Shoulder Replacements

with R. Sean Churchill, M.D., Orthopaedic Surgeon, Advanced Healthcare

Posted: May 1, 2005

If raising your arm to wave or wash your back in the shower without pain is something you take for granted, consider yourself lucky. For people with arthritis in the shoulder joint, pain and restricted motion can severely limit their ability to perform simple tasks.

“When you can’t have your elbow above shoulder level, think of all the things you can’t do,” Dr. R. Sean Churchill said. “Some of these people can’t even reach up to put their coat on a hanger.”

Dr. Churchill, an orthopaedic surgeon/shoulder and elbow surgeon with Advanced Healthcare, performs approximately 50 shoulder replacements each year. The procedure, while less commonly known and performed less often than hip and knee replacement surgeries, is life-changing for patients.

Sean Churchill, M.D., Orthopaedic Surgeon/Shoulder and Elbow Surgeon, Advanced Healthcare "The number one reason to do the replacement is pain control; number two is to improve your range of motion, and the procedure is very reliable at producing both of those results."

“I always tell people if you have bone-on-bone contact and markedly reduced range of motion, then it’s time to proceed with a shoulder replacement if you’re having pain,” he said. “The number one reason to do the replacement is pain control; number two is to improve your range of motion, and the procedure is very reliable at producing both of those results.”

By the time Dr. Churchill sees many of his shoulder replacement patients, their pain is bad enough that they are unable to sleep and they feel stiff, sore and in pain when awake, even when not using the affected arm.

Arthritis the main cause of pain
Arthritis is the most common reason for shoulder replacement surgery. Both osteoarthritis (the general wear-and-tear variety) and rheumatoid arthritis (an autoimmune disease) can wear away or damage the cartilage covering the ball-and-socket joint, and the muscles that allow for the rotation of the arm in all directions. (Range of motion in the shoulder is determined by the proper articulation of the ball upon the socket.)

Post-traumatic arthritis can occur at the site of an injury or trauma, with onset years or even decades after the original injury. Patients who have had chronic rotator cuff tears can develop a form of arthritis known as rotator cuff arthropathy.

A fourth condition cited by Dr. Churchill is related to a procedure common in the 1970s and 1980s to help patients who, after traumatically dislocating their shoulders, were unable to keep from continually dislocating again. Doctors treated the condition, called shoulder instability, by tightening up the muscles in front of the shoulder. The procedure, however, after 10 to 15 years led to early-onset arthritis severe enough to require shoulder replacement.

Before recommending surgery, Dr. Churchill attempts to treat his arthritic patients with anti-inflammatory drugs, physical therapy and, in some cases, cortisone injections. If the pain and restricted motion persist, he recommends shoulder replacement.

How is the procedure performed?
The shoulder replacement procedure takes between 90 minutes and two hours. After being positioned on an operating table as though lounging in a beach chair, the arm is scrubbed to prevent infection. Next sterile drapes are placed around the shoulder, allowing Dr. Churchill to move the arm up or down as needed during the procedure.

After anesthesia is administered, he makes a four-inch incision over the front of the shoulder joint. It is gradually deepened until the bones of the shoulder joint, located beneath the subscapularus muscle, are exposed. He then dislocates the humeral head (ball) from the socket, and removes damaged cartilage and bone surface. The inside of the bone is then shaped to match the shape of the implant. Next the socket is cleaned, shaped, and prepared to accept the new socket. The socket is fixed in place with a body-inert cement called polymethylmethacralate.

When all the implants are in place, the metal ball, which is attached to a stem in the upper arm bone, is placed into the new socket. Dr. Churchill then stabilizes the muscles around the new shoulder before closing the incision.

“You have to balance the muscles surrounding it, because the shoulder is kept in place by muscle forces,” he said. “It’s not like the hip, which has a deep ball and socket. The shoulder has a very shallow socket, so if it’s not balanced, it will be unstable.”

Recovery period
Patients stay in the hospital for two nights, Dr. Churchill said, but complete rest is not on their agenda. Because many haven’t been able to move without pain for years, they’re apprehensive about doing too much right away. Within 24 hours of surgery, however, they’re working on stretching exercises in physical therapy and feeling less pain than they have in years.

“I go to great lengths to release scar tissue in the operating room and open it up,” he said, “and I want to make sure my patients are stretching and keeping it that way.”

He is equally emphatic about making sure patients take the time and care to affect a complete recovery.

“I tell patients not to do anything that involves force for the first six weeks,” he said. The reason is because he has to remove and reattach the subscapularus, and any forceful motion, such as the slamming of a car door, can damage the muscle. He also cautions his patients about motion to the side, for the same reason. Moving the arm overhead, however, is encouraged.

Lifting anything heavier than a coffee cup is generally discouraged, although if a patient appears to be doing well enough before leaving the hospital, Dr. Churchill will increase that limit to five pounds.

Once home, patients continue stretching exercises and out-patient sessions with a physical therapist. Most of Dr. Churchill’s patients don’t need pain medication longer than two weeks, at which point they are able to resume driving. Once the surgical recovery period ends, patients are able to resume pre-pain activities, with two exceptions.

“The only things I tell people not to do are chop wood or use a sledgehammer because of the sudden stop impact that occurs,” he said. “They can swing hammers, shoot guns, play tennis, golf, swim or do anything else.”

Dr. R. Sean Churchill:
Good Hope Clinic
3003 West Good Hope Rd.
Milwaukee, WI 53209
414-352-3100

East Mequon Clinic
12203 N. Corporate Pkwy.
Mequon, WI 53092
262-387-8200

For more information related to shoulder and elbow problems, visit ortho.ah.com.

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