Shoulder Replacement Surgery

Dr. Grant Garcia: I am Dr. Grant Garcia. I’m one of the shoulder and sports specialists here at Orthopedic Specialists of Seattle. Just to introduce myself, I did my undergraduate at Brown in Rhode Island, and then did my residency training in New York in a place called Hospital for Special Surgery. We got extensive train for shoulder replacements as well as other sports procedures. And then did my medical school at University of Pennsylvania. And then was fortunate enough to do a fellowship at Rush University and focused on shoulder, especially shoulder replacements. And then went into France for a bit and did some shoulder replacements as well over there. So that’s the background of me, I’ve been here, a shoulder Orthopedic Specialist of Seattle have been quite happy. And we’re going to talk to you about shoulder replacement today and what involves some symptoms related to it and then the procedure itself.

So, shoulder replacements or shoulder arthritis is the reason most people get replacements is because the shoulder socket or we call it, you know, the humerus and then you have the socket itself here, which is the glenoid and they start to wear down. Now there’s lots of different variations that you can get, but the most common type is ones to patients who just have had unfortunate events of a previous injury to the shoulder, maybe dislocation, et cetera.

Generally, patients are a little bit older in their 50s or 60s or even 70s when they get this because they’re not walking on their shoulder, similar to knees, which tend to be a slightly younger patient population. You know, you have this, or you might consider you have shoulder arthritis. If you start feeling pain in the shoulder, you start noticing that your range of motion. I think the range of motion is the biggest prognostic factors as to whether or not you have a problem going on that’s arthritis related. So, they’ll notice that maybe they start off able to reach their arms up as far as they can. And then over the next 5, 6, 10 years, they noticed that motion becomes less and less. And the biggest one is this one. So, they noticed that they can’t reach behind their backs. So, for women that can’t do their bra. For men, they just have trouble reaching behind their back to get their wallet out. And those tend to be some indications. When you start having night pain, we get pretty concerned that it’s likely the arthritis in combination with that range of motion stuff that I discussed with you. And those are when we start talking about considering not operative treatments or at least getting an evaluation.

There’s two variations of patients. Some just come directly to me without ever having this diagnosed. And that’s fine as well. Or you can see your primary care doctor, usually they get an x-ray and the x-ray will show whether or not you have, you know, a lot of joint space like this, or whether the ball has turned into a sort of nice round ball and socket to sort of a square peg like this and a flattened socket. And this is a one-dimensional view I’m showing you. And then once that we identify that, then the discussion as to what to do next.

So, first thing again, there’s variations, not everybody’s the same, but if we see that it’s pretty flattened, we start thinking about, you know, should we try some physical therapy to see if we can get you stronger to stabilize the joint better. And the next things we start talking about our injections. There are not a lot of good injections, unfortunately for shoulder. For knee arthritis, we have a lot more, and you’ve probably seen those before on our website, et cetera talking about the different things, but for shoulder, that pretty much the main injection is a steroid injection. We can do no more than three of those a year, but we tend not to try to do too many of them because even despite having an injection or two, you can jeopardize the rotator cuff the more we have. So, I usually no more than one or two injections for my patients.

If you’ve tried those injections, some people get a whole year’s worth of relief two years, three years, and those are great, and we continue on with that treatment. If the injections only help for a short period of time, then either you’ve already seen we’ve done the injections or that’s when you are primary care or physiatrist or other doctor will refer you to an orthopedic surgeon and generally, or for you to somebody that’s a specialist in shoulder replacements.

And the reason it matters, if you have someone that’s a specialist in shoulder replacements, this is much different than the hip and the knee. And a lot of doctors that do the hip and knee replacements, that’s their main bread and butter, but when it comes to the shoulder, it’s a different animal. It tends to be done by people with a shoulder specialist background or a sports/shoulder background. And that’s because of the anatomy of the shoulder. The approach the shoulder is it’s a lot smaller compartment need to work into, patients tend to be a lot stiffer because they come in a lot later, because obviously they’re not walking on their shoulder. And then when you get in there, we’re dealing with a lot smaller anatomy and you have a lot less variation in the socket. The socket is really the most important part, and that’s really where we have to use our tools that we learned through our specialized fellowships and training to make sure you have the best possible result.

So, once we sort of talked about you’ve had the non-operative treatment, you know, unfortunately that’s still not working for you, then we start talking about considering something surgical. Now, for younger patients under 50, we start becomes a challenge because we want to make sure that we can get this shoulder placement to last as long as possible. So, we start thinking about some fancier options that we have, maybe we do a partial replacement, or we have components that have different types of metals that are a little bit softer that may be better for you. So, you don’t wear it out as fast. For the general population, we talk about three main shoulder places, if not two. And the two shoulder replacements are replacement where we replaced everything exactly the way you were born.

Again, on the humeral side or that humorous side right here, we remove the top portion and we can show this on our – you’ll see us on our website, on my personal website as well, how we do it, remove that, and we put a metal ball on. And there’s two options for that. One is a stemless option. This is a little bit newer. This is some of the training we’ve had in France and the company that we work with. And this is for patients that are a little bit more active, good bone quality, but this is a good operation. It reduces time, reduces pain afterwards, especially in the short term, and it’s a really good option I like to do on as many of my patients as I can. The other option is to do that ball and put a stem down there. Again, not really a major difference in terms of the overall outcome. So, if you have to do that, it doesn’t make a difference in the long run. But that’s another option to the stem and that’s a anatomic shoulder.

And then for the socket, we put a plastic liner in there and the reason you want to do the liner, you don’t really want to do a partial replacement, especially if you start to get older is because the socket is never usually a perfectly flat surface. And this is why there are some anatomy and technical aspects you need to understand. And that’s why it’s important to be at a specialist because most sockets are not just perfectly like this. A lot of times they’re really tilted like this, and the longer you wait, they can be worse than that. And so, we need special instrumentation and it’s much smaller than my hand, maybe the size of these two fingers that we’re dealing with when we’re doing the socket. And again, we have it tilted and we have this small socket. So, we have to place the pin in a perfect location. We use different tools to do that.

And again, so we have this plastic socket and we have ways to backfill that with certain implants so that we make sure that that is stable for the patients. And you have the best possible outcome because if the plastic socket is not put in properly and you get this anatomic shoulder replacement, it’ll wear out much faster and that’s a concern. And so again, this is why it’s important that you see someone that’s a shoulder specialist.

Now, again, this is the best option if we can do it. And this is for people that have a intact rotator cuff. So, we try this as much as possible because the results of these are outwards in the satisfactions of 90 to 95% with really good longevity. We’ve seen upwards of 90% longevity at 10 to 15 years. So, it’s really important if we can do that, that we do it. Now, it doesn’t mean that if you can’t get that option, that you’re going to have a bad option for you. It just means that you’re a different patient population and with different expectations. So, the expectation, like I said about again, is to hopefully get a lot more emotion back, you know, we were up here and reduce pain. Like we talked about down to a level one, if not zero. And again, and the strength comes back to because again, a lot of times the strength for these patients have already been tested for a rotator cuff tear. And if they don’t have it, their strength comes back because they’re not in pain anymore. And so those are the pauses of have that type of implant.

The second implant, or we’re not going to go through a lot of details. It’s called the reverse shoulder implant. And that’s where we take the exact same thing and we flip it around. So the humerus becomes the cup and the socket becomes the ball. And this is a really cool option. And this has become really popular in the United States, and it’s becoming more popular as we find more and more ways of this. It becomes a very successful surgery because not every person comes into my office being like I’ve got shoulder arthritis and look at all how I can get my arm. A lot of times these patients come in and they can’t lift their arm like this, they’ve had a bad fracture, all the things. In the anatomic shoulder, that one I told you about, like this, it just doesn’t work very well for that, and actually do quite poorly if you do that. If you do this other option, where you have it like this and the socket, the results are not as good in terms of the range of motion, but those patients have different expectations. That’s a person that comes in, I can’t lift their arm. If I can get them up to here, that makes me quite happy and that’s considered a very good result.

And so, when we do this socket and ball reversed, we can get patients that can’t lift their arm to have them to be up to here, here, or maybe even here. And the biggest thing for a patient, especially, you know, ones above 65, 70, is that you can wash your hair, do your daily activities of living, but also on both of these, the return to sport is good, in sports doesn’t have to mean high level athletics or football, but you can go back to golf, you can go back to swimming, you can go back to tennis. If you do it, as long as you were able to do that sport, at some point, you know, three to five years before your problem started, we’ve seen in some of my own research has seen the data shows that you’ve got a pretty high chance to really do it again. I mean, if we’re able to correct your problem.

Again, both of these are specialized implants. So, you need a specialist that does this, and we can offer this here at Orthopedic Specialists of Seattle. And again, when we do these things, the other kind of innovative techniques, we have, we actually use something called a CT scan. And what a CT scan is, this was sort of like an x-ray, but a lot of them combined, and then we can 3D print or 3D model your shoulder, which is pretty cool. And what we do with that is I actually can plan your surgery out ahead of time. And so, I know when I go in there, what implants I’m going to use, if there’s going to be any difficulties and I can order special things as needed, we can even order custom guides for each patient. And what we do is we get your socket printed out 3D. And for the ones have these difficult sockets. You want to make sure you can catch that ahead of time. And that’s the importance of, again, going to someone that specializes in this.

So, with the socket that has been more challenging, we get it printed out on the table in the operating room sterile, and we can identify where we’re going to put that pin and how we’re going to start the whole procedure, which is the most important part of this surgery. And now we can make it as precise as possible. And with this instrumentation, we’re able to get to almost near perfect shoulder replacements, which I think in the future, again, this is relatively new stuff over the last five years, but that date I told you will probably be extrapolated and maybe even better than what we’re saying. Because again, when you hear data 15, 20 years, that’s a 15, 20 year old implant. We don’t have data on some of the newer ones that are 5, 6 years old. We just have five to six year old data, which is showing 95% success and 95% longevity of the implants.

So overall, I’d say the one thing I get from most of my patients is that they wished they had thought about this earlier, and they struggled for a long enough, barely able to use their arms and using the other arm. That’s the benefit of having two arms. If one shoulder has arthritis, you can kind of work around it, but you shouldn’t suffer because this is a very good option and done by the right surgeons has low complications and high success rates. And I would say in my practice, some of my most satisfied patients are my shoulder replacement patients, and this is why I continue to offer this option for my patients.

So, if you’re thinking about it or anybody you know is thinking about it, please contact our office at Orthopedic Specialists of Seattle. As I also have my own website at Either way you can get ahold of us. We’re happy to do an evaluation and we’ll give you the non-operative or operative treatments if necessary.




About Grant H. Garcia

Dr. Grant Garcia is a board-certified orthopedic surgeon with advanced accredited fellowship training in Sports Medicine and Shoulder Surgery. Dr. Garcia’s primary focus for his practice is Sports Medicine, having a great interest in returning athletes safely to their sport after shoulder, knee and elbow injuries and surgeries.