Case Studies

Case studies in orthopedic care: Joint Replacement

Patient history

The price of lifting too heavy an object too high overhead was, for this 68-year-old female, a massive rotator cuff tear in one shoulder.

She was a few years younger when the injury occurred. After a time, surgical repair was attempted but proved ineffective. Subsequent to that operation, shoulder arthritis developed – in part because of the damaged rotator cuff, in part because of the normal aging process. Then, as the arthritis advanced, it came to involve both her shoulders, not just the one. If activities of daily living involving outward and upward extension of the arms were difficult before, they were by this point much more so owing to the increased pain and stiffness.

Case description

A friend of this woman’s who had been well-satisfied with the care delivered by Tahoe Fracture referred her to us.

Upon first encounter, we performed a comprehensive workup of the patient to establish the degree of functionality in her upper body, identify the pain location and quantify the level of pain experienced. Included were tests to assess shoulder range of motion. Radiographic studies were taken, including an MRI. These delineated the scope of the rotator cuff tear and showed arthritis in the glenohumeral joint, but also and more significantly, they articulated a high-riding and significantly subluxated humeral head.

Treatment plan

Attempted first was conservative treatment, with physical therapy as the capstone of this particular strategy. Unfortunately, the patient failed physical therapy, which greatly limited the success of the other prescribed elements of the conservative treatment plan.

Ultimately, it was decided that a reverse shoulder arthroplasty would afford this patient the best prognosis. The procedure, lasting more than two hours, was performed in textbook fashion and without complications. Only one shoulder was operated on, the one that had sustained the rotator cuff tear.

Postoperatively, the shoulder was kept immobilized for a period of about four weeks to ensure muscle rest and repair. At the end of that time, the patient began physical therapy for work on restoring range of motion and development of strength. We continued to follow the patient at intervals of four to six weeks for six months.

Outcome

The patient is now able to reach overhead without pain or difficulty using the surgically treated side. She is scheduled soon to undergo a different procedure to treat the arthritis affecting the opposite shoulder. Prognosis for that intervention is also good.

Discussion

A reverse shoulder arthroplasty entails changing the center of rotation of either the humeral head or the glenohumeral joint. This is accomplished by relocating the ball of the humerus or the joint to the cup side and then bringing the cup itself to the humerus side, a feat requiring the use of FDA-approved implants. The resultant shift of the center of rotation renders the rotator cuff nonessential for overhead reaching/functionality and utilizes instead the deltoid muscle.

It is imperative in this procedure that the nerves around the shoulder be protected at all times. That is because there exists the need to sufficiently expose the bones and joints as prelude to placing the implants. And although reverse shoulder arthroplasty is a relatively new procedure in the U.S. (it was cleared by the FDA in the early 2000s following extensive research and clinical trials), there already is a considerable amount of scientific evidence throughout the literature demonstrating its safety and efficacy. In the right hands and utilizing the right technologies, reverse shoulder arthroplasty can be a very viable option.

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