Shoulder Surgery

with Dean Ziegler, M.D., Orthopaedic Surgery, Columbia St. Mary’s

Posted: April 1, 2004

The patients Dr. Dean Ziegler sees don’t necessarily have the weight of the world on their shoulders. They only feel that way. “When I see a person who comes to me because they’re having problems with their shoulder, I look to see what problems they have – whether it’s stiffness, instability, roughness or weakness,” he said. “Usually they just tell me it’s painful, and it’s my job to figure out why it’s painful.” For Ziegler, an orthopedic surgeon at Columbia St. Mary’s, the cause of the pain is crucial to diagnosing the problem.

Dean Ziegler, M.D., Orthopaedic Surgery, Columbia St. Mary's "When I see a person who comes to me because they're having problems with their shoulder, I look to see what problems they have - whether it's stiffness, instability, roughness or weakness. Usually they just tell me it's painful, and it's my job to figure out why it's painful."

Most people, he said, think only of the ball and socket joint of the shoulder. But the shoulder is actually comprised of five different joints or articulations and has at least four specific attributes. A healthy shoulder has a wide range of smooth motion, good stability and good strength.

A weak shoulder may be caused by a torn rotator cuff, a nerve injury or other irritation. If the problem is instability, the problem may be recurring dislocations, in which the ball of the shoulder slips out of the socket.

Someone with arthritis in the shoulder may experience popping, grinding or clicking when they move their shoulder, and any one of these problems or a situation where the tissue-paper-thin shoulder capsule has tightened, can weaken or cause pain in a previously functional shoulder.

Treatment options
In some situations, patients arrive at Dr. Ziegler’s office after having had one or more rounds of physical therapy. But in all cases, he will lay out the options – surgical and non-surgical – for each patient.

“They can live with the shoulder as it is,” he said. “They can do exercises to try and make it better, or we can do surgery if it is a problem that surgery will help.”

Patients opting to go the surgical route will experience a different procedure and recovery period, depending on the diagnosis.

If a rotator cuff is the culprit, Dr. Ziegler will perform arthroscopic surgery to find out the exact nature of the problem. If the problem can be corrected arthroscopically, he will do so.

If the tendon is torn, he will either repair it arthroscopically or make a slightly larger incision and repair it in an “open fashion.” When the rotator cuff tendon is torn completely off the bone he will use sutures to anchor the tendon back onto the bone in order to facilitate a complete repair.

With recurrently unstable shoulders, there are two types of instabilities.

The surgeries generally take about 90 minutes, and are done under a general anesthetic in an outpatient surgical center.

“One is where there was a traumatic event where the shoulder dislocated and many times it will dislocate over and over again. We can perform arthroscopic surgery to fix that, and patients can return to full pre-dislocation activity and health,” he said. “The other is a shoulder that slips out of place without fully dislocating. These shoulders can often be managed with rehabilitation but may require arthroscopic stabilization.”

For stiffness, a stretching program is prescribed. If that proves ineffective, surgery can be performed to release the capsule around the shoulder where the tightness is occurring.

“The capsule is normally tissue-paper thin and allows the incredible motion we all have and take for granted. When it’s thickened and tightened, you have to cut it all the way around so that a person can regain his or her motion,” he said. “They still have to stretch it to get full motion back, but this procedure jump-starts the process.”

The surgeries generally take about 90 minutes, and are done under a general anesthetic in an outpatient surgical center.

Recovery times
Recovery for each procedure is different. For a rotator cuff injury, patients can expect a minimum three-to-four-month recovery period; for a capsule release operation patients can get moving right away.

Shoulder stabilization patients generally don’t engage in any activity for the first six weeks; during the second six-week period, motion is gradually increased. Full non-contact activity is resumed after three months, but people who engage in contact sports need to wait four to six months before resuming team play.

Shoulder replacement surgery
When it comes to shoulder surgery, Dr. Dean Ziegler has no problem choosing his favorite procedure.

“The best procedure I do is shoulder replacement,” he said. “And the reason I say that is because we take a very stiff, rough, painful shoulder and replace the rough parts with smooth parts.”

The most common condition leading to a shoulder replacement procedure is osteoarthritis or rheumatoid arthritis of the shoulder, causing erosion of the cartilage on the ball and socket.

“You’re replacing this horribly bad ball and socket with a good one, and there’s no big question as to why a patient will do much better,” he said.

Dr. Ziegler can perform a total replacement, “as long as there’s good enough bone to support a socket and a good rotator cuff to hold the ball in the socket,” he said. “Sometimes people will actually develop a very arthritic shoulder because they have a huge rotator cuff tear, and in that case we replace only the ball.”

Whether a full or partial replacement is performed, the result is the same. A shoulder that was highly dysfunctional becomes, instead, a shoulder that is healthy enough for a patient to resume many of the activities he or she was forced to give up. In one study of 24 golfers who’d had to abandon the game prior to surgery, 23 were able to resume playing 18 holes within four months of the procedure. In addition, Dr. Ziegler said, 18 who had had a handicap before surgery were able to reduce it by an average of five strokes post-surgery.

“We’re able to get people back and doing things that are fairly normal for them, including bowling, canoeing, lifting weights and even gun and bow hunting,” Dr. Ziegler said.

The most common condition leading to a shoulder replacement procedure is osteoarthritis or rheumatoid arthritis of the shoulder, causing erosion of the cartilage on the ball and socket.

The drawback, he said, is that many patients aren’t aware that shoulder replacement surgery is an option.

“It isn’t nearly as common as hip and knee replacements are,” he said. “I frequently hear patients say that they know someone who has had one of those procedures, but not as many know about shoulder replacements.”

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