In the News - Who Knew? Joint Replacements You Never Heard Of

Autumn Years magazine recently published an article discussing various types of joint replacements that are less-commonly known than hip and knee replacement, including shoulder replacement. A number of HSS experts shared their insights, including Michael Fu, MD, MHS.

Dr. Fu said shoulder replacement is considered when first-line treatments such as pain medication, activity modification and physical therapy no longer help. “While the primary reason is painful arthritis, the procedure and results have improved to the point where it could be considered for a massive rotator cuff tear or a really bad shoulder fracture,” he added.

Read the full article from the Autumn Years.

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS) in New York City (NYC) and New Jersey (NJ), the best hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu is an expert at shoulder rotator cuff repair surgery, shoulder instability surgery, and shoulder replacement. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.

Journal Club - Return to Golf and Golf-Specific Performance After Anatomic Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty

Michael Fu, MD

Journal Club is a recurring series where we highlight the latest orthopedic shoulder research, and discuss potential applications and ramifications for our patients.

Title

Return to golf and golf-specific performance after anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty

Authors

Drew A. Lansdown, MD, Edward C. Cheung, MD, Mya S. Aung, BS, Alan L. Zhang, MD, Brian T. Feeley, MD, C. Benjamin Ma, MD

Journal

Seminars in Arthroplasty: Journal of Shoulder and Elbow Surgery. 2021 February 8.

Abstract

Background

Golf is a common sporting activity that patients continue to participate into older age, including after joint replacement surgery. The influence of shoulder replacement on golf performance remains unclear. We hypothesized that patients undergoing anatomic total shoulder arthroplasty (TSA) would have significantly better return to play rates and better performance metrics, including handicap, driving distance, and 7-iron distance, after shoulder replacement relative to those treated with reverse total shoulder arthroplasty (RTSA).

Methods

Patients were retrospectively surveyed after anatomic TSA and RTSA with regards to return to golf and golf performance before and after shoulder replacement. Patients reported if they were able to return to golf after shoulder replacement, timing of return to golf, and driving distance, 7-iron distance, handicap, and difficulty with specific shot types upon returning to golf. Significance was defined as P < .05.

Results

The survey was completed by 31 patients with a total of 37 replaced shoulders (68.0 ± 8.1 years; 87% male) out of 44 patients who indicated they played golf. The overall return to golf rate was 74%. Patients undergoing anatomic TSA returned at a significantly higher rate relative to patients treated with RTSA (93% [14 of 15] vs. 56% [9 of 16], P= .037). There was no difference between groups with regards to drive distance, 7-iron distance, and handicap. There were also no differences between preoperative and postoperative values for patients who were able to return to golf. Overall, patients played golf less frequently afterward than they did prior to shoulder replacement (P= .013).

Conclusion

Patients are able to return to golf after shoulder replacement, at an overall rate of 74%, including a rate of 93% for patients with anatomic TSA and 56% for patients with RTSA. Golf performance was similar before and after shoulder replacement surgery for both groups among those who were able to return to play, though overall frequency was decreased after shoulder replacement.

Level of evidence

Level III; Retrospective comparative study.

Keywords

Shoulder replacement; Return to golf; Reverse shoulder arthroplasty; Anatomic total shoulder arthroplasty; Golf performance

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Discussion - Return to Golf after Total Shoulder Replacement

As shoulder replacement becomes increasingly popular and the technology continues to evolve, patient outcomes and post-surgical expectations continue to improve as well. While total shoulder replacement is quite reliable at relieving pain and restoring function with activities of daily living, patients often want and expect to return to sports. Among patients considering shoulder replacement, the most common sports include golf, tennis, and swimming, among others.

In this study by Dr. Lansdown and colleagues at UCSF, the authors surveyed 31 golf players that underwent total shoulder replacement, both anatomic and reverse replacement. The patients were mostly men (87%), with an average age of 68 years. The authors found that patients that had anatomic shoulder replacement returned to golf at a significantly higher rate (93%) than patients that had reverse shoulder replacement (56%). Among the patients that were able to return to golf, however, there was no difference in drive distance, 7-iron distance, and handicap between the anatomic and reverse shoulder replacement patients.

This discrepancy in return to golf rates between anatomic and reverse shoulder replacement is consistent with my clinical experience as well. Compared to the reverse, anatomic shoulder replacement typically provides greater range of motion after surgery, however, the rotator cuff must be intact for an anatomic shoulder replacement to work well. This is because the anatomic shoulder replacement, as the name indicates, recreates the normal anatomy of the shoulder. For patients with rotator cuff issues in conjunction with shoulder arthritis, or rotator cuff tear arthropathy, reverse shoulder replacement is usually the better option because it does not require a rotator cuff to work. The reverse shoulder replacement is able to function in the absence of a rotator cuff because it is a more constrained prosthesis - there is more congruency between the ball and the socket, and the socket is also much deeper. Unfortunately, the trade-off for this increased stability and constraint is reduced range of motion. This likely contributes to the lower rate of return to sports after reverse shoulder replacement relative to anatomic shoulder replacement.

While the total arc of motion will be less after reverse compared to anatomic shoulder replacement, the position of that arc of motion can be influenced by surgical positioning of the implants. This is where my colleagues and I at the Hospital for Special Surgery are devoting much of our research efforts. Every patient is unique in terms of their anatomy, activities, and expectations. The ultimate goal is to perform shoulder replacement operations that are tailored to each individual patient through understanding each patient’s post-surgical goals, and patient-specific surgical planning. For example, for a patient planning to undergo reverse total shoulder replacement and wants to return to golf, we could load her CT scan into surgical planning software, create a render of her unique anatomy, consider whether this is her lead shoulder or her trail shoulder in the golf swing, and plan her surgery in such a way as to maximize the range of motion that would hopefully allow her to return to golf.

Patient-specific surgical planning for reverse total shoulder replacement, with range of motion optimization.

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS) in New York City (NYC) and New Jersey (NJ), the best hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu is an expert at shoulder rotator cuff repair surgery, shoulder instability surgery, and shoulder replacement. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.

Journal Club - Stemless vs. Stemmed Humeral Components in Total Shoulder Arthroplasty

Michael Fu, MD

Journal Club is a recurring series where we highlight the latest orthopedic shoulder research, and discuss potential applications and ramifications for our patients.

Title

Prospective, Blinded, Randomized Controlled Trial of Stemless Versus Stemmed Humeral Components in Anatomic Total Shoulder Arthroplasty: Results at Short-Term Follow-up

Authors

J. Michael Wiater, MD , Jonathan C. Levy, MD, Stephen A. Wright, MD, Stephen F. Brockmeier, MD, Thomas R. Duquin, MD, Jonathan O. Wright, MD, Timothy P. Codd, MD

Journal

The Journal of Bone and Joint Surgery. 2020 Sep 28. 10.2106/JBJS.19.01478.

Abstract

Background

Stemless humeral components for anatomic total shoulder arthroplasty (aTSA) have several reported potential benefits compared with stemmed implants. However, we are aware of no Level-I, randomized controlled trials (RCTs) that have compared stemless implants with stemmed implants in patients managed with aTSA. We sought to directly compare the short-term clinical and radiographic outcomes of stemless and stemmed implants to determine if the stemless implant is noninferior to the stemmed implant.

Methods

We performed a prospective, multicenter, single-blinded RCT comparing stemless and short-stemmed implants in patients managed with aTSA. Range-of-motion measurements and American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant scores were obtained at multiple time points. Device-related complications were recorded. Radiographic evaluation for evidence of loosening, fractures, dislocation, or other component complications was performed. Statistical analysis for noninferiority was performed at 2 years of follow-up for 3 primary end points: ASES score, absence of device-related complications, and radiographic signs of loosening. All other data were compared between cohorts at all time points as secondary measures.

Results

Two hundred and sixty-five shoulders (including 176 shoulders in male patients and 89 shoulders in female patients) were randomized and received the allocated treatment. The mean age of the patients (and standard deviation) was 62.6 ± 9.3 years, and 99% of the shoulders had a primary diagnosis of osteoarthritis. At 2 years, the mean ASES score was 92.5 ± 14.9 for the stemless cohort and 92.2 ± 13.5 for the stemmed cohort (p value for noninferiority test, <0.0001), the proportion of shoulders without device-related complications was 92% (107 of 116) for the stemless cohort and 93% (114 of 123) for the stemmed cohort (p value for noninferiority test, 0.0063), and no shoulder in either cohort had radiographic signs of loosening. Range-of-motion measurements and ASES, SANE, and Constant scores did not differ significantly between cohorts at any time point within the 2-year follow-up.

Conclusions

At 2 years of follow-up, the safety and effectiveness of the stemless humeral implant were noninferior to those of the stemmed humeral implant in patients managed with aTSA for the treatment of osteoarthritis. These short-term results are promising given the potential benefits of stemless designs over traditional, stemmed humeral components.

Level of Evidence

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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Discussion

As shoulder replacement technology continues to evolve and improve, humeral implant stems have trended toward being smaller and smaller over time. More recently, “stemless” humeral implants have been developed, which I was trained to use during my fellowship at Midwest Orthopaedics at Rush in Chicago. To me, there are four main benefits of stemless humeral implants: 1) it removes significantly less bone than traditional stemmed implants, which means more of your native bone is preserved, 2) if the shoulder replacement fails and it needs to be revised for whatever reason, a stemless implant is much easier to remove than a stemmed implant, 3) if there is pre-existing bone deformity due to a prior fracture, for example, a stemless implant is more easily accommodated by the abnormal anatomy compared to a stemmed implant, and 4) if the patient were to unfortunately fall on the shoulder after shoulder replacement, a fracture around a stemless implant would be much easier to treat than a fracture around a larger stem.

One potential concern with stemless implants is a fear of loosening, as there is less surface area for bony ingrowth and no apposition against the humeral shaft. However, stemless implants now have a medium-term track record in the United States, and the rates of loosening have not been found to be higher than stemmed implants. The track record with stemless implants was excellent during our experience in Chicago.

In this current prospective, randomized study comparing stemless and stemmed total shoulder replacement, Dr. Wiater and his team found that at 2 years after surgery, there was no difference in patient-reported outcomes between the groups. The rate of implant-related complications was the same between the groups as well. Finally, no loosening was seen in either group in this study.

This paper is an important contribution to the growing evidence in favor of stemless humeral implants. In my practice, the implant choice is specific to each patient, as there is not a one-size-fits-all solution. Anatomic total shoulder arthroplasty with a stemless humeral implant may be a good option that we would discuss during your pre-surgical consultation.

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About the Author

Dr. Michael Fu is an orthopedic surgeon and shoulder specialist at the Hospital for Special Surgery (HSS), the No. 1 hospital for orthopedics as ranked by U.S. News & World Report. Dr. Fu treats the entire spectrum of shoulder conditions, including rotator cuff tears, shoulder instability, and shoulder arthritis. Dr. Fu was educated at Columbia University and Yale School of Medicine, followed by orthopedic surgery residency at HSS and sports medicine & shoulder surgery fellowship at Rush University Medical Center in Chicago. He has been a team physician for the Chicago Bulls, Chicago White Sox, DePaul University, and NYC’s PSAL.

Disclaimer: All materials presented on this website are the opinions of Dr. Michael Fu and any guest writers, and should not be construed as medical advice. Each patient’s specific condition is different, and a comprehensive medical assessment requires a full medical history, physical exam, and review of diagnostic imaging. If you would like to seek the opinion of Dr. Michael Fu for your specific case, we recommend contacting our office to make an appointment.