The evidence for alternatives to shoulder replacement
Danielle R. Steilen-Matias, MMS, PA-C
In this article, we will explore options and alternatives to Shoulder Joint Replacement and Reverse Total Shoulder Replacement
We frequently see patients who have had surgery for shoulder pain, but are subsequently left with chronic pain after surgery. The surgery, 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 and subsequent arthritis. At some time then in the future shoulder replacement will be recommended.
According to the American Academy of Orthopaedic Surgeons website, total shoulder replacements are successfully performed in many patients with shoulder arthritis, however, the procedure is not as beneficial for patients with large rotator cuff tears who have developed “cuff tear arthropathy,” a degenerative condition causing excessive shoulder joint instability.
- Shoulder instability is very treatable with Prolotherapy, see our main page Prolotherapy for Shoulder Pain for more treatment information.
Understanding the reverse total shoulder replacement and conventional shoulder replacement surgery.
For these patients, conventional total shoulder replacement may result in pain and limited motion. Therefore 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.
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 semiconstrained prosthesis, (that is implants which create an artificial stability by limiting the prosthesis range of motion) 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. Please see Dr. Hauser’s article on Stem cell therapy for bone repair in osteoarthritis on our site.
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.”(1)
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.(2)
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.(3)
- 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.” (4)
Ironically – shoulder replacement surgery is seen as a main contributor to problems of rotator cuff inflammation. In other words, the surgery to correct the problem is the main cause of the problem.
This is supported by researchers from Texas Orthopedic Hospital, the University of Houston, University of Texas, who 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.(5)
This of course will throw a big concern at patients – shoulder replacement recovery time – complications are often lengthy and sometimes never go away.
In other research some doctors suggest shoulder replacement surgery is the only answer
Yet in other research some doctors suggest shoulder replacement surgery is the only answer: “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.” (6)
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.”
Complications leading to reoperation 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.(7)
- Shoulder replacement infection: In another study, doctors say that one of the greatest risk factors for infection after shoulder replacement were history of a prior failed shoulder surgery. So replacing the shoulder in an attempt to fix the first shoulder surgery had high risk of infection.
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%).(2)
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 problem
- 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.(8)
Doctors from the Mayo Clinic writing in the Journal of bone and joint surgery discuss the problems of obesity causes 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.(9)
Alternatives to shoulder replacement surgery
In regenerative injection techniques like Prolotherapy, Platelet Rich Plasma Therapy or Stem Cell Prolotherapy, the goal is always to preserve and regenerate these cushions and connective tissues rather than remove them. (See cartilage repair). 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.
Caring Medical Research:
A Retrospective Study on Hackett-Hemwall Dextrose Prolotherapy for Chronic Shoulder Pain at an Outpatient Charity Clinic in Rural Illinois
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.
- 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), to the p<.0000001 level 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.
If you have questions and would like to discuss your shoulder pain issues with our staff you can get help and information from our Caring Medical staff.
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