Arthritis implies inflammation of a joint, but in common usage usually means wearing out of that joint - either the joint surfaces (cartilage) or the muscles and capsule of that joint have degenerated and given way.

In the shoulder Primary Arthritis applies to the wearing out of the cartilage while the muscles and capsule remain intact, whereas "cuff arthropathy" applies to the giving way and disintegration of the muscles and cuff with secondary destruction of the cartilage, an even worse combination.

Symptoms

1. night pain due to the accompanying inflammation - a reaction to the wear and tear particles within the joint over a life time.
2. creaking or grating of the joint with moving as the joint surfaces are no longer smooth.
3. limited movement as the capsule has shrunk and the joint is too painful to move because of above.

Investigations

1. X-rays show the changes in the bone structures and the "joint" space between the bones.
2. Ultrasound (U/S): show the soft tissues about the joint i.e. the cuff and the muscles, as well as the amount of movement really occurring at the joint surfaces.
3. CATScan: may show the 3 dimensional structure of the bones and the state of the muscles - whether replaced by fat or good contracting muscle which will work to move the joint after a joint replacement.
4. MRI: also to show the state of the muscles to predict the eventual functional recovery after a shoulder joint replacement.

Treatments

Conservative

1. Anti inflammatory tablets: but beware they do not affect you badly such as stomach irritation - indigestion as they can sometimes cause ulcers in susceptible individuals.
2. Physiotherapy: to settle inflammation, maintain movement and most importantly to advise, set and monitor an exercise programme to keep the joint balanced and controlled. Hydrotherapy is especially useful for shoulder arthritis.
3. Cortisone (or hydrocortisone or steroid) injections into the joint may help to settle a flare up of the arthritis.

Operative - minimally invasive

Arthroscopic debridement can be performed either as a day case or overnight stay. There is little pain, short 30 - 40 minute operation through 2 stab wounds (no large cuts) and immediate use of the limb. However the outcome is uncertain. Many patients have been delighted and requested the other shoulder to be treated in the same manner but some will come back within a few years and ask for the full total joint replacement operation.

The procedure is done with the arthroscope to look inside the joint so that any loose bodies can be removed, any cartilage flaps or fragments can be smoothed, the inflamed synovium (joint lining) can be sclerosed and any noxious enzymes or wear particles can be washed out of the joint.

Patients commonly report much less pain the next day and strangely better movement, although this is probably more related to the less pain and less muscle spasm than any improvement in the joint surface !

Postoperatively the patients are encouraged to undergo a programme of exercises under the instructions of a physiotherapist.

Joint Replacements

There are many types of joint replacements which are available to the specialist shoulder surgeon. The choice of prosthesis must match the needs of the patient and the nature of the condition the patient has, such as the age of the patient, the quality of bone, the state of the rotator cuff muscles, whether intact or non functioning, or if replaced with fatty degeneration. Therefore the correct prosthesis can only be determined by consulting your shoulder specialist, being investigated usually with Xray, Ultrasound and MRI and then discussion with the specialist and your family. Here are some of the choices.

Fortunately the expectations and results of the shoulder joint replacements are markedly improved over the last 10 years and generally good pain relief and much improved function can be achieved with the appropriate selection of the correct prosthesis.

Operative - Total Shoulder Replacement (TSR)

There have been many advances in shoulder joint replacements over the last 20 years. The first generation artificial joints were basically one size to fit all, but of course people are of all different sizes and so many did not fit all that well and would loosen.

The second generation of shoulder prostheses allowed for different sizes of the ball and socket as well as the length and width of the arm bone so allowed better fit and function.

The third generation of shoulder joint replacements were only released for world distribution in 1999 although designed and trialled for a period of 8 years in France (Walch, Boileau) with impressive results. These allow the normal shape of the patient's joint surfaces to be exactly reproduced in surgery, so the patients muscles can act normally and therefore better function is achieved as well as the good pain relief.

The old worn out ball of the head of humerus is removed and a highly polished metal surface (part of a sphere) is replaced on the humerus which exactly fits on the cut surface. Usually a plastic cup is cemented onto the scapula (shoulder blade) on which the smooth metal slides. Thus friction is minimised, the painful surfaces removed and the muscles which move the joint returned to their correct length.

Postoperatively

1. Patient stay 3 - 5 days in hospital for pain relief and physiotherapy, until they are independent and can look after themselves.
2. We encourage early movement of the shoulder at first in a sling but this can be removed quite early for periods but will be useful for upto 6 weeks.
3. Hydrotherapy is extremely useful to help relax muscles, regain movement in a soothing less painful environment and can be begun after 3 days if facilities are available, as a waterproof dressing is applied in theatre to cover the wound. The sooner the return to function the better the eventual result.

Operative - Resurfacing

In the younger patient or if only the joint surface of the humerus is involved the least destructive alternative may be the resurfacing of the head of humerus (ball) with a highly polished cap. Often it is not necessary to place a plastic cup in the glenoid although that is available in certain circumstances (please discuss with your surgeon). These have been used in England by Mr. Stephen Copeland and more recently gaining popularity over here as well as in the rest of the world.

Operative - Reverse Total Shoulder Replacement

For Cuff Arthropathy when the are no muscles or cuff remaining about the shoulder joint (which is also worn out), there used to be no good solution. The standard artificial joint relies on the surrounding muscles to hold it in position and to move it. When these are not present then the metal prosthesis would migrate upwards and erode the bones causing more pain and trouble sometimes necessitating a joint fusion (occasionally, but not well tolerated be older people).

In 2000 a Reverse shoulder prosthesis has been released for use in Australia which is designed for this condition. It holds the shoulder down and does not let it migrate upwards to erode the bony arch and keeps the joint centered on the shoulder blade. Also it allows the remaining outside muscle (the Deltoid), to act in a more mechanically advantageous manner so that control of the joint is regained, often quite soon after the surgery. This allows patients to open doors, reach for cupboards, eat, attend to their hair and other personal care without holding their arm with the other hand, in addition to reducing the pain - which is the primary aim.

Again this has been used for many years in France (since 1987) prior to its release here with good long term results.

Postoperatively

1. Patient stay 3 - 5 days in hospital for pain relief and physiotherapy, until they are independent and can look after themselves.
2. We encourage early movement of the shoulder at first in a sling but this can be removed quite early for periods but will be useful for upto 6 weeks.
3. Hydrotherapy is extremely useful to help relax muscles, regain movement in a soothing less painful environment and can be begun after 3 days if facilities are available, as a waterproof dressing is applied in theatre to cover the wound. The sooner the return to function the better the eventual result.
4. Function returns quicker than convention replacement but there is a limitation of internal rotation (arm behind back - can usually reach bottom but not bra strap)

 Operative - CTA (Cuff Tear Arthropathy ) prosthesis

If there are no rotator cuff muscles that can be repaired and the wear of the glenoid is concentric with an intact coracoacromial ligament to hold the prosthesis under the arch without displacing anteriorly or superiorly, then this may relieve some pain and give moderate active movement. It is useful in the younger patient as it removes less bone and can later be revised to a Reverse type prosthesis later. In the older patient it may be better to proceed to the Reverse in the first instance as usually better function can be achieved earlier and in the longer term.

 Operative - Arthrodesis or Fusion

Before the above advances in shoulder replacements became available some patients needed to have their shoulders fused especially if they had a previous failed shoulder replacement or if there was no cuff and the shoulder was unstable and dislocating either anteriorly or superiorly.

Movement of the arm was still available by moving the shoulder blade about the rib cage although no movement between the arm and the shoulder blade. It often reduced the pain, prevented other problems but had limitations (to be expected).