What To Do When the Patient Isn’t Right for a Shoulder Replacement

In this article, surgeons from the Cleveland Shoulder Institute in Ohio offer their best advice about how to treat three groups of patients who might not be right for a shoulder replacement but need treatment just the same.

The diagnosis of shoulder osteoarthritis usually leads to successful results (less pain, better motion and function) with a shoulder replacement. But there are certain patients for whom studies show conventional shoulder replacement doesn’t always result in good outcomes.

In particular, young patients (younger than 60 years old) with osteoarthritis, adults with posttraumatic arthritis, and individuals with specific lesions (damage, defects) to the head of the humerus (upper arm bone) fall into this category.

The biggest concerns are for how long the implant will last in someone who may live another 20 years (or more) and the increased likelihood of revision (second) surgery. The most common problem that develops in the younger age group is loosening of the implant.

If the traditional shoulder replacement won’t work for these patients, then what else can be done for them? The authors discuss two separate categories of potential treatment: types of arthroplasty (surgical repair of the joint) and nonarthroplasty (but still surgical) alternatives.

Arthroplasty options include: shoulder resurfacing, using a short-stem humeral implant, and glenoid “reaming” without an implant (called ream and run). Humeral head resurfacing has been around for 25 years but the short-stem humeral implant is fairly new technology. “Ream and run” involves smoothing the glenoid (socket side) of the shoulder joint and restoring the round shape as much as possible.

Nonarthroplasty treatment suggested included debridement with capsular release, microfracture, autologous chondrocyte implantation, and osteochondral allograft resurfacing. In the future, long-term results of these alternative approaches will aid shoulder surgeons in determining which technique is best for each patient. For now, evidence is limited but outcomes are promising.

Here are a few more details about these alternative options to traditional shoulder replacement in young patients with osteoarthritis. The main advantage to shoulder resurfacing and a short-stem humeral component is that these techniques preserve (save) bone. Only the damaged portion of the shoulder is replaced (not the whole shoulder). Bone spurs (called osteophytes are shaved away. The normal anatomy can be restored with less bone removal. Bone preservation makes it possible to delay (but not prevent) total shoulder replacement if and when further surgery is needed.

There is also a newer approach to resurfacing the shoulder joint and that’s called biologic glenoid resurfacing. In this case, the socket side of the joint (rather than the head of the humerus) is resurfaced. This can be done with a variety of different soft tissues to smooth the joint surface. The technique is called interpositional arthroplasty and uses human skin matrix, human tendon graft from a donor, the patient’s own connective tissue from the fascia lata along the outside of the thigh, or pig graft material.

On the nonarthroplasty side of things, the focus has been on trying to repair the damaged cartilage. The goal is to provide relief from pain and improve function. This is done by removing torn, damaged, or loose pieces of joint cartilage and smoothing or filling remaining holes, lesions, or “defects.”

Microfracture aids in repairing the joint surface by causing bleeding into the joint. The body creates new fibrous cartilage in the area where tiny holes have been drilled through the joint surface into the bone marrow. Alternatively, the surgeon can use cartilage cells (either harvested from the patient or from a donor) to fill in and then smooth over defects. Using the patient’s own chondrocytes (cartilage cells) is ideal because there’s a greater chance for cells to survive the transplantation process. But patient grafts also come with potential for problems at the donor site.

In summary, traditional shoulder replacement doesn’t always provide the hoped-for results. And it’s difficult to predict who will have a good result and who won’t. Therefore, alternative treatments have been proposed, used, studied, and reported on. Shoulder surgeons will find the information in this review article on the many alternative operative techniques to treat shoulder osteoarthritis in young patients of interest.