What is Arthritis of the shoulder?
Arthritis implies inflammation of a joint, but in common usage usually means wearing out of that joint - either the joint surfaces (cartilage) or the muscles and capsule of that joint have degenerated and given way.
In the shoulder Primary Arthritis applies to the wearing out of the cartilage while the muscles and capsule remain intact, whereas "cuff arthropathy" applies to the giving way and disintegration of the muscles and cuff with secondary destruction of the cartilage, an even worse combination.
Symptoms
- night pain due to the accompanying inflammation - a reaction to the wear and tear particles within the joint over a life time.
- creaking or grating of the joint with moving as the joint surfaces are no longer smooth.
- limited movement as the capsule has shrunk and the joint is too painful to move because of above.
Investigations
- X-rays show the changes in the bone structures and the "joint" space between the bones.
- Ultrasound (U/S/S): show the soft tissues about the joint i.e. the cuff and the muscles, as well as the amount of movement really occurring at the joint surfaces.
- CATScan: may show the 3 dimensional structure of the bones and the state of the muscles - whether replaced by fat or good contracting muscle which will work to move the joint after a joint replacement.
- MRI: also to show the state of the muscles to predict the eventual functional recovery after a shoulder joint replacement.
Treatments
| Conservative ( no operation)
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- Anti inflammatory tablets: but beware they do not affect you badly such as stomach irritation - indigestion as they can sometimes cause ulcers in susceptible individuals.
- Physiotherapy: to settle inflammation, maintain movement and most importantly to advise, set and monitor an exercise programme to keep the joint balanced and controlled. Hydrotherapy is especially useful for shoulder arthritis.
- Cortisone (or hydrocortisone or steroid) injections into the joint may help to settle a flare up of the arthritis. If appropriate this can be given during your out patient consultation
| Operative - minimally invasive
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Arthroscopic debridement can be performed either as a day case or overnight stay. There is little pain, short 30 - 40 minute operation through 2 stab wounds (no large cuts) and immediate use of the limb. However the outcome is uncertain. Many patients have been delighted and requested the other shoulder to be treated in the same manner but some will come back within a few years and ask for the full total joint replacement operation.
The procedure is done with the arthroscope to look inside the joint so that any loose bodies can be removed, any cartilage flaps or fragments can be smoothed, the inflamed synovium (joint lining) can be sclerosed and any noxious enzymes or wear particles can be washed out of the joint.
Patients commonly report much less pain the next day and strangely better movement, although this is probably more related to the less pain and less muscle spasm than any improvement in the joint surface !
Postoperatively the patients are encouraged to undergo a programme of exercises under the instructions of a physiotherapist.
Operative - Resurfacing Shoulder Replacement
I
f your shoulder is well centred and the glenoid (cup) is not too worn then resurfacing the humeral head (the ball) may be your best option
| Operative - Total Shoulder Replacement (TSR)
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There have been many advances in shoulder joint replacements over the last 20 years. The first generation artificial joints were basically one size to fit all, but of course people are of all different sizes and so many did not fit all that well and would loosen.
The second generation of shoulder prostheses allowed for different sizes of the ball and socket as well as the length and width of the arm bone so allowed better fit and function.
The third generation of shoulder joint replacements were only released for world distribution in 1999 although designed and trialled for a period of 8 years in France (Walch, Boileau) with impressive results. These allow the normal shape of the patient's joint surfaces to be exactly reproduced in surgery, so the patients muscles can act normally and therefore better function is achieved as well as the good pain relief.
This is the shoulder replacement most commonly used by Mr Hamlet
The old worn out ball of the head of humerus is removed and a highly polished metal surface (part of a sphere) is replaced on the humerus which exactly fits on the cut surface. Usually a plastic cup is cemented onto the scapula (shoulder blade) on which the smooth metal slides. Thus friction is minimised, the painful surfaces removed and the muscles which move the joint returned to their correct length.
Postoperatively
- Patient often only need to stay overnight in hospital for pain relief and physiotherapy, until they are independent and can look after themselves.
- We encourage early movement of the shoulder at first in a sling but this can be removed quite early for periods but will be useful for up to 6 weeks.
- Hydrotherapy is extremely useful to help relax muscles, regain movement in a soothing less painful environment and can be begun after 3 days if facilities are available, as a waterproof dressing is applied in theatre to cover the wound. The sooner the return to function the better the eventual result.
| Operative - Reverse Total Shoulder Replacement
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For Cuff Arthropathy when there are no muscles or cuff remaining about the shoulder joint (which is also worn out), there used to be no good solution. The standard artificial joint relies on the surrounding muscles to hold it in position and to move it. When these are not present then the metal prosthesis would migrate upwards and erode the bones causing more pain and trouble sometimes necessitating a joint fusion (occasionally, but not well tolerated be older people).
A Reverse shoulder prosthesis has been released for use in Great Britain which is designed for this condition. It holds the shoulder down and does not let it migrate upwards to erode the bony arch and keeps the joint centred on the shoulder blade. Also it allows the remaining outside muscle (the Deltoid), to act in a more mechanically advantageous manner so that control of the joint is regained, often quite soon after the surgery. This allows patients to open doors, reach for cupboards, eat, attend to their hair and other personal care without holding their arm with the other hand, in addition to reducing the pain - which is the primary aim.
Again this has been used for many years in France (since 1987) prior to its release here with good long term results.
Postoperatively
- Patient stay 3 - 5 days in hospital for pain relief and physiotherapy, until they are independent and can look after themselves.
- We encourage early movement of the shoulder at first in a sling but this can be removed quite early for periods but will be useful for up to 6 weeks.
- Hydrotherapy is extremely useful to help relax muscles, regain movement in a soothing less painful environment and can be begun after 3 days if facilities are available, as a waterproof dressing is applied in theatre to cover the wound. The sooner the return to function the better the eventual result.
- Function returns quicker than conventional replacement but there is a limitation of internal rotation (arm behind back - can usually reach bottom but not bra strap).
Operative - Arthrodesis or Fusion
Before the above advances in shoulder replacements became available some patients needed to have their shoulders fused especially if they had a previous failed shoulder replacement or if their was no cuff and the shoulder was unstable and dislocating either anteriorly or superiorly.
Movement of the arm was still available by moving the shoulder blade about the rib cage although no movement between the arm and the shoulder blade. It often reduced the pain, prevented other problems but had limitations (to be expected).