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Total Shoulder Resurfacing (TSR)

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Dr. Kovack’s radio chat on shoulder resurfacing

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Total shoulder resurfacing or TSR is an alternative to conventional total shoulder arthroplasty or TSA for younger patients or highly active middle aged or older patients with advanced glenohumeral arthritis who have failed conservative or non-operative treatment. Total shoulder resurfacing (TSR) is bone conserving and less invasive than conventional TSA. It allows patients to move their shoulder earlier, start therapy faster and leads to a quicker recovery. It is an outpatient procedure which means the patient is home the same day after surgery. Shoulder exercises start the day of surgery and formal therapy starts within 10-14 days after surgery. Full recovery is about 8-12 weeks. After full recovery the patients have no restrictions in their activities, unlike a conventional TSA. Figures A and B below is a TSR before and after.

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Figures A and B: A/P Radiographs of a right shoulder with severe glenohumeral arthritis before (left) and after (right) a Total Shoulder Resurfacing (TSR) with Arthrosurface.

Total shoulder resurfacing has been performed on the ball or humeral head for several years with good results. The longest study on shoulder resurfacing in the orthopedic literature is a minimum 20 year followup study by Pritchett, J.W. that found a 95% patient satisfaction with a 96% survivorship of the humeral component. The study was done with an older prosthesis with a sphere on the head and a cemented plastic socket on the glenoid or “onlay” glenoid. We now know that the humeral head is not a perfect half circle or a sphere and the onlay plastic socket cemented on the glenoid can loosen early over time with a higher activity level. A newer prosthesis is now being used from Arthrosurface with an “anatomic” humeral head, not a sphere and an “inlay” cemented plastic socket that sits in the glenoid which does not seem to have the early loosening seen with the other “onlay” glenoid prosthesis. The Arthrosurface TSR has the potential to be more “anatomic” with less chance of loosening over time. Patients can potentially return to a high level of activity, unlike that allowed with a conventional TSA. To find out more about the Arthrosurface prosthesis go to www.Arthrosurface.com.

Watch Jeff’s Story On Total Shoulder Resurfacing

Why is TSR a better option than TSA for certain patients?

Conventional shoulder replacement or “total shoulder arthroplasty” is usually performed with a metal humeral implant with a stem and a ball (figure F) after resecting the arthritic ball side of the joint and a plastic socket or cup that is cemented in (onlay), (figure E), after reaming down the arthritic socket. This surgery has had consistent results of good pain relief and functional increases performed for end stage osteoarthritis. Longevity has been reported to be from 15-20 years with a survival rate of 84-95%. However, a shoulder replacement is typically performed on patients greater than 60 years old with severe glenohumeral arthritis who have failed conservative care with ongoing pain and functional deficits. These patients are usually lower demand. Figures C and D are radiographs before and after a conventional TSA.

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Figures C and D: Radiographic views of a shoulder with severe glenohumeral arthritis before (left) and after (right) a conventional total shoulder arthroplasty (TSA) with a metal ball and stem on the humeral side and a cemented plastic socket (onlay).

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Figures E and F: Intraoperative pictures of the cemented plastic socket (onlay) on the left and impacted metal humeral head on the stem on the right.

But what if some one is much younger in their 30′s, 40′s, or 50′s, highly functioning or even athletic and wants to continue their activity level? Even those over 60 years old may have a high level of function or be involved in athletic activity and not a good candidate for a conventional total shoulder replacement. Why is this? On the humeral or ball side with a conventional shoulder replacement, more bone is taken or resected. This can be an issue with younger patients that would need another surgery in the future to revise the shoulder replacement if they “wear it out”. There would be less bone available for the next surgery and eventually another replacement may not be possible. On the glenoid or socket side there is potential with loosening of the component with a conventional cemented cup or poly (onlay) with patient’s high activity level. Also, the results of a revision surgery are usually not as good as the first primary surgery. This is why a total shoulder resurfacing (TSR) is being performed for those who are not ideal candidates for a conventional total shoulder arthroplasty.

Humeral Head Resurfacing (HHR)

This procedure has been performed for several years with a metal cap, figure H, that is sized and placed specifically to the patient’s anatomy. The implant is “press fit” which means on the part that contacts the bone it is coated and textured in a way that the bone “grows into” the prosthesis. It has shown good long term results. It can be performed alone or in conjunction with a procedure with the glenoid. There is also a “partial” humeral head resurfacing available that can be performed if the arthritis or damaged cartilage is isolated to a region on the humeral head.

Glenoid Resurfacing (GR)

This procedure is relatively a newer procedure that resurfaces the glenoid or socket side of the glenohumeral joint either with an “inlay” glenoid component with a  plastic or poly implant, figure G, or a fresh osteochondral allograft from a donor similar to the arthroscopic biologic resurfacing. With conventional total shoulder arthroplasty the glenoid implant is placed on the socket or onlay and cemented in. It is more prone to “loosening” over time with very active and/or athletic patients. It can “rock” back and forth with more weighted stress over time. With an inlay glenoid implant there is less “rocking” and thus less potential chance for loosening because it sits within (inlay) and not on (onlay) the bone. With fresh osteochondral allograft from a donor there is maximal bone preservation. The decision to use either one is dependant on several factors including the patient’s age, activity level, and a discussion of pros and cons with each.

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Figures G and H: Intraoperative picture on the left of a resurfacing “inset” glenoid poly and on the right a Humeral Head Resurfacing with a press fit metal implant. 

Watch Charles’ Story On Total Shoulder Resurfacing

 

Conclusion

Total Shoulder Resurfacing or TSR is an alternative to conventional Total Shoulder Arthroplasty or TSA for younger patients or highly active older patients that have failed conservative treatment and want to maintain their high activity level and lifestyle without the restrictions that they would have with a conventional TSA. Dr. Thomas Kovack has performed many of these procedures with good results. Below are examples of a few patients after this procedure. You can contact Dr. Kovack about this procedure through his email address at columbusshoulderdoc@gmail.com or call for an appointment at 614-930-6489.

Watch David’s Story On Total Shoulder Resurfacing

 

Patient Examples

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Male patient in his 40′s just over 8 weeks s/p left shoulder TSR with Arthrosurface. Minimal pain with 2x more motion than before surgery.

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Male patient in his 50′s just over 6 weeks s/p right shoulder TSR with Arthrosurface. Minimal pain with 2x more motion than before surgery.

total-shoulder-ex3-1 total-shoulder-ex3-2  total-shoulder-ex3-3total-shoulder-ex3-4

Male patient in his 50′s at 6 weeks s/p left shoulder TSR with Arthrosurface. No pain with 2x more motion than before surgery.

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