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Shoulder arthritis: Shoulder a bit stiff? You might need your bone shaved

Thousands of Britons with shoulder arthritis end up needing a shoulder joint replacement. Trevor Laflin, 63, a bank official from Southend-on-Sea in Essex, underwent a new procedure to avoid this, as he tells CAROL DAVIS.

THE PATIENT

A new technique smooths away the bony spur and removes any damaged and scarred tissue

As a keen ballroom and Latin dancer who did martial arts for 20 years, I’ve always been incredibly active. Then two years ago, I woke up with my right shoulder in agony — I’d spent the previous day cutting back the overgrown garden in my daughter Fay’s new cottage, and knew I had clearly done something wrong.

I can’t take anti-inflammatories because I’m on warfarin for abnormal heart rhythms, so I just put up with the pain. It gradually eased, but didn’t go completely.

I have private health insurance, so four weeks later I saw a physiotherapist who thought it was muscle damage, and gave me exercises — which helped. But as I swam backstroke on holiday last August, I felt agonising pain tear through my right shoulder. The physiotherapist again put it down to damaged muscle.

This time, however, the stiffness and pain just didn’t go — it made gardening difficult, and in the gym I couldn’t work as hard as I liked. It even hurt to dance with my wife Alison. Eventually, the physiotherapist referred me to a shoulder surgeon, Professor Tony Kochhar, whom I saw in January.

He thought a cortisone injection into the joint would help reduce the inflammation, but also suggested I might be developing arthritis, so sent me for an MRI scan.

It was bad news — I did have arthritis, and as a result, a large bony spur was growing into my shoulder joint, pressing on the soft tissue and ligaments (slings of tissue which stop the joints from moving excessively).

This was causing inflammation and scarring of the ligaments, and was also putting pressure on a nerve, which was why it was so painful. On top of that, I’d also torn a tendon.

Professor Kochhar explained that the usual option was a shoulder replacement, with a recovery time of three to six months.

But he was pioneering a new U.S. technique, called comprehensive arthroscopic management, whereby instead of replacing the damaged arthritic bone, he’d smooth away the bony spur and remove any damaged and scarred tissue.

I had the 90-minute operation under general anaesthetic in March and went home that day after being shown some exercises by the physio. I had a month off work, with physio every couple of weeks, and was suddenly able to move the joint much more easily.

But it wasn’t entirely pain-free — I’d reach easily for a door handle, and then wince with pain as I was still healing. But now there’s only the odd twinge, and I know from friends that a shoulder replacement could’ve been far more painful. I’m feeling great and looking forward to international dance championships in October, and to swimming in the sea this summer.

THE SURGEON

Professor Tony Kochhar is consultant shoulder and upper limb surgeon at South London Healthcare NHS Trust and BMI The Sloane Hospital in Kent.

Around three in ten adults in the UK have shoulder disorders such as osteoarthritis, which can mean years of pain and stiffness, and around 5,000 have a shoulder replacement every year (it’s the third most common form of joint replacement after hips and knees).

Shoulder arthritis often affects older people, but also very active younger people.

This is because repeated minor injuries can damage the shoulder joint, roughening the bone.

The joint grows new bone to try to protect itself — these bony spurs start to grow at the edges of the joint, and catch on the surrounding soft tissues, causing stiffness and pain, and damage; the ligaments and tendons also become inflamed and scarred.

The spurs and swollen and scarred tissue can also press on an important nerve called the axillary nerve, which controls the shoulder muscle — the nerve becomes trapped and gets pushed out of place.

The shoulder is a very mobile joint, so this can have a huge impact on people’s lives, making simple things like brushing teeth difficult and painful. As well as painkillers, anti-inflammatories and steroids can be prescribed to dampen down swelling.

Another option is shoulder arthroscopy, where bits of floating debris — caused when the joint becomes worn away — are removed using an arthroscope (a rigid tube through which we perform keyhole surgery).

If that doesn’t help, we can offer a shoulder replacement — here we make a 15cm incision to replace the damaged end of the arm bone, and socket of the shoulder joint, with an artificial version made of steel and plastic, rather like a hip replacement.

This involves a two to five-day hospital stay, and three to six months’ recovery, as well as a  5 per cent risk that the shoulder will become unstable and prone to dislocations.

Furthermore, this joint could wear out and need replacing, sometimes in under ten years, so we hesitate before offering it to under-65s.

An entirely new approach, developed by Dr Peter Millett in the U.S. two years ago, offers a very exciting alternative.

This recognises that the shoulder is very different from other joints — unlike a hip, the shoulder is not load-bearing, so most of the pain and stiffness comes from the damaged soft tissue, not from bone pressing on bone in the joint itself (as with hip arthritis). Instead of replacing the joint, we smooth away the bony spurs causing the damage, and remove damaged soft tissue and any scarred ligaments.

We can then move the axillary nerve back into its correct position so it’s no longer under pressure from bone and scarred tissue. And because we get the shoulder moving straight away after the procedure, scar tissue cannot re-form.

These patients can be free of pain and stiffness for years. Data from the U.S. shows a 96 per cent success rate, so these patients may never need a shoulder replacement but can go back to normal life without pain.

The operation takes one-and-a- half to two hours under general anaesthetic.

The first thing I do is make three or four incisions of under a centimetre, so I can put an arthroscope into the joint and examine the damage using a tiny camera.

I use tiny surgical instruments — burrs and shavers — to shave away the bone spur. I remove the damaged loose tissue surrounding the socket of the joint, and then release or cut away any scarred ligaments and tissues around the joint to restore the shoulder’s range of movement.

Then I gently move the nerve back to its correct position.

The operation carries standard risks of infection and bleeding, and the risk of damage to the axillary nerve, but I haven’t had that happen.

In Trevor’s case, I also stitched the torn tendon (called the rotator cuff), as this was contributing to the pain and weakness.

The patient starts physiotherapy even before leaving the hospital so that scar tissue will not build up, immobilising the joint again.

I’d like to see this procedure more widely known and offered to many more to save younger patients a shoulder replacement or years of pain and immobility.

The operation costs the NHS around £3,500-£4,000, and a similar amount privately.

 

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