Shoulder Arthritis and Shoulder Replacement Surgery Webcast June 22, 2010 Matthew Saltzman, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Introduction Shoulder arthritis is among the most prevalent causes of shoulder pain and loss of function. How can you get relief? Well, coming up, an orthopedic surgeon who specializes in shoulder treatment will discuss the diagnosis and treatment of shoulder arthritis including shoulder replacement surgery. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by Northwestern Memorial Hospital. I'm Andrew Schorr. Well, we cover a lot of ground on our Patient Power programs, and I hope you'll look at our huge library in the health library section of nmh.org and widely on the web, and we connect you with leading experts from Northwestern Memorial Hospital. Some are in orthopedics. One area of orthopedics, sort of a subspecialty, is dealing with the shoulder, and I don't know if it's happened to you, but it's happening to me right now. I've had just terrible shoulder pain. Could it be arthritis, and then if it is what do you do about it? I want you to meet Richard Allen who joins us from the far northwest part of Chicago. He's 72 years old, always been athletic in his life, used to play racquetball and go all around doing that, but does so many different sports. Let's go back about ten years, Richard, you started to have shoulder pain. When did you first notice that? Richard s Story I had a child late in life, at age 50, and I was playing basketball with him here at the house, just a hoop on the garage, and it seemed to me that every time I took a shot my arm hurt a little bit, and I almost used that as a gauge. In the next four or five years I went from playing basketball to not playing basketball. The pain increased each year substantially, and I knew that I had a problem at that point. Now, shoulder pain can be pretty disruptive to your life. Some people with shoulder pain, it happens to me too, it can even disrupt your sleep if you turn on that side. Was that happening to you? Absolutely. It disrupted my entire life. I could no longer swim. I used to swim three days a week, half a mile a day. I biked 15 to 20 miles two or three times a
week. I lifted weights two or three times--all of that went. I couldn't do any of that. By the time I finally went in to see Dr. Saltzman, it was gone, and I could barely move my arm. And I was up at least four or five times a night. We're going to meet Dr. Saltzman in just a minute who helped you a great deal and hear more about what can be done, but first, it's not just about the sports you couldn't do or sleeping, and of course that's so vital for us, but also how did this affect your weight, your blood pressure? Well, I think it's twofold. Obviously nobody wants to live with pain and you'd really like to get rid of it, but when you look and research shoulder surgery it looks like you might be inviting more pain, not less pain. And so that fear factor certainly kept me from doing what I should have done earlier. But the important thing is if you've been active all your life, and I have as I just mentioned, and all of a sudden you stop, in five or seven years you can easily, and I did, put on 20 pounds. My blood pressure went from normal to prehyper or whatever 150 over 80 is. Not what it should be, for sure. Not what it should be. And my resting heart rate went from the 50s to 70s. So let me recap this. For a man who had always been active and now you layer on pain, sleep problems, weight control problems, blood pressure problems, doesn't sound like living your quality of life. You've got to do something or you're just going to be in trouble. And who wants to live like that? Right. Now, as an athlete I understand you had, years before, had arthroscopic shoulder surgery, and you had a concern about recovery with a new shoulder surgery. With the recovery from the arthroscopic you had been concerned about that and were worried about repeating that. I did. I ripped a muscle playing racquetball, which I played a lot of, two hours a day, seven days a week for almost 25 years, and I finally ripped the muscle in the same shoulder that I had the replacement with Dr. Saltzman, and I had a very bad experience. It was arthroscopic. The surgeon repaired the muscle, and when I went back to the first interview he said, well, I hate to tell you this, but there's just a ton of arthritis in there, and I guess we're going to see you again when we put in 2
a new shoulder. And that arthroscopic surgery was painful, very painful, and I'd have to say I was using ice bags and had my arm in a sling for two months, maybe three. And so I was very skeptical about going in for shoulder surgery until the pain just got too great. I couldn't deal with it anymore. Well, we should mention, first of all, that wasn't the doctor we're going to meet, Dr. Saltzman. No, it wasn't. It wasn't the hospital that we're talking about either. Right. And it was some years before. It was 20 years before. Yeah. So even arthroscopic surgery has come a long way in the right hands, as they say. So how are you doing now? We should mention that you had total shoulder surgery, we're going to hear about that, and also because of arthritis you needed hip replacement too, done by another physician at Northwestern, so kind of one and then the other. Do you have your life back now? Are you an active guy? Absolutely. This isn't for me, this is for anyone who is listening, but I freestyle 44 laps in the pool. I did that yesterday. Wow. Today I just came back from a 15- or 17-mile bike trip. Sunday I lifted weights and swam again. Richard, how old are you? 72. You're one of these guys we love to hate. You're 72 and you look like 52. 3
No, I don't look like 52. I look like an old beat up guy, but the bottom line is my resting heart rate is now in the 50s. In fact when I came back from the bike trip today I rushed up stairs and took my blood pressure because the damn machine on the bike kept telling me I had, and this is when I was going up a hill on a bike, my heart rate was 52 or 54, and I thought this thing's broken. I can't be at that rate. Oh, well, good for you. After two or three months of working hard it is. My resting heart rate is 48, 50, 52. Well, congratulations. Let's meet this doctor who helped you so much, and that's Dr. Matthew Saltzman, who is an orthopedic surgeon and a subspecialist in shoulder treatment. Dr. Saltzman, first of all, you hear a story like Richard's, it's got to make medicine worthwhile for you. Absolutely. It's a pleasure to take care of Richard and patients like Richard. Really, that's why I do what I do, to try to help people get back to the active life style that they formerly enjoyed. All right. Let's talk about arthritis. So as we get older it's not uncommon to have arthritis. Typically we think about it in the hip, and hundreds of thousands of people probably have hip replacement surgery. Maybe a little less common in the shoulder but not at all uncommon, right? That's exactly right. So the knee and the hip are the most commonly involved with regular osteoarthritis, and the shoulder is actually the third most commonly involved joint. And if you think about shoulder replacement compared to knee replacements, there's about 400,000 knee replacements done each year in the US and only about 25,000 shoulder replacements. And shoulder replacement surgery, and I know there are different types, but it's--like a total replacement like Richard had, that's what you'd describe as a big surgery, wouldn't it be? That's correct. I think it's very similar to knee or hip replacement in that regard. 4
Arthritis All right. Now, before we get there, how do you get to a point with a patient in saying, first, you have arthritis and then looking at what are the range of treatment options and help us understand what those are. So there are a variety of treatment options for somebody with shoulder arthritis, and they start with simple things like avoiding aggravating activities, using moist heat, taking anti-inflammatory medications or even Tylenol, and then they progress up from there. Sometimes cortisone shots are used to relieve pain, although that's usually a temporary solution, and then people that have exhausted all those options are then candidates typically for shoulder replacement. So there's some people, though, might say, well, the pain is not too bad, I'm not nearly as active as now we hear from Richard, so maybe for them their life is not interfered with or affected that much. These more conservative approaches might be satisfactory for them. That's exactly right, and I always tell people that this is an elective procedure and it really comes down to a quality of life issue. If you're able to live with your shoulder the way it is, even if you have arthritis, that may be a perfectly reasonable solution. But if you would like to be more active, have better pain relief and better motion, then you may want to consider a shoulder replacement. Now, let's just understand types of arthritis. By far the most common, osteoarthritis as we age, right, the cartilage and all that is wearing down, and we develop pain and movement issues, right? That is the most common type. And then someone can have an autoimmune inflammatory condition that could be in multiple joints, like rheumatoid arthritis. Yes, that is correct as well. Not an insignificant amount of people, but fewer. And then somebody could have had an accident, athletic injury, anything like that years before, and then develop arthritis from that, correct? 5
That's post-traumatic arthritis, yes. Okay. So those are the three main types, but any of them could be an indication for shoulder surgery. That's exactly right. Shoulder Surgery Okay. So let's understand that. So Richard is there, you do, I imagine, certain imaging of the joint. How do you decide how extensive a surgery you need to do? We talked about total shoulder surgery, but there are also more limited ones too, correct? That is correct. So the way we decide is by talking to the patient, evaluating their range of motion, assessing their pain level, and then we typically will get x-rays which will image the joint. And it's a ball and socket joint that is worn out typically, and in that case what we'll frequently see is no joint space remaining and large bone spurs. And in addition to that sometimes there are cysts both in the humeral head or the ball, and the glenoid as well, which is the socket. And so that's bone on bone arthritis that affects both the ball and socket, and that would be the most severe form. If somebody has that type of arthritis then they would be a candidate for a total shoulder replacement which replaces both the ball and the socket. So you have these, I guess, I don't know if they're metal and synthetic, what materials you use now for the ball that goes on one side and the socket where the ball goes in. So the ball is made out of a metal alloy, and it's connected to a titanium stem that sits inside of the arm bone. And then the socket or the glenoid component is polyethylene, which is a special type of plastic that's made to last for many years. What's the length of time that a new joint might last? So with the modern implants that we use I think it's reasonable to expect at least 20 years out of any type of replacement including a shoulder replacement. That is 6
influenced by how active the patient is and whether or not the components were placed in the proper position. If they're lined up well and the patient is reasonable as far as their activities then they can expect it to last I think at least that long. Let's talk about recovery from a total shoulder surgery. So, Richard, first to you. So how long did it take to recover from it? Oh, it was in my case a minor miracle. I literally went off pain pills I think seven days. It might have been nine, but I think it was seven. I took no pain pills after that, nothing. I took my regular medicine, whatever that was. And what about moving your arm? I had amazing movement within two weeks. I continued during the entire time--because I had had hip surgery I couldn't go to the physical therapist, so I continued using the stretching motion that Dr. Saltzman had instructed me to do. And I did quite a few of those every day, maybe 250, 300 of them, where I raised my right hand up and stretched as far as I could and left it there for a while and tried to stretch it out. But I was prohibited from doing anything else because a month after I had the shoulder surgery I had the hip replacement. Right. So, Dr. Saltzman, this gentleman is an athlete his whole life. So give us the range of recovery time after a total shoulder replacement. So the day after surgery I like patients to start moving their arm the way that Richard did so that they're elevating their arm up overhead, and that continues for the first six weeks. And after that then they can start stretching it in different directions and then ultimately start strengthening their muscles sometime between six and 12 weeks after surgery. So it's not uncommon for the shoulder to be more comfortable several weeks after surgery, but it can take up to several months to get complete relief of their symptoms and return of function. So what about age? So Richard, we've already determined, he was 72 going on 22, I would say, but what about in older people? After all, arthritis typically is in the second half of life. What about--how do you make an assessment of who is really up for the surgery? Anyone who has end-stage osteoarthritis or any of the other types of arthritis that we spoke about are candidates for shoulder replacement surgery. When they're 7
younger, particularly younger than 50 years of age, there is a concern that the implant may wear out over their lifetime, so those patients are still candidates but they need to understand that they may need a revision or a second or third operation down the road. But we don't have a strict age limit as far as who would and would not be a candidate for the surgery. So men or women who fortunately nowadays are much more active in their 70s, if their health is otherwise good they would be candidates for it. Absolutely. There really is no upper age limit for it either. In fact, just recently in the last two months I did a shoulder replacement on an 86-year-old lady who is very active and had very bad arthritis, and she's recovering very well. So it's certainly reasonable to do in that age group as well. All right. Now, I understand there's a kind of surgery called a reverse shoulder replacement. What is that? That's a special type of shoulder replacement that's meant for patients that not only have arthritis of their shoulder but they also have a very large rotator cuff tear. So the rotator cuff is responsible for lifting the arm up overhead. So somebody who has a combination of the two problems, arthritis and a rotator cuff tear, have what's called cuff tear arthropathy. So they are unable to lift their arm up at all, and you can't do a regular total shoulder replacement for them because the rotator cuff is not there to lift their arm up after surgery. So in that case a reverse shoulder replacement can occasionally be considered, and that changes the mechanics of the shoulder and actually allows the deltoid muscle to lift the arm. So it still is a type of shoulder replacement, but the ball and socket are actually reversed in their position, and that changes the mechanics of the shoulder to allow people to lift their arm overhead and also to relieve the pain that they have from the arthritis. As I listen to this I recognize it's really pretty specialized. I should mention that Richard is a businessman and part of his business is dealing with, Richard, I think you told me, maybe 50 physicians. So you are definitely well connected in the medical field. And it was another orthopedic surgeon who referred you to Dr. Saltzman. What would you say to people about connecting with the right subspecialist when it comes to major shoulder surgery? It's by far the most important decision you're going to make. I was at--i wasn't at one. I was at two or three orthopedic people and--surgeons, and I just didn't feel 8
comfortable. I didn't feel like I was where I needed to be, and I just continued to search until finally one of those surgeons said you know, I could do this, I do do this, but you need to wait for Dr. Saltzman. He was the chief resident here. He went out for a special program where he studied under the master for shoulder surgery for three years. I don't know who that is, but whoever it is for three years. I think he's going to do all the shoulders here at Northwestern. Wait for him. And I am so happy I did. And by the way, I referred three people to Dr. Saltzman. One is delayed because he's got a heart problem, he's got to wait a year to have a new shoulder. The second one went elsewhere, and she's been in pain for the last three months. She's a lawyer's wife on the north side. And the third one has had the surgery and has had the same response I did. And she is not an athletic person. She is not somebody who has spent her life--she's a little overweight and she's--i mean, she walks every day, but that's about it. So who you pick as a doctor is extremely important. Yes. And I'm glad that Dr. Saltzman came back and is doing these surgeries. And thank you very much, Doctor. So, Dr. Saltzman, shoulder problems are your focus. That's correct. My practice is focused really on shoulder-related problems. Determining the Problem All right. I commented at the beginning, I had a frozen shoulder once on the right, now I've got some pain on the left, so I'm not lifting weights quite like I used to. How do we know whether I might be suffering from arthritis or could it just be like a pulled muscle or something like that? How do you determine that? Somebody comes to you, how do you know what are you dealing with? So the first thing I do is I sit down and I talk to them and try to understand how long their symptoms have been going on, what type of symptoms they've been having. And then the second step is to do a very thorough physical examination and assess the range of motion. And somebody who has restricted range of motion can have that for a variety of reasons, so the next step would typically be to get some x-rays, and if the x-rays reveal that there's no joint space left and there's 9
bone on bone arthritis, then we know that that's the cause of your pain and loss of motion. So it's important to go through that sequence of steps to figure out what the right diagnosis is. Oh, my. I'm raising my shoulder now, trying to now. It hurts. Oh, my. I may be coming to see you. So there we are. You can have shoulder surgery, but how might someone try these other approaches to see if they'd work? How long do you give it, physical therapy or the other approaches, to just see could they be effective short of surgery? It really is individualized to the patient, but it sort of depends on the duration of symptoms, what types of things they've tried, whether or not they really want to consider surgery or if they really would like to avoid it at all costs. But I think it's reasonable to try all those things for several months if not several years. But the issue is if you do have arthritis of the shoulder and you do things like physical therapy it may actually aggravate it because there's no cartilage remaining in the shoulder joint so by doing physical therapy and moving the shoulder and doing exercises it may actually aggravate the symptoms and make the pain worse. So I think it comes back to the idea that you really need to know what the diagnosis is in order to prescribe the right treatment. I had a frozen shoulder, as I said, on the right some years ago and I'd say that--shoulder pain is really, it's maybe even worse than a tooth ache. Is that what people tell you? Richard, what do you think? I'm surprised how bad shoulder pain could be. Well, I guess I'm a bit of an expert in that I've had the hip and the shoulder done, but what I garnered out of all that is that once that cartilage goes around the shoulder or around the hip it is incredibly painful and to the point where I'm walking with a crutch or I've got my right arm in a sling. Who wants to live like that? You might as well check out, folks, because you've got to do something about it. You've got to be brave enough to go see Dr. Saltzman or go see the hip surgeon of your choice. And you just have to go do it because otherwise 70 and 80 and 90 is a terrible time of your life, and it could be a wonderful time of your life. Yeah, well said. You're celebrating on your bike ride today. So you waited a long time. Now, maybe the stars wouldn't have been aligned if you'd done it years earlier and it would have been another surgeon but hopefully a shoulder specialist who would have been great for you. But there are people out there, whether they're in Chicago and have an opportunity to go to Dr. Saltzman or somewhere 10
around the world, what would you say to them about getting an evaluation and seeking an appropriate specialist and really considering care rather than, like you, just saying I'm just going to suffer? Many people just unfortunately go to the local doctor for an ear ache, and then they keep going to the local doctor for their shoulder ache, and they go to the local guy for their hip and their knee aches, and they end up at a less than--in my opinion, and I guess you can cut this part of the story out if you want, but it's true. There are a lot of people that just don't take the time to go to a first-class operation like Northwestern, and there you're going to get the right care. You're going to eventually find the right doctor. You're going to have a lot of choice of doctors, and they're not going to try to make their next Mercedes payment with your operation. They're interested in curing what ails you. You need to go to a teaching hospital. You need to go to somebody who's, like Dr. Saltzman, been through the program, been a chief resident, gone out and studied an additional three years for it. I just think it's imperative to go to the right institution and find the right doctor. Well, getting your shoulder back has really played a key role in getting your life back. My best advice to anybody who is going to get surgery is, first of all, if it's your shoulder call Dr. Saltzman. Get in an airplane and fly out here and see him. And, secondly, go to a major center, go to a Northwestern. Right. Well, I agree with you. I really do. Dr. Saltzman, so how do you feel about second opinions? So there may be somebody listening who may live in the Chicago-land area, maybe not. They say, well, I've already seen this other doctor. I'd kind of be curious what Dr. Saltzman says. So I want to ask you about that. And how do you feel about people who have seen you first getting a second opinion somewhere else? How do you feel about both? Well, I think it's a really big decision to go through a shoulder replacement surgery or any other major operation, so I always encourage patients to seek out a second or third opinion if it's going to make them more comfortable moving forward. So, you know, it's a two-way street. I certainly see people for second opinions, and I'm sure people see other people for a second opinion after I've visited with them. So I think that that's a very important thing to do, and I would encourage any patient to do that if they feel more comfortable. 11
Risks All right. Let's give some caveats about surgery because surgery has with it risks and complications. I know it doesn't often happen but help us, let's take total shoulder surgery, Doctor. What are the risks and complications, and how often do they happen in your practice? Sure. It is a major operation so it requires a general anesthetic, and there are risks associated with that, particularly pertaining to the heart or lungs. There's also a risk of bleeding or infection. The infection rate should be far under one percent with this type of surgery. There's a risk of blood clots after surgery. If one of those blood clots were to break off and go to the lungs it could be potentially be fatal, so it's definitely not without risks. But that being said at our hospital and many other hospitals we have a very experienced team who frequently does shoulder replacements. Our anesthesiologists are very experienced in treating patients with these conditions, so I think that overall it's a very safe operation, and fortunately we don't see a lot of those complications, but they can happen. So, Richard, you were in the hospital about how long after the surgery? I went home 15 hours, 14 hours later. Wow. Is that typical, Dr. Saltzman, or might somebody be there, you know, two or three days? Not typically two or three days. Usually one or two nights in the hospital, depending on their progress with therapy and with just getting comfortable. Those are the major parameters that we look at before somebody is able to leave the hospital. Treatment in the Future Dr. Saltzman, you're at a teaching hospital, as Richard mentioned. Research goes on there. Where are we now in orthopedics that would apply to the shoulder joint about maybe growing new cartilage or something to try to solve the problem in some sort of high tech way? 12
We're still really in the infancy as far as being able to grow cartilage. It's not really an available technology. There is a lot of interest in it and there is a lot of ongoing studies, most of which are done in animal models, like rat models and things like that. So we don't have any available cartilage for human use. And the main issue with arthritis is that it affects the whole joint, so in the case of the shoulder the entire ball and socket are devoid of any cartilage, so it's not just a small area that could be patched with, say, an artificial cartilage or some cartilage that we could grow in a lab. It really is an entire joint surface that has been affected. So as of today in 2010 the only solution that we have for that type of arthritis is to replace the joint with artificial components. So where the innovation has been is trying to have the best materials and then the way for you to align the joint as precisely as you can. That's correct. So the implants, the materials, have come a long way, and there's modularity now, which means you can really size each implant for a specific patient so you make sure it fits their anatomy and so it can closely function like their joint did prior to having arthritis. Let's ask Richard. So you have a sort of synthetic shoulder, your right shoulder. How does that perform compared to the way it used to be? I mean, it's not what you were born with, but how is it? Well, I think it's as good as it ever was. As I mentioned earlier in the interview, I played racquetball for 25 years on the national circuit, as good as it gets, two hours a day, seven days a week, and I was always afraid to go back after the surgery. But my best friend is a Chicago champion, and so he was playing and I was watching him. And I said, you know, I'm probably going to do a dumb thing but I just can't stand it anymore. I love the sport. Can I just hit a few with you? And I was astounded. I was able to play racquetball. I mean, not--not on a level like I used to, but I actually could swing and no pain and no hurt, no anything. I think it's as good as it ever was. That's a great story. Well, I think we've inspired a lot of people. Obviously if it gets to the point where you're considering surgery, questions to ask, second opinions to get, but certainly there are subspecialists like Dr. Matthew Saltzman who this is what they did, and they can help you. Richard Allen, I want to thank you for being with us. It's great meeting you this way, and hopefully when I'm in Chicago sometime you can take me on a bike ride. I'm 59. I doubt I could keep up with you, but it would be fun to try. 13
Well, thank you so much for being with us and just keep riding, riding, riding, and playing with all your friends, young and old and being as active as you are. And, Dr. Matthew Saltzman, thank you for being with us and really devoting yourself to helping people like Richard. Thank you. Well, I just love doing these programs with folks who are at Northwestern or touched by the skill of Northwestern Memorial, and you can see how people can get their lives back with the right care and right procedure for them. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all. Thanks for joining us. For more information or to schedule an appointment with a Northwestern Memorial physician, please contact our Physician Referral Service at 1-877-926-4664 or visit us online at www.nmh.org. Please remember the opinions expressed on Patient Power are not necessarily the views of Northwestern Memorial Hospital, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 14