Dr. Christian Schoch is a renowned specialist in shoulder and elbow surgery and endoprosthetics. As a senior physician at the St. Vinzenz Klinik Pfronten in the Allgäu region, he has many years of experience in the treatment of complex diseases and injuries to these highly specialized joints. His particular expertise lies in modern endoprosthetics of the shoulder joint, where he implants both anatomical and inverse prostheses - including innovative stemless models that allow for gentler treatment. He is also an experienced surgeon for frozen elbows, instabilities and rotator cuff tears.
Dr. Schoch completed his medical studies at the renowned Albert-Ludwigs-Universität Freiburg and deepened his specialist knowledge at the Sportklinik Stuttgart and during an international fellowship with Dr. Graham King in Canada. There he specialized further in complex elbow surgery, an expertise that plays a central role in his daily work today. He has been working at the St. Vinzenz Clinic since 2012, where he has established modern surgical procedures - from minimally invasive arthroscopic interventions to sophisticated revision procedures for failed prostheses or complex deformities.
Athletes, especially from the ice hockey sector, also rely on his expertise. As team doctor for EV Pfronten, he is very familiar with the special challenges of sports-related shoulder and elbow injuries. In addition to his clinical work, Dr. Schoch is intensively involved in scientific research. He has authored numerous specialist publications and is a regular speaker at national and international congresses. As chairman of the elbow commission of the AGA and an active member of leading specialist societies, he makes a significant contribution to the further development of orthopaedic and trauma surgery care. His aim is to offer his patients the best possible treatment using innovative techniques and the highest precision.
The editors of the Leading Medicine Guide spoke to Dr. Schoch about modern endoprosthetics and how precise shoulder and elbow surgery is today.
Diseases and injuries to the shoulder and elbow can severely restrict mobility and quality of life. Today, modern endoprosthetics and precise surgical techniques open up new ways of restoring function, strength and freedom from pain in the long term. Individually adapted implants, minimally invasive procedures and the latest surgical techniques allow patients to be treated in a targeted and gentle manner. The goal: optimal restoration of joint function with faster recovery and long-term durability of the results.
Shoulder and elbow problems that make shoulder and elbow endoprosthetics necessary are usually caused by advanced joint wear and tear diseases such as osteoarthritis or inflammatory processes in rheumatoid arthritis.
Complex fractures, particularly in older patients, can also damage the joint to such an extent that an artificial replacement is required. In addition, massive and long untreated tendon damage to the rotator cuff of the shoulder and post-traumatic changes following injuries often lead to irreparable joint destruction. In rare cases, tumor diseases also make joint replacement necessary. “We make a rough distinction between primary omarthrosis and secondary omarthrosis. No clear medical cause can be defined for primary omarthrosis, but risk factors include older age, physical work and female gender. Secondary omarthrosis refers to all wear and tear caused by other damage: post-traumatic (fracture-related malalignment), after shoulder dislocation, long-term tendon damage to the rotator cuff, circulatory disorders, rheumatism or other inflammatory or infectious diseases. The same ultimately also applies to the elbow. Due to the unclear genesis of primary omarthrosis, there is naturally little that can be done to prevent it. In general, the shoulder in particular is a very muscular joint, which means that the best protection against rapid wear and tear is good function with moderate exercise. Strength training can accelerate the development of osteoarthritis (the dose/load makes the poison). However, exercise and moderate stress in itself promotes cartilage nutrition. Secondary osteoarthritis can only be counteracted in the early stages, i.e. before the final stage of osteoarthritis develops, the underlying problems can be remedied. This at least slows down the development of osteoarthritis. This means that a stable joint is needed again after shoulder dislocation, and a refixed tendon on the bone in the case of tendon damage,” explains Dr. Schoch.
Early treatment of inflammation and minor injuries can help to prevent secondary damage such as osteoarthritis. A healthy lifestyle with a balanced diet, abstaining from nicotine and avoiding obesity also makes a significant contribution to maintaining joint health. In old age, fall prevention also plays a key role in avoiding serious fractures of the shoulder and elbow.
Shoulder endoprosthetics have developed considerably in recent years. Particularly noteworthy are improvements in implant design, surgical technique and the individualization of treatment depending on the patient's situation.
“In modern shoulder endoprosthetics, implants are becoming increasingly variable and better adapted to the individual needs of patients. In some cases, the prostheses are even custom-made from titanium using a 3D printing process. The anchoring of implant components is now predominantly cement-free. In my practice, I generally use stemless implants for primary shoulder prostheses, which means that a long stem in the humerus is not used if the bone substance is well preserved. This preserves valuable bone material. The theoretical advantages of this technique are shorter operating times, a lower risk of infection, less blood loss, better bone preservation and simplified options for subsequent replacement operations should the prosthesis become loose,” says Dr. Schoch.
Whether a patient is better suited to an inverse shoulder prosthesis or an anatomical shoulder prosthesis depends primarily on the function of the rotator cuff and the condition of the joint.
Dr. Schoch explains: “An anatomical shoulder prosthesis is generally only useful if the rotator cuff is intact and functional. These muscles and tendons are responsible for stabilizing the joint and controlling movement. However, if the rotator cuff is damaged or no longer functional - for example due to chronic inflammation, injury or wear and tear - an anatomical prosthesis is often no longer the optimal solution. In such cases, the inverse shoulder prosthesis is usually preferred, as it reverses the function of the joint and thus uses other muscles, in particular the deltoid muscle, to guide movement. Another important criterion is the position of the joint. For an anatomical shoulder prosthesis, the joint should be relatively 'centered', which means that the humeral head sits well in the socket and there is no pronounced instability. If the joint is unstable or deformed, the inverse prosthesis is often the better choice as it offers a more stable form of joint mechanics. The shape of the joint socket also plays a role. An anatomical prosthesis requires a relatively well-preserved, normal socket shape, without severe deformities or inclinations. If the socket is severely worn or has fallen off at an angle, an inverse shoulder prosthesis is usually more suitable, as it offers a functional solution even with irregular or destroyed socket shapes. Factors such as the patient's age, the bone substance, the degree of joint destruction and individual activity requirements also play a role in the decision. The aim is always to find the best functional and most durable solution for the patient in question."
Minimally invasive surgery on the shoulder and elbow has made great progress in recent years. Thanks to modern arthroscopic techniques, high-resolution cameras and special instruments, complex damage can now be treated gently. Smaller access points also mean less tissue damage when implanting prostheses. For patients, this means less pain, a lower risk of infection, faster healing and usually shorter or outpatient hospital stays.
Preoperative planning plays a key role in the success of shoulder and elbow prostheses today. Modern imaging techniques such as high-resolution X-rays, computer tomography (CT) and, increasingly, magnetic resonance imaging (MRI) enable an exact analysis of the individual anatomy and the severity of the joint damage.
The 3D image provides crucial information about the shape, position and condition of the humeral head and joint socket, particularly in the case of severely deformed or damaged joints. “The quality of an operation is already decisively influenced in the planning phase - on the drawing board, so to speak. For joints with only minor wear and tear, simple X-ray images are usually sufficient to adequately plan the implant. However, the more severely the joint - especially the acetabular side - is damaged, the more important detailed 3D planning using CT images becomes in order to optimally prepare the procedure. Although intraoperative navigation is not yet part of the general standard, it can help to implement the implant position as precisely as possible in accordance with the preoperative planning and thus achieve the best possible result in severely damaged joints,” explains Dr. Schoch.
In the case of severe rotator cuff tears where reconstruction of the tendons is no longer possible - for example because the tendons are severely retracted or scarred or the muscles are already considerably degenerated - there are several therapeutic approaches to restoring or at least improving shoulder function.
If direct tendon reconstruction fails or no longer makes sense, an attempt can first be made to support the function using so-called “biological” measures, for example muscle or tendon transfer surgery. This involves rerouting neighboring muscles or tendons to partially replace the missing function. However, such procedures are technically demanding and not suitable for all patients.
“Depending on the shape and location of the tear, the age of the patient and the remaining tissue quality, different treatment strategies can be considered. In younger patients with a centered joint and a large central tear, conservative treatment may be appropriate, possibly supplemented by partial closure of the tendon cap to prevent further tear enlargement. In addition, the long biceps tendon can be used to biologically reinforce the reconstruction. In certain cases, muscle relocation is also possible, in which larger muscles are redirected to the torn area in order to restore shoulder function. Other approaches, such as the use of placeholders (e.g. inflatable balloons or implants under the acromion), have only shown limited success to date. I see such so-called 'salvage' procedures more as an option for very young patients and not as a long-term solution. In contrast, the inverse shoulder prosthesis has proven to be the most reliable method for patients over the age of 60 to 65. Today, it is the 'workhorse' of shoulder surgery for this age group. In younger patients in particular, a stemless version is preferred in order to preserve as much of the patient's own bone as possible,” emphasizes Dr. Schoch.
Interdisciplinary cooperation between surgery, physiotherapy and sports medicine is crucial to the success of rehabilitation following shoulder or elbow prosthesis implantation.
“Close collaboration with the physiotherapists is crucial to the success of the treatment. Even if optimal mechanical stability and joint structure are achieved in the operating room, this alone is not enough: Without targeted restoration of function through active exercises - both independently and under the guidance of a therapist - the success of treatment remains limited. Short phases of immobilization, the targeted use of movement splints (CPM devices) and consistent physiotherapeutic care, supplemented by inpatient rehabilitation if necessary, are important. The shoulder generally takes a long time to heal; recovery periods of three to four months are completely normal. To ensure successful therapy, it makes sense to define clear targets and coordinate these with the therapists. Nevertheless, the treating therapist should first and foremost react flexibly to the current findings and adapt the rehabilitation program accordingly. For patients who are particularly active in sports, it makes sense to carry out a 'back-to-sport' test at the end of rehabilitation to ensure that the joint can bear weight again and that a return to sport or intensive exercise is possible without risk,” explains Dr. Schoch, and with that we end our conversation.
Thank you very much, Dr. Schoch, for this insight into your work!
