Is Shoulder Arthroplasty a Good Option for Younger Patients?
Dr. Matthew Ramsey answers questions from ICJR about shoulder arthroplasty in younger patients who present with osteoarthritis.
ICJR: What are some of the difficulties in treating osteoarthritis (OA) of the shoulder in young patients?
Matthew L. Ramsey, MD: There are 3 things to keep in mind with younger patients who present with shoulder OA.
Outcomes. It’s very important for the surgeon to have an open discussion with the patient preoperatively about the historical outcomes in younger versus older patients. In general, outcomes are not as good in younger patients as in older patients. A complicating factor is glenoid bone loss, which can be can be greater in younger patients, creating more difficult reconstructive challenges.
Patient expectations. Although we know their outcomes may not be as good, younger patients tend to have much higher expectations than older patients for the functional results of shoulder replacement surgery, especially their post-surgery activity levels. The surgeon should temper these expectations by highlighting that this is a mechanical replacement and that it will be subject to wear and loosening.
Historically, patients have been advised to limit overhead lifting to no more than 25 pounds. However, patients often ignore restrictions like this when they feel better and their shoulders seem to be functioning well. The key is to help patients understand that the choices they make can profoundly influence the longevity of their implants and that aggressive activity levels will put the implant at risk for failure.
Implant longevity. Implant longevity, particularly with the glenoid, and attritional rupture of the rotator cuff are significant issues. Fortunately, there are strategies the surgeon can employ to improve implant and rotator cuff longevity. Examples include using alternate bearing surfaces that may not require glenoid replacement (ie, pyrocarbon), inset glenoid components, and resurfacing instead of stemmed replacement.
ICJR: Do you have a minimum age for a patient before you will perform a shoulder arthroplasty procedure?
Dr. Ramsey: No, I don’t have a minimum age. The decision to recommend surgery is done on a case-by-case basis and is grounded in the presenting pathology and the viability of alternative options for treatment.
Joint replacement surgery is generally indicated for patients who have end-stage destruction of the glenohumeral joint and who have failed non-operative options for treatment. Before surgery, make sure they understand that a replacement is not a permanent solution and that they will likely need revision surgery down the road.
ICJR: What advances in technology or perioperative treatment are needed to improve the current state-of-the-art for treating the young, active OA patient?
Dr. Ramsey: As I mentioned earlier, implant longevity is a major issue for these patients. We need better solutions to manage the glenoid and to minimize the risk of implant-related attrition of the rotator cuff.
One potential improvement on the horizon is the use of pyrocarbon on the humeral head, which may preclude the need for glenoid replacement in the future.
If glenoid replacement is required, inlay glenoid components that allow load sharing with the surrounding bone may improve glenoid loosening rates.
The issue of attritional tears of the rotator cuff is poorly understood but may be related to compromise of the vascularity of the rotator cuff at the time on stemmed component insertion. Potential options include resurfacing or stemless humeral components that might not adversely affect the cuff vascularity.
About the Expert
Matthew L. Ramsey, MD, is a board-certified shoulder and elbow specialist. He is chief of the Shoulder & Elbow Division of The Rothman Institute, Philadelphia, Pennsylvania.
Dr. Ramsey has no disclosures relevant to this article.