Shrug Off Shoulder Pain for Good: Advances in Shoulder Replacement Surgery

Intro: This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell.

Deborah Howell (Host): Well, hello there, and welcome to the show. I am Deborah Howell, and today we'll be talking about how to shrug off shoulder pain for good, and about the advancements in shoulder replacement surgery. Our guest today, I'm pleased to tell you, is Dr. Trong Nguyen, an orthopedic surgeon and medical director of the Total Shoulder Replacement Program at the MemorialCare Joint Replacement Center at Orange Coast Medical Center. Welcome, Dr. Nguyen.

Trong Nguyen, MD: Thanks, thanks for having me.

Deborah Howell (Host): Roughly 53,000 people in the US have shoulder replacement surgery every single year. So my first question is, what is shoulder replacement surgery and who's the ideal candidate for this type of procedure?

Trong Nguyen, MD: Well, basically a shoulder replacement surgery is a replacement of the ball and socket joint of the shoulder. And if you can imagine it being sort of like a flat tire on your car. The cartilage has worn out to the point where essentially patients are moving their shoulder bone on bone. And so when they try to try to move their shoulder up and down or rotating their arm, they have significant pain and disability because of it. And so essentially what you're doing is replacing or resurfacing the ball and socket joint just like replacing a tire, similar to hip and knee replacement. The ideal patient typically is a patient who has exhausted all non-operative alternatives, and it gets to the point where they're severely debilitated and their quality of life has been significantly affected by the pain and disability.

Deborah Howell (Host): And what types of symptoms do individuals typically have that might prompt them to consider shoulder replacement?

Trong Nguyen, MD: Well, the main symptoms depending on the cause of the arthritis typically are loss of motion, stiffness, pain, inflammation, and dysfunction of the shoulder. Not being able to raise your shoulder above shoulder level or not being able to sleep because of the pain, that's usually the symptoms that bring patients in to see a doctor.

Deborah Howell (Host): Okay, now I know there's not one size fits all, so what are the different types of shoulder replacement surgeries that are offered to patients, and how are they performed?

Trong Nguyen, MD: Well, depending on the cause of the arthritis, there's different kinds. There could be rheumatoid arthritis, patients could have rheumatoid arthritis. Patients can have osteoarthritis, post-traumatic arthritis, arthritis related to osteonecrosis, or avascular necrosis. Those are all different etiologies or causes of arthritis of the shoulder. Fractures, of course, can also be a problem. And depending on the problem, different options are offered or necessary. For standard osteoarthritis with severe bone on bone degeneration, typically a shoulder replacement, a standard shoulder replacement with a replacement of the ball and socket is done. Implantation of the glenoid, which is the socket, and the humeral head, which is the ball part of the joint, is done with a standard, what we call a deltopectoral approach from the front of the shoulder. And that's where the ball and socket joint is replaced with a typically a metal implant and a plastic socket component. That's done typically if the rotator cuff is intact. If the rotator cuff is not intact, then it's usually recommended to do a what's called a reverse shoulder replacement. That's typically done more for where patients have a torn rotator cuff with significant weakness, severe arthritis or rotator cuff arthropathy, which is arthritis related to chronic long-standing rotator cuff tearing. Or if a patient had a previous failed, previously failed shoulder replacement, then a reverse shoulder replacement is usually indicated. And that's where the ball and socket joint are actually reversed and switched. Where the socket becomes the ball, and the ball becomes a socket.

Deborah Howell (Host): Oh, that's so interesting.

Trong Nguyen, MD: Yeah, that's relatively new, and what it does is it changes the center of rotation to allow for the deltoid muscle to take over for the loss of a rotator cuff, a functioning or damaged rotator cuff tendon. There are other options such as resurfacing or hemiarthroplasty. Those aren't as common and those have different indications as well, and that typically is discussed with the surgeon which ones are the best ones.

Deborah Howell (Host): I just had shoulder surgery last year, as a matter of fact. I didn't have my shoulder replaced, but I know a lot of things about being a recuperating patient from shoulder surgery, like when you can't even hold a cup of coffee.

Trong Nguyen, MD: Right, right.

Deborah Howell (Host): So a lot of people want to postpone these things. And are there any long-term repercussions of postponing a necessary shoulder replacement?

Trong Nguyen, MD: The one thing that most surgeons are concerned about when evaluating patients with significant osteoarthritis is having a good glenoid base. And I'll describe that as being, or I'll relate that as having a good foundation for your house. So if a shoulder replacement requires building on top of a strong glenoid socket, the more and more severe arthritis becomes, the more wearing down of the bone and the glenoid occurs. So if the glenoid, which is a relatively small bone compared to other parts of the shoulder, if that wears down to a significant level, it makes the surgery more difficult and perhaps possibly the recovery more difficult. And then you have to do additional surgery if there's significant bone loss. So you know, delaying a shoulder replacement surgery is, you know, individual. Everybody's a little bit different in terms of how mentally ready they are for a shoulder replacement surgery. But usually, what I do in my practice and I know a lot of surgeons do as well, is they'll monitor the amount of bone stock or bone availability. And if there's too much wear of the glenoid, most surgeons will most likely recommend doing the surgery sooner than later in order to prevent significant bone loss. Because if you can't, if you don't have a good foundation, it's hard to build or it's hard to have a good shoulder replacement, just like if you don't have a good foundation for your house, you can't really build a good house. It's gonna huff and puff and blow it all down.

Deborah Howell (Host): Exactly. And that's one of the main things I would say would not be good if you delayed a shoulder replacement surgery. But that's typically done by monitoring patients on a serial basis, with serial x-rays just to make sure that there's no significant wearing.

Deborah Howell (Host): Okay, what's the recovery process like after surgery? And really, how soon would a patient be able to go back to their usual everyday activities?

Trong Nguyen, MD: Typically after the surgery, patients are in a sling. And there's certain restrictions that are necessary, and that's usually discussed with your surgeon depending on the exact surgery that was done. But for the first couple weeks, most patients are able to perform simple daily activities such as eating, dressing, and grooming. There's gonna be some expected pain for the first several weeks after surgery and sometimes at night. Driving isn't usually allowed for on average two to four weeks, depending on how quickly patients recover. But typically patients start a light exercise program with simple passive motion just to prevent stiffness for the first couple weeks. But after six to eight weeks typically a lot of those restrictions are lifted, and people are able to advance their activity levels to allow to do, so they're allowed to do more and more stuff.

Deborah Howell (Host): And along with that, what type of support is offered to patients before and after surgery as part of the MemorialCare Joint Replacement Program?

Trong Nguyen, MD: The joint replacement program includes hip and knee replacements, but the shoulder replacement program also is included in the pathways that we have. Those include preoperative evaluation, assistance with coordination with specialists that are needed with, or that are needed for medical clearance and evaluation prior to surgery, such as if you had a cardiac issue, coordinating the pre-op cardiac evaluation, pulmonary evaluation, and other subspecialties. Coordination with preoperative medications and postoperative medications. Usually we have a nursing coordinator that helps advise patients along with the primary care doctor and the surgeon to see which medications can be continued before and after surgery or need to be discontinued before or after surgery. We also have a nurse that helps with teaching patients in a preoperative class, kind of like an orientation for the patient.

Deborah Howell (Host): Really?

Trong Nguyen, MD: And if they... and if they have a quote unquote coach, typically we advise patients to have either a family member or a good friend to come with them to the preoperative classes. And it basically goes over what to expect before, during, and after surgery in a stepwise fashion. Yeah, and it really eases the anxiety that people have prior to surgery, which is of course expected. So the preoperative nurse and the preoperative classes have been highly rated and really successful and patients usually really like it. Obviously during the surgery there's a streamlined pathway for patients where we use evidence-based medicine and evidence-based surgery to maximize the outcome for the patient. And then the postoperative recovery is also streamlined and coordinated with the nursing staff and the discharge planners to make sure patients have everything they need when they go home.

Deborah Howell (Host): It sounds like you've got a team you can't fail, right?

Trong Nguyen, MD: Well, I think all the surgeries that we do, you definitely have to have a team. Because there's so many things that are needed and there's so many things that you want to go right. And so when everybody is on the same page, it makes a huge difference.

Deborah Howell (Host): I want to thank you so much for your time today, Dr. Nguyen. It's been so good to have you on the show, we really appreciate it.

Trong Nguyen, MD: No problem.

Deborah Howell (Host): For more info or to listen to a podcast of this show, please visit memorialcare.org/podcasts. That's memorialcare.org/podcasts. That's all for this time. I'm Deborah Howell, have yourself a terrific day.