Shoulders that have a decreased active and passive range of motion to examination should have X-rays performed as part of their work up to assess the state of the glenohumeral joint. Shoulder arthritis that occurs secondary to chronic rotator cuff tearing / dysfunction has a different X-ray appearance and is called rotator cuff arthropathy. If symptoms fail to settle with appropriate non-operative management of simple analgesia, activity modification and physiotherapy, then specialist referral may be appropriate.
Shoulder arthroplasty continues to improve in accuracy and reliability. Advances in regional anaesthesia, reduction of blood loss with the use of tranexamic acid, and post operative analgesia protocols allow this operation to be performed safely with a single overnight stay in hospital. Through the use of preoperative 3D templating, patient specific instrumentation and computer navigation, the accuracy and reliability of surgical implantation continues to improve and allows surgeons to attempt more difficult cases involving structural bone grafting and the use of custom prosthesis when needed.
Anatomic total shoulder replacement is a reliable operation for relieving pain and improving range of motion in cases of osteoarthritis. It relies on patients having a functional rotator cuff. Most cases of osteoarthritits in patients under 75 years of age are treated this way with excellent results. The most reliable results come from the use of a cemented glenoid component. Recent advances in hybrid glenoid components (central press fit cage and peripheral cemented pegs) show improved radiographic results at 2 years compared to cemented components, and are used in my practice. Cementless glenoid components should rarely be used due to their inferior results. For humeral bone preservation the use of a modular prosthesis that can be easily converted to a reverse system without stem revision, or a stemless humeral component is preferential.
The indication and use of reverse total shoulder systems continue to increase and they represent more than 70% of shoulder prosthesis now inserted. They are a very reliable operation in older patients, patients with rotator cuff tear arthropathy, massive rotator cuff tear / failure, complex proximal humeral fractures, and cases with severe glenoid wear. They provide excellent relief of pain and improvement in forward elevation. The amount of improvement in rotation does rely on the degree of function in infraspinatus and teres minor.
Modern designs have very low rates of dislocation (<1%), scapula notching and acromial stress fractures compared to the original design and help improve the range and strength of internal and external rotation. Post operative rehabilitation protocols allow a rapid gain of function within the first 2-3 months post surgery. In younger patients with irreparable rotator cuff tears, a superior capsular reconstruction may be considered as an alternative to reverse shoulder replacement if there is only mild arthritis present.
Dr Hamish Rae, MD FRACS
Dr Hamish Rae has more than 12 years' experience in orthopaedic surgery and has worked in public and private hospitals throughout Sydney, Australia and the United Kingdom. He established the Orthoelite practice with Dr Razvan Stoita to provide specialist orthopaedic services to the community of Sydney and the Southern Tablelands.
Dr Rae has a passion for joint replacement surgery of the hip, knee and shoulder as well as arthroscopic and open surgery of the shoulder. He incorporates modern technology including robotic surgery (now routinely used for knee replacements at Hurstville Private), patient specific instrumentation and computer navigation into his practice to ensure accuracy and precision of the placement of joint replacements during surgery. He has completed fellowships in Shoulder and elbow surgery in Sydney and complex hip and knee arthroplasty (joint replacements) in London, UK. He has worked as a consultant orthopaedic specialist at Prince of Wales Hospital, St George Hospital, Sutherland Hospital and Canterbury Hospital, before helping establish the modern orthopaedic department at Goulburn Base Hospital.
Dr Rae has a keen interest in research and has published in numerous international journals, and presented at international meetings, which he continues to attend and contribute to nationally and internationally.