Innovations in shoulder replacement surgery

Posted on 24 March 2022

A leading orthopaedic surgeon explains the new subscapularis and deltoid-preserving anterior approach for reverse shoulder arthroplasty.

“One of the most exciting major advances in shoulder surgery is that we’re now able to perform a full shoulder replacement without cutting the deltoid or subscapularis tendons,” explains Dr Joe de Beer, an orthopaedic surgeon at IOR Mediclinic Winelands Orthopaedic Hospital, Stellenbosch. “This is called a reverse subscap-on approach and while the technique is more challenging and intricate for the surgeon, the patient benefits are numerous.”

Having suffered ongoing, debilitating shoulder pain for years, retired switchboard operator and great-grandmother Maria Basson agrees. “In 2007, I started experiencing a very high level of pain and stiffness in my right shoulder,” she says. “I initially thought I’d just bumped it and it would heal on its own, but it didn’t get better. I eventually had an orthoscopic (minimally invasive) rotator cuff operation. This helped for a while, but when the pain returned, it prevented me from doing my housework and gardening.”

Eventually, when Maria was unable to hold a teapot in her right hand – and was finding it uncomfortable to sleep at night because of her ongoing shoulder pain – her doctor in Oudtshoorn, Western Cape, referred her to Dr De Beer, who decided she needed a reverse total shoulder replacement.

The shoulder is one of the most complex joints, and, like the hips and knees, it suffers a lot of wear and tear. As Dr De Beer explains, this generally presents as thinning or loss of the cartilage lining of the joint (arthritis). “Arthritis is increasingly common as we age. It presents as gradually increasing pain and loss of motion, ultimately making it difficult to participate in sports or perform basic activities of living, such as getting dressed.”

Prior injuries, such as dislocation, can accelerate the loss of cartilage in the joint, leading to arthritis at a younger age, Dr De Beer adds. “Total shoulder joint replacement surgery (arthroplasty) helps restore comfort and function to shoulders damaged by osteoarthritis or rheumatoid arthritis.”

“In the past, we had to suture the tendons afterwards in order to repair the ‘damage’ we’d caused and the patient would endure a great deal of stiffness and pain after surgery,” he explains. “Now that we don’t have to cut the tendons, the patient doesn’t need to wear their arm in a sling for up to six weeks and instead can be mobilised immediately after surgery. On the same day of their shoulder replacement, a patient is now able to raise their arms above their head and can drive ” Patients also benefit from a shorter hospital stay, which lowers costs, and they no longer go to a stepdown facility after the procedure. Rehabilitation is minimal and postoperative pain is much reduced.

“Previously, when we had to cut the subscapularis tendon to perform this procedure, there was an increased risk of dislocation and infection of the prosthesis,” Dr De Beer says. “Now, we leave the muscles and tendons intact, which means the soft tissue and blood supply aren’t disturbed. Early stats are very promising when it comes to this innovative subscapularis and deltoid-preserving anterior approach.

For Maria, the benefits are enormous. “I was able to move my shoulder straight after surgery and I was out of hospital in two days,” she says. “Today I’m back to doing all my household chores. It’s wonderful that I don’t have my arm in a sling – I would hate to not be able to garden!”