Shoulder Replacement Advances

Sep 14, 2022 at 07:14 am by steve

Jonathan Isbell, MD in surgery.

"At least 50 to 75 percent of shoulder replacements have gone home the same day," says Jonathan Isbell, MD, about the 100-plus surgeries he performed in the past year. "Five years ago, 100 percent would have been admitted for at least a night." Without a required overnight stay, shoulder surgeries have grown beyond hospital boundaries and are now being performed in ambulatory surgery centers.

Not only has the post-care and recovery improved on these procedures, but the number has skyrocketed in the last few decades. From 2005 to 2017, shoulder revision surgeries rose 210 percent and 730 percent since 1995, according to a 2020 paper in The Journal of Bone & Joint Surgery. "The indications have grown, more surgeons are being trained, and we've found a lot of better ways to do this over the years," says Isbell, who practices at Southlake Orthopeadics.

Technological advances in the last decade have improved the process. Before digital software options entered the field, surgeons had only x-rays to assess the shoulder's condition and determine placement options for the components being inserted.

These days, a 3D rotatable image of the patient's joint area appears on a screen alongside the available shapes, lengths, and sizes of the replacement elements being inserted. "You see the different components, different augmentations, rotations, sizes--all on the PC," Isbell says. "Then when you start the case, you know exactly where the implant will go."

The enhanced view not only offers a 360-degree view of the surgical area, but reveals information that can change the procedure and the outcome. "Sometimes x-rays underestimate how much bone loss there is or how much tilt there is," Isbell says.

Since bone loss determines the viability of a site for the guide pin and anchors to hold the implant, any inaccuracy of that one piece of information can require a time-consuming adaptation while the patient is on the table. "Bone loss on a substantial area of the glenoid is a critical factor because as you lose more bone on glenoid, a small area to begin with, it changes how you place the implant. If you're too far off one way or the other or remove more than you should, it can change what you're able to do and can affect your outcome."

The computer builds the 3D view from CT scans. "That gives you imaging in several different planes, instead of one single picture like with an x-ray, so through serial slices you can see the entire shoulder socket and blade and entire humerus," Isbell says.

That precision saves time, which lowers risks. Standard shoulder replacements generally take 60 to 90 minutes or longer with more complex cases, such as significant deformity on the glenoid. "But when you know exactly what kind of replacement you need, and when things go well, even though it's a pretty difficult case, it can go very smoothly, and take 20 to 30 minutes less," Isbell says.

For the complex cases, makers now offer custom-built guides, opening the door for life changing improvements to those restricted by the pain and limitations of decimated shoulders. The guide pin is stationed in the socket. A series of reamers sit atop that pin to smooth and expose exactly where needed to suit the implant. "If you feel you have very, very little room for error in the OR and very little room for variability, you can have these patient-specific guides made to allow you to put everything exactly where you have it planned," Isbell says.

In post-care advancements, shoulder procedures have become opioid-free. "Shoulder replacements can be done with no narcotic pain management if you use a multi-modal approach," Isbell says. By working with anesthesiologists, using nerve blocks preoperative, the shoulder can be numbed for the crucial 12 to 16 hours post-operative. With several medications as simple as Tylenol and anti-inflammatories, and local anesthetics, the patient experiences minimal pain the first few sensitive days after surgery.

With the age of 90 percent of shoulder replacement patients dropping from the 70s to the 50s, and the procedure evolving to become available to a wider array of conditions, including severe rotator cuff tears, the procedure is destined to become more common. "This means better things for the field," Isbell says. "With more indications, more surgeons becoming comfortable doing replacements, and people getting more active and living to older ages, that will drive more innovation."

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