Shoulder Replacement Arthroplasty
A History of Shoulder Replacement Surgery
Surgeons have performed shoulder replacements, also known as shoulder arthroplasty, since the late 1800's. The shoulder joint is a ball and socket joint made up from four bony parts, the humeral head, clavicle (collar bone), scapula (shoulder blade), and the glenoid cavity. It isthe most flexible of all the joints and has the greatest range of motion. It can be raised and lowered, move forward, to the side, and behind. It can also twist and bend. (2) The glenoid is saucer shaped and the rounded end of the humerus smoothly glides against it. Shoulder arthroplasty is the removal of the end of the humerus, or humeral head and the glenoid, or socket of the shoulder and replacing these with artificial substitutes, called prostheses or prosthetic implants. Only in the last 30 or 40 years has this procedure become a common practice in the United States. (4) This paper explores the development of the types of procedures and prostheses used for shoulder replacement surgery.
Today there are three different types of shoulder replacements, hemi-arthroplasty, total replacement and reverse total replacement. Hemi-arthroplasty replaces only the head of the humerus and not the glenoid socket. This type of replacement is used when the glenoid is not arthritic or for fractures not involving the glenoid. Total shoulder arthroplasty; replacing the humeral head and the glenoid socket. This approach is appropriate when both humeral head and glenoid are arthritic or damaged but there is still enough glenoid bone and rotator cuff for the shoulder to function properly. Reverse shoulder arthroplasty, replaces both the humeral head and glenoid socket. Reverse shoulder arthroplasty is used when there is a loss of muscle function due to inadequate tendon and muscle function. (2, 3, 7)
The first replacements were actually hemi-arthroplastys. They were first preformed on patients suffering from chronic joint infections mainly due to tuberculosis and syphilis. Today, shoulder arthroplasty is still being done for a wide variety of conditions. Some are still performed to address chronic infections. However, more commonly, shoulder replacement addresses conditions such as osteoarthritis or degenerative arthritis, also referred to as ware and tear arthritis. Rheumatoid arthritis is a systemic disease that affects one or all of the joints in the body. Post-traumatic arthritis occurs when there has been an injury to the joint. Other conditions necessitating joint replacement are vascular necrosis, a condition resulting in bone death from insufficient blood supply; a previous failed replacement and rotator cuff arthropathy; or dysfunction of the tendons in the shoulder.
Jules Emile Pean was the first surgeon to attempt a shoulder replacement. Pean along with the help of a dentist, constructed the first prosthesis from platinum and rubber. (3) The patient did well at first but the prosthesis was later removed because of continued infections. It wasn't until the 1950's that the next attempt was made. It was also at this same time that shoulder replacements were first used in the United States. (3)
There have been three basic transitions in the evolution of the hemi-arthroplasty and total replacement prosthesis. The first generation of prosthesis had a number of problems. In the early 1950's Charles S. Neer was credited with the construction of the modern prosthesis. (3) This first model was constructed in one piece and did not provide as much movement as wanted. Dr. Near's replacement was monoblock prosthesis called the Mark (I and II), and actually some of these are still being used today. (3, 4, 5) This is a one-piece unit with a ball and stem in a fixed position. The Neer prostheses didn't actually fit patients as well as desired, but seemed to work well nonetheless. The monoblock prosthesis was not actually a total replacement. When, a few years later, a glenoid piece made of polyethylene was added, the first true “total” replacement occurred. These monoblock devices didn't wear well and often became loose.
The second stage in the development of shoulder prosthetics provided better fit for patients. Modular prosthetics were developed so that the head and stem components could be varied in size to fit the patient better. These modular devices gave better movement but still interfered some with the existing muscles and tendons. (6) These wore better than the monoblock but still were not quite right
The third generation of the shoulder prosthesis is basically only slightly different than the second. It is still a modular component; however the pieces now are more closely matched to our natural anatomical structure. These pieces are more varied in size for an even better “fit” and to allow free movement of muscles and tendons. Today all of the prosthetic devices used are made of highly polished types of metals and polyethylene. (4) They offer a greater range of motion and are more anatomically adaptable. Allowing for a near perfect fit. When a replacement prosthetic device is used, it is held in place with screws, cement and allograft, bone from a donor, materials.
The newest type of shoulder replacement is Dr. Paul Grammont M.D. development of the reverse shoulder replacement in 1987. The Food and Drug Administration approved this reverse replacement for use in the United States in 2004. (3, 5) In Dr Grammont's design, the ball is positioned where the socket used to be and the head of the humerus becomes the socket. This type of replacement helps the patient who until now was not a candidate for replacement surgery because of deteriorated or severely torn rotator cuff along with severe arthrosis. The reverse components were designed to keep the humerus bone from sliding off the glenoid due to loss of muscle function. (3)This makes for better leverage in the arm.
Shoulder replacements are the third most replaced joint with about 23,100 being done each year, far less that that of knees at 400,000 and hips at 343,000. Approximately 80% of these replacements can last 10 to 15 years if no other complications occur. (1) The recovery period for these procedures can be 6 months to 1 year. Most patients, after the recovery period, having any of these procedures preformed feel much less or no pain at all. They return to full or near full range of motion, have improved strength, and have better quality of life.
Since the inception and constant improvements in techniques and mechanics involved in shoulder replacement surgeries, a patient no longer has to lose the use of the arm completely to amputation or give up any of the function of the shoulder. Most patients are now able to return to a fully productive life thanks to the innovative works and contributions of Doctors Jules Emile Pean, Charles S. Neer, and Paul Grammont, along with the many other shoulder surgeons available today. What was once considered to be an unrepairable joint because of injury, disease, or infection is now a thing of the past.
Works Cited
1. "Arthritis of the Shoulder." American Academy of Orthopedic Surgeons. 2006. 12 Mar.-Apr. 2008 <http://www.orthoinfo.org>.
2. "How the Normal Shoulder Works." American Acedemy of Orthopedic Surgeons. Aug. 2007. Mar.-Apr. 2008 <http://www.orthoinfo.com>.
3. Katz, Denis, Greg Otoole, Lucy Cogswell, Philippe Sauzieres, and Philippe Valenti. "A History of Reverse Prosthesis." The Journal of Bone and Joint Surgery 1 (2007): 108-113.
4. "Shoulder Replacement." American Acamedy of Orthopedic Surgeons. Aug. 2007. Mar.-Apr. 2008 <http://www.orthoinfo.org>.
5. "Shoulder Surgery." American Academy of Orthopedic Surgeons. Aug. 2007. Mar.-Apr. 2008 <http://www.orthoinfo.com>.
6. Smith, Blair, Connie Lee, Daniel Solomon, Matthew Whitson, and Stephanie Chang. "Joint Replacement History." Brown. 02 May 2004. Mar.-Apr. 2008 <http://biomed.brown.edu/Courses/BI108/BI108_2004_Groups/Group01/jrH.htm>.
7. "Total Shoulder Joint Replacement." Cleveland Clinic. 29 Apr. 2004. Mar.-Apr. 2008 <http://www.clevelandclinic.org/health/health-info/docs/2000/2032.asp?index=8290>.
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