Dr. Andrew Ritting reduces shoulder replacement recovery time from months to just weeks with revolutionary, minimally invasive surgery technique.
For generations, patients with severe shoulder arthritis had two options: deal with the terrible pain or endure a shoulder replacement surgery that would leave them out of commission for four to six months.
Now for patients at Bucks County Orthopedic Specialists (BCOS), there is a new option thanks to Dr. Andrew Ritting and a new technique called SWAT (Subscapularis Sparing Window Anterior Technique), that makes shoulder replacement surgery a minimally invasive, outpatient procedure that reduces recovery time to weeks. Dr. Ritting is one of the only surgeons in the entire region offering this state-of-the-art surgery to patients.
Here Dr. Ritting, who specializes in upper extremity surgery and shoulder replacement, discusses the SWAT technique, his extensive training with it, the astonishing results for patients, and how this is an absolute “game changer” for BCOS patients.
Before we dive into specifics, what has been your overall experience and what results have you seen with the new SWAT procedure for shoulder replacement?
Dr. Ritting: It’s fascinating. There are not a lot of things in my professional career that I think have been true game changers. This one’s a big shift.
This technique for shoulder replacement makes it so much better for patients and their recovery. I’ve seen a huge population of patients who have been putting off shoulder replacement forever. And as soon as I talk to them about this procedure, they respond with enthusiasm, saying, “we’re doing this, sign me up.”
Why would someone need a shoulder replacement?
Dr. Ritting: It’s typically due to painful arthritis, which can be really excruciating. Shoulder arthritis can lead to so many things for patients; they have no motion in their arm; they have a ton of pain; or they can’t sleep at night.
What is the procedure and recovery for typical shoulder replacement surgery?
Dr. Ritting: Currently, nearly 100% of surgeons performing an anatomical shoulder replacement do so using a conventional method, which requires entering the shoulder by cutting through the rotator cuff to replace the joint. Afterward, the rotator cuff is reattached. The major limiting factor in recovery is that the rotator cuff has to heal before you can fully use your shoulder. Typically, this can mean up to two months in a sling followed by very slow and restricted progression of function.
This extended recovery period often deters patients from undergoing the surgery, despite experiencing significant pain and limited shoulder function. While they need a shoulder replacement, they may hesitate because the recovery is long, with the first two months in a sling followed by a gradual increase in shoulder use and extensive physical therapy. By four months, most patients can use the shoulder for daily activities. However, for athletes or weightlifters, recovery can take closer to six or seven months.
How does the SWAT procedure differ from traditional shoulder replacement surgery?
Dr. Ritting: The actual shoulder replacement procedure is the same, but the new technique uses a specialized guide and custom instruments that allow us to perform the surgery through a very small window between the rotator cuff muscles. This means we don’t have to cut through the rotator cuff at all.
In terms of shoulder replacement surgery, this has become a major game changer for recovery and patients’ willingness to undergo the surgery. There are many people who have physical jobs, who need to use their arms and shoulders for work, and they can’t give up their livelihood for four to six months.
Now, with this new technique, we don’t have to cut through the rotator cuff, and we can still do the same exact procedure. So, instead of months in a sling, patients are in a sling for about a week and half, then they’re using their shoulder. After that, they start physical therapy to maximize function, but they really don’t have any major restrictions other than heavy lifting.
I’ve had patients who have been avoiding surgery for years, opting instead for cortisone injections that help with the pain, but don’t fix the problem. Now that I can offer this procedure to them, they’re going from “I’m never going to do it,” to “When can we do it?” So, it’s exciting to be able to offer patients an option that can improve their quality of life so dramatically, with so little disruption.
Can you share one of your SWAT procedure success stories?
Dr. Ritting: There have been a lot of them, to be honest. But one recent patient who I just saw stands out a bit. She came into my office for her six-week post-op appointment, and she said she didn’t have any pain. She said she was doing everything she wanted to do. When I examined her, I found she already had full range of motion and full strength. I discharged her from my care at six weeks. It’s amazing. Patients should understand there is still a recovery phase which continues with time, but it’s such a huge difference. I usually don’t discharge patients until six months with the conventional procedure, and with her it was six weeks, because she was doing so well.
How did you learn the SWAT procedure for shoulder replacement?
Dr. Ritting: I make a point to stay on top of new developments in the field. When I learned about SWAT, I took courses, and went through extensive training on it, including some training with the doctors who helped develop it.
If I were to have shoulder replacement surgery using the SWAT procedure on a Tuesday, what would my Wednesday look like?
Dr. Ritting: Most patients receive a nerve block from the anesthesiologist before the surgery, which numbs the entire arm. The idea is that this block will keep you pain-free for around 18 to 24 hours. So, right after surgery, you’ll have no pain, and you can go home, sleep in your own bed, and remain comfortable through the night.
By Wednesday morning or midday, the nerve block will likely start to wear off, and that’s when you might experience the most discomfort. However, the block gets you through what would have been the worst part of the post-surgery pain.
After surgery, I prescribe pain medication. Many patients take a dose or two but find they don’t need much. Some may need pain meds for a week or so, but it’s common for patients to say they only took Tylenol to manage discomfort, which is often much less intense than the pain that they were experiencing before surgery.
When the chronic arthritis pain they’ve been living with for years is gone, any surgical pain tends to feel minor in comparison.
By Wednesday, you’ll likely have some discomfort, but you’ll still be able to use your hand, wrist, and move your elbow to prevent stiffness. Around a week and a half after surgery, we’ll have you come back to the office to remove the sutures and start physical therapy. By then, you’ll be out of the sling and able to use your shoulder for everyday activities, just avoiding heavy lifting.
Why doesn’t everyone who needs a shoulder replacement get this kind of surgery? In other words, are there patients who cannot get a shoulder replacement using with this procedure?
Dr. Ritting: Yes. To put it very simply, you have to a have an intact rotator cuff to have shoulder replacement surgery using the SWAT procedure.
When I see patients and evaluate them for this type of shoulder replacement surgery, the basic dividing factor is, do you have a functional rotator cuff? If the answer is yes, then you’re likely a candidate for, SWAT, although there are some variables. If the answer is no, then the patient needs what we call a reverse shoulder replacement surgery.
In those cases, this technique would not work because your rotator cuff is already torn and repairing that is part of the replacement process.
At this point, I have not seen anybody who met the requirements who I did not feel the SWAT procedure could be done on.
In shoulder replacement surgery, what you are technically “replacing?”
Dr. Ritting: The technical term for the shoulder joint is the glenohumeral joint, which is similar to the hip joint in that it’s a ball-and-socket structure. The orthopedic term refers specifically to the glenohumeral joint, but it’s essentially the entire shoulder. In the procedure, you’re removing all the arthritic bone, which is extra bone that has become rough and uneven. This is what causes pain and prevents smooth movement between the bones.
In a shoulder replacement, you’re replacing the damaged bone with a new, artificial joint made of metal and high-grade plastic. This creates a frictionless, smooth surface for the bones to move against each other.
I often explain to my patients that, ideally, your shoulder joint surface should be as smooth as if it were an eggshell and the movement as frictionless as melting ice on a smooth surface. However, when you have arthritis, it’s like moving around with cauliflower or broccoli in the joint. That rough surface has pain fibers, it grinds, and it feels like there’s gravel in the joint. With the replacement, you’re removing all that “gravel” and restoring a smooth joint.
Do you see this as the future of shoulder replacements?
Dr. Ritting: I do. My prediction is that, in 20 years, everyone will be doing shoulder replacements this way. Right now, it’s not common because most surgeons aren’t trained in it yet. But I saw that this is where the field is headed and trained in the technique.
When patients hear that one person took four or six months to recover from a shoulder replacement, but another took only four or six weeks, they’ll naturally choose the shorter recovery. This is the direction I believe shoulder replacement surgery is moving.
The technique is truly cutting-edge and minimally invasive. I also perform these shoulder replacements through only one incision that is a smaller incision than usual.
Why has the SWAT procedure become such an appealing option for BCOS patients who need a shoulder replacement due to painful shoulder arthritis?
Dr. Ritting: There are so many reasons. Obviously, I think the faster recovery is a great thing. But it’s also appealing because it’s outpatient surgery. Many times, it can even be done at our Bucks County Suites Surgical Suites, so there is no hospital stay or even hospital visit. Even to this day when I tell patients, that we will replace their shoulder and it’s going to take under an hour, they don’t have to go to the hospital, and they’ll get to go home the same day, they are pleasantly surprised.”
Shoulder replacement is not something you hear about all the time. Why?
Dr. Ritting: If you go back a few decades, shoulder replacements were a rare entity. The old dictum was that people just had to live with the pain. And patients had to deal with not doing the things that they want to do, whether it be for fun, for work, or with their family. Their painful shoulder was so limiting. The main reason was the actual equipment of the shoulder replacement was still evolving and improving. This has now all changed. Instead of just living with it for as long as you can, you can have your shoulder replaced and you can have a great outcome for a long duration.
So, things have shifted, shoulder replacements have become the new knee replacement. They have really taken off. When you look at the data on the number of shoulder replacements that are done on a yearly basis, it’s completely skyrocketed because the technology has gotten so much better with the longevity of the implants. With the adoption of the new SWAT technique, brand new technology can be placed into the shoulder in a minimally invasive way that also allows for expedited recovery.
In the Philadelphia region, where can patients go to get the new SWAT surgery for shoulder replacement?
Dr. Ritting: Bucks County Orthopedics! As far as I know, I am the only surgeon in this area performing SWAT surgery for shoulder replacement at this point. I’ve spoken with contacts from various hospitals, and they confirm that this technique, which is so state-of-the-art, is only just starting to catch on, and are not aware of any other surgeons who provide this option.
