Shoulder Pain Management

Patient Studies^1,2,3

In general, osteoarthritis is the most common condition leading to joint replacement, including shoulder replacement.

Arthroscopic Surgery

In a study designed to identify factors that affect outcome results, 127 patients who underwent arthroscopic repair of a rotator cuff tear were followed for 2 years.⁴ At 2 years, there was a significant increase in the percentage of healed tendon, at 75.42%, compared to the 3-month and the 1-year time points.

The authors concluded that rotator cuff characteristics, such as tear size, biceps pathology, acromioclavicular joint pathology and tissue quality, have a significant effect on post-operative tendon integrity. Arthroscopic rotator cuff repair demonstrated significant patient improvement in clinical outcomes and good rate of healing by post-operative ultrasound.

Fifty shoulders in 46 patients underwent stabilization surgery for multidirectional instability.⁵ Patient satisfaction was associated with greater forward elevation and greater external rotation. Multivariate analysis showed that an independent determinant of patient satisfaction with outcome included change in instability symptoms. Subjective variables of symptoms and motion had the greatest correlation with patient satisfaction following surgery for multidirectional shoulder instability.

Shoulder Resurfacing

Cementless humeral resurfacing arthroplasty is a bone-conserving arthroplasty option for patients with glenohumeral arthritis that has been successful in older patients.⁵ A recent study followed active patients who were less than 55 years of age for 2 years after humeral resurfacing.⁶ Prospectively collected clinical data was reviewed on a series of thirty-six patients under fifty-five years of age with end-stage glenohumeral arthrosis, but without osteonecrosis, who had undergone a cementless humeral resurfacing hemiarthroplasty performed by a single surgeon. All patients were followed for a minimum of two years. Pain, function, and patient satisfaction were assessed and all complications documented. Radiographs were evaluated for implant loosening. The thirty-six patients had a mean age of 42.3 years and were followed for a mean of 38.1 months. Scores measured with a visual analog pain scale, the Single Assessment Numeric Evaluation (SANE) scale, and the American Shoulder and Elbow Surgeons (ASES) scale all improved significantly from preoperatively to two years postoperatively. Complications included one traumatic subscapularis rupture at six weeks, three cases of arthrofibrosis, and one deep hematoma. No obvious radiographic evidence of loosening was noted at the time of the latest follow-up. One shoulder was converted to a stemmed total shoulder arthroplasty at twenty-four months because of pain, but the implant was not loose at the revision. The remaining thirty-five patients were satisfied with the outcome at the time of the latest follow-up and had returned to their desired activity. No obvious radiographic evidence of loosening was noted at the time of the latest follow-up. 97% of patients were satisfied with the outcome at the time of the latest follow-up and had returned to their desired activity levels. The authors concluded that cementless humeral resurfacing arthroplasty is a viable treatment option for active patients, and that patients can return to the desired function and expect pain relief. Implant loosening and glenoid wear did not appear to be concerns in the short term despite the high activity levels of many patients.

Partial Shoulder Replacement

Hemiarthroplasty (partial shoulder replacement) has been considered the traditional treatment for osteoarthritis. Improvement in range of motion and strength are equivalent when comparing total shoulder arthroplasty to hemiarthroplasty.¹ Hemiarthroplasty limits the amount of glenoid resurfacing (a technically difficult portion of the surgery) and adds concern about potential glenoid loosening. Advantages of hemiarthroplasty compared with total shoulder arthroplasty include:

• Decreased operative time
• Lower cost
• Less blood loss

Up to 80% of patients with osteoarthritis who received humeral head replacement alone reported good or excellent pain relief 2 years post-surgery.² In a randomized, double-blind clinical trial of 41 patients (ages 61-79) with osteoarthritis of the shoulder, researchers compared the quality-of-life outcome following hemiarthroplasty with that following total shoulder arthroplasty.² The patients included in the study had a diagnosis of primary osteoarthritis of the shoulder, had a failure of a minimum of six months of nonoperative treatment (including analgesics, anti-inflammatory medication, and physiotherapy), and wished to have surgical intervention. Primary osteoarthritis of the shoulder was defined as shoulder pain; no history of major trauma, infection, osteonecrosis, cuff tear arthropathy, chronic dislocation, or a secondary cause of osteoarthritis; and radiographic evidence of joint space narrowing, osteophyte formation, and/or subchondral sclerosis. The 41 patients were randomized to receive a hemiarthroplasty or a total shoulder arthroplasty. One patient died, and all others were evaluated preoperatively and at six weeks and three, six, twelve, eighteen, and twenty-four months postoperatively with use of a standardized format including a disease-specific quality-of-life measurement tool (Western Ontario Osteoarthritis of the Shoulder [WOOS] index), general shoulder rating scales (University of California at Los Angeles [UCLA] shoulder scale, Constant score, and American Shoulder and Elbow Surgeons [ASES] evaluation form), general pain scales (McGill pain score and visual analogue scale), and a global health measure (Short Form-36 [SF-36]). When a patient required revision of a hemiarthroplasty to a total shoulder arthroplasty, the last score before he or she “crossed over” was used for the analysis. Significant improvements in disease-specific quality of life were seen two years after both the total shoulder arthroplasties and the hemiarthroplasties. There were no significant differences in quality of life (WOOS score) between the group treated with total shoulder arthroplasty and that treated with hemiarthroplasty.²

Hemiarthroplasty has been considered advantageous for active patients with reasonable glenoid anatomy and a balanced joint, with the possibility of future conversion to total shoulder arthroplasty, if necessary. However, hemiarthroplasty outcomes may be unpredictable for active patients with high physical demands and expectations. The option to convert a hemiarthroplasty to a total shoulder arthroplasty allows the high-demand patient an alternative when the arthritic condition exceeds the pain threshold and reduces implant performance.

Total Shoulder Replacement

Total shoulder arthroplasty may provide relief of shoulder pain in patients with osteoarthritis. When compared to hemiarthroplasty, total shoulder arthroplasty may have more predictable long-term effect in relieving pain and restoring function with potentially fewer long-term complications or re-operations.² In a randomized, double-blind clinical trial of 41 patients (ages 61-79) with osteoarthritis of the shoulder, researchers compared the quality-of-life outcome following hemiarthroplasty with that following total shoulder arthroplasty.² The patients included in the study had a diagnosis of primary osteoarthritis of the shoulder, had a failure of a minimum of six months of nonoperative treatment (including analgesics, anti-inflammatory medication, and physiotherapy), and wished to have surgical intervention. Primary osteoarthritis of the shoulder was defined as shoulder pain; no history of major trauma, infection, osteonecrosis, cuff tear arthropathy, chronic dislocation, or a secondary cause of osteoarthritis; and radiographic evidence of joint space narrowing, osteophyte formation, and/or subchondral sclerosis. The 41 patients were randomized to receive a hemiarthroplasty or a total shoulder arthroplasty. One patient died, and all others were evaluated preoperatively and at six weeks and three, six, twelve, eighteen, and twenty-four months postoperatively with use of a standardized format including a disease-specific quality-of-life measurement tool (Western Ontario Osteoarthritis of the Shoulder [WOOS] index), general shoulder rating scales (University of California at Los Angeles [UCLA] shoulder scale, Constant score, and American Shoulder and Elbow Surgeons [ASES] evaluation form), general pain scales (McGill pain score and visual analogue scale), and a global health measure (Short Form-36 [SF-36]). When a patient required revision of a hemiarthroplasty to a total shoulder arthroplasty, the last score before he or she “crossed over” was used for the analysis. Significant improvements in disease-specific quality of life were seen two years after both the total shoulder arthroplasties and the hemiarthroplasties. There were no significant differences in quality of life (WOOS score) between the group treated with total shoulder arthroplasty and that treated with hemiarthroplasty (90.6 + 13.2 and 81.5 + 24.1 points, respectively; p=0.18). The other outcome measures demonstrated similar findings. Two patients in the hemiarthroplasty group crossed over to the other group by undergoing a revision to a total shoulder arthroplasty because of glenoid arthrosis. Both total shoulder arthroplasty and hemiarthroplasty improved disease-specific and general quality-of-life measurements of physical symptoms, sports/recreation/work, lifestyle, and emotions.

A recent clinical review article of various studies on the subject by R. John Naranja, MD and Joseph P. Iannotti, MD, PhD, found that shoulder replacement surgery reduced pain in the shoulder joint in most people.³ They also noted an improved range of motion in those who underwent shoulder replacement. The studies they looked at found that the use of modular implants had a favorable impact on the results of shoulder replacement surgery.³

In one study, an average of >90% of patients who underwent total shoulder arthroplasty experienced pain relief.¹ Total shoulder arthroplasty may be the best initial choice for patients who would gain only minimal pain relief from arthroscopy or for patients who experienced a complication from previous surgery.

Reverse Shoulder Replacement

In a prospective outcomes study of reverse shoulder arthroplasty for the treatment of a rotator cuff deficiency, authors found that advances in reverse shoulder arthroplasty allowed for improvement in patient outcomes. From February 2004 to March 2005, 112 patients (114 shoulders) were treated with a reverse shoulder arthroplasty. 94 patients were available for a minimum follow-up of 2 years.⁷ Of the ninety-six shoulders, thirty-seven had a primary rotator cuff deficiency, thirty-three had a previous rotator cuff operation, twenty-three had a previous arthroplasty, and three had a proximal humeral nonunion. The patients were prospectively followed clinically (the American Shoulder and Elbow Surgeons [ASES] score, the Simple Shoulder Test [SST], and self-reported satisfaction) and radiographically (mechanical failure, loosening, and notching). Patients were videotaped while performing a standard active range-of-motion protocol before and after treatment. These videos were then analyzed in a blinded fashion by three independent observers using a digital goniometer. At two years, the average total ASES scores had improved from 30 preoperatively to 77.6; the average ASES pain scores, from 15 to 41.6; and the average SST scores, from 1.8 to 6.8. Blinded analysis of range of motion showed that average abduction improved from 61° preoperatively to 109.5°; average flexion from 63.5° to 118°; and average external rotation, from 13.4° to 28.2°. The patients rated the outcome as excellent in fifty-three shoulders (55%), good in twenty-six (27%), satisfactory in eleven (12%), and unsatisfactory in six (6%). There was no evidence of mechanical failure of the baseplate or scapular notching in any of the patients. Six of the ninety-four patients in this study had a complication. Authors concluded that advances in reverse shoulder arthroplasty have allowed for improvement in patient outcomes while minimizing early mechanical failure and scapular notching and decreasing the overall complication rate at short-term follow-up.

References