Failed Shoulder Replacement

Overview

For patients in Richmond, VA seeking specialized care, understanding the mechanics of a failed shoulder replacement is the first step toward recovery. Shoulder replacements are a durable solution for many shoulder conditions, but failures do occur. These are among the most complex problems in orthopaedics. "Failure" can mean mechanical loosening (the implant unbonding from the bone), instability (dislocating), or infection.

Dr. Wall specializes in the workup of painful arthroplasties. A thorough evaluation is always needed to determine the cause of why your shoulder replacement might be persistently painful or problematic. This always begins with a detailed history in clinic of your shoulder’s surgeries and an exam. X-rays, bloodwork, and advanced imaging, such as a CT scan, are often all necessary. If there is any concern for infection at all, an aspiration - where a needle is inserted into the joint and fluid is pulled out - or a brief arthroscopic surgery will be required to see if any bacteria are growing.

Symptoms

Failed shoulder replacements can present in multiple ways. This is because there can be many reasons why a shoulder replacement might fail. Symptoms may be present from the time of surgery or they can develop over time, even years later. Some of the more common reasons are:

  • Pain: Persistent pain at your shoulder replacement that lasts longer than the first few weeks from surgery.

  • Loss of motion: Everyone loses some motion after shoulder surgery, the goal of PT is to restore it during your recovery. If full motion is never achieved after months of therapy, or if full motion is achieved but is then progressively lost over time, that can be a sign that there is an issue with your replacement.

  • Wound issues: Any time surgical wounds begin opening up or draining is concerning for infection, which may or may not track down to the implants.

  • Instability: Rarely, shoulder replacements can become unstable and feel abnormal or even dislocate. When this happens, the patient would have a sudden, painful inability to move their arm.

Common Modes of Failure

  • Implant Loosening: Implants on either the humerus or glenoid (the former ball and socket, respectively) can loosen for many reasons such as infection, trauma or just without any apparent cause at all.

  • Tendon Pathology: Anatomic replacements and hemiarthroplasties cease to work if the rotator cuff tears around them. The conjoined tendon (which attaches to the coracoid at the front of the shoulder) can also suffer from impingement, or accidental overlengthening in reverse shoulder arthroplasty, particularly with smaller patients.

  • Infection: Often caused by P. acnes, a slow-growing bacteria common on the shoulder skin that can infect implants silently.

  • Fracture: A shoulder replacement needs intact bones around it to function appropriately. Some fractures are more likely depending on the patient and the type of replacement present.

  • Impingement: Occasionally implants are not positioned perfectly for a patient’s anatomy. They can then start to hit (impinge) on adjacent structures like the glenoid or coracoid - two bony parts of the scapula.

  • Normal Wear: All joint replacements have a lifespan, just like tires on a car. It’s impossible to accurately predict when individual components might wear out - it might be within a few years if there is something else wrong with the shoulder, or it might be decades later if the shoulder replacement was performed well. The part that typically wears first is the small piece of plastic used in anatomic and reverse shoulder replacements.

When is Surgery Needed?

Surgery is often needed when shoulder replacements fail. The decision always depends on the degree of disability, the prognosis for the type of failure, and the overall health of the patient.

Surgical Solutions

  • Revision Shoulder Arthroplasty: The type of revision required is different for every patient. The goal of any revision is to treat the underlying problem. Sometimes that means removing all of the old implants, sometimes only one of them. Bone loss needs to be addressed and new implants often need to be inserted in such a fashion that the shoulder has the best chance of having optimal function again. In infections, sometimes two procedures are required (removal of all implants, cleaning the shoulder, allowing multiple weeks of rest and IV antibiotics, then a second surgery to put new implants in).