Disappointed with the Results of Your Total Shoulder Replacement?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.
In this article, surgeons from Philadelphia bring us up to date on revision total shoulder arthroplasty (shoulder replacement). The results of this second surgery are somewhat dependent on the reason for the failed replacement. 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.
The authors provide other surgeons with 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 a decision-making algorithm. Not all patients can or will benefit from a second procedure. Worst case scenarios include arthrodesis (joint fusion) or even amputation (e.g., in the case of infection that doesn't respond to treatment).
In summary, orthopedic surgeons and patients facing the possibility of a failed total shoulder replacement will find the information in this article timely and helpful. The reader is taken through the process of evaluation and decision-making step-by-step. Goals of treatment and expectations for each type of problem and solution are reviewed as well.
Joseph A. Abboud, MD, et al. Soft-Tissue Management in Revision Total Shoulder Arthroplasty. In Journal of the American Academy of Orthopaedic Surgeons. January 2013. Vol. 21. No. 1. Pp. 23-31.
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