Shoulder Prosthesis: Indications

What is a shoulder prosthesis?

A shoulder prosthesis is a medical device that allows for the complete or partial replacement of the shoulder joint damaged by disease or trauma.

The procedure of implanting the prosthesis is considered when all conservative treatments (pharmacological and physiotherapy) have failed and the patient's quality of life is penalized by chronic pain and limited movement.

The objectives of the surgery are therefore the elimination of pain (a condition that is achieved in more than 80-90% of cases) and the improvement of shoulder mobility. It is important to note, however, that mobility may not return to its initial level, especially in cases where the joint is more severely affected.

However, even after the operation, excessive strain on the joint remains contraindicated, and particular attention should be paid to any fall, which could damage the device and the remaining anatomical parts and necessitate a new shoulder prosthesis.

When is the implantation of a shoulder prosthesis indicated?

Osteoarthritis and shoulder prosthesis

The most frequent reason for implantation of a shoulder prosthesis is osteoarthritis, a disease related to the wear and tear of the joint cartilage and the formation of bony outgrowths (called osteophytes). Osteoarthritis leads to the disappearance of the distance between the humeral head and the glenoid cavity and therefore of the contact and friction between the two bone surfaces. This condition is characterized by pain and stiffness.

Osteoarthritis is favored by the natural aging of cartilage, which dehydrates and gradually loses thickness, and can be accelerated by trauma or repeated dislocations. Osteoarthritis of the shoulder can also occur as a result of metabolic diseases (diabetes, gout) or due to anatomical malformations of the bones.

Arthritis and other rheumatic diseases

Shoulder prosthesis implantation is often performed to improve pain and mobility in the case of rheumatic diseases. Diseases such as rheumatoid arthritis and psoriatic arthritis involve chronic inflammation of the synovial membrane which, over time, is no longer able to produce synovial fluid, leading to damage to the articular cartilage.

Arthritis can also be a complication of an injury that has caused severe damage to the bone, tendon, and muscle components of the joint. Post-traumatic arthritis is due to cartilage degeneration following injury and is associated with pain and limited mobility.

Other conditions

Shoulder prosthesis surgery may be decided due to avascular necrosis (osteonecrosis) of the humeral head, a condition in which a part of the humeral head does not receive blood, for various reasons, and undergoes necrosis.

Avascular necrosis can be promoted by chronic cortisone treatment, alcohol abuse, or severe fractures.

Joint replacement may also be necessary after poorly set fractures, serious injuries that have not been properly managed and have resulted in deformation of the bone surfaces in contact.

The operation can also be prescribed following the failure of a previous implant: this is then called a revision procedure. This is a longer and more complex operation involving the use of specific prostheses and instruments.

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The case of the reverse shoulder prosthesis

Reverse shoulder prostheses are total shoulder prostheses that involve the use of a surgical technique different from that of anatomical prostheses. Unlike the anatomical structure of the shoulder, with the reverse shoulder prosthesis, the surgeon implants a device characterized by a concave humeral component and a convex glenoid component.

Surgical access, in this case, can be either from the deltopectoral area (particularly chosen in the case of revision procedures), or from the supero-lateral area. Data in favor of one procedure or the other are reported in the literature without agreement on which is safer. The reverse shoulder prosthesis reverses the anatomy of the joint to restore limb function. Before the implantation of a reverse shoulder prosthesis, the orthopedist explains to the patient that pain may persist after the operation and that the function of the joint may not be fully restored.

The reverse shoulder prosthesis is particularly indicated in patients with irreparable rotator cuff lesions, in which the humeral head has lifted, the cartilage is worn, and the joint undergoes progressive loss of function (arthropathy due to an inveterate rotator cuff lesion). A reverse prosthesis is also chosen in the case of multi-fragmentary (or poorly consolidated) fractures of the proximal humerus (the part closest to the shoulder). The implantation of a reverse prosthesis requires that the deltoid muscle be perfectly efficient, as it must replace the function of the rotator cuff to make arm lifting movements possible.

The implantation of a reverse prosthesis is contraindicated in the presence of nerve lesions or severe osteoporosis, which increases the probability of iatrogenic fractures (i.e., occurring during surgery) and premature mobilization of the prosthesis. The risk of complications concerns about 20% of implants. General complications (stroke, heart attack, embolism) are rare and certainly much less frequent than for hip or knee prostheses.

Among the general complications that can occur for all types of prostheses, the most frequent ones related to reversals are instability and strength deficit. Instability leads to frequent dislocations, which can be reduced without bloodshed, but if the episodes recur, revision surgery may be necessary. In these cases, it is not necessarily necessary to replace the entire prosthesis, but it is often sufficient to implant a few new parts, leaving the old ones in place. On the other hand, when dislocations are frequent, an articular infection must be excluded. The patient may also experience a strength deficit, which can be improved by physiotherapy.

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