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12 Articles in Volume 21, Issue #2
Advanced Practice Matters with Theresa & Jeremy: MAT and the DATA Waiver Debate
Analgesics of the Future: The Potential of Vocacapsaicin Injections for Knee Pain
Authorities Update Opioid and Naloxone Prescribing Policies as Overdoses Soar
Autologous Adipose-Derived Biocellular (Stem Cell-Rich) Prolotherapy into Hoffa’s Fat Pad Improves Knee Osteoarthritis
Behavioral Medicine: How to Utilize Acceptance and Commitment Therapy in Primary Care
Case Report: How We Grew Our Pain Practice Amidst Pandemic, Opioid Crisis
Chronic Overlapping Pelvic Pain Disorders: Differential Diagnoses and Treatment
Fentanyl Transdermal Patch: Variability is Key When Prescribing
Optimizing Opioid Therapy with Pharmacogenetics
Research Insights: Advances in Shoulder Arthroplasty and Revision Surgery
Research Insights: How to Address Osteoarthritis Treatment Gaps in Women
Topical Anti-Inflammatories: Analgesic Options for Arthritis Beyond NSAIDs

Research Insights: Advances in Shoulder Arthroplasty and Revision Surgery

As shoulder replacement surgery becomes more common, consideration should be given to further reducing pain and reducing the need for revision surgery.

In 1893, surgeon Jules Emile Péan had a problem. His patient was dying of tuberculosis of the shoulder joint but refused an amputation. Péan managed to remove the damaged humeral tissue and replace it with a metal prosthesis, marking the first time metal was used to replace a damaged joint. The surgery went well, and the patient recovered, reportedly using his shoulder for most of his daily activities, until radiographs just two years after surgery revealed that the prosthesis had ossified and had to be removed.1

Medical knowledge, surgical technique, and prosthetic design have since improved drastically. Modern shoulder arthroplasty recipients can expect significantly reduced pain, a greater range of motion, and a longer prosthesis lifespan. But despite all that we have learned since 1893, 10% of patients will still experience pain 3 years after surgery, and 11% will need some kind of surgical revision.2

“Shoulder arthroplasty can be technically challenging, but with recent advances and techniques we are getting much improved outcomes with implants that last a lot longer than prior generations,” said Oke A. Anakwenze, MD, MBA. (Image: iStock)

Presurgical Considerations

Until the 1970s, patients could expect only 8 to 10 years from their prosthesis.2 Because of this, patients generally were not referred for shoulder replacement until they were in their 70s or 80s and the condition of their shoulder joint had degraded to the point of significantly affecting their mobility and independence.3 Improvements in surgical technique and prosthetic design have increased that span considerably but today’s candidates for shoulder arthroplasty may delay surgery with similar fears in mind. Research shows, however, that approximately 90% of shoulder replacements last for longer than 10 years and patient-reported benefits are sustained.4

“Shoulder arthroplasty can be technically challenging, but with recent advances and techniques we are getting much improved outcomes with implants that last a lot longer than prior generations,” said Oke A. Anakwenze, MD, MBA, an orthopedic surgeon at Duke University School of Medicine. “Patients come in with a wide variety of shoulder disorders. The most common ones I see are complex rotator cuff tears, shoulder arthritis, and shoulder fractures,” he told PPM.

Shoulder Replacement: Limitations and Risks 

With the ongoing COVID-19 pandemic, some hospitals have postponed shoulder arthroplasties and other elective surgeries to reduce viral exposure and conserve hospital resources. While both are important concerns, delaying arthroplasty may lead to additional joint degradation that can reduce a patient’s treatment options, complicate recovery, and decrease quality of life.5

Over the past 10 years, patients have come into the operating room with more preexisting conditions, yet the overall rate of complications following surgery has decreased.6 Clinicians should be aware of certain preexisting conditions, however, so that they can best counsel their patients on their options and risks.

As an example, patients with osteoporosis often face a high rate of fracture and bone degradation if given a stemmed prosthesis.7 Women are also three times more likely than men to suffer from an intraoperative fracture, and research is needed to determine whether this is due to anatomical differences, prosthetic design, or some combination of the two.8 Patients with major depression tend to report lower satisfaction with their surgery than their peers, however, they still report less pain than they had before surgery.9 Patients are often asked to quit smoking or start a physical fitness regimen before surgery, as studies show this is linked to fewer complications and better outcomes; however, this can be challenging for patients who are already struggling with chronic pain.3

Shoulder Prosthesis: Potential Complications

Patients receiving a capped prosthesis are not at greater risk of long-term complications than patients with stemmed prostheses, however, the cap is a common point of failure if it has not been properly fitted or cemented to the humeral head.2,10 In addition, the link between metal hypersensitivity and surgical complications has been a subject of much discussion in recent years. Metal sensitivity is a likely explanation in patients who experience otherwise unexplained pain after surgery; however, there are very little data on the incidence of metal hypersensitivity.

One study estimates that it occurs in 15% of the general population but is responsible for up to 60% of unexplained pain after surgery.2 Another study reported that 49% of women with unexplained pain after surgery were found to have metal sensitivity, compared with 38% of men. This suggests that women may have a more aggressive immune response to metal prostheses than men.11

Many patients with unexplained postsurgical pain may be referred to a dermatologist for patch testing. Patients and clinicians typically decide together on a case-by-case basis whether replacing the prosthesis is the best choice when the patient tests positive for metal sensitivity. Testing for metal sensitivity before surgery can help reduce the need for revision, thereby reducing healthcare costs and improving patient quality of life.

Infection: Reverse Arthroplasty Compared to Anatomical Arthroplasty

Reverse shoulder arthroplasty (RSA) has provided a new treatment option for patients with damaged rotator cuff muscles. RSA has become increasingly frequent since its debut in 1972; however, the surgery comes with an increased risk of infection compared to anatomical shoulder arthroplasty (ASA).1 More research is needed on this discrepancy as many studies tracking infection rates do not differentiate between ASA and RSA.12 The bacteria most commonly responsible for joint infections are slow-growing and well adapted for anaerobic environments, which can make them difficult to detect and treat. Patients who have received a shoulder steroid injection up to 3 months before surgery are at double the risk of infection.12

Treating infected joints typically involves a one- or two-stage revision process. In a single-stage revision, the prosthesis is removed, infected tissue is aggressively debrided, and a replacement prosthesis is installed along with an antibiotic cement spacer. The patient is usually given oral antibiotics as well. A two-stage revision is similar. The first stage ends after damaged bone and tissue are removed and the patient is sewn up with an antibiotic cement spacer. Several weeks later, the patient returns for the second stage during which a replacement prosthesis is inserted.13 The single-stage method is as, if not more, successful than the two-stage method, although, ultimately, surgeon proficiency and preference play a large part in the success rate.14

Patients who undergo a revision to convert their ASA to an RSA often face a higher rate of complications than patients who receive an RSA during their first surgery.15 To reduce the risk of complications for these patients, modular prostheses have been developed that allow a conversion without the need to remove a well-fitted or well-cemented stem.16

The skill and experience of the surgeon play a large part in ensuring the prosthesis is well fitted.  Cementless prostheses can be more difficult to fit; however, they reduce operating time and improve patient outcomes if the patient needs a revision, as it is easier to remove an uncemented prosthesis than a cemented one.16 Whether the prosthesis is cemented or not, careful shaping is required to ensure that neither the prosthesis nor the patient faces unnecessary wear and abrasion.2 Cementless prostheses were only recently approved in the United States, however, they have been approved in Europe for more than 20 years.2 As new techniques are developed clinicians should choose early candidates for these techniques carefully to reduce the risk of complications during the learning curve.

Practical Takeaway

Although shoulder arthroplasty is still developing, the majority of patients experience a significant reduction in pain, increased range of motion, and improved quality of life.

“It is most gratifying to see patients get back to their families and athletes get back to sports,” said Dr. Anakwenze. “More research is needed on those who still experience pain despite or because of their surgery, but we have many promising avenues of study through which we can improve patient outcomes and quality of life,” he concluded.

Last updated on: March 2, 2021
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Autologous Adipose-Derived Biocellular (Stem Cell-Rich) Prolotherapy into Hoffa’s Fat Pad Improves Knee Osteoarthritis
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