We will soon be publishing two new research papers:
- Treatment of Shoulder Osteoarthritis and Rotator Cuff Tears with Spun and Whole Bone Marrow Concentrate Injections
- Comparing Outcomes of Spun and Whole Bone Marrow Concentrate injections in Hip and Shoulder Pain Patients
In these papers we have documented the positive aspects of bone marrow derived stem cell therapy for patients who have shoulder osteoarthritis.
The goal of treatment – pain free movement through a full range of motion
There are many ways to tackle the problem of painful degenerative shoulder disease.
- Replace the ball and socket of the shoulder joint.
- Manage the shoulder with “conservative non-surgical treatments,” such as painkillers, anti-inflammatories, cortisone, physical therapy, and other remedies for as long as you can until the pain or loss of function becomes unbearable.
- Try regenerative medicine such as stem cell therapy and platelet rich plasma therapy.
When someone comes into our institute it is usually after the “conservative treatments,” have failed and that a surgery is being strongly recommended.
What people, perhaps one day like yourself, who come into our office want is a realistic plan to get them to a pain-free range of motion in a functioning shoulder. Many times we can get people to this goal, many times we come close to getting people to this goal with significant improvement to their quality of life. There are times when we can only help a little. There are times we cannot help at all. People we cannot help would be significantly advanced cases of degenerative shoulder disease. Perhaps 10 to 20% of patients who seek regenerative medicine will not be good candidates. This is why I invite people to email me to discuss before they make an appointment. You can do so as well by using the form below.
A lot of shoulder osteoarthritis research centers on the problems of shoulder replacement and fixing a failed replacement.
We do a lot of research in our clinic, one topic we research often is shoulder osteoarthritis. It truly amazes me how many new studies there are on the problems of shoulder replacement and fixing a failed replacement.
Here is a 2018 study from a Swedish research team. It appears in the journal Acta orthopaedica (1) and discusses shoulder hemiarthroplasty.
- Shoulder hemiarthroplasty is a procedure where the ball of the shoulder is replaced with a prosthetic, while the socket remains intact.
The two types of Shoulder hemiarthroplasty are:
- shoulder resurfacing hemiarthroplasty (a protective metal cap is placed over the ball of the humerus head)
- shoulder stemmed hemiarthroplasty (Imagine a thumb tack, the metal cap is attached to a metal stem which is pushed into the humerus head)
Shoulder hemiarthroplasty comes with a high risk of need for second surgery. To quote the research: “. . . while patients receiving resurfacing hemi and stemmed hemi, reported similar shoulder functionality and quality of life, the revision rate for resurfacing hemi (12%) . . . stemmed hemi (6.7%).
The purpose of this study was to find why there was such a difference.: The results were:
- The younger patients were more likely to receive the resurfacing shoulder hemiarthroplasty and since younger people live longer, the chances of need or more revision surgery is greater. So a skewed result is achieved resurfacing shoulder hemiarthroplasty have a higher risk for revision because the patients were young enough to have multiple surgeries.
- The older you were, the more likely you would get the shoulder stemmed hemiarthroplasty because you suffered from primary osteoarthritis. Then you had a 6.7% chance of going back to surgery. Since the patients were older, as we have seen in other studies, they would be less likely to want to undergo a second or revision surgery. Older adults fearful of revision surgery also can skew results.
What the realistic outcomes a younger patient can expect is that when they agree to the surgery, they have to be prepared for the likely outcome of the necessity for multi-surgeries.
You have had a successful surgery if you still have severe pain. How?
You have probably all seen a variation of the VAS Visual Analogue Scale. We are going to need it for the next study.
Researchers tried to gauge what constituted the minimum results necessary to call a shoulder replacement surgery a success
In the Journal of shoulder and elbow surgery, researchers tried to gauge what constituted the minimum results necessary to call a shoulder replacement surgery a success. In 326 patients who had either a total shoulder replacement, a primary reverse shoulder replacement, or hemiarthroplasty, in averaging out the patient response outcomes, the researchers found that patients treated with a shoulder arthroplasty require a 1.4-point improvement in the VAS pain score.(2)
- If you went to surgery with, for an example 8.4 very severe pain, you qualified for a minimal clinically important difference (success) if you reported that pain down to a 7.0. The successful surgery still left you in severe pain.
Patients with poor lifestyle choices, those who do not bounce back well from adversity, those whose shoulders have significant degeneration of the soft tissue, should be offered an alternative to shoulder replacement.
The above statement is not an opinion, it is in the research:
- In a paper published in the March 2017 issue of the Journal of Shoulder and Elbow Surgery, doctors in Germany evaluated and identified risk factors for the development of intraoperative and postoperative surgical complications in total shoulder arthroplasty in patients with primary osteoarthritis.Twenty-seven complications (9.8%) in 275 shoulder arthroplasties were recorded. Mostly from patients who practiced poor lifestyle choices.(3)
- Also appearing in the Journal of Shoulder and Elbow Surgery, February 2017 issue, doctors at the Steadman Hawkins Clinic of the Carolinas wrote that patients’ resilience, that is the ability to bounce back or recover from stress, an increasingly recognized psychometric property, would do better than patients who do not do well with stress. The patients with low resilience would suffer from greater shoulder complications.(4)
- Doctors at the University Medical Center of Cologne in Germany also published new research in which a bad problem is can be made much worse by shoulder replacement. The German doctors suggest that a preoperative evaluation of humeral head subluxation (the head of the shoulder is not where it is supposed to be) and glenoid erosion (the shoulder labrum has deteriorated), two factors associated with less favorable postoperative shoulder replacement results, should be considered before moving forward to surgery.(5)
These are just a few of the new studies which if you read them as a whole tells us that patients with poor lifestyle choices, those who do not bounce back well from adversity, those whose shoulders have significant degeneration of the soft tissue, should be offered an alternative to shoulder replacement.
Here is a report from doctors at the Mayo Clinic. It was published in the Journal of shoulder and elbow surgery December 18, 2017 edition. Here are the highlights:
- 42 patients who had shoulder replacement, two patients had both shoulders replaced. Minimum 10 year follow up. Goal: Long-term assessment of shoulder replacement
- Studies have demonstrated mixed results after humeral head replacement for osteoarthritis at short- and medium-term follow-up intervals.
- Some patients experienced significant pain relief postoperatively that was maintained during the long-term follow-up
- 11 patients more than 25% of the study group reported persistent moderate or severe pain minimum ten years out
- Ten of 44 (22.7%) shoulders underwent revision surgery, predominantly for glenoid arthrosis (arthritis) (n = 9).
- In the 25 shoulders with 5 years of radiographic follow-up, patients demonstrated moderate to severe glenoid erosion in 50% at 5 years, which increased to 59% at 15 years and 88% at 20 years.
Humeral head replacement remains a successful operation for osteoarthritis at long-term follow-up. However, there is a substantive subgroup with continuing pain and a high rate of glenoid bone erosion after 10 years. Surgeons should carefully consider patients’ needs and desires when judging the indications for humeral head replacement.(6)
Despite research showing increasing numbers of surgical failures, more patients are having shoulder replacement surgery.
The above study shows the concern for the high number of complications measured long-term in shoulder replacement patients. In a study published in the journal Radiographics, radiologists looked for key imaging features in patient shoulders to help them distinguish between the shoulder problems listed above. If they could find MRI evidence for the source of pain, radiologists could guide surgeons in choosing the type of replacement surgery the patients should get. This they suggested would help limit surgical failures and get the shoulder to as normal a range of motion as possible.(7)
Sounds good, but as we have seen in patients here in our clinic that had an MRI, had the source of their pain pinpointed, had preoperative planning, had the best prosthetic device for them, had the best intention of the health providers to get that shoulder to as good as new as possible. The surgery still failed catastrophically.
In a study in the Journal of Elbow and Shoulder Surgery, doctors put a great degree of surgical failure on the shoulder instability the surgery itself caused.
Here is the researchers report:
- 27 patient case studies were reviewed. These patients had experienced shoulder replacement postoperative instability
- The type of surgeries were 8 hemiarthroplasties (ball replacement and structural fix of the bone),
- 14 total shoulder replacements with metal-backed glenoid components, and
- 5 total shoulder replacements with cemented glenoid components.
The patients had:
- 10 isolated subscapularis tears,
- 6 massive rotator cuff tears,
- 8 component malpositions,
- 2 component dissociations or loosening, and
- 1 humeral shortening. (8)
One thing certainly that would help prevent surgical failure is not having a surgery.
In the Mayo clinic study above, bone disintegration was a great concern. In a recent study, also in the Journal of shoulder and elbow surgery, doctors discuss hardware failures known to plague patients: “The longevity of total shoulder replacement is primarily limited by the performance of the ultra high-molecular-weight polyethylene glenoid component. [This study] demonstrates that glenoid component fracture associated with oxidation has not been eliminated with the advent of modern materials (HXL) in the shoulder domain.”
In other words, the hardware caused an oxidation problem which disintegrated the bone.(9)
The health of bone is obviously very important in shoulder replacement. As you can imagine a revision surgery to fix the problems created by bone disintegration caused by the first replacement will be a complex one.
The following research also from the Journal of Shoulder and Elbow Surgery explains why patients must be given information on treatment options outside of surgery:
- “The management of a failed shoulder represents a complex and difficult problem for the treating surgeon, with potential difficulties and complications that are related to the need to remove a well-fixed stem.”(10)
If the prosthesis is removed due to failure, the bone becomes compromised, and it is even more difficult to place another prosthesis.
The search for shoulder replacement alternatives
The problem with shoulder replacement failures are leading researchers to look at shoulder replacement alternatives. One study found that surgical repairs of degenerate and torn tissue are often prone to failure, and that some biological (biomedical) therapies (such as Platelet-Rich Plasma Therapy or Stem Cell Therapy) might improve outcomes. In fact, injections of platelet-rich plasma have led to reduced pain and improved recovery in other degenerated areas, together with the restoration of function.
Doctors in Germany looked at repairing cartilage defects and soft tissue injury in the shoulder before it leads to advanced osteoarthritis. They concluded that Stem Cell Therapy for cartilage regeneration was a minimally invasive approach for shoulder joint preservation and an alternative to shoulder replacement.(11)
In the video below, I demonstrate of technique for giving PRP Injections into the shoulder
- Notice that multiple areas if the shoulder are treated in this treatment
- The procedure is well tolerated by this patient.
Can PRP and stem cell treatments be an option?
In the worst case of shoulder replacement I have seen, an elderly man presented with right shoulder pain. When I asked him to lift his arms, he lifted his right arm, but had no motion at all in his left shoulder. I was perplexed and asked if his left shoulder also hurt. His response was alarming. He told me that he had a left shoulder replacement, and the arm prosthesis had dislocated out the the shoulder, and he had absolutely no use of his left arm since the dislocation that could not be relocated into the false joint. He obviously wanted to avoid surgery to his right shoulder.
When a patient comes into our office with a recommendation to shoulder replacement, we do a detailed examination, we look at range of motion and what type of function that patient has. We then discuss with them, the realistic healing we may expect with bone morrow stem cell therapy. If it is appropriate, we start the treatments as you have seen in the videos.
Ask Dr. Darrow about alternatives to shoulder replacement
STEM CELL INSTITUTE
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1 Ödquist M, Hallberg K, Rahme H, Salomonsson B, Rosso A. Lower age increases the risk of revision for stemmed and resurfacing shoulder hemi arthroplasty: A study from the Swedish shoulder arthroplasty register. Acta orthopaedica. 2017 Dec 5:1-7.
2 Tashjian RZ, Hung M, Keener JD, Bowen RC, McAllister J, Chen W, Ebersole G, Granger EK, Chamberlain AM. Determining the minimal clinically important difference for the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog scale (VAS) measuring pain after shoulder arthroplasty. Journal of shoulder and elbow surgery. 2017 Jan 1;26(1):144-8.
3 Leschinger T, Raiss P, Loew M, Zeifang F. Total shoulder arthroplasty: risk factors for intraoperative and postoperative complications in patients with primary arthritis. J Shoulder Elbow Surg. 2017 Mar;26(3):e71-e77. doi: 10.1016/j.jse.2016.08.001. Epub 2016 Oct 10.
4 Tokish JM, Kissenberth MJ, Tolan SJ2, et al. Resilience correlates with outcomes after total shoulder arthroplasty. J Shoulder Elbow Surg. 2017 Feb 10. pii: S1058-2746(17)30012-5. doi: 10.1016/j.jse.2016.12.070.
5 Leschinger T, Raiss P, Loew M, Zeifang F. Predictors of medium-term clinical outcomes after total shoulder arthroplasty. Arch Orthop Trauma Surg. 2017 Feb;137(2):187-193. doi: 10.1007/s00402-016-2602-x. Epub 2016 Dec 7.
6 Robinson WA, Wagner ER, Cofield R, Sanchez-Sotelo J, Sperling JW. Long-term outcomes of humeral head replacement for the treatment of osteoarthritis; a report of 44 arthroplasties with minimum 10-year follow-up. Journal of shoulder and elbow surgery. 2017 Dec 18.
7 Lin DJ, Wong TT, Kazam JK. Shoulder Arthroplasty, from indications to complications: what the radiologist needs to know. Radiographics. 2016 Jan-Feb;36(1):192-208. doi: 10.1148/rg.2016150055.
8 Kany J, Jose J, Katz D, Werthel JD, Sekaran P, Amaravathi RS, Valenti P. The main cause of instability after unconstrained shoulder prosthesis is soft tissue deficiency. Journal of Shoulder and Elbow Surgery. 2017 Feb 27.
9 Ansari F, Lee T, Malito L, Martin A, Gunther SB, Harmsen S, Norris TR, Ries M, Van Citters D, Pruitt L. Analysis of severely fractured glenoid components: clinical consequences of biomechanics, design, and materials selection on implant performance. J Shoulder Elbow Surg. 2016 Jan 14. pii: S1058-2746(15)00588-1. doi: 10.1016/j.jse.2015.10.017
10 Cisneros LG, Atoun E, Abraham R, Tsvieli O, Bruguera J, Levy O. Revision shoulder arthroplasty: does the stem really matter? J. Shoulder Elbow Surg. 2016 Jan 25. pii: S1058-2746(15)00578-9. doi: 10.1016/j.jse.2015.10.007.
11 Banke IJ, Vogt S, Buchmann S, Imhoff AB. [Arthroscopic options for regenerative treatment of cartilage defects in the shoulder]. Orthopäde. 2011 Jan;40(1):85-92. doi: 10.1007/s00132-010-1682-5.