint on top of that.

When a patient has arthritis, what happens to their range of motion?

Dr. Wall: Typically, what happens when a patient develops pain because of the arthritis and also because of the failure of the rotator cuff, they lose their ability to raise their arm above the level of their head. In fact, most patients can only raise their arm approximately 30 degrees or 40 degrees, typically.

Is an injury to the rotator cuff common?

Dr. Wall: The rotator cuff, I think, is a very misunderstood structure, as far as the general public goes. I think there are high profile injuries, baseball pitchers, for example, who have problems with their rotator cuff. However, the vast majority of patients that have problems with the rotator cuff are actually in their 50's or 60's or 70's, so it's actually a problem with the older population. It's a very common injury.

What is the traditional method of treating a rotator cuff injury?

Dr. Wall: In the past, we had very, very limited options. We would ctually replace part of the shoulders and tell patients that, 'Well, we're going to just have a limited goals rehabilitation for you,' meaning that we'll replace your shoulder, we'll try to take care of the pain from the arthritis, but your arm is just not going to work very well, you're just going to not be able to elevate it. Obviously, that's not an ideal solution. The reverse shoulder replacement that we use now allows us
to not only replace the joint that's become arthritic, but it puts the shoulder in a better mechanical position and changes the mechanics of the shoulder to allow people to elevate their arm.

How does the procedure work?

Dr. Wall: What we do is we reverse the joint. Everybody knows that the shoulder is a ball and socket joint, with the socket being on the shoulder blade side, and the ball being on the arm bone side. By reversing the joint and putting the ball on the shoulder blade side and the socket on the arm bone side, we're actually able to create a captured joint. What that does is it puts the deltoid muscle, which is
the largest muscle in the shoulder, in a better mechanical position, in order to allow the arm to elevate.

Is an implant used in the procedure?

Dr. Wall: Yes. The implant is typically made out of metal and plastic. There's a metallic ball that goes on the shoulder blade that's fixed in usually with screws, and then there's a stemmed implant that goes into the center of the arm bone that has a plastic cup on it that can be just fit into the arm bone, or sometimes just fixed with cement.

How does the reverse shoulder replacement affect patients' lives?

Dr. Wall: It can be fairly life-altering, particularly in patients who are older and patients who have bilateral problems. You don't think about the ability to raise your arms very much. However, say you're in your 70's living by yourself. If you can't raise your arms above the level of your waist, you can't use half the cabinets in your kitchen, you can't wash your hair, you can't fix your hair, you have a difficult time brushing your teeth and feeding yourself, so it can be very,
very dramatic, as far as the effect on these people's ability to live independently, and function.

Who's a good candidate for this procedure?

Dr. Wall: Typically, I would say that a good candidate is an older patient who's less active. While I'd love to say that all patients would be a great candidate for this, what we think is that patients who are younger put a tremendous amount of wear and tear and stresses and strain on the shoulders, just because they're more active and they do more aggressive activities. The shoulder implant isn't great at dealing with those types of problems, and the concern is that over time,
the shoulder implant will loosen and fail. The older patient, who is say in their 60's or 70's, typically isn't going to have that same level of activity, so we don't worry about that quite as much, so we think that's probably a better candidate for the procedure. That being said, we do use it in younger patients at times as a salvage procedure, such as patients who have advanced tumor reconstruction or sometimes patients who have significant problems after a regular shoulder
replacement and we have to revise it.

Is the procedure widely available?

Dr. Wall: It's becoming much more common in the United States. It's been done in Europe since 1986 – that's when the first type of this implant was done. It was actually done in the United States back in the 60's and 70's, but what we found is we have problems with those implants, so a gentleman named Paul Grammont, who is a French surgeon in Lyon, France, redesigned the implant in 1986, and started placing them in France. They came out with their second generation in
1991, which is fairly similar to the implant that we're using today, so it's been used in Europe in this form since 1991. In the United States, it's been available since about 2004.

Is this a procedure patients with cuff tear arthropathy must have?

Dr. Wall: This is sort of an elective procedure in every sense of the word. What I tell every patient who comes to me asking when they need to have this done, is that they never need to have this done. Nobody's ever died from cuff tear arthropathy. You may have shoulder pain, you may have inability to raise your arm, but it's not that you need to have this done. The time to have this done is the time when the patient decides that they'd rather have this surgery, they have
some potential consequences that go along with surgery, being in the hospital, outpatient rehab, those sorts of things. When they decide that it's time to do that rather than continue to live their life the way they are, that's the time for them to have the surgery.

How long is the actual surgery time, hospital time, and recovery time?

Dr. Wall: It's an inpatient surgery, so you're going to be, on average, about two days in the hospital. Most patients will be in a sling anywhere from about two to six weeks. Outpatient rehab is usually anywhere from six weeks up to three to six months. Most patients are going to feel a lot better than they did before surgery at about six weeks, and I tell most patients that they're going to get about 100
percent of their function wherever they're going to be, at about a six month post operative time.

What type of patients typically wants to have this procedure?

Dr. Wall: If you look at the larger series that's in the scientific literature that we published out of France, the average age was 72, so it is a little bit older than the average age for the population for joint replacement in general. It's patients who are older and active who are the ideal candidates for this procedure. Those are typically patients with the cuff tear arthropathy. Anybody who is in their 60's or
above really who has this problem and wants to maintain their activity level, I think they're a great candidate for it, and particularly patients who have pain, too, because it's a very, very effective operation in relieving pain. I think there's a second set of patients who are good candidates for it, and those are patients who had previous shoulder replacements, either because they've had fractures or arthritis surgeries that have failed. It's a very, very good option for revision of
failed previous shoulder replacement surgery.

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