Ross A. Hauser, MD, Danielle R. Steilen-Matias, PA-C.

Many patients have excellent outcomes following shoulder replacement surgery. Some people do not succeed, and this results in complications. This article will review some of the more recent research surrounding complications.

Part 1: Shoulder replacement complications

•  People have very successful shoulder replacements, some doctors suggest; however, that shoulder replacement surgery may make things worse.
• The list of shoulder replacement complications – pain after shoulder replacement.
• Complications that patients face after reverse shoulder replacement.
• Acromial fractures and scapular spine fractures post-operatively.
• For many, shoulder replacement is a good operation.
• Patient-reported outcomes following shoulder replacement are mostly good.
• Does prior surgery increase the risk of shoulder replacement complications?

Part 2: Patients at increased risk for shoulder replacement complications

• Does prior surgery increase the risk of shoulder replacement complications?
• Do prior cortisone injections increase the risk of shoulder replacement complications?
• Understanding the reverse total shoulder replacement and conventional shoulder replacement surgery.
• Who does reverse total shoulder replacement work best for? Glenohumeral osteoarthritis with intact rotator cuff.
• Shoulder replacement works better for older patients…but complications and painkiller use are still a concern to surgeons.
• Shoulder strength after reverse shoulder replacement.
• Overuse or “radical use of reverse total shoulder replacement in patients without rotator cuff deficiency may cause more harm than good.
• People have failed shoulder surgeries, and researchers say, “no adequate explanation in the literature” can provide a reasonable explanation why.
• Soft tissue damage after shoulder replacement is a leading cause of surgery failure.
• Shoulder replacement in younger patients under 60.
• Obesity is a complication of concern in shoulder replacement.
• Getting the poor-health patient ready for shoulder replacement.
• Mental health aspects.
• Alcoholism

Part 3: Treatment after you have had shoulder replacement

• Is a surgery successful if there are no complications?
• Exercise and physical therapy after reverse shoulder replacement.
• Complications after Revision Surgery.
• Complications leading to re-operation are often multiple and underestimated.
• Why was the patient sent for a revision shoulder replacement? What were the revision surgery complication rates?
• 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?
• Danielle R. Steilen-Matias, MMS, PA-C, discusses treating nerve pain following shoulder surgery.
• Nerve Release & Regeneration Injection Therapy.

Part 1: Shoulder replacement complications

People have very successful shoulder replacements, some doctors suggest; however, that shoulder replacement surgery may make things worse.

Complications from shoulder replacement surgery are a risk factor for the surgery. That is well understood and has concerned doctors for many years.  Ten years ago, back in 2015, researchers from Texas Orthopedic Hospital, the University of Houston, University of Texas (1) noted great increases in the number of shoulder replacements being performed and that with more shoulder replacements being done, more shoulder replacement revision surgeries will be needed to address complications from the first surgery.

• In this 2015 paper, 21.6% of patients followed post-surgery  (8 out of 37 patients) required a second surgery for postoperative complications.
• Overall, 54% of patients (20 out of 37) suffered from intra- or postoperative complications.

The paper concluded that shoulder replacement improved function in many patients, but with a high rate of complications and reoperations.

That was then. Now in 2024, the same complication rates and concerns exist. Let’s follow the new research that demonstrates that many of the same problems still exist.

In September 2022, research from the Medical College of Georgia at Augusta University published in the Journal of Orthopaedics (2) assessed the risk factors for shoulder instability following reverse total shoulder replacement in patients with no history of shoulder surgery.

In this study of 194 reverse total shoulder replacements, a small number of patients, seven, just over 3.5% sustained a post-surgery dislocation. On average, the shoulder dislocation occurred 60 weeks after the surgery. Five of the seven patients had a re-operation using larger hardware to keep the shoulder in place, one had bone spurs removed, and the time to dislocation was 60.4 weeks. Five required open reduction with placement of either a larger humeral tray or polyethylene spacer. One required open reduction with osteophyte removal, and one was converted to a resection arthroplasty (the ball of the shoulder or prosthesis is removed, and this is considered a salvage operation of failed shoulder replacement). The researchers suggested based on data that dislocations were an uncommon complication but were clearly associated with overweight and obese patients, worse health, and increased liner size (the part of the prosthetic was large).

The list of shoulder replacement complications – pain after shoulder replacement.

An October 2019 study (3) outlined to radiologists what they needed to look for in an 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. Throughout the notes from this study, we will update the current research in 2025.

• 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 replacement or specific to each. The complications included:
    • Infection.
    • Periprosthetic fractures.
    • Humeral component loosening
      • An August 2024 study in the Journal of Shoulder and Elbow (4) surgery suggested “Reverse shoulder replacement provides improved pain and function for properly selected patients with proximal humerus nonunion. Dislocation, humeral loosening, and reoperation rates remain high when Reverse shoulder replacement is performed for nonunion compared to other diagnoses. In this study, younger age and diabetes mellitus increased the odds of reoperation.”
    • Heterotopic ossification. The development of bone in soft tissue where bone should not be. Typically treated with cortisone, physical therapy, or surgery to remove the bone pieces.
      • An October 2023 study in the journal Cureus (5) suggested that Heterotopic ossification after shoulder arthroplasty does not display a significant impact on postoperative symptoms or functional outcomes in the majority of patients.
    • Implant failure and nerve injury.
  • Specific to reverse shoulder replacement implantation:
    • Instability.
    • Scapular notching. (The implant is rubbing against the scapula.)
    • Acromial fractures.
  • Specific complications of total shoulder replacement:
    • Glenoid component loosening.
    • Rotator cuff tear
      • Side note reference: A February 2023 German paper (6) explained glenoid loosening, including protrusion (the prosthetic part of the replacement has loosened and is now sticking out), rotator cuff insufficiency, including instability, and early/late infection as primary concerns. These concerns can be addressed by replacing the bone of the glenoid socket defects, but can still include post-operative complications, including dislocation, component loosening, and infection. They do note: “Revision of anatomical to reverse arthroplasty shows better clinical outcomes and lower complication rates than anatomical revision.”
  • Specific to partial shoulder joint replacement:
    • Progressive wear of the native glenoid.

The authors noted: “Knowledge of (these) different types of shoulder (replacement implants) prostheses and their complications’ radiological signs are crucial for the radiologist to initiate prompt and adequate management.” In other words, the above provides a list to radiologists looking for the source of pain following a shoulder replacement.

Complications that patients face after reverse shoulder replacement.

A March 2021 paper in the journal Clinics in Shoulder and Elbow (7)  lists the complication challenges some patients 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 is also increasing.

The rate of complications in reverse shoulder arthroplasty was reported to be 15%-24%.

The following complications have been reported in order of frequency:

• periprosthetic infection,
• dislocation,
• 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 prostheses used, improvement of implant and surgical skills, and different definitions of complications.”

Acromial fractures and scapular spine fractures post-operatively

Doctors at the Rothman Orthopaedic Institute, University of Florida, and the Mayo Clinic, Jacksonville (8) examined complications following reverse total shoulder replacement and how osteoarthritis and bone spurs at the acromioclavicular joint could lead to acromial and scapular spine fractures. This study was conducted on 11 patients who underwent primary reverse shoulder replacements (8 women and 3 men), with six of the patients having acromial fractures post-operatively and five having scapular spine fractures. The average age of the patient was about 70 years old. When these patients were compared to 44 control patients who did not suffer a post-surgical fracture, the researchers found that patients with the fractures had worse acromioclavicular joint osteoarthritis and larger bone spur formation. The researchers concluded, “acromioclavicular joint osteoarthritis is common in patients undergoing reverse shoulder replacements. Severe acromioclavicular joint osteoarthritis  with completely spanning or fused osteophytes (bone spurs) may predispose patients to acromial or scapular spine fractures after reverse shoulder replacements.”

 

For many, shoulder replacement is a good operation.

In a September 2024 study from Balgrist University Hospital, Zurich, Switzerland (9), 133 patient outcomes were followed over a ten-year period following reverse shoulder replacement. Of these patients, the average age of 69, 56% of women, clinic improvements in shoulder pain and function were observed in the short term and were sustained in the long term without notable deterioration.

Patient-reported outcomes following shoulder replacement are mostly good

Does prior surgery increase the risk of shoulder replacement complications?

A June 2021 paper (11) in The American Journal of Sports Medicine assessed whether a previous failed arthroscopic shoulder surgery would lead to a greater risk for failed total shoulder replacement. To do this, the researchers looked at:

• A total of 56 patients, under 70 years old, who either had total shoulder replacement or arthroscopic surgery first, then total shoulder replacement, were followed up two years after their last surgery.
• 19 patients had the arthroscopic surgery first, then total shoulder replacement, and 37 patients had the total shoulder replacement without prior arthroscopic shoulder surgery.
  • There were 4 patients (7.1%) who had a failure, and failure rates did not differ significantly between the arthroscopic surgery first, then total shoulder replacement, and the primary total shoulder replacement only group.
• 50 patients did not have a surgical failure (17 arthroscopic surgery first, then total shoulder replacement, and 33 primary total shoulder replacement). Each patient completed surveys almost five years after their last surgery. Both groups improved significantly from preoperatively to postoperatively in all survey scores.

The conclusion of this research: “Patients with severe glenohumeral osteoarthritis who failed previous arthroscopic surgery benefited similarly from total shoulder replacement compared with patients who opted directly for total shoulder replacement.”

An April 2023 study published in the Journal of Shoulder and Elbow Surgery (12) examined reverse total shoulder replacement, initially suggested in elderly patients with significant rotator cuff damage, for elderly patients with primary glenohumeral osteoarthritis and an intact rotator cuff. The idea is that this surgery could help patients avoid revision surgery. The researchers found that reverse total shoulder replacement and total shoulder replacement surgeries in patients 70 years or older, with glenohumeral osteoarthritis and an intact rotator cuff, had a similar need for revision risk. Also, the same likelihood for 90-day emergency room visits and readmissions.

Do prior cortisone injections increase the risk of shoulder replacement complications?

There has been much research speculating on the adverse effects of shoulder corticosteroid injections prior to shoulder replacement. A June 2024 study (13) in the Journal of Shoulder and Elbow Surgery suggests that when cortisone is used judiciously prior to shoulder replacement, post-surgical complications are minimal.

• Researchers reviewed 230 records of patients who had shoulder replacement or reverse total shoulder replacement. 134 patients had cortisone injections prior to surgery, and 96 did not.
• In assessing outcomes, the researchers found that the 134 patients who received an injection within 12 months prior to the replacement surgery had no worse patient-reported pain and function outcomes during a minimum of 2-year follow-up than the 96 patients who did not receive cortisone. Although more complications occurred in the injection group, it did not reach statistical significance.

Understanding the reverse total shoulder replacement and conventional shoulder replacement surgery.

The procedure of a reverse shoulder replacement 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.

Let’s look at the last few years of research to see the development in popularity of the reverse shoulder replacement. The benefits and realistic application of the reverse procedure are studied in a paper published in the medical journal Orthopedics (14) in 2016.

• 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’s 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.”

An October 2023 paper in the Journal of Shoulder and Elbow Arthroplasty (15) did suggest higher revision rates were identified following anatomic total shoulder replacement; however, anatomic total shoulder replacement displayed equal functional results and postoperative complications compared to reverse total shoulder replacement in patients over 70 without a full-thickness rotator cuff tear.

Who does reverse total shoulder replacement work best for? Glenohumeral osteoarthritis with intact rotator cuff.

A May 2024 study in the Journal of Shoulder and Elbow Surgery (16) examined the published data on patient outcomes following total shoulder replacement, looking to determine the factors that influence patient satisfaction following the surgery at a minimum two-year follow-up. What they found was that patients with a diagnosis of glenohumeral osteoarthritis rated better satisfaction on all metrics when compared to patients with a diagnosis of cuff tear damage or massive rotator cuff tear.

• Records from 5234 patients and their 5288 shoulders were taken from 45 published studies.
• The overall study population was 61.2% female.
• Overall patient satisfaction ranged from 77.7 to 87.8%.

Shoulder replacement works better for older patients…but complications and painkiller use are still a concern to surgeons

A September 2023 paper (17) in the Journal of Shoulder and Elbow Surgery suggested that shoulder replacement in patients 80 years and older “is safe and effective, demonstrating low rates of perioperative mortality and reoperation, durability that exceeds patient longevity, satisfactory postoperative range of motion, and excellent pain relief.”

An August 2023 paper in the journal Cureus (18) aimed to determine the change in functional capacity and quality of life in patients who underwent reverse shoulder replacement due to rotator cuff tear damage and degeneration.  The researchers found that reverse shoulder replacement for rotator cuff tear damage leads to an improvement in functional outcomes and quality of life. Although there was a considerable improvement after surgery on the shoulder in patients 65 years or younger, many did not achieve a “normal” shoulder based on function and pain scores. Many patients over the age of 65 did.

A February 2024 study published in the Journal of Orthopaedics (19) suggested that doctors assess the mental health of elderly patients being recommended for shoulder replacement. The paper writes: “Considering the fact that mental health illnesses increase with age and that shoulder arthroplasty procedures are often indicated in the older population, exploring the relationship between mental health and shoulder arthroplasty outcomes can have pivotal implications for shoulder surgeons and patients worldwide. The literature has shown that patients with poor mental health report lower patient-reported outcomes, higher peri-operative complications (such as anemia, infection, delirium, and others), lengthier hospital stays, and higher readmission rates than the normal patient.”

Shoulder strength after reverse shoulder replacement

A November 2019 study (20) from Turkish doctors compared the isometric strength and endurance of shoulder abduction and internal and external rotation in a patient’s shoulder that had a reverse shoulder replacement because of rotator cuff failure and the same patient’s other shoulder that did not have a shoulder replacement surgery.

These patients had degenerative rotator cuff disease; the group of 41 patients had an average age of about 71 years old. Each patient had rotator cuff damage significant enough for shoulder replacement in one shoulder but not the other. The point of the study was to see how close the shoulder replacement could get to the strength of the operated shoulder to that of the non-operated shoulder. After an average 34-month follow-up, many patients showed marked improvement in functional ability in the operated shoulder. The researchers found in this group of patients, durability, and strength of abduction (Straightening your arm outwards and lifting your arm from the side as high as it will go), similar results with the unaffected shoulder may be accomplished (just as good as the non-operated shoulder); nonetheless, the surgeon should be aware that durability and strength of rotation would be weak. (The rotational ability of the shoulder did not meet that of the non-operated shoulder.)

Finding out why strength could not be returned to a certain range of motions of the shoulder has led some researchers to explore subscapularis repair. The subscapularis is the tendon that runs in front of the shoulder.

In December 2021 (21), doctors from the University of California, Los Angeles, Dartmouth College, and the Steadman Philippon Research Institute suggested in patients examined that “There is no difference in abduction, internal rotation, or external rotation strength after reverse total shoulder arthroplasty with or without subscapularis repair. . . However, consensus has yet to be reached on whether postoperative strength after reverse total shoulder replacement differs based on subscapularis management.

A November 2023 paper in the Journal of Clinical Medicine (22) looked at fifteen patients aged 60-70 years (13 women and 2 men) who had a reverse total shoulder replacement and compared the range of motion in the non-operated-on and operated-on shoulder.  The found in these patients 18 months after the reverse total shoulder replacement, the non-operated upper limb has significantly greater muscle strength in flexion/extension and abduction/adduction movements compared to the operated limb. The non-operated limb also has a significantly greater range of motion compared to the operated limb. 

Overuse or “radical use of reverse total shoulder replacement in patients without rotator cuff deficiency may cause more harm than good.

An August 2022 study in the journal Medicine (23) wrote: “Reverse total shoulder replacement, which was originally designed mainly for irreparable rotator cuff damage, has gained popularity in recent years for the treatment of advanced shoulder osteoarthritis instead of the clinically standard total shoulder replacement. However, this Reverse total shoulder replacement has some non-negligible flaws, such as higher complication rates and economic cost (this means that the patient requires much more medical services), not to mention the following problems caused by irreversible physical structural damage. Therefore, the employment of reverse total shoulder replacement needs to be carefully considered.”

What the researchers did in this study was to compare reverse total shoulder replacement with standard total shoulder replacement in osteoarthritis patients with or without rotator cuff damage. The focus is on rotator cuff damage and recommendations that could help surgeons in their clinical decision-making process.

What the researchers noted was that they believed the overuse of “radical use of reverse total shoulder replacement in patients without rotator cuff deficiency may cause more harm than good. The researchers then assessed the medical records of 57,156 shoulder replacement patients. Patients were divided into 2 groups according to the presence of rotator cuff deficiency.

• Reverse total shoulder replacement patients in the rotator cuff deficiency group had significantly higher transfusion rates and longer hospital stays.
• Reverse total shoulder replacement patients without rotator cuff deficiency had a statistically significantly higher number of implant-related mechanical complications, acute upper respiratory infections, and postoperative pain.
• Overall, reverse total shoulder replacement incurred higher costs in both groups.
• For osteoarthritis patients with rotator cuff deficiencies, reverse total shoulder replacement has its benefits, as complication rates were comparable to total shoulder replacement. For those patients without rotator cuff deficiencies, the use of reverse total shoulder replacement should be reconsidered, as there were more complications with higher severity.

People have failed shoulder surgeries, and researchers say, “no adequate explanation in the literature” can provide a reasonable explanation why.

Now let’s look at a University of Copenhagen paper published in June 2022 (24). Here, the study team found: “worse outcomes for patients with previous surgery for instability independent of age, sex, and arthroplasty (the type of shoulder surgery, whether it was shoulder resurfacing or shoulder replacement, reverse or traditional) type. The reason cannot be deduced from our study, and there is no adequate explanation in the literature. Several factors could, in theory, have an adverse effect on the outcome for these patients. A long history of instability and previous surgery may lead to eccentric glenoid wear and subsequently a technically demanding operation with risk of persisting instability, subluxation of the humeral component, or loosening of the glenoid component.”

Soft tissue damage after shoulder replacement is a leading cause of surgery failure.

In September 2019, a paper in the Clinics in Orthopedic Surgery (25) 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.

Shoulder replacement in younger patients under 60

An April 2024 study in the Journal of Orthopaedics (27) looked further into shoulder replacement in younger patients, examining potential complications and implant longevity in patients under 60 years of age.

A June 2017 study in The Journal of Bone and Joint Surgery (29) from doctors at the University of Alabama at Birmingham (27) 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.

Malnutrition, obesity, and anemia

A January 2022 study published in the Journal of Shoulder and Elbow Surgery (30) added to this by suggesting: “Malnutrition, obesity, and anemia contribute to significantly higher costs (need for medical intervention) 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 (31) 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.”

A February 2024 study in the Chinese Journal of Reparative and Reconstructive Surgery (32) found that age and body mass index are related to postoperative joint function and complications, and different occupations and postoperative exercise levels affect recovery. “The patients with severe degenerative diseases, poor preoperative function, and long disease duration have lower expectations and higher satisfaction with the effectiveness, and a bad lifestyle has a negative impact on the effectiveness.”

In February 2025, (44) doctors at the Baylor College of Medicine, UT Southwestern Medical Center, and the Icahn School of Medicine at Mount Sinai examined the association between morbid obesity and perioperative outcomes in reverse shoulder replacement patients. The study included 4850 morbidly obese patients matched against 55,075 control patients.

• The Morbid-Obesity group was younger (mean age: 67.74 vs. 71.67 years) and more likely to be from minority groups, particularly Black patients (7.71 % vs. 3.94 %). They had significantly longer lengths of hospital stay and higher rates of discharge to non-routine (care) facilities.
• Major complications were more common in the Morbid-Obesity patients, including:
  • periprosthetic dislocation
  • deep vein thrombosis
  • blood loss anemia
  • and acute renal failure

Getting the poor health patient ready for shoulder replacement

A July 2023 study in The Orthopedic Clinics of North America (33) suggested to surgeons that to effectively optimize patients before total shoulder replacement, “the surgeon should be familiar with recognizing and treating common medical comorbidities found in an orthopedic patient, including anemia, diabetes, malnutrition, cardiovascular conditions, and history of deep venous thrombosis. Screening for depression or other mental illnesses should also be conducted preoperatively and managed accordingly before surgery. Preoperative opioid use and smoking have significant effects on postoperative outcomes and should be addressed before surgery.”

Mental health aspects

A February 2024 study (34) from the Rothman Orthopedic Institute published in the Journal of Orthopaedics looked at mental health considerations in gauging the success or risk of poorer outcomes in shoulder replacement. “Considering the fact that mental health illnesses increase with age and that shoulder arthroplasty procedures are often indicated in the older population, exploring the relationship between mental health and shoulder arthroplasty outcomes can have pivotal implications for shoulder surgeons and patients worldwide. The literature has shown that patients with poor mental health report lower patient-reported outcomes, higher peri-operative complications (such as anemia, infection, delirium, and others), lengthier hospital stays, and higher readmission rates than the normal patient.”

A May 2024 study in the Journal of Shoulder and Elbow Surgery Reviews, Reports, and Techniques (35) found: “Patients with mental health conditions may have lower preoperative range of motion, worse postoperative shoulder function, and higher postoperative pain levels than patients without mental health conditions. Patients with mental health conditions demonstrated improvements in range of motion and functional outcomes after shoulder replacement, but had higher reported complication and revision rates when compared to patients without mental health conditions. Depression and anxiety were the leading conditions correlated with lower outcomes in patients with mental health conditions after shoulder replacement.”

Alcoholism

A July 2024 study (36) suggested alcoholism is associated with increased risks for revision surgery within two years following primary surgery.  Further, alcohol abuse increases the risks of  90-day readmission and 90-day transient mental disorder following primary total shoulder replacement

Part 3: Treatment after you have had shoulder replacement

In this section, we will address how we may be able to help a patient after they have 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.

Is a surgery successful if there are no complications?

A November 2021 study in the JSES Journal of Shoulder and Elbow Surgery (37) from doctors at the Oregon Health & Science University and the University of Virginia compared patient-reported outcomes (PROs) and range of motion (ROM) measurements in patients following shoulder replacement. What the researchers were looking for were the factors that caused some patients to achieve a Patient Acceptable Symptom State (PASS) after anatomic total shoulder arthroplasty, and those who did not achieve successful results from the surgery.

• 301 patients who had primary total shoulder replacement at least two years prior to being enrolled in the study.
• Researchers were looking for differences in the active range of motion (ROM) between patients achieving and failing to achieve the Patient Acceptable Symptom State positive or successful outcomes. They also looked for the difference in self-reported pain levels between those achieving and failing to achieve the minimum requirement.

The researchers found that the percentage of patients who achieved a minimally successful total shoulder replacement ranged from 69% to 87% depending on the patient-reported outcome scoring systems.

Exercise and physical therapy after reverse shoulder replacement

A January 2023 paper (38) in the Journal of Shoulder and Elbow Surgery compared the range of motion (ROM) and patient-reported outcomes (PROs) between a structured home exercise program (HEP) and active, supervised physiotherapy (PT) after primary Reverse Total Shoulder Arthroplasty. A patient group of 89 was split into two groups. In the home exercise program group (46 patients) was given a handout and a rope pulley were given, or a supervised physiotherapy group (43 patients), in which they were given a standardized program.

• Complications occurred in 13% of home exercise programs and 17% of supervised physiotherapy (PT) patients. Otherwise, there were no significant differences between groups at the final follow-up. These findings suggest that it may not be necessary to recommend PT as a protocol for all patients after Reverse Total Shoulder Arthroplasty.

We see many patients following failed surgery or failed physical therapy. Not every treatment will work for every patient. Some people will experience great surgical results, some will not. Some people will experience great physical therapy results, some will not. Our own treatments offered here at our center show patients who experienced outstanding outcomes, some people had good outcomes, and some people had poor outcomes. There are many factors to treatment success and failure.

Complications after Revision Surgery

A study from Dr. Pascal Boileau of the Department of Orthopedic and Sports Surgery at Pasteur 2 Hospital, University Institute of Locomotion and Sports in France (39) 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.

German orthopedic surgeons noted in their January 2023 paper (40) that “current data show a mean complication rate for reverse shoulder replacement of around 4%. The most common complications are instability, infection, component loosening, and periprosthetic fracture. . . Also, “Revision surgery for reverse shoulder replacement is challenging, and an individual treatment plan is necessary.”

Complications leading to re-operation are often multiple and underestimated

• 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%).

Why was the patient sent for 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. (41)

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 or the reverse shoulder replacement) when used in revision surgery.”

Why was the patient sent for a revision shoulder replacement? According to the researchers, the indications for revision include:

• 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 that arose during the revision surgery, during 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).
• The intraoperative complication rate was 8%, the postoperative complication rate was 22%, and the 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 benefits 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.

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 (42) 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 a 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 (43) 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.

In this video, Danielle R. Steilen-Matias, MMS, PA-C, discusses Prolotherapy for shoulder pain and arthritis and how we determine if someone is a good candidate!

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.”

 

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