A new kind of shoulder joint replacement is ending pain and restoring movement to people thought to be untreatable 15 years ago.
Reverse shoulder joint replacements — the installation of implants that operate in the opposite manner of the body’s joint — are growing at three times the rate of hip and knee replacements, according to John Sperling, a doctor and professor of orthopedic surgery at the Mayo Clinic.
“The reverse shoulder replacement has really revolutionized shoulder replacement surgery,” Sperling said.
Dr. David Coons, who practices at MultiCare’s Allenmore Hospital in Tacoma agreed.
“The reverse has become a solution for many things that were previously unsolved or not taken care of,” Coons said.
Approved by the FDA in 2003, reverse shoulder joints were the majority of the 125,000 shoulder replacements performed in the United States in 2017.
People living with arthritis are common candidates for the procedure. Other patients might need it after a massive rotator cuff tear, shoulder fractures, reconstructions following tumor removal and bone loss.
U.S. Supreme Court Justice Sonia Sotomayor had a reverse shoulder joint replacement earlier this year after suffering an injury in a fall.
Having a non-functioning or painful shoulder can be life-changing. Putting on a jacket can be a Herculean effort. Reaching the top shelf is out of the question. Those airport X-ray machines where you must raise your hands? Forget about it.
“When you have the inability to raise your arm, it’s hard to go through life that way,” Sperling said.
And shoulder pain doesn’t go away at night, making sleep difficult, he said.
Going in reverse
An anatomical shoulder joint replacement is essentially a copy of the normal anatomy of a shoulder. The socket you were born with is replaced with a synthetic cup and the head of the humerus (arm) bone is replaced with a metal ball.
A reverse replacement switches the ball and socket configuration. The synthetic ball is fixed to the body’s socket and the synthetic cup is fixed to the top end of the humerus.
In a normal body, the rotator cuff is involved in lifting. A reverse joint replacement employs the deltoid muscle to do most of the work.
That makes it especially attractive to patients with damaged rotator cuffs, said Coons, who has embraced the reverse shoulder joint replacement.
He was one of the first surgeons in the nation to use the reverse joint while he completed his residency in Dallas. He clearly remembers his first patient.
“This was a guy who couldn’t lift his arm,” Coons recalled. “When I saw him for his first post-op visit he said, ‘Look at what I can do,’ and he lifted his arm. I couldn’t believe it. I thought it was an absolute miracle.”
That feat, it turns out, is rather uncommon for a patient to do on their first visit, Coons said. But it made a lasting impression on what the reverse joint could do.
“For people who have lost function, it’s an amazing thing,” he said. “It’s a game changer.”
Most patients get about two thirds of their range of motion back with a reverse joint, Coons estimated. About 30 percent get full motion back.
The holy grail of success is for a patient to be able reach behind his or her head following surgery and physical therapy, Coons said.
Patients are usually thrilled with the results.
“They can live a fairly normal life,” he said.
The procedure is usually performed on older adults. They’re not trying out for “American Ninja Warrior” but instead just want to complete the normal tasks and activities of life without pain.
Rex Cook is one of those. The 78-year-old Tacoma resident had a reverse shoulder joint replacement earlier this year after his torn rotator cuff had immobilized his arm. Coons performed the procedure.
“I just got to the point where I could hardly lift anything,” Cook said. “It was really painful.”
He spent Friday splitting firewood.
“I can do anything now,” Cook said. “I can pick up a pretty good size chunk of wood and put it up on my splitter now. And run my big chain saws for an hour no problem. No hurt at all.”
Coons performs about five shoulder replacements per week, with about half being anatomical and the others reverse. Until the reverse option came along, some patients had shoulder joint replacements that would relieve pain but not restore motion.
“Those patients would say, ‘I feel better, but I still can’t lift my arm.’ Those patients uniformly now get reverses,” Coons said.
The procedure has some requirements: There must be enough of a socket to install the metal alloy components, and the patient needs a functioning deltoid muscle to lift the arm.
The operation takes about an hour and usually involves one night in the hospital. Physical therapy can be conducted at home.
The procedures are generally covered by insurance following a doctor’s approval. Patients should check with their insurance company to determine coverage limits and requirements before surgery. The procedure is covered by Medicare, a MultiCare spokesman said.
The reverse joint and its success still are filtering out through the medical community.
“One of the first times I did this here in this hospital, I got a call from the radiologist,” Coons said between operations at Allenmore. “He said, ‘Tell Dr. Coons he put the implant in backwards.’ He had never seen one before.”
Shoulder joints are now the third most replaced joint in the United States, behind hip and knee and ahead of ankle, elbow and other joints.
Coons and Sperling both expect shoulder joint replacements will become more popular, possibly outpacing knee and hip replacements.
“I’m seeing a lot more demand,” Coons said.
Some patients were told years ago that nothing could be done about their shoulder pain or motion, even with an anatomical replacement. Some of those people are now candidates for the reverse procedure, Coons said.
The growth in popularity is about more than just the procedure’s success, he said. It’s a change in lifestyles and attitudes.
“It was just expected that, after a certain age, you were kind of done,” Coons said. “You were the horse that went to the glue factory. It was expected that you would suffer from this point on. But as people have become healthier and living longer, people want to remain functional.”
That includes Coons’ own parents. They have undergone hip and knee replacements. He knows the odds are that he will need a joint replaced at some point.
“It’ll probably happen to me when I get older,” he said.