Brian Shackelford doesn’t make a living behind a desk.
As a firefighter with the Corinth Fire Department, Shackelford is often on his feet, lifting heavy objects — and the occasional person.
Much of his work is with the department’s emergency medical service. He has to lug around and operate heavy gear when fighting fires, and he has to lift people when doing EMS work.
In May 2016, Shackelford took an extended leave from his post for a series of surgeries. One of those operations was a shoulder replacement using a new technology — called a stemless shoulder replacement. He and his orthopedic surgeon hoped the replacement would relieve his chronic pain and keep him in the job he loved for years to come.
“Before I got the surgery done, I had gotten to the point where it was hurting all the time,” Shackelford said. “A deep aching. To me it felt like the pain was on the inside of my bone. ... It got to where doing anything would increase the pain. It was really limiting me on my job.”
A medical condition with a funny name
Shackelford, 49, was dealing with chronic pain well before an orthopedic specialist recommended the shoulder replacement for both of his ailing shoulders.
Shackelford was diagnosed with ankylosing spondylitis, an inflammatory arthritis that typically affects the spine and the large joints.
“For some reason, it affects my peripheral joints more than it affects my back,” Shackelford said. “It really started affecting me about four or five years ago. It got progressively worse about a year and a half ago.”
Shackelford said the spondylitis limited his range of motion. He couldn’t lift his left arm over his head.
“On my right arm, I couldn’t lift my arm behind my back to turn on my air tank. I had to get my partner to turn it on for me,” he said.
And then there was the pain. He was having a hard time sleeping through the night.
“I’ve been on several medications for the ankylosing spondylitis, most of them steroids,” Shackelford said. “That caused me to gain lots of weight. And I always use lots of ibuprofen when I’m not using [steroids]. I also used an anti-inflamatory. And I did injections, too.”
Deconstructing the shoulder
Dr. Ian Wilkofsky, an orthopedic surgeon who practices in Flower Mound and Lewisville, said most people have heard of knee replacements. Fewer have heard of shoulder replacements.
“I think the reason people don’t hear about it is because it is less frequent,” Wilkofsky said. “Hips and knees are weight-bearing. They wear out faster. But people are living longer, and the shoulder is the third most common joint replacement done in this country.”
Wilkofsky said shoulder replacements come in two major forms — anatomic shoulder replacement and reverse shoulder replacement.
“The anatomic replacement is, 'I’m just going to put this back how God made it,'” Wilkofsky said. “The reverse total shoulder replacement, that’s a newer implant to the United States. It’s a technology that we started using when you’d go in to replace the joint and find that the patients didn’t have much of a rotator cuff.”
The rotator cuff is a group of four muscles that Wilkosfky said form a “blanket of tendons over the humeral head.” The humeral head is the ball-like cap of the humerus, the upper arm bone.
In a reverse total shoulder replacement, the synthetic socket and the metal ball are reversed.
“When we were putting anatomic replacements in people with no rotator cuff, they were wearing those joints out a lot faster,” he said.
The newer technology, the “stemless” shoulder replacement, is for patients like Shackelford who need an anatomical replacement.
“If you went into Google and looked for ‘old shoulder implant’ you’d see that it would come down two-thirds of the humerus,” Wilkofsky said. “You had to cement these things if you had to really get in there and kind of take down someone’s arm. The newer replacements had smaller stems.”
Then came the stemless replacement. Much smaller than its predecessor, the stemless joint is an egg-shaped, coated titanium object with ridges on it — Wilkofsky describes them as “fins” — that are reminiscent of a Phillips screwdriver head. The ridges are coated with a special material.
“They have a porous, gritty material that is favorable to the bone,” he said. “When you put the fins to the bone and hammer it in, it’s right in there.”
No long rod has to be inserted down into the bone to keep the new joint in place. The stemless joints are less invasive, and involve less bone.
Wilkofsky said he trained for the surgery during a fellowship in Dallas.
“The stemless was coming down the pipeline, and to me, seemed like a really good alternative. Why not do as little as possible to the joint, instead of involving more of the body than what needs to be addressed?” Wilkofsky said.
He said his typical shoulder patient is 67 years old. Shackelford is one of his younger patients.
On the mend
Shackelford had partial replacements — just the humeral head — in both of his shoulders. The partial replacements will last longer, he said, and bring relief faster after years of pain.
“Everyone told me it would be worse than my knee replacement, and it wasn’t,” he said. “I think I slept on a recliner for two months, or just a little more, with each one.”
Shackelford recalls that he was ordered to keep his arms in a therapeutic sling for several weeks before he started moving the shoulders around. Rehabilitation included squeezing a ball, and shoulder replacement patients are usually ordered to do specific activities at home.
“You hit a point where your muscles remember they can do stuff,” Shackelford said. “It wasn’t that bad. The time and being off of work was the worst part.”
For Shackelford, the hardest part of recovery was getting into and out of the bathtub. After surgery, patients can’t get their wound wet, so showers are almost impossible. But hoisting yourself out of the tub usually means using the shoulder muscles. Shackelford had to enlist his wife’s help.
Wilkofsky said the replacement surgery is done as an inpatient procedure for those on Medicare, and that some patients with private insurance will go home on the day they have surgery.
“I try to sell it as an outpatient procedure,” he said. “You might have to go to the hospital, but it’s safe enough to be considered an outpatient procedure.”
The typical patient will take about three months to heal.
“I start people with two weeks of not doing much, and then after two weeks, we start them on some kind of therapy. In three months, they’re back to playing golf and lifting weights,” Wilkofsky said.
Wilkofsky said patients get back to their maximum in two years.
“I’m always cautious about telling people that they aren’t going to have a teenager shoulder. Most of these patients aren’t teenagers. But they’ll be at 80 percent the year after surgery, and they should make up the other 20 percent in the second year. Two years after the surgery, the average person can put their arm over their head. And women can put on their bra.”
Some patients might never get back to were before they had the surgery, but Wilkofsky said most patients will feel better and be able to do more after the operation.
Shackelford had his first replacement in May 2016, and then the second in August 2016. He also had wrist surgeries.
“I’m kind of a mess, so we took care of a bunch of things at once,” he said.
Shackelford said he went back to work, and was on the cautious side about the physical demands of EMS and fire fighting.
“But I was able to do it,” he said. “I had some issues with my breathing, but that was about being a fat 49 year-old guy and needing to get in shape.”
Wilkofsky said how long a replaced joint lasts depends on the patient. People ages 65 and older probably won’t need another replacement. Younger patients might have to have what’s called a revision, where surgeons repair or replace parts of an existing joint replacement. Or they might need a new replacement all together.
“I think sometimes people hear about this new tehnology, and they say, ‘I want the minimally invasive thing,’” he said. “I would caution that it’s not a panacea. Just because there’s a new technology available doesn’t automatically mean it’s the best choice. This is a decision you have to make with your orthopedic surgeon.”
Patients are approved for joint replacement surgery after their primary care practitioner refers them to a orthopedic surgeon, who ultimately recommends a course of action.
“I’m glad I did it,” Shackelford said. “It isn’t the easiest recovery in the world, but it’s not the worst either. But it got me back to work, and it was worth it.”
LUCINDA BREEDING can be reached at 940-566-6877 and via Twitter at @LBreedingDRC.
FEATURED PHOTO: The Simpliciti stemless shoulder implant is an option that's less invasive and involves less bone than older shoulder im