Uplifting surgery for the shoulder

`Reversal' of ball joint allows seniors to do everyday tasks again without pain


Helen Richardson leads an active life. The 87-year-old Rosemont resident swims three mornings a week, teaches deep-water exercise classes and piano lessons, plays golf and helps care for her husband, James, who has had several small strokes.

So when a combination of arthritis and damaged tendons caused pain and limited movement in her right shoulder last year, Richardson really felt restricted.

"I couldn't raise my arm above my shoulder - it was just stuck there," she says. "I know it sounds crazy, but one of my favorite things to do is hang my washing out, and I couldn't do that. I couldn't swim, and it just made my life very difficult."

When a procedure to clean out damaged tissue, called a debridement, failed to help, Richardson's internist of 30 years, Dr. Michael Rudman of Middletown, did research and learned of a new operation - a "reverse" shoulder-replacement surgery.

During a three-hour procedure last year at the University of Maryland's Kernan Hospital, Dr. Anand Murthi reconstructed the ball-and-socket joint connecting the top of Richardson's arm bone, the humerus, to her shoulder, using an implant recently approved by the U.S. Food and Drug Administration. The prosthesis allows surgeons to reverse the way the joint normally fits together.

The top of the arm bone is shaped like a ball, which fits into a socket in the shoulder blade. In standard shoulder-replacement surgery, the natural ball is removed and replaced with a metal ball supported by a stem. This fits into a new plastic socket inserted in the shoulder blade.

In the reverse procedure, the surgeon implants a metal ball into the shoulder-blade socket and replaces the ball at the top of the arm bone with a socket supported by a metal stem.

The reason for the reversal is that standard shoulder-replacement implants rely on the rotator-cuff muscles and tendons to help hold them in place. But for many seniors who, like Richardson, have a condition called cuff tear arthropathy, those muscles and tendons are worn by overuse and arthritis and can no longer keep the shoulder joint intact, even with a prosthesis. The reverse procedure allows the deltoid muscle, the large triangular muscle that forms the rounded contour of the shoulder, to carry the load.

After three months of physical therapy, Richardson was back in the pool doing the backstroke.

"It's wonderful to be swimming again," she says, "though I still haven't tried my golf."

Shoulders outlived

The instability of the shoulder joint, coupled with arthritis, can cause extreme pain as well as loss of movement. About 5 percent to 8 percent of seniors with arthritis have cuff tear arthropathy, says Dr. David Dines, president of the American Shoulder and Elbow Surgeons.

"They're outliving their shoulders," Dines says. People often have no symptoms until an event like a fall sets it off, he says.

Before the FDA approval of the reverse prosthesis last spring, there wasn't much doctors could do for these patients. But using the new prosthesis, developed in 1987 by French orthopedic surgeon Paul Grammont, the stronger deltoid muscle allows patients to move their shoulders without relying on the rotator-cuff muscles.

"It's afforded people with no other alternative the opportunity to get pain relief," Dines says. "They're being brought back to a functional level for people their age."

Though most candidates for the surgery are 70 or older, Murthi says he and other surgeons will consider the operation for younger patients in whom previous shoulder-replacement surgery has failed, or for those with serious shoulder dysfunction. After the procedure, patients are instructed to avoid repetitive heavy lifting. Twenty pounds is the maximum weight limit Murthi advises.

Not everyone who receives the implant fares as well as Richardson, says Dr. Edward McFarland, director of adult orthopedics at Johns Hopkins Hospital, who has performed about 20 of the procedures.

In terms of success rates, McFarland says, "some [procedures] are home runs, some are not. But by and large, almost all patients see some improvement in their range of motion."

For 80-year-old James Lockhart of North East, the risks of surgery were worth it. His left shoulder and side were injured in World War II, and if he hadn't had the surgery to repair his right shoulder, he says, "I would have no shoulder to use at all."

The operation allowed him once again to be able to comb and shampoo his hair. "I recovered quite easily," Lockhart adds. "My mobility is good, but if I do something strenuous, I still have pain."

Procedure studied

There are few long-term studies regarding the reverse procedure, though the experience of shoulder surgeons and patients from Europe, where the implant has been used for the past 15 to 18 years, indicates that 85 percent to 90 percent of patients who have the surgery "obtain excellent pain relief," McFarland says.

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