Can I avoid shoulder replacement surgery? The evidence for shoulder replacement alternatives
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.
In this article, we will explore options and alternatives to Shoulder Joint Replacement. We will also discuss the various non-surgical regenerative medicine injection techniques. Many people do very well with shoulder replacement surgery. These are not the people that we see in our practice. We see the people who are looking for answers who are not good surgical candidates, have been told that there is a good chance the surgery will not work for them or have already had the surgery with less than happy results. We also see the patient who is exploring their options, maybe the waiting list to get the surgery is long and the only treatments that can be offered at this time are cortisone and increased medications.
What will we be discussing in this article?
- You wake up in the morning, your shoulder is killing you.
- “I am leaning towards the shoulder replacement because I do not know what else to do.”
- The last treatment available – shoulder replacement.
- Doctors aren’t helping you despite the medications and cortisone.
- The road to shoulder replacement.
- Conservative Care followed by arthroscopic shoulder surgery
- A case history of a patient who came to Caring Medical following extensive shoulder surgery.
- So here you are, years of treatment, maybe a past surgery, you still have pain. Why?
- Your rapidly degenerating shoulder is trying to function and survive. It swells up so it can function as best it can. Swelling holds the shoulder together. Your shoulder is trying to hold itself together.
- A heightened sense of shoulder pain is caused by runaway inflammation. Your shoulder hurts worse than it should because your shoulder is trying to get your attention.
- Your shoulder is under stress physical and emotional. Yes, your shoulder gets stressed out.
- The shoulder becomes highly inflamed.
- Now let’s talk shoulder replacement – Some doctors suggest shoulder replacement surgery is the only answer
- The research: When the shoulder is “too far gone.”
- Some doctors suggest shoulder replacement surgery may make things worse – shoulder replacement recovery time – complications are often lengthy and sometimes never go away.
- Why was the patient being sent to a revision shoulder replacement? What were the revision surgery complication rates?
- The list of shoulder surgery complications.
- Soft tissue damage after shoulder replacement, a leading cause of surgery failure.
- No clear consensus on returning to activity or sport after reverse shoulder replacement.
- 70% return to sports – overhead sports remain problematic.
- Understanding the reverse total shoulder replacement and conventional shoulder replacement surgery.
- Postoperative outcomes are disappointing, and the complication rate is high.
- Shoulder replacement works better for older patients…but complications, painkiller use, and complications are still a concern to surgeons.
- Complications leading to re-operation are often multiple and underestimated.
- Obesity is a complication concern in shoulder replacement.
- The realistic assessment of revision total shoulder replacement.
- Will your shoulder be stronger after shoulder replacement?
- Alternatives to shoulder replacement surgery.
You wake up in the morning, your shoulder is killing you
You wake up in the morning, your shoulder is killing you. No matter which way you turn, your shoulder hurts. You hardly slept because of your shoulder. You get up, you stand at the foot of your bed and you begin your morning trying to figure out how far you can lift your arms up. Then you start “loosening up,” and hoping you can get by today without a lot of help from medications.
Hopefully going to the toilet, washing, and getting dressed will not be a big chore and you will not have to bother your spouse or other loved ones to help you do these simple tasks.
“I am leaning towards the shoulder replacement because I do not know what else to do.”
We see shoulder pain patients, and no matter how unique their story is, most have the same common problems and the same common medical history. They tell stories like this:
The last treatment available – shoulder replacement
I have had shoulder pain for a long time, my line of work is physically demanding. I have been to my doctors and specialists many times. I have been given varying doses of different pain medications, muscle relaxants, and anti-inflammatories. I have had cortisone twice. I have been sent to physical therapy, tried chiropractic and various electro-stimulation products. I am at the point now that my visits to the orthopedics are long discussions about surgical options.
I am here to explore other options. I do have a good range of motion in my shoulder though I cannot lift my arm over my head because of weakness. I can pick up objects and carry them, I just can’t leave them on a table or platform above my waist.
Doctors aren’t helping you despite the medications and cortisone
During the initial medical history review, our patients tell us about the long list of treatment options that were recommended for their degenerative shoulder disease. These treatments do help some people. For some, perhaps like yourself, symptom relief was temporary. For others, the pain relief lasted hours or days if at all.
If you are reading this article it is more than likely you are in that group of patients who are still seeking answers despite years of these treatments and even a past history of “shoulder preserving arthroscopic surgery,” which at this point, does not appear to be successful in preserving your shoulder.
At your last follow-up visit with your orthopedic surgeon, a long discussion may have taken place over whether to continue with your conservative care options or pursue the shoulder replacement. Your concern with these “conservative care” treatments is that you will continue to have more pain, more grinding, more popping, and more clicking. You recognize that you are only being symptom managed and you need to fix it once and for all.
The road to shoulder replacement Conservative Care followed by arthroscopic shoulder surgery
- You may be on Anti-inflammatory medications. This is not something we recommend. Please see our article When NSAIDs make the pain worse.
- Stronger pain medications. This particular recommendation has very little long-term appeal as it can make your situation worse. Please see our article, when Painkillers make the pain worse.
- Corticosteroids/cortisone or steroid injection. This is also a treatment we do not recommend. Please see our article Alternative to cortisone shots
Arthroscopic shoulder surgery
- We frequently see patients who have had surgery for shoulder pain but are subsequently left with more chronic pain after surgery. The surgeries, such as arthroscopic surgery for glenoid labrum tears, Slap lesions of the shoulder, and of course for various degrees of rotator cuff tears and damage will sometimes lead to rapid shoulder deterioration. When these surgeries fail, shoulder replacement will be recommended.
Here is a case history of a patient who came to Caring Medical.
Here is a case history of a patient who came to Caring Medical. The patient had extensive shoulder surgery. Seemingly, the surgeon tried to “fix” everything he thought was damaged enough to cause pain. The surgery went as planned, with no complications, and the surgeon accomplished everything he set out to do. Two years following the surgery the patient came to our office, still in pain. How could this be? Let’s look at exactly what was done.
The patient had an arthroscopic procedure for:
- partial-thickness rotator cuff tear, Type I (least severe),
- a labral tear,
- grade III to IV (nearly most or most severe) chondromalacia of glenohumeral joint and
- subacromial bursitis.
The labrum is a lip of cartilage that helps keep the end of the humerus in the shallow socket (glenoid). Chondromalacia is the degeneration of the cartilage inside the joint. Bursitis refers to the bursa, one of the fluid-filled sacks that provide cushioning in joints.
During the procedure, the surgeon debrided the labral tear and the rotator cuff tear. Then, where the chondromalacia was most severe, he performed a chondroplasty. This consists of scraping the damaged cartilage which covers the surface of the bone in hopes of having healthy cartilage grow back. He scraped both the humeral head and the glenoid. He then performed a bursectomy, removing the inflamed bursa. This is fairly typical of what we see in an arthroscopy report of the shoulder.
The patient expressed a desire to return to tennis as a key to surgery outcome, and surgery did not help him with this, and he was left with chronic pain.
So here you are, years of treatment, maybe a past surgery, you still have pain. Why?
Many times a patient will come into our office with advancing osteoarthritis of the shoulder. When they describe their shoulder pain they say things like:
- “My shoulder is barking at me today,” or
- “My shoulder is letting me know it is there.”
When we manipulate their shoulder to test for range of motion and we all hear the audible pops, clicking, and grinding, sometimes the patient tells us “My shoulder is talking.”
Intuitively these people know that their shoulder is talking to them. Do they understand what their shoulder is saying? Do you?
Your rapidly degenerating shoulder is trying to function and survive. It swells up so it can function as best it can. Swelling holds the shoulder together. Your shoulder is trying to hold itself together.
When your shoulder swells up. It is talking to you. It is saying “I am not stable, I have instability. I am going to swell up to hold myself together.” If you are reading this article, this may be happening to you all the time. Here is the science of what your shoulder is doing. When you understand what your shoulder is doing, you can understand what may be the best treatment for you.
This is research published in the Journal of Shoulder and Elbow Surgery. (1)
Here are the highlights:
- Shoulder osteoarthritis is a gradual wearing of the articular cartilage accompanied by degenerative rotator cuff tears. This pathologic (disease) disorder is related to inflammation, oxidative stress, and angiogenesis.
- What does this mean? What is your shoulder saying?
- Angiogenesis is the formation of new blood vessels. In degenerative shoulder disease, new blood vessels can be beneficial as they bring healing and growth factors to the site of injury or they can be harmful as they open new highways for chronic inflammation (chronic swelling) which eventually erodes joints.
- So your shoulder is telling you that it is creating more blood vessels to bring more inflammation to it.
- Degenerative alterations in the shoulder may prompt the production of cytokines and angiogenesis-related proteins, evoking rotator cuff diseases.
- What does this mean? What is your shoulder saying?
- Cytokines are small proteins that cells secrete when they want to communicate with each other. Cytokines, while beneficial in acute injury to help heal damage, become detrimental in chronic pain situations. They sustain chronic inflammation and create more pain. How? We are going to briefly discuss a 2007 paper that researchers have heavily cited for its understanding of Cytokines that appeared in the journal International anesthesiology clinics. Here we will see that your shoulder is no longer talking but yelling at you!
A heightened sense of shoulder pain is caused by runaway inflammation. Your shoulder hurts worse than it should because your shoulder is trying to get your attention.
- In this paper from the University of Cincinnati, (2) doctors say:
- “There is significant evidence showing that certain cytokines/chemokines (part of the cytokines family of inflammation) are involved in not only the initiation but also the persistence of pathologic pain by directly activating nociceptive sensory neurons. (Simply excessive messages sent to nerve cells that something is hurting), but also certain inflammatory cytokines are also involved in nerve-injury/inflammation-induced central sensitization and are related to the development of contralateral hyperalgesia/allodynia. (A heightened sense of pain caused by runaway inflammation).
What all this means is that your shoulder hurts worse than it should because your shoulder is trying to get your attention. What is your shoulder trying to get you to do? It wants you to stop doing what you are doing to make it hurt.
Your shoulder is under stress physical and emotional. Yes, your shoulder gets stressed out.
For someone in chronic pain, if you told them that shoulder is stressed out, burnt out, ready to give up. They will probably not argue with you. Because that is the way they feel some days. Stressed, tired, ready to talk about shoulder replacement. Let’s recap what we discussed to this point:
- Your shoulder is unstable. The ball and shoulder socket are banging against each other because your rotator cuff tendons, muscles, labrum, and shoulder ligaments are damaged and not holding your shoulder together.
- Your shoulder is asking your immune/repair system for more inflammation to bring swelling to act as a “cast,” to hold the ball and shoulder socket in proper alignment.
- But the shoulder knows it cannot stay in a constant state of swelling. Chronic inflammation is toxic. It burns out and erodes the joint. Your shoulder is hurting more because it is trying to send you more pain signals that this situation is on the verge of joint “death,” – your shoulder will not survive prolonged chronic inflammation and will need to be replaced.
The shoulder becomes highly inflamed
Back to the research, we cited above (1):
- In the two groups of patients examined and divided by less severe and more severe osteoarthritis and rotator cuff tear, measurements of the patients:
- Cytokines (a way to determine the number of pain signals and messages going back and forth in your shoulder between cells),
- growth factors (healing chemicals that your body is sending to the shoulder)
- and angiogenic biomarkers to determine if and how much blood vessel making activity was happening
- Findings: Well-known inflammatory factors such as interleukin 8, tumor necrosis factor α, and interleukin 1β were considerably elevated in synovial fluids of the patients.
- (The whole joint was highly inflamed and in a state of erosion).
- The joint inflammation highly enhanced insulin-like growth factor 1 and transforming growth factor β1 (TGF-β1) in the synovial fluids and serum.
- (The inflammation was more destructive, potent, and lethal to cells.)
- The toxic situation is shown by upregulated inflammatory factors that have created oxidative stress throughout the shoulder).
Now let’s talk shoulder replacement – Some doctors suggest shoulder replacement surgery is the only answer
You may be wrestling with the idea of shoulder replacement because you are a worker who needs to work. Shoulder replacement brings with it possible hope, but it also brings with it, the risk of surgery, possibility of complications, surgical recovery, and rehab time. For some, the problem with the surgery is not the surgery itself, it is the rehabilitation and the downtime away from exercise, physical activity, and sports involvement. For others, it is time away from work. For these workers, some consider shoulder replacement as a means of “forced retirement,” or “disability.” At what price do you have the surgery? At the cost of your job? At the cost of maintaining a fitness lifestyle? Is replacement surgery the only way?
Here is a sample email from someone asking about shoulder replacement options:
My MRI report says I have advanced narrowing of the glenohumeral joint space. Bone spurs. Subchondral cystic change (Bone cysts). Mild Acromioclavicular Joint degeneration. I already had a shoulder replacement in my left shoulder and I do not want to go through another surgery. I have a great deal of pain from my shoulder that radiates into my arm. I am getting physical therapy and while this is helping my range of motion, it is not helping with the pain. Is surgery the only way for me?
Often we will see a patient who says, “I went to two reputable orthopedists, both said surgery was the only way.” Below we are going to show you research that surgery is not the only way for many people. Surgery is usually the only way when the shoulder bones are fractured or there is a gross anatomical failure, bone spurs, complete or near loss of range of motion, no cartilage at all.
The research: When the shoulder is “too far gone.”
Some doctors suggest shoulder replacement surgery is the only answer: This is from the journal Arthritis Research and Therapy: (3)“While research in cartilage regeneration has not yet been translated clinically, the field of shoulder arthroplasty has advanced to the point that joint replacement is an excellent and viable option.”
Why? Because of poor tendon healing and irreversible changes associated with rotator cuff inflammation.
- In other words, the shoulder is “too far gone.”
- But the same researchers also say: “Future treatment types involving biologics and tissue engineering (stem cells) hold further promise to improve outcomes for patients suffering from shoulder pathologies.”
- Stem cells used during the course of surgery – Many of you reading this article may have already had a consultation for shoulder surgery. The surgeons may have advised you that they were able to bring stem cells into the surgery to facilitate healing. We address this in our article My surgeon wants to use Platelet Rich Plasma and Stem Cell Therapy during surgery.
Some doctors suggest shoulder replacement surgery may make things worse – shoulder replacement recovery time – complications are often lengthy and sometimes never go away.
Researchers from Texas Orthopedic Hospital, the University of Houston, University of Texas, (4) released their findings and documented that the number of shoulder replacements being performed has increased exponentially in recent years, with a corresponding increase in the number of second surgeries to fix the first one.
- In patients surveyed for this study: 21.6% (8/37) required reoperation for postoperative complications.
- Overall, 54% of patients (20/37) suffered from intra- or postoperative complications.
CONCLUSION: Shoulder implant replacement improved function in the present series, but with a high rate of complications and reoperations.
This, of course, will throw a big concern at patients – shoulder replacement recovery time – complications are often lengthy and sometimes never go away.
The list of complications
An October 2019 study, (5) using this complication study as a reference outlined to radiologists what they needed to look for in MRI and x-rays of patients complaining of pain after shoulder replacement. The research came from the Angers University Hospital in France and was published in the European Society of Radiology’s journal Insights Into Imaging.
- Shoulder arthroplasties are divided into three categories: reverse shoulder arthroplasty, total shoulder arthroplasty, and partial shoulder joint replacement (including humeral hemiarthroplasty and humeral head resurfacing arthroplasty). Each of these prostheses can present complications, either shared by all types of arthroplasty or specific to each.
- Infection, periprosthetic fractures, humeral component loosening, heterotopic ossification, implant failure, and nerve injury can affect all types of prostheses.
- Instability, scapular notching, and acromial fractures can be identified after reverse shoulder arthroplasty implantation. Glenoid component loosening and rotator cuff tear are specific complications of total shoulder arthroplasty.
- Progressive wear of the native glenoid is the only specific complication observed in partial shoulder joint replacement.
- Knowledge of different types of shoulder prostheses and their complications’ radiological signs is crucial for the radiologist to initiate prompt and adequate management.”
Why was the patient being sent to a revision shoulder replacement? What were the revision surgery complication rates?
An August 2021 study comes to us from the Brighton and Sussex Medical School and the University Hospitals Sussex and Dorset in the United Kingdom. It was published in the journal Bone & joint open.(6)
The researchers of this paper told their fellow physicians that “it is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty (replacement). Currently, this has not been well quantified. This review aims to address that deficiency (lack of understanding of what is causing the complications and what can realistically be done about it) with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses (should you get the anatomically correct shoulder replacement of the reverse shoulder replacement) when used in revision surgery.”
Why was the patient being sent to a revision shoulder replacement? According to the researchers the indications for revision included:
- Component loosening 20% (601/3,041 patients),
- Shoulder instability 19% (577/3,041 patients),
- Rotator cuff failure 17% (528/3,041 patients), and
- infection 16% (490/3,041 patients).
The complications after the revision shoulder replacement were recorded as:
- Intraoperative complication (a complication arose during the revision surgery, during the surgery) was 8% (this was measured as 230 shoulder complications out of 2,915 patients in the study).
- Postoperative complication was 22% (825 of 3,843 patients in the study).
- Reoperation rates were 13% (584 of 3,843 patients in the study).
The researchers then left us with these take home messages:
- Revision to reverse total shoulder arthroplasty is associated with better outcomes than revision to anatomical total shoulder arthroplasty (better to have a reverse shoulder replacement the second time around).
- Intraoperative complication rate was 8%, postoperative complications rate was 22%, and reoperation rate was 13% following revision shoulder arthroplasty. (Revision shoulder surgery has a high complication rate).
- Outcomes from revision shoulder arthroplasty show clinically important improvement in patient-reported outcome measures. (Many people got great benefit from the revision shoulder replacement).
- Revision to reverse geometry total shoulder replacement rather than to anatomical total shoulder replacement from any index (primary procedure whether reverse or anatomically correct shoulder replacement) procedure appears to result in lower complication rates and better postoperative outcome scores.
Soft tissue damage after shoulder replacement, a leading cause of surgery failure
In September 2019, a paper in the Clinics in Orthopedic Surgery (7) noted that “The majority of patients with shoulder instability after anatomic shoulder arthroplasty (replacement) have both soft tissue imbalance and component malposition. Rotator cuff (surgical) repair after shoulder replacement has also had a poor success rate. Additionally, revision surgery with anatomic components and soft tissue reconstruction has had a high failure rate. Consequently, both instability and symptomatic rotator cuff dysfunction after anatomic shoulder arthroplasty are preferably treated with revision to a reverse prosthesis.” In common terms, Reverse shoulder surgery.
No clear consensus on returning to activity or sport after reverse shoulder replacement
A July 2019 study published in the journal Shoulder & Elbow (8) states clearly that “Reverse total shoulder arthroplasty is now the most frequently performed form of shoulder replacement. There is currently no consensus on recommended levels of activity and sport following Reverse total shoulder arthroplasty.”
However, these researchers do suggest that “Return to sport is tolerated following Reverse total shoulder arthroplasty; however, studies are short to medium term only and although the reported complication rate is low, the studies did not include a radiographic evaluation. Longer-term studies with subgroup analysis evaluating common recreational activities after reverse total shoulder arthroplasty are required, particularly in the younger population, in order to establish clear post-operative guidelines.”
70% return to sports – overhead sports remain problematic
A June 2021 study in the Orthopaedic journal of sports medicine (9) led by the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota offers this opinion: “Patients who had undergone primary uni (one-sided)- or bilateral (both-sided) reverse shoulder replacement reported a 70.1% rate of return to sports with the maintenance of the same level of intensity, duration, and frequency of preoperative sport participation. Rates of return to high-demand sports were lower than low- and medium-demand sports. Patients also had difficulty returning to overhead sports.”
In this report, none of the patients returned to these “high-demand sports”:
Understanding the reverse total shoulder replacement and conventional shoulder replacement surgery.
When conventional total shoulder replacement is judged not to be effective, a reverse total shoulder replacement may be suggested as an option.
The procedure sounds exactly as it is named. In a traditional shoulder replacement, a plastic “cup” is fitted into the shoulder socket (glenoid), and a metal “ball” is attached to the top of the upper arm bone (humerus). In a reverse total shoulder replacement, the socket and metal ball are switched.
The benefits of the reverse procedure are studied in a paper published in the medical journal Orthopedics. (10)
- The paper suggests that a reverse total shoulder arthroplasty is better suited for older patients with glenohumeral arthritis and a deficient rotator cuff.
- However, as a semi-constrained prosthesis, (that is implants that create artificial stability by limiting the prosthesis range of motion) a conventional reverse total shoulder replacement in a young patient could fail over time because of the polyethylene wear and subsequent osteolysis – the joint replacement causes accelerated bone loss.
Postoperative outcomes are disappointing, and the complication rate is high
- The researchers in the current study suggest at first that a metal-on-metal prosthesis may avoid this type of failure. However, they concluded: “Although metal-on-metal total shoulder replacement may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are disappointing, and the complication rate is high.”
Another study from Dr. Pascal Boileau of the Department of Orthopedic and Sports Surgery Pasteur 2 Hospital, University Institute of Locomotion and Sports in France examined outcomes and complications in young patients undergoing revision reverse total shoulder arthroplasty (RTSA) for failed prior total shoulder arthroplasty or ball replacement and compared them with those of older patients undergoing the same procedure.
- While reverse total shoulder arthroplasty is effective in reducing pain and improving function after failed arthroplasty in young patients, complication rates are high and expectations should be managed appropriately. Subjective outcome scores are worse for older patients. (11)
Update on complications:
Many people get great benefits from a reverse shoulder replacement. Some people do not.
A March 2021 paper in the journal Clinics in Shoulder and Elbow (12) lists the complication challenges some patients to face after reverse shoulder replacement. Here is what these researchers wrote:
“Reverse shoulder arthroplasty is an ideal treatment for glenohumeral dysfunction due to cuff tear arthropathy (degenerative disease). As the number of patients treated with reverse shoulder arthroplasty is increasing, the incidence of complications after this procedure also is increasing.
The rate of complications in reverse shoulder arthroplasty was reported to be 15%-24%.
Recently, the following complications have been reported in order of frequency:
- periprosthetic infection,
- periprosthetic fracture,
- neurologic injury,
- scapular notching (a wearing away of the scapular)
- acromion or scapular spine fracture,
- and aseptic loosening of the prosthesis.
However, the overall complication rate has varied across studies because of different prosthesis used, improvement of implant and surgical skills, and different definitions of complications.”
Shoulder replacement works better for older patients…but complications, painkiller use, and complications are still a concern to surgeons
Here are the bullet points to recent medical studies:
- Doctors in the United Kingdom write in the medical journal Shoulder and Elbow that the management of glenoid bone loss is a major challenge in both complex primary and revision arthroplasty surgery. (13)
- Doctors writing in The Journal of Bone and Joint Surgery noted that shoulder surgery was seen as a further complication of rotator cuff disease. “Secondary rotator cuff dysfunction is a recognized complication following shoulder arthroplasty. We hypothesized that the rate of secondary rotator cuff dysfunction would increase with follow-up and result in less satisfactory clinical and radiographic outcomes.” (14)
- A February 2020 (15) update from the Hospital for Special Surgery’ journal offered this:
- A total of 824 cases of revision shoulder arthroplasty were found. Eighty-seven patients (10.5%) had infections prior to revision and 133 patients (16.1%) had dislocations prior to revision. . .The most common complication of revision shoulder arthroplasty was found to be surgical site infection, affecting 10.9% of patients. In the time period studied, 89 patients underwent more than one revision shoulder arthroplasty.”
Complications leading to re-operation are often multiple and underestimated
Doctors writing in the Muscles, Ligaments and Tendons Journal, suggest that if you had a surgery that failed to fix your shoulder pain – it is not recommended that you get a second surgery to fix the first one because 36% of those surgeries fail too. (16)
- Shoulder replacement infection: In another study, doctors say that one of the greatest risk factors for infection after shoulder replacement was a history of prior failed shoulder surgery. So replacing the shoulder in an attempt to fix the first shoulder surgery had a high risk of infection.
Back to the study from Dr. Boileau: The most common causes of revision surgery after reverse total shoulder arthroplasty (RTSA) are:
- prosthetic instability (38%),
- infection (22%),
- humeral problems (21%) including loosening, unscrewing, and fracture,
- and, lastly, problems of polyethylene glenoid loosening (13%). (11)
Doctors at the University of Washington sum up shoulder failure surgery as: “…surgery has failed when it does not achieve the expectations of the patient and the surgeon. Failure can result from stiffness, weakness, instability, pain, or failure to heal as well as from complications such as infection or nerve injury
Every surgery has a risk of failure whether it is an operation for dislocation, rotator cuff tear, arthritis, or fracture. Because fracture fixation, Bankart repairs, rotator cuff repairs, shoulder joint replacements and reverse total shoulders are performed commonly, a substantial number of patients have experienced these failures.”
Obesity is a complication concern in shoulder replacement
- Doctors at the University of Alabama at Birmingham found that patients suffering from Metabolic syndrome, that is large waistlines (obesity), high triglyceride levels, high cholesterol, high blood pressure, and high cholesterol, are associated with considerable complication risk before, during, and after shoulder replacement surgery. (17)
Doctors from the Mayo Clinic writing in the Journal of Bone and Joint Surgery discuss the problems of obesity caused in patients after shoulder replacement surgery.
Here is what they said:
- Increasing Body Mass Index (Obesity) was associated with an increased risk of the need for a second or revision surgical procedure, reoperation, revision for mechanical failure, and superficial infection.
- Increased BMI was also associated with an increased risk of revision for mechanical failure.
- The most marked association between increasing BMI and any complication in shoulder arthroplasty was its association with superficial wound infection.
- It is important to consider these findings when counseling patients, estimating risks, and estimating complication risks in policy decisions. (18)
Malnutrition, obesity, and anemia
A January 2022 study published in the Journal of Shoulder and Elbow Surgery (19) added to this by suggesting: “Malnutrition, obesity, and anemia contribute to significantly higher costs after shoulder arthroplasty. Medical strategies to optimize patients before shoulder arthroplasty are warranted to reduce total 90-day encounter charges, length of stay, and risk of readmission within 90 days of surgery. Optimizing patient health before shoulder surgery will positively impact outcomes and cost containment for patients, institutions, and payors after shoulder arthroplasty.”
Obese patients do get benefits
Another January 2022 study published in the Journal of Shoulder and Elbow Surgery (20) suggested: “Both non-obese and obese patients can expect clinically significant improvements in pain, motion, and functional outcome scores following (shoulder and reverse shoulder replacement). Obese patients reported significantly more postoperative pain, lower outcome scores, and less ROM compared with non-obese patients after both (shoulder and reverse shoulder replacement) at an average follow-up of 5 years.”
The realistic assessment of revision total shoulder replacement. The revision surgery is a high risk, if it works out the patient is better off. If it does not work out?
A June 2020 study in the journal Current Reviews in Musculoskeletal Medicine (21) offers a surgeon’s eye view of the realistic outcomes following failed shoulder surgery:
“Despite relatively high complication and reoperation rates with revision shoulder replacement, revision of failed hemiarthroplasty or total shoulder arthroplasty to reverse total shoulder arthroplasty improves outcomes for many patients. A failed hemiarthroplasty or total shoulder arthroplasty is frequently disabling for the patient and because the surgical revision options are often limited only to reverse total shoulder arthroplasty, the potential improvement is often worth the higher surgical complication or reoperation rate.”
The revision surgery is high risk, if it works out the patient is better off. If it does not work out?
A June 2019 study in the Journal of Shoulder and Elbow Surgery (22) found good results for the revision surgery. The learning points of this study were:
- In the 110 patients involved in the study, the revision surgery implant survival was 92% at 2 years and 74% at 5 years.
- Seventy percent of patients were “very satisfied” or “satisfied with their outcome.
- Complications occurred in 18 patients (20%), and 10 patients (11%) underwent re-operation.
It is the last group of people that we usually see in our office looking for non-surgical help.
Will your shoulder be stronger after shoulder replacement?
A January 2022 study from the University of Florida published in the Journal of Shoulder and Elbow Surgery (23) sought to determine whether preoperative shoulder strength is predictive of postoperative outcomes and improvement after primary total shoulder arthroplasty. In other words, does having more shoulder strength help your total shoulder replacement outcome?
The researchers looked at data from 160 shoulders with a minimum 2-year follow-up after primary total shoulder arthroplasty. Preoperative external rotation strength, supraspinatus strength, and abduction strength (the ability to raise your arms to 90 degrees from your side) scores were analyzed to determine their correlation with postoperative outcomes and improvement in shoulder strength, range of motion (ROM), and outcome scores.
They found: “Preoperative shoulder strength is moderately associated (it helped moderately) with postoperative outcomes and improvements in shoulder strength, ROM, and outcome scores after primary total shoulder arthroplasty. It is important to note that we identified preoperative strength values that led to a decrease in strength postoperatively but not ROM or outcome scores. The results of our study demonstrate that abduction strength may be a useful indicator of patient outcomes after primary total shoulder arthroplasty. Our findings will provide surgeons with useful prognostic insight to aid in guiding patient expectations. In other words, does preoperative shoulder strength help with recovery, range of motion, and replacement surgery outcomes? In some people yes in others no.”
A study where the average patient was a 71 one-year-old woman
A study from the Department of Orthopedics and Traumatology, Istanbul University Faculty of Medicine and published in November 2019 (24) compared the strength and endurance of shoulder rotation between shoulders who had a reverse shoulder replacement and the patient’s other shoulder which was not replaced. The patients in this study had one shoulder replaced because of
- Patients exhibited improvement in functional level in the replacement shoulder.
- The limitations however following surgery were strength and endurance of internal and external rotation.
- While some patients saw improvement in function shoulder durability and strength of rotation would be weak.
Alternatives to shoulder replacement surgery. PRP and Prolotherapy
In this section, we will discuss the realistic treatment options to shoulder replacement surgery. We will focus on Prolotherapy and PRP injections.
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint and spine deterioration.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.
- Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on extensive research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.
Caring Medical Research:
In the same manner, we present research on shoulder replacement surgery, we would like to present information on regenerative medicine injections. Our focus is on simple dextrose Prolotherapy as the first course of action. In more problematic cases, we may rely on Platelet-rich Plasma injections or bone marrow concentrate commonly referred to as stem cell therapy.
Hauser RA, Hauser MA. A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois. Journal of Prolotherapy. 2009;1(4):205-216. The article in its entirety can be downloaded as a PDF
What are we seeing in this image?
A shoulder x-ray showed a large bone spur. This is an x-ray of a patient who was only in their ’30s. The patient suffered from significant shoulder pain and limited range of motion. In this image, the shoulder cartilage is fairly well preserved but the large osteophyte or bone spur is present. This is a situation where Prolotherapy can be helpful with the elimination of the patient’s pain, the bone spur causing restricted movement may require surgery.
94 Patients treated with Prolotherapy with the hopes of avoiding surgery
Here is a summary of our research:
- We studied a sample of 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy.
- An average of 20 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment.
- The results of this study showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation), with Prolotherapy, including the 39% of patients who were told by their medical doctors that there were no other treatment options for their pain and the twenty-one percent who were told that surgery was their only option.
- Over 82% of all patients experienced improvements in sleep, exercise ability, anxiety, depression, and overall disability with Prolotherapy. Ninety-seven percent of patients received pain relief with Prolotherapy.
Conclusion: In this study, patients with chronic shoulder pain reported significant improvements in many clinically relevant parameters and overall quality of life after receiving Hackett-Hemwall dextrose Prolotherapy.
In our research, published in Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders, (25) Ross Hauser, MD and Danielle R. Steilen-Matias, MMS, PA-C contributed to findings suggesting Dextrose Prolotherapy has been able to reduce pain and disability of traumatic and nontraumatic rotator cuff conditions.
- The research revealed that treatment of moderate to severe rotator cuff tendinopathy due to injury with injections of hypertonic dextrose on painful entheses (the ligament and tendon attachments to the bone) resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline.
- A study published in the journal Archives of Physical Medicine and Rehabilitation found that treatment of moderate to severe rotator cuff tendinopathy with injections of hypertonic dextrose (Prolotherapy) on painful entheses (the tendon attachments to the bone) resulted in superior long-term pain improvement and patient satisfaction. (26)
- Another study also published in the journal Archives of Physical Medicine and Rehabilitation, demonstrated dextrose Prolotherapy improved in pain, disability, isometric strength, and shoulder active range of motion in patients with refractory chronic non-traumatic rotator cuff disease. (27)
- In the journal, Alternative Therapies in Health and Medicine, (28) doctors presented a case study at the Medical Center at Southwest College of Naturopathic Medicine in Tempe. Here a middle-aged male with a long-term history of untreated shoulder pain received injections into the glenohumeral joint space, the acromioclavicular joint, the subacromial space, and the insertion of the supraspinatus.
- Results: Following 3 sessions of Prolotherapy, the patient reported a 90% reduction in pain and full restoration of normal activity. The findings suggest that dextrose Prolotherapy may be an effective treatment for chronic shoulder pain and may be an alternative to surgery or other more costly and invasive interventions.
- A March 2019 study in the Journal of Ultrasound in Medicine (29) found that ultrasound-guided Prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate-to-severe acromial enthesopathy and acromioclavicular joint arthropathy.
A November 2020 study in the Journal of Back and Musculoskeletal Rehabilitation (30) accessed the effectiveness of Prolotherapy in shoulder disorders. To do this the researchers evaluated existing studies to see if they could form a consensus on how effective, or not effective Prolotherapy can be.
Here are the summary learning points:
- “Wide variation exists regarding usage patterns of prolotherapy.”
- Explanatory note: These variations included the number of injections given within a treatment (some of the studies these researchers assessed were a single injection treatment. Similar to the way cortisone is given. In our 28 years of experience, we never offer a single shot of Prolotherapy as “the treatment.” It is not effective. Read more you will see these researchers came to this conclusion as well.)
- “Interestingly, amongst the Prolotherapy studies evaluated in this review, the two in which significant pain relief was sustained long-term both utilized multiple injections and the three with either non-significant or non-sustained pain relief used a single injection.”
- Explanatory note: Multiple injections at treatment is superior to a single injection at treatment. This is what we have been saying for three decades.
The researchers suggested: “Prolotherapy (appears) to be a safe treatment option with perhaps greater efficacy for shoulder pathology when provided through a series of injections using higher concentrations of dextrose.”
Poor candidate for Prolotherapy
This x-ray shows an image of a patient that we would consider a poor candidate for Prolotherapy treatment. There is the loss of cartilage in the glenohumeral joint and the patient has developed multiple bone spurs. These bone spurs significantly restricted his range of motion.
A patient who would be considered a fair candidate for Prolotherapy
In this x-ray, we see a patient with shoulder impingement and a moderately limited range of motion with abduction and external rotation. The x-ray image reveals a significant decrease in cartilage which limited the patient’s shoulder and arm range of motion. This patient was considered a fair candidate for treatment and realistic expectations of treatment outcomes should be expected.
A patient who would be considered a good candidate for Prolotherapy
In this x-ray image, we see a patient who would be considered a good candidate for Prolotherapy. The overall architecture and integrity of the shoulder have been maintained in the joint. There is some loss of joint space. Because the overall shoulder structure has been maintained and the patient exhibited a full range of motion in his shoulder, this patient was considered a good candidate for Prolotherapy.
Research outcomes on PRP injections and quality of life in shoulder pain patients.
At our center, we typically do not offer PRP injections as a stand-alone treatment. We combine PRP with Prolotherapy treatments to offer what we believe to be an optimal repair of the soft tissue of the shoulder and to provide shoulder stability to help this soft tissue damage from reoccurring once repaired. This treatment approach has helped many people we have seen.
A research study on PRP injections alone was published in November 2021 in the journal Clinics in Shoulder and Elbow (31) which asked the question: “Can platelet-rich plasma injections provide better pain relief and functional outcomes in persons with common shoulder diseases?”
Here is the answer suggested by the study research team:
- PRP injections were associated with better pain relief and functional outcomes than control interventions.
- PRP injections were also associated with greater Quality of life.
- Compared with placebo and corticosteroid injections, PRP injections provided better pain relief and functional improvement.
In this video, a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:
- PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
- This patient, in particular, came to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
- With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
- PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
- PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments, in this case, it was in his anterior shoulder attachments to address the chronic dislocations.
Will these injection treatments help you avoid a shoulder replacement?
Caring Medical has over 27 years of experience in helping patients avoid surgery. Once we do an examination on the patient we give a clear picture of what he or she can expect from our treatment. Sometimes we are very optimistic that we can offer a lot of help. Sometimes someone comes into our office with shoulder osteoarthritis and rotator cuff damage significant enough that the reality of the situation says surgery and we recommend the surgery. How would you know who you are? An examination usually does a great job determining that. Even if you have been told surgery is the only answer, which we addressed in the research above, we have done countless second opinions where we were able to provide the patient non-surgical options for their shoulder damage.
Treatment after you had shoulder replacement
In this section, we will address how we may be able to help a patient after they had the shoulder replacement surgery. It makes our job here at Caring Medical a little more difficult when treating a patient who has had an extensive procedure, but it is still possible to achieve healing after surgery.
In this video, Danielle R. Steilen-Matias, MMS, PA-C discusses treating nerve pain following shoulder surgery.
It is not uncommon for us to see patients after shoulder surgery who continue to have shoulder instability issues. Other times we will see patients after shoulder surgery who have continued pain. It may be the same pain that they had before surgery or it may be a different type of pain. What we find in many of these people is that even though healing is occurring and the shoulder looks well, the pain they are having is related to the nerves that may have been impacted during the surgery. We treat these patients with Nerve release injection therapy or more commonly hydrodissection.
Nerve Release & Regeneration Injection Therapy
NRRIT is a nerve hydrodissection technique that is highly successful in releasing peripheral nerve entrapments. It is a quick, straightforward process injection procedure often providing instant relief results for the patient! In the procedure, the practitioner uses ultrasound guidance to identify the nerves being entrapped. Next, simple dextrose is injected around the nerve to nourish the nerve and mechanically release it from the surrounding tissue, fascia, or adjacent structures.
What are we seeing in this image?
Nerve Release Injection Therapy (hydrodissection) of an entrapped nerve. In this image, a 5% dextrose solution is injected around the nerve which releases or separates it from the surrounding tissue. The nerve, which is the central circular object has a dark ring forming around it, as seen strongly in the B image. That is the dextrose solution from the needle, the straight image from the right of the screen. The nerve as seen in B is now surrounded by the nerve-release fluid and therefore “released.”
Questions about our treatments?
If you have questions about shoulder replacement alternatives and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated January 15, 2022