The pain in Carol Driesen's left shoulder started out as the kind of
garden variety arthritis ache that many people usually begin to notice
sometime in their 50s. Driesen tried a variety of arthritis
medications with little effect. Then came the day when she decided to
do something more. "I was taking a class, sitting at a desk, not
doing anything physical and still practically whimpering from the
pain," Driesen said.
First, she tried arthroscopy,
a minimally invasive procedure to smooth the roughened edges of bone
within her left shoulder joint. Finding little relief from that
procedure, she took the next step, a full joint replacement, in 2000.
A year after that surgery, not only was there again little change in
pain, but she also lost much of her shoulder's range of motion.
Driesen gave up. "I just figured I had to make do with it."
Driesen did her best to make do. She is right-handed; after several
years, however, she noticed that her increasing dependence on that
right arm had a downside: The pain in that shoulder increased, too.
Not wanting to push that shoulder beyond its limits, Driesen finally
decided to risk another surgery. This time, she would make certain
that she would choose the most experienced orthopaedic surgeon she
could find and someone who specialized in shoulder replacement.
"I really wanted to make sure that this time it would be done
right," she said. Even at 76, she was still active, a busy woman
who often baby-sat her toddler granddaughter. She was not willing to
settle for pain reduction only; she wanted function, too.
After some considered looking, she found John Costouros,
MD, at Stanford Hospital & Clinics. Costouros told her what
she already suspected: Her only option was a surgery very different
from her original. To restore her ability to move her shoulder, she
needed a reverse
The anatomy of the shoulder presents a special challenge for
repairs. The ball-shaped top of the humerus bone fits neatly into the
glenoid, the curved space at the end of the scapula. A standard
shoulder replacement puts a new cap on the humerus and a new lining on
the curved wall on the glenoid. But the joint gains most of its
mobility from a ring of muscles and tendons called the rotator cuff.
If that cuff is torn beyond repair, the standard shoulder replacement
will do little to restore the shoulder's function or to eliminate pain.
With the reverse shoulder replacement, the humerus is transformed
into the new base for the socket, capped with a socket-shaped top; the
curve of the glenoid becomes the new ball, implanted with a rounded
platform. The deltoid muscle then takes over for the rotator cuff and
acts as the lever for the arm, becoming the prime mover of the
Driesen's bone loss was so substantial and her rotator cuff so
damaged that the reverse shoulder procedure was the only option.
Costouros also would need to take part of her pelvic bone as a graft
to reconstruct her glenoid so it would be stable enough to support the
It would be a complicated surgery, but Driesen had confidence in
Costouros. The reverse shoulder procedure was performed in Europe for
decades before it was approved for use in the United States, in 2004.
Costouros did an additional fellowship in Switzerland with one of the
field’s most prominent surgeons to gain additional experience with the
reverse shoulder replacement and other innovative procedures.
"I really had the opportunity to learn from everything they'd
learned over the years in Europe," Costouros said. By the time
Driesen came to see him at Stanford, he had completed more than 300
reverse shoulder surgeries. He had also become a well-known trainer of
other surgeons throughout the country.
"I liked him very much," Driesen said. "He didn't
push and he told me what I might expect. He was very confident and his
confidence built mine."
Shoulder replacements are a relatively new procedure. The first
widely used shoulder implant became available in the early 1950s and
was based on designs for hip replacements. It was very much a
one-size-fits-all, Costouros said, with little adaptability for
differences in body size. "They didn't perform very well,"
he said. By the 1990s, the parts for shoulder replacements had become
more modular, so surgeons could choose the proper size for each patient.
In the last 10 to 15 years, we've really seen an explosion in our understanding of the anatomy and biomechanics of the shoulder and of things that happen at the molecular level.
- John Costouros, MD, orthopaedic surgeon, Stanford Hospital & Clinics
Discovering New Options
The combined improvements, and the introduction of the reverse
shoulder procedure, have made shoulder replacements the fastest
growing segment of joint replacement types, Costouros said. "In
the last 10 to 15 years, we've really seen an explosion in our
understanding of the anatomy and biomechanics of the shoulder, better
surgical techniques, and things that happen at the molecular
level," he said. "Because of that, we've been able to design
better implants and better implantation methods. Outcomes and
longevity of shoulder implants today are far superior, enabling
patients to obtain predictable pain relief and function that in past
years was not possible"
In Driesen's shoulder, Costouros saw the kind of deterioration that
has become well known to occur in older implants. "The prosthesis
had loosened in the socket, and its plastic showed wear. It had all
shifted and migrated due to the development of a rotator cuff
tear." Without the surgery, Driesen would have lost more and more
function, he said, and her pain would have increased. "This
procedure really is a life-changing and dramatic intervention for
In the future, Costouros said, such replacements may be outdated by
cell-based therapies to modulate conditions like arthritis.
Driesen was hospitalized for just two days after her surgery.
"I was progressing so quickly and I was off all pain medications
after 10 days," she said. "I've had no pain since
then." She began physical therapy, which she said hasn’t been
painful either and continues now at two months following surgery.
"It has increased my range of motion to the point where lying
down I can lift my arm from down at my side to up over my head and
hold my arm straight up pretty much indefinitely," she said.
Working with a physical therapist is very important, Costouros said,
"because of the complexity of the shoulder, it can be predisposed
to stiffness. It's important to work with a therapist throughout the
different phases of recovery, which usually take three to four months."
Even though Driesen's recovery will continue as she builds back
strength in her left arm, she is happy with the improvement. "It
certainly has made me more comfortable and more able to do the things
I want to do," she said.
Outcomes and longevity of shoulder implants today are far superior, enabling patients to obtain predictable pain relief and function that in past years was not possible.
-John Costouros, MD, orthopaedic surgeon, Stanford Hospital & Clinics