FAQ Category: Shoulder

You will likely need more information either from your mother-in-law or directly from her doctor (this requires her giving written permission for you to communicate with her physician).

Anyone who gets a shoulder replacement is told there can be unexpected complications that develop either during or after the surgery. One of those problems may be a humeral fracture around the prosthesis (or implant). The humerus is the upper arm bone. A fracture of the humeral bone next to the implant is called a periprosthetic fracture.

Treatment of these fractures requires surgery either by removing the implant and replacing it or using hardware to hold everything together until healing takes place. This second option is a surgical procedure referred to as open reduction and internal fixation (ORIF).

Treatment decisions are affected by many factors such as the patient’s age, general health, smoking/tobacco use history, and the presence of other problems such as heart disease, diabetes, high blood pressure, etc.

The type of shoulder replacement implant can make a difference, too. She may have the traditional shoulder replacement where the humeral component replaces the humeral head, or the ball of the joint. The glenoid component replaces the socket of the shoulder, which is actually part of the scapula. In the “normal” artificial shoulder prosthesis, the glenoid prosthesis is a shallow socket made of plastic and the humeral component is a metal stem attached to a metal ball that nearly matches the anatomy of the normal shoulder.

Or she may have a reverse shoulder prosthesis. In the reverse shoulder replacement, the ball and the socket are reversed. Patients who have a severely damaged (and irreparable) rotator cuff are the most likely candidates for the reverse arthroplasty. This type of shoulder replacement provides pain relief as well as a stable, functional shoulder.

X-rays will provide the surgeon with some details about the location, type, and severity of bone fracture. This information in conjunction with type of implant and patient characteristics all factor into the final treatment decision-making process.

That is a bit of bad news. But perhaps we can offer some encouraging words. According to a recently published study following patients with humeral shaft fractures after shoulder replacement, return of prefracture motion and function is possible.

Treatment of these fractures usually requires surgery either by removing the implant and replacing it or using hardware to hold everything together until healing takes place. This second option is a surgical procedure referred to as open reduction and internal fixation (ORIF).

In the study we mentioned, two surgeons from the Florida Orthopaedic Institute in Tampa, Florida reported on the results of 36 patients. Each one was surgically treated for a humeral shaft fracture after they had a shoulder replacement.

One thing that makes this study unusual is the fact that like your husband, some of their patients had a reverse shoulder prosthesis. Up until now, only single case reports or small case series have provided any information on humeral fractures associated with reverse shoulder arthroplasty. This study reports on outcomes (bone healing, shoulder motion) after surgical treatment for these patients.

The reverse shoulder prosthesis is made up of two parts. The humeral component replaces the humeral head, or the ball of the joint. The glenoid component replaces the socket of the shoulder, which is actually part of the scapula. In the “normal” artificial shoulder prosthesis, the glenoid prosthesis is a shallow socket made of plastic and the humeral component is a metal stem attached to a metal ball that nearly matches the anatomy of the normal shoulder.

In the reverse shoulder replacement, the ball and the socket are reversed. Again, just like your husband anyone who has a severely damaged (and irreparable) rotator cuff is the most likely candidate for the reverse arthroplasty. This type of shoulder replacement provides pain relief as well as a stable, functional shoulder.

Of the 36 patients in the study, 35 had complete healing of the fracture and a return of shoulder motion equal to their prefracture level of motion. The first group who had the open reduction and internal fixation (ORIF) had good fracture healing without any stem loosening in the follow-up period.

The second group (patients who had the implant removed and replaced) showed X-ray evidence of femoral shaft loosening, which is why they ended up having a revision arthroplasty instead of the ORIF. They were also able to return to their preinjury level of motion and function. In fact, some of these patients were even better than before the fracture developed. There was evidence that the loosening of the stem component was the reason the fracture developed in the first place.

Your husband’s surgeon is the best one to advise you as to the recommended treatment and expected outcomes. Without a lot of evidence, it does look like what has been reported so far is quite favorable.

Shoulder replacements are wonderful inventions. They help restore pain free shoulder and arm motion. Patients are almost always fully satisfied with the results. But from the surgeon’s point-of-view, the results aren’t always 100 per cent acceptable. Complications can occur such as joint infection, dislocation, or nerve injury. Problems with the implant including loosening and subsidence (sinking down into the bone) also occur more often than they would like.

The results of a recent study from Germany may help offer some clues to the loosening you are experiencing. One surgeon followed 39 of his patients for 10 to 15 years and reported on the long-term results. He used the same third-generation cemented total shoulder replacement in each patient so that results could be compared directly. Pain, shoulder range-of-motion, and X-ray findings were the main measures of outcomes. Third generation refers to the number of times the implant has been redesigned, revised, and improved.

In all cases, pain, range-of-motion and function improved. And along with those results were consistent reports of patient satisfaction. Loosening of the glenoid component (socket side of the implant) occurred in 36 per cent of the group. Despite the loosening, the implant remained intact and the patients still had good, pain free motion.

Reasons for the high rate of loosening were explored. Possible risk factors include: the design and shape of the glenoid component, surgical technique (removing too much of the arthritic bone before putting the implant in place), and cementing technique. It is also possible that there are some as yet unknown patient factors.

No one developed any loosening of the humeral component (round ball that fits into the socket at the top of the upper arm bone). So that draws the attention back to the glenoid (socket side) part of the implant.

Younger patients tend to develop loosening more often than older adults, so maybe a higher activity level is part of the picture. And then there is always the possibility that some aspect of the postoperative protocol (either right after surgery or during rehab) that could be a contributing factor. These are all variables that must be evaluated more closely in future studies.

Radiologists examining X-rays for any signs of implant loosening look are radiolucency around the implant. Radiolucency describes a greater transparency than should be seen. In other words, the X-rays pass through the area because of a space between the bone and the implant.

They also use a scoring system that takes into consideration the radiolucent lines, position of those lines, thickness of the lines, and tilt of the implant. Each of those factors is given points. The more points that add up, the greater likelihood of implant loosening. So for example, someone with up to six points would NOT be considered “at risk” for implant loosening. A patient with a score of seven to 12 points IS at risk. And someone with more than 12 points using this scoring system has implant loosening.

X-rays taken right after surgery can be compared with your follow-up X-rays to look for any obvious changes from then to now. Lines drawn around the implant and through various parts of the shoulder can show shifts in the implant position that might indicate subsidence (implant sinks down into the bone).

And they also look for something called cranial migration of the humerus (upper arm). This refers to a gradual change in the position of the humerus upwards toward the top of the shoulder socket. Cranial migration can be classified as mild, moderate, or severe based on how far up the humerus had moved. The problem develops as a result of rotator cuff failure that cannot be corrected surgically.

The fact that you are not experiencing any pain, loss of motion, or change in function is fairly typical. In many cases, loosening is only seen on X-rays and does not appear to hamper the patient in any way. Of course, your surgeon will continue to follow you closely so you will want to be sure and go to all of your follow-up appointments.

Many adults (mostly women) between the ages of 40 and 60 years of age develop shoulder pain and stiffness called adhesive capsulitis. Sometimes this condition is referred to as “frozen shoulder.” But, in fact, adhesive capsulitis and frozen shoulder are two separate problems.

As the name suggests, adhesive capsulitis affects the fibrous ligaments that surround the shoulder forming the capsule. The condition referred to as a frozen shoulder usually doesn’t involve the capsule.

A true frozen shoulder might have some joint capsule changes but the shoulder stiffness is really coming from something outside the joint. Some of the conditions associated with frozen shoulder include rotator cuff tears, biceps tendinitis, and arthritis. When the normally loose parts of the joint capsule stick together the shoulder’s ability to move is limited causing the shoulder to get stuck or “freeze”.

The natural history of either condition: frozen shoulder and adhesive capsulitis (what normally happens with this condition may depend on what is causing the problem. In many cases, there is a gradual improvement over a long period of time (12 to 42 months).

Treatment may speed up improvements to less than one-month, which is why many patients are referred to physical therapy. Early goals in rehab are to reduce pain and interrupt the inflammatory cycle. Treatments are directed at getting the muscles to relax in order to help you regain the motion and function of your shoulder. This can be done with modalities such as ultrasound and/or electrical stimulation, the use of cold, and iontophoresis. Iontophoresis is a way to push medications through the skin directly into the inflamed tissue.

The therapist will address the capsular tightness and adhesions. Joint mobilization techniques are used to keep the joint sliding and gliding smoothly and to prevent scar tissue from forming. Keeping full shoulder and scapular (shoulder blade) motion is a priority. Special stretching techniques are used to prevent pain that could cause muscles around the shoulder to tighten even more.

Unless the nurse practitioner has a specific reason why physical therapy would not be helpful for you, this type of treatment is usually a critical part of recovery from frozen shoulder (or adhesive capsulitis). Besides hands-on therapy, you will be given exercises and stretches to do as part of a home program. You may need therapy treatments for three to four months before you get full shoulder motion and function back but in many cases, direct treatment speeds up the recovery process and save patients months of pain, loss of motion, and altered shoulder function.

Research efforts are underway around the world to find effective ways to treat adhesive capsulitis (also known as “frozen shoulder”). Physical therapy is widely accepted as the most beneficial treatment for this problem. We found one study from Korea that used whole body cryotherapy (WBC) for adhesive capsulitis with good results.

Whole body cryotherapy refers to spending brief periods of time in a very cold walk-in chamber. The room is kept at -110 to -140 degrees Celsius (that’s -230 down to -284 degrees Fahrenheit). Patients who received the cryotherapy treatment were exposed to four-minutes of cold twice a day, three times a week for a month. There was an elaborate procedure to prevent frostbite, discomfort from the cold, and damage to the lungs from breathing cold air.

For example, a warmer (but still cold) prechamber was entered first for one-minute. Everyone wore a surgical mask and told to avoid holding their breath in order to protect the upper airways. Each person wore a protective hat, triple-layer gloves, dry socks, and shoes. Everyone was monitored by microphone and camera whenever they were in either of the chambers.

In this study, cryotherapy was not the only form of treatment. The patients were actually randomly placed in one of two groups. Everyone in both groups received physical therapy modalities (e.g., ultrasound, electrical stimulation) and manual therapy (joint mobilization) techniques used for adhesive capsulitis. One group also experienced the cryotherapy whereas the second group did not. There was not a control group (patients who did not receive any therapy) as this approach withholds any treatment and is not considered ethical.

Using pain, range-of-motion, and shoulder function as test measures, patients in both groups got better. But the cryotherapy group had more significant improvements in all areas compared to the group who did not receive the cold therapy.

The authors offered several suggestions why whole-body cryotherapy might aid patients with adhesive capsulitis more than just physical therapy modalities and joint mobilization. First, cold has a way of anesthetizing the area, which in turn, reduces pain. With less pain, patients are better able to move the arm and shoulder.

Second, joint mobilization has been shown to improve the flow of synovial fluid in the joint. This makes it easier for the head of the humerus (upper arm bone) to slide and glide inside the shoulder socket.

Mobilization can also break up adhesions and scar tissue. This effect makes it possible for the collagen fibers that make up the joint capsule (soft tissue surrounding the head of the humerus) to line up better. The end result is improved gliding of the capsular fibers during movement. And joint mobilization seems to calm or quiet down cell receptors (called nociceptors) that set up a pain response in the first place.

It has been suggested that cold applied in this way to the whole body increases the release of chemicals in the body such as norepinephrine. Norepinephrine is known to decrease pain messages from the skin in the spinal cord and reduce (or stop) pain (or at least the perception of pain).

This may be the first study to compare physical therapy for adhesive capsulitis using standard mobilization techniques and modalities with whole-body cold (WBC) therapy. Although the results do show a significant improvement for patients who received WBC, there were some limitations to this study.

The authors pointed out that using a multimodal (many treatments) approach to the problem of adhesive capsulitis does not help sort out what each treatment component does. It is possible that just using one of these techniques would be enough to gain the same results.

The natural history of adhesive capsulitis (what normally happens with this
condition is a gradual improvement over a long period of time (12 to 42 months). Treatment may speed up improvements to less than one-month, which is why efforts are being made to find the best treatment or combinations of treatment approaches. As this study showed, adding whole-body cryotherapy to modalities and mobilization did work better than modalities and mobilization alone.

In very rare instances, infection can develop and become so chronic and virulent (strong) that it cannot be treated with antibiotics. Amputation of the arm may be the only thing that can save the patient’s life.

Most of the time, intravenous antibiotics and surgery to debride (clean out) the joint is successful in addressing acute and/or chronic infections. Infection can destroy the shoulder implant so in extreme cases, once the infection is cleared up, the original implant may have to be removed and replaced. If there has been too much bone loss or destruction, arthrodesis (fusion) may be necessary.

All of these procedures are done in an effort to save the joint and save the limb. Amputation is the last step when all else has failed and the person’s life is at risk. Again, this is a very rare occurrence and one that is taken very seriously.

With more and more older adults having a total shoulder replacement (TSR), it’s expected that more patients will experience unexpected problems. Persistent pain, restricted range of motion, and loss of function can mean a second or revision surgery. An unstable shoulder (one that partially or fully dislocates) will also require further treatment.

Some of the decision about whether (and how) to treat may depend on the underlying cause for the implant failure. For example, soft tissue problems such as rotator cuff deficiency or capsular adhesions are more difficult to treat than problems with the bone. Infection is another challenging problem that may require removing and replacing some or all of the implant.

Before a second surgery is considered, the surgeon will re-evaluate the patient closely. The reason for the first shoulder replacement (e.g., inflammation, trauma, rotator cuff rupture) is important. The patient’s cognitive and psychologic state are important. Someone who has dementia or Alzheimer’s and cannot follow postoperative directions may not be a good candidate for another surgery even when the shoulder is unstable or painful.

The surgeon’s examination includes assessment of muscle strength, shoulder motion, and nerve function. Clinical tests and imaging studies help pinpoint whether the problem is coming from the prosthetic (implant), soft-tissue structures, bone, or all three. X-rays may not be enough so that more advanced imaging such as MRIs or CT scans could be needed. Basic lab tests are also done to look for any sign of infection.

When after all these tests the cause of the problem is still unknown, then arthroscopic examination may be helpful. Inserting a scope with a tiny TV camera on the end into the joint gives the surgeon a direct view of the shoulder. Loosening of any part of the implant will be seen as well as infection, instability, or component loosening or wear.

Most surgeons use a flowchart called an algorithm to help when deciding what’s wrong and what to do about it. At the top of the chart is “painful arthroplasty.” Infection workup is first and the chart flows according to whether the test results are positive or negative. If infection is positive, then a determination is made whether this is acute (early onset) or chronic (long-standing problem). Treatment is determined on the basis of this classification.

On the negative side (no infection present), the surgeon must evaluate stiffness versus instability/weakness. In either case, physical therapy is often the next step in treatment with subsequent treatment based on whether there is improvement or not. If the problem cannot be corrected with rehabilitation, then a revision surgery may be necessary.

The decision to perform a revision procedure is not the final decision the surgeon must make. There are many different possibilities including removing just one component of the implant and replacing it, removing the entire implant and replacing it with a reverse shoulder arthroplasty, correction of the soft tissue failures, or perhaps even a do-nothing policy.

Soft tissue deficiencies pose additional challenges depending on which tendon or muscle is torn, worn, or weak and whether or not there are other soft tissue imbalances. In all cases, patients facing a second or revision surgery will be warned that the procedure may not clear up all deficiencies. For example, they may experience pain relief but may not gain any more shoulder motion.

For best results, patients should be evaluated carefully and selected for revision surgery based on the decision-making algorithm described. Patients considering revision surgery may want to ask their surgeon to walk them through the decision-making process used to come up with this recommendation. And your mother should be prepared that a second surgery may help with pain relief but does not always restore motion or full function.

All shoulder dislocations cause some amount of bone damage. In the most common type of dislocation, the head of the humerus (upper arm bone) is forced forward and out of the shoulder socket. This is known as an anterior shoulder dislocation.

Even if the shoulder is reduced (head of the humerus is put back in the socket), the soft tissues around the shoulder have been overstretched. If the humeral head hits the rim of the socket with enough force, there can be damage to both areas (the humeral head and the glenoid rim). This type of injury is referred to as a Hill-Sachs lesion.

An engaging Hill-Sachs defect describes a situation in which the bone defect catches on the glenoid rim during shoulder motion. This is more common with large defects. And the end result is that the arc of motion as the humeral moves, slides, and glides in the socket is off biomechanically. The joint no longer matches up causing what’s referred to as an articular arc mismatch.

It is good that this problem has been identified before treatment. Studies show that it may not be enough to repair the torn or damaged soft tissues (tendons and ligaments) if there is also a bony defect. The soft tissue repair or reconstructive surgery is more likely to fail if the bony lesion(s) are not addressed as well. The patient ends up with a chronically dislocating shoulder from the abnormal shoulder biomechanics.

We hope this explanation helps you understand the surgeon’s explanation when looking at the CT scan together. Your treatment plan will depend on a number of variables including the presence of this type of Hill-Sachs lesion. Your age, activity level, severity of injury, and bone quality are some of the factors that must be evaluated when determining the best plan of care. Your surgeon may have some additional concerns or comments for you as well.

All shoulder dislocations cause some amount of bone damage. In the most common type of dislocation, the head of the humerus (upper arm bone) is forced forward and out of the shoulder socket. This is known as an anterior shoulder dislocation.

Even if the shoulder is reduced (head of the humerus is put back in the socket), the soft tissues around the shoulder have been overstretched. If the humeral head hits the rim of the socket with enough force, there can be damage to both areas (the humeral head and the glenoid rim). This is the type of injury you have referred to as a Hill-Sachs lesion.

Studies show that there is always some amount of bone damage with a first-time anterior dislocation. If the defect is moderate-to-severe, the loss of bone results in abnormal shoulder motion (biomechanics). Many patients develop recurrent shoulder instability meaning the shoulder dislocates over and over.

Experts in this area say it may not be enough to repair the torn or damaged soft tissues (tendons and ligaments) if there is also a bony defect. The soft tissue repair or reconstructive surgery is more likely to fail if the bony lesion(s) are not addressed as well.

Anatomic repair (putting everything back the way it was meant to be) is always preferred. But a nonanatomic approach (e.g., using bone grafts, removing the humeral head, shoulder replacement) may be necessary in cases where there is more severe damage. Your surgeon is the best one to advise you. When formulating the best plan of care for you, he or she will take into consideration your age, activity level, severity of injury, and bone quality.

All studies show the same thing: the natural history of Hill-Sachs lesions (i.e., what happens without treatment) is chronic instability. In other words, the shoulder dislocates over and over further stretching the soft tissues and damaging the bone.

The Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow (KJOC) questionnaire has been tested and is considered to be a valid and reliable tool. It measures the functional status of overhead throwing athletes. It measures several different components needed to return to play. So it is considered a good predictor of return-to-play.

Studies show that the results of the KJOC survey can be influenced by outside, independent variables. For example, the type of surgery, type of sutures used to repair the damaged soft tissues, and severity of injury (partial versus full-thickness tears) can also influence the final results.

Players with both a rotator cuff tear and a labral tear are less likely to return to full sports participation. The partial tear and small labral tear that you describe would not necessarily put you out of the running for a full return to the game. About 55 per cent of professional baseball players with this type of injury are able to return to their preinjury level of play. Results are less favorable when there is a full-thickness tear of the rotator cuff, especially if combined with a labral tear of any size.

Regaining normal kinematics (motion) of the shoulder after complex shoulder injuries can take quite a bit of time in rehab. There is a delicate balance needed between mobility (movement) and stability (keeping the shoulder in the socket during activity) required for an overhead throwing athlete.

Your health care/sports team (e.g., surgeon, physical therapist, coach, athletic trainer) are the best ones to advise you. The fact that you have taken the KJOC test and been given a favorable score suggests you are receiving some useful guidance to help in the decision-making process.

From your description, it sounds like you may have something going on inside the shoulder that should be evaluated before doing exercises that might make it worse. Impaired performance with decreased velocity, early fatigue, and loss of control are often the symptoms present when there is a rotator cuff tear and/or a labral tear.

You probably know the rotator cuff is a group of four muscles that surround the shoulder and allow it to move in all directions without dislocating. The labrum is a rim of fibrous cartilage around the shoulder socket. It is designed to create greater depth in an otherwise fairly shallow socket. The labrum helps aid in maintaining shoulder stability.

Overuse with repetitive overhead throwing at high velocities can lead to tears, damage, and other injuries to these soft tissue structures. Pain, clicking, and weakness are the most commonly reported early symptoms suggesting a problem. But the type of impaired performance you described is also a warning flag.

Early evaluation and diagnosis is advised. You will want to avoid stressing the shoulder even more until you know what’s going on. This could be a simple problem for which exercises are helpful. But exercise is not recommended until you’ve been examined and possibly had some X-rays or more advanced imaging. Talk to your coach and see your team physician as soon as possible — certainly before practicing or playing again.

You may be experiencing one of two things: referred pain or centralized hypersensitivity. Or you could be having both things at the same time. Referred pain means the problem is in the shoulder (for example, something is getting impinged or “pinched”) but the pain pattern causes symptoms at a site distant from the source. You still have what’s called a peripheral pain problem (the arm).

In the case of centralized pain, the nervous system itself has become heightened in its responses. So even a light touch that would normally not hardly register creates a painful response. Pain is felt with lower mechanical pressure than would normally cause pain. And this doesn’t just occur in the arm or leg that’s hurt. The heightened pain response is perceived throughout the body. That’s what we mean by “central” hypersensitivity.

Pain can be a good thing. For one thing, it is protective. It is a normal response of the body when there is an injury. The body uses pain to protect itself while it is healing. But in time, the healing processes are completed and the pain goes away. That is the normal healing response.

But it’s not good when a persistent pain response gets turned on in the central nervous system and it doesn’t get turned off. The result is chronic pain from this phenomenon we call central hypersensitivity.

People with central hypersensitivity clearly have reduced pain thresholds (it takes less pressure than normal to cause pain). The reduced pain thresholds are observed at the site of the problem (shoulder for you) and in other parts of the arm unaffected by the injury.

People with centralized hypersensitivity have much lower pain thresholds compared with normals. For example, people with centralized hypersensitivity feel a painful response when a rubber tip is touched to the skin sooner and with less pressure compared with normal adults. And the sensation causes pain in the centralized hypersensitive group when it was just felt as pressure to the control group.

There are other possible causes of persistent pain that should be ruled out before going any further. You may need more advanced imaging studies to examine the bone and soft tissues to fully identify what’s going on in the shoulder.

Pain can be a good thing. For one thing, it is protective. It is a normal response of the body when there is an injury. The body uses pain to protect itself while it is healing. But in time, the healing processes are completed and the pain goes away. That is the normal healing response.

But in cases like yours, a persistent pain response gets turned on in the central nervous system and it doesn’t get turned off. The result is chronic pain from this phenomenon we call central hypersensitivity. Pain is felt with even a small touch or input. Pain is felt with lower mechanical pressure than would normally elicit a painful response. And this doesn’t just occur in the arm or leg that’s hurt. The heightened pain response is perceived throughout the body. That’s what we mean by “central” hypersensitivity.

The pain response of patients with subacromial impingement syndrome or SIS can become centralized. Studies show, once the tissue has healed, the hypersensitivity continues causing persistent pain even after treatment. This has been proven by testing pain responses to mechanical pressure applied to the skin.

People with central hypersensitivity clearly have reduced pain thresholds (it takes less pressure than normal to cause pain). The reduced pain thresholds are observed at the site of the shoulder problem and in other parts of the arm unaffected by the injury.

Comparing the pain responses of the individuals with SIS to normal controls (people without shoulder problems) confirms that patients with SIS have much lower pain thresholds compared with the control subjects. In other words, the patients with SIS feel a painful response when a rubber tip is touched to the skin sooner and with less pressure compared with normal adults. And the sensation causes pain in the SIS group when it is just felt as pressure to the control group.

What can this information do to help you? First, it offers reassurance that what you are experiencing is a real event and it’s something controlled by the nervous system. Second, it may help answer the question which came first: the chronic pain or the central hypersensitivity. And third, by treating the nervous system component of pain (not just the anatomic or biomechanical aspects of the problem), it might be possible to end this problem.

The treatment you have already tried is a good place to start. It may just take longer to get the pain responses turned around than might normally be expected. Adding relaxation techniques such as meditation, tai chi, qi gong, and/or physiologic quieting (something your physical therapist can help you with) may be helpful, too.

In some cases, medications used to quiet the central nervous system have proven helpful. These may include antidepressants and off-label use of other medications. If you don’t need a specific referral to a pain clinic, then your primary care physician is probably the best one to prescribe the right medication to help you.

You can also seek the counsel of a pharmacist who may be able to recommend the right medication for your situation. Often, it takes a whole host of treatment combinations. Be patient in finding the right choice(s) for you. And be aware that what works today or this week may have to be changed or tweaked a week or a month from now.

Shoulder replacement or arthroplasty is not unusual anymore. Regular replacements of the ball and socket joint are often done for people with painful and limited range of motion. But the standard shoulder replacement isn’t the best choice for everyone. Some patients need the reverse shoulder arthroplasty (RSA) you mentioned. This is mostly used for people who have injuries of the rotator cuff and shoulder arthritis that leave the shoulder unstable.

The rotator cuff is a group of four muscles that wrap around the shoulder to hold it in the socket. They also help move the shoulder. RSA is an option when the rotator cuff is no longer strong enough or functioning well enough to hold the shoulder in the socket. The RSA provides pain relief as well as a stable functioning shoulder.

Reverse replacements put the ball of the joint just off the shoulder blade with the socket off the upper arm. This placement is different from the usual ball at the top of the humerus (upper arm bone) and the socket on the shoulder blade.

The reverse shoulder joint isn’t a perfect solution. As you heard, it comes with problems of its own. For example, some patients end up with pain, loss of motion, and a problem called impingement. Impingement results in an inability to put the arm all the way down at the side. The implant design, location, and angle result in the two parts of the implant bumping up against each other, preventing full motion.

Failure is the word surgeons use when the patient has to have a second surgery to fix something about the implant. This next procedure is referred to as a revision surgery. Revision surgery may be needed when some part of the implant comes loose or breaks or the bone graft used around the implant is resorbed (broken down and absorbed) by the body. Bone loss around the implant can cause it to sink down into the bone (called subsidence).

Implant failure can happen but reports so far are that the majority of patients (96 per cent) have a good result that lasts a minimum of six years. More studies are being done to follow patients for longer periods of time and will report problems, failures, and results. In the meantime, don’t hesitate to ask your surgeon how often he or she does this procedure and what his or her “success” rate is with these surgeries. (It’s probably better to ask about the success rate than to ask about his or her “failure” rate).

The majority of patients who have this surgery are pleased with the results. They have less pain, more motion, and greater function. Overall, there are few complications and many, many more successes than failures.

Shoulder joint replacement surgery (also called shoulder arthroplasty) can ease pain from shoulder arthritis. Most people experience improved shoulder function after this surgery. But, some people like your father are not candidates for joint replacement of the shoulder because they lack the muscle function necessary to stabilize the joint. A different type of shoulder replacement, called reverse shoulder replacement or reverse shoulder arthroplasty (RSA), is used instead.

The reverse shoulder arthroplasty (RSA) is used for several different types of problems. The most common reason for choosing the RSA is a weak or deficient rotator cuff. The rotator cuff is a group of four muscles that wrap around the shoulder to hold it in the socket. They also help move the shoulder. RSA is an option when the rotator cuff is no longer strong enough or functioning well enough to hold the shoulder in the socket. The RSA provides pain relief as well as a stable functioning shoulder.

According to a recent study from the Florida Orthopaedic Institute and Foundation for Orthopaedic Research and Education in Tampa, Florida the average length of time these implants last is 73.5 months (a little more than six years). In their study, almost all implants were still in place and working well at the end of six years. Five patients had to have revision surgery because some part of the implant came loose or the bone graft used was resorbed (broken down and absorbed) by the body.

There was no sign of bone loss around the implant in any of the patients. A new development not seen in the previous study was the presence of scapular notching. This change was seen in about nine per cent of the group. Scapular notching describes a problem that occurs when the medial (inside) edge of the socket (now located at the top of the humerus) bumps up against the lateral (outside) edge of the scapula (shoulder blade) where the new round ball (glenosphere) is located. Loss of shoulder motion occurs from this type of impingement.

The surgeons concluded from this mid-term study of their RSA patients that the shoulders remained stable and the implants durable. The new development of scapular notching is concerning and all patients will continue to be followed for the next five years (total of 10 years since the first RSA surgery).

Because reverse shoulder arthroplasty is a fairly new procedure, long-term results aren’t available yet. Your father will likely be someone whose response over time will be of interest to surgeons. Early to mid-term results are very encouraging at this point. Patient motion is restored, pain is reduced, and function improved. At least in the short to mid-term period of time, patients report this surgery was well worth it!

The explanation of an engaging Hill-Sachs injury may take a few steps. Let’s start with a little bit of anatomy. The shoulder joint is a ball-and-socket joint. The socket is fairly shallow. This puts the joint at risk for dislocation. To help deepen the socket, the shoulder joint has a rim of cartilage called a labrum. The labrum forms a cup for the end of the arm bone (humerus) to rest and move inside.

A Bankart lesion is an injury to the labrum caused by forward (anterior) shoulder dislocation. The force of the head of the humerus (upper arm bone) as it dislocates, tears the labrum and the ligaments attached to it. The shoulder joint is unstable when the labrum is torn. There isn’t anything to keep the head of the humerus from slipping forward out of the socket again. Surgery to repair the damage is usually needed.

A Hill-Sachs lesion is an injury that causes damage to the head of the humerus. It also occurs with shoulder dislocation and usually develops after the Bankart lesion occurs. When the shoulder dislocates, the smooth surface of the humerus hits against the bony edge of the socket (called the glenoid). The collision causes a dent in the bone of the humerus. This is also called an impaction fracture.

When pain occurs as the arm is rotated and moved away from the body (movements called external rotation and abduction) in someone who already has a Hill-Sachs lesion, it’s referred to as an engaging Hill-Sachs lesion.

Surgery to repair the torn labrum and stop the humeral head from banging against the edge of the socket is usually very successful. Athletes are able to return to a pre-injury level of sports participation. The only concern is for recurrent shoulder dislocation; this can be prevented by repairing all aspects of damage in the shoulder. A careful and thorough orthopedic (and sometimes arthroscopic) exam is necessary to identify all soft tissue damage and bony defects requiring attention.

We read the results of the first study using the Remplissage procedure (combined with a Bankart repair) and comparing it to doing the Bankart procedure alone. The initial results are very impressive with a zero per cent rate of recurrent shoulder dislocations in the Remplissage/Bankart group compared with a 20 per cent rate for the Bankart repair without Remplissage.

The authors do mention that it was a small study of 50 patients (25 athletes in each group) and under the care of only two surgeons. So further studies (like yours) will be very helpful in determing results and any disadvantages to this approach.

Their recommended postoperative rehabilitative approach did include close supervision by the physical therapist. Capsular stretching exercises were allowed on the first day after surgery. The therapists must keep in mind that too much stretch, too soon, with too much force can undo the surgical repair. But without appropriate motion, the patient could end up with a signicant loss (or tightness) of external rotation. Throwing athletes need this motion in order to return to their preinjury level of play.

Twice a week supervision of an exercise program that is then carried out at home daily is advised for the first two weeks. Regular weekly follow-up visits can then be done for the next two months following a traditional rehab program used for Bankart repairs.

It’s always a good idea to observe orthopedic surgeries in order to fully appreciate the damage present at the time of surgery, as well as changes in anatomy as a result of the surgery and potential for change in biomechanics. A visual appreciation for the surgical repair and understanding the surgeon’s concerns along with the surgeon’s precautions and goals for the treatment is usually very helpful in developing an appropriate rehab program for each individual patient.

If you had a perfectly shaped shoulder with good bone stock, you probably wouldn’t need a shoulder replacement. But the long-term effects of osteoarthritis (the number one reason for joint replacement) alter joint shape and biomechanics. And if those changes are not corrected during joint replacement, the chance of implant failure increases dramatically.

Surgeons performing shoulder replacements are often faced with challenging joint deformities. There can be areas of uneven or increased points of joint contact, defects in the bone, and twists or torsions of the bone structures. Poor bone quality can make it difficult for the implant to have the support it needs to function properly and last for a long time.

The technical difficulty of correcting shoulder joint deformities can contribute to the problems you are describing. Modifications must be done during shoulder replacement surgery but before inserting the new joint (called a prosthesis or implant).

It may be necessary for the surgeon to use a technique called eccentric reaming. Reaming helps restore normal, even contact between the round head of the humerus (upper arm bone) and the glenoid fossa (shoulder socket).

The surgeon uses a shaver to reshape the curvature of the shallow socket and make it the same depth from front to back. Proper reaming is required for the implant to sit inside the socket and move with even contact and force between the two parts of the prosthesis. If there is more than 15 degrees of retroversion (backward twist), then eccentric reaming cannot be used effectively. Anything more than that requires the second treatment option: bone grafting.

When there isn’t enough bone to work with, then the surgeon turns to bone grafting to smooth out uneven wear. There are many advantages to this approach and a few disadvantages. On the positive side, the bone graft usually lasts a long time and is considered a permanent solution. The surgeon can use the patient’s own bone by using the removed humeral head.

Using bone graft material also gives the surgeon a chance to restore a more normal joint line. This effect prevents altered joint motion, which could lead to implant failure. On the downside, bone grafts can break down and dissolve or fail to bond with the natural bone. This may have happened to you.

The third solution (augmented glenoid component) refers to the use of plastic liners to help restore a normal joint line and build up areas of thin or deficient bone. Long-term studies to show results with this solution are not yet available. But it may be something your surgeon considers as a way to salveage (save) the implant and the joint.

When choosing the best surgical procedure, the surgeon must evaluate each patient individually to determine all possibilities. Every effort is made to avoid implant loosening or failure for any reason. The surgeon takes into consideration the amount and severity of bone loss and the type of deformities present. Eccentric reaming works well for mild bone loss or minor joint changes. More severe problems may require more extensive surgery (e.g., augmentation, bone graft, or joint resurfacing).

Implants that sink down (an event called subsidence) or that loosen may do so because of deficiency (weakness) in the bone. There may be other factors as well. Your surgeon is the best one to help you understand why (if there is a known ‘why’) these problems have developed and what is the next step in treatment.

There may be some surgical options as well as some choices in rehab that could help you. A strengthening program or some time focusing on reducing painful symptoms may be helpful during this transition phase. The next step is certainly to make a follow-up appointment with your surgeon (if you haven’t already done so). You may also want to consider a second opinion from another surgeon who has expertise with shoulder replacement surgery.

Total shoulder replacements are much newer compared with hip or knee replacements. Instead of the hundreds of thousands of these implants (like hips and knees) being done, there are only about 25,000 shoulder replacements done each year in the United States.

Problems and the need for revision (a second) surgery are much more common with shoulder replacements. In fact, up to seven per cent of patients receiving their first shoulder replacement will end up with a second surgery for one reason or another.

The most common reason for implant failure is malposition of the glenoid component. That’s the socket or cup-side of the joint. Even a small amount of twist off-center can cause uneven load, force, and wear. Surgeons are often faced with complex challenges when the reason the patient developed severe shoulder osteoarthritis was because of a natural off-angle in the shoulder.

That deformity must be corrected before inserting the new implant. And getting a perfectly shaped socket that matches the new implant can take extreme technical expertise on the part of the surgeon. Post-operative loosening, malunion, or failure for any other reason may be the result of the type of surgery used to reshape the socket first before putting the implant in place.

Making the selection of the “best” procedure for each patient requires considerable preoperative planning. The surgeon evaluates the strength of your bone, studies any deformities that might be present, and calculates which technique (or combination of techniques) will be best for you. Three-dimensional (3-D) CT scans with software that helps the surgeon plan the reconstruction can help reduce the risk of failure.

Sometimes there isn’t a clear reason why an implant loosens or failures to take hold. Even minor defects in the joint shape and/or surface can make a difference. There are always limits to what can be done to create a perfect result. And even when everything looks perfect, implant failure can still occur.