Saturday, July 2, 2016

What is a Reverse Total Shoulder?

The shoulder is a ball-and-socket joint with the round ball found on top of the arm bone (humerus) and the socket on the shoulder blade (glenoid).

Bony anatomy of the shoulder joint
(Courtesy of

reverse total shoulder replacement is a design in which the location of the ball and the socket are swapped.  The metal ball is attached to the glenoid (socket) while the plastic socket is attached to the top of the humerus (upper arm bone).  This design allows the deltoid muscle to lift the arm instead of the torn rotator cuff.  

Reverse Total Shoulder Replacement

In a healthy shoulder, the rotator cuff (a group of 4 muscles) envelops the shoulder joint providing stability and movement.  When the rotator cuff is substantially torn, the shoulder joint will become unstable and may lose much of its ability to move.  

Rotator Cuff anatomy
Supraspinatus, Infraspinatus, Subscapularis, and Teres Minor
(Courtesy of

When a total shoulder replacement surgery is performed, the orthopedic shoulder surgeon determines which type of replacement design to use based on the status of the rotator cuff and the quality and quantity of bone available at the glenoid (socket).  

An anatomic total shoulder replacement is used when the rotator cuff is in good condition.  The metal and plastic components resemble the native shoulder joint.

Anatomic Total Shoulder Replacement

If the rotator cuff is not in good condition or if there has been a failed prior shoulder surgery, a reverse total shoulder replacement is used.  The reverse total shoulder will give the best results in these cases, typically allowing the patient to now raise the arm higher and without pain.

Shoulder replacement surgery is a procedure that takes specialized surgical training and experience to optimize patients' results.  In the right hands, shoulder replacement surgery is very effective in relieving pain and restoring function to those suffering from shoulder arthritis.

Michael A. Cohn, M.D. 
Orthopedic Surgeon 
Shoulder to Hand Surgery 
Orthopedic Center of Palm Beach County 
(561) 967-6500

Sunday, June 26, 2016

Shoulder Replacement Surgery: An Overview

Shoulder arthritis is a disabling condition for many adults.  It is usually the result of wear and tear processes as we age.  Sometimes it can be set into motion earlier with recurrent shoulder instability, fractures, or genetic diseases such as rheumatoid arthritis.

The signs and symptoms include loss of motion, pain, grinding sensation, and difficulty getting a good night's rest due to pain.

Traditional nonoperative treatment often includes activity modification, NSAIDs, cortisone injections and physical therapy.  These measures are often quite helpful in the earlier stages of the disease process.

Once these measures fail, you really have two potential treatment options to provide pain relief: PRP and/or stem cell therapy OR shoulder replacement surgery.

Briefly, PRP and stem cell therapy involve injection procedures (done in our office) to decrease inflammation and turn on the reparative processes with the goal of avoiding or delaying definitive surgical management for painful shoulder arthritis and other conditions.  Treatments can involve one to three injections over the course of 3-6 months.  This is a newer treatment option that holds significant promise and we have had high patient satisfaction rates of greater than 80% achieving significant pain relief.  While there have already been numerous published studies on the subject, this is an area of abundant active research and we should have better data from high quality studies in the coming years.

Otherwise, shoulder replacement surgery is usually chosen.  Shoulder replacement surgery is a highly successful, time-tested procedure for relieving the pain from arthritis.  Patient satisfaction rates are over 90% and implant survival rates at 10 years are also typically over 90% per published data.  To achieve the best outcome, patients should seek only an orthopedic surgeon who specializes in this procedure as research has shown the best outcomes in high volume shoulder surgeons.

Shoulder replacement surgery holds a lot of similarities to hip and knee replacement surgery.  The arthritic joint surfaces are replaced with highly polished medical-grade metal alloy and plastic components.  With improved understanding and implementation of pain management strategies, some of my patients in Palm Beach County, Florida are able to go home the day of surgery.  As of today, most of my patients stay in the hospital for 1-2 days after surgery before going home.

The rehabilitation process after surgery includes use of a sling for the first 4-6 weeks, during which time a physical therapy program is started to minimize stiffness.  Return to light daily activities is typically within 2 weeks.  Return to non-contact sports such as golf and tennis can usually begin 3-4 months postoperatively.

Michael A. Cohn, M.D. 
Orthopedic Surgeon 
Shoulder to Hand Surgery 
Orthopedic Center of Palm Beach County 
(561) 967-6500

Stem Cell and PRP Therapy for Shoulder Arthritis

Both stem cell and PRP therapy have been in use for quite some time now. In the past, the products were very difficult and expensive to extract and utilize, limiting benefits and availability to only professional athletes.  Now, with newer technologies, harvesting techniques, and manufacturers producing more affordable and advanced equipment, these products can more easily be obtained and put to use for your benefit.

Biological Benefits

·      Growth factors to signal cell recruitment and stimulate tissue repair pathways

·      Stem cells to give added cell signaling power to supercharge tissue repair pathways (note: includes bone marrow concentrate and amniotic membrane-derived injections

Treatment Options

Platelet-rich plasma (PRP) therapy

PRP uses a patient's own blood components to stimulate a healing response in damaged tissues. In response to an injury or tissue damage, your body naturally recruits platelets from the blood to initiate a healing response. Under normal conditions, platelets store numerous growth factors that are released in response to signals from the injured tissue. Modern technology allows us to concentrate platelets from your blood, and induce this growth factor release as we inject the solution directly into your shoulder joint, simulating this same healing response in a more powerful form to relieve shoulder arthritis pain. By enhancing the body's natural healing capacity, the treatment may lead to a more rapid, more efficient, and more thorough restoration of the joint's biologic environment's to a more healthy state. 

Bone Marrow–Derived Stem Cell Therapy

It is well established that a significant population of our body’s stem cells are contained within our bone marrow. By harvesting blood and tissue from the bone marrow of the hip, an injectable product can be produced by concentrating platelets and cells withdrawn through a needle aspiration procedure done with local anesthetic in the office procedure room. Bone marrow-derived stem cell therapy contains all of the growth and healing factors in PRP, along with concentrated mesenchymal stem cells, which further contribute to the regenerative process.

Amniotic–Derived Stem Cell Therapy

Processed tissue derived from human amniotic membrane includes adult epithelial stem cells and growth factors.  The product is derived from the placenta's amniotic membrane obtained from volunteers after childbirth, from tissues that would otherwise be thrown away.  Amniotic membrane provides an enhanced environment for tissue growth, repair, and healing along with anti-inflammatory and anti-scarring properties.  This combination of properties is excellent to aid in relieving shoulder pain due to arthritis.

Treatment plan

Depending on the severity and duration of your injury, one to three injections are suggested. Following the initial treatment, a follow-up visit occurs 3-4 weeks later. At this visit an evaluation of your response to the initial therapy is performed and a decision will be made regarding the potential need for additional treatments.  

Frequently Asked Questions

Are these treatments safe?

Research and clinical data show that these therapies are extremely safe, with minimal risk for any adverse reaction or complication. There is a small risk of infection from any injection into the body, but this is rare.  

Are these stem cells the same as embryonic stem cells?

No. The stem cells obtained from your bone marrow or from amniotic tissue are adult stem cells.  There is no ethical or FDA concern about the use of these stem cells as opposed to either embryonic stem cells or so-called “more than minimally manipulated” adult stem cells, both of which we do not offer as treatments.

What should I expect after my stem cell or PRP treatment?

Often, following the initial injection, an "achy" soreness is felt at the site of injury. This "soreness" is seen as a positive sign that the healing response has been set in motion. This effect can last for several days and gradually decreases as healing and tissue repair occurs. It is important that anti-inflammatory medications such as Ibuprofen, Naproxen and Aspirin be avoided following treatments. These medicines may block the effects of the intended healing response facilitated by the injection itself. It is acceptable to use over-the-counter pain medication, such as Tylenol and in some cases a prescribed analgesic, which does not have anti-inflammatory properties, to control discomfort as needed.  Your physician will discuss pain management options with you. You may be permitted to resume normal day to day activities and light exercise soon after the injection. More strenuous exercise typically should be avoided for 4-6 weeks.

If the in-office stem cell or PRP therapy procedure does not work as well as I hoped can I still have surgery?

Yes. For those patients wanting to do everything they can to avoid surgery, stem cell or PRP therapy should definitely be considered before surgery if your diagnosis is an appropriate indication for treatment.  There is nothing about these procedures that would preclude you from having surgery in the future if pain persists or worsens over time.  

How long does it take to notice improvement after treatment?

Stem cell and PRP therapy work by decreasing inflammation and improving the biological environment of your joint.  As such, results do not usually occur overnight.  Some individuals start to feel better in less than a week, but this is variable per patient.  The tissue reparative process takes 2-3 months.  Various factors such as age, physical activity level, nutrition, and the disease state of the joint being treated, may all effect an individual’s response and rate of symptom improvement.

What should I expect after treatment?

You may experience some pain and soreness for 2-7 days. The initial inflammatory phase may last up to 7 days, and the secondary phase may last up to 14 days.

You may utilize Tylenol for pain, and/or ice as needed for pain and swelling (30 minutes on, 30 minutes off), repeat as needed.

Some patients soon after injection will feel great one day, and for no apparent reason the area treated may begin to experience pain again. This is a normal part of the healing process. However, if you experience any excessive pain or swelling, or have any concerns, do not hesitate to contact your physician.

My goal is to achieve an 80% improvement in arthritis pain, if possible, and this may take only 1 injection or up to 3 over the course of 3-6 months.  Results can vary greatly based on many patient factors such as severity of the arthritis, activity level, nutrition, overall health status, and lifestyle.  

Michael A. Cohn, M.D.
Orthopedic Surgeon
Shoulder, Elbow, Wrist and Hand Surgery
Orthopedic Center of Palm Beach County
(561) 967-6500

PRP Therapy for Rotator Cuff Tear

Platelet-rich plasma, aka PRP, is a growth factor treatment for arthritis, tendon tears, and ligament tears. For many individuals looking to avoid surgery, such as a total shoulder replacement, it's a powerful pain-reliever that does the trick. Platelets are natural powerhouses for several different growth factors that stimulate tissue repair. For the purposes of this article, we will focus on PRP therapy's use for the treatment of rotator cuff tears. 

Many adults over 40 years of age with shoulder pain are ultimately diagnosed with shoulder arthritis with x-rays or a partial rotator cuff tear by MRI. In those cases for which non-operative treatments such as rest, anti-inflammatory medications, cortisone injections, and physical therapy do not cure the pain, the next option is most commonly arthroscopic shoulder surgery. 

While arthroscopic shoulder surgery is an excellent option in these cases, not all individuals want to proceed with surgery for a variety of reasons. High-deductible insurance plans are becoming more and more common and, therefore, the patient is often forced to pay most of the costs associated with surgery (medical clearance and testing, equipment and operating room expenses, anesthesiologist fees, surgeon fees, and postoperative physical therapy) instead of the insurance company. Others are anxious to proceed with an operation. Still others cannot afford the sometimes lengthy time away from work to recover from a surgical procedure. 

Regenerative medicine therapy is another group of non-operative treatments to consider before proceeding with surgery in these types of cases. This group of treatments includes such things as PRP therapy, Bone marrow-derived stem cell therapy, and Amniotic-derived stem cell therapy. Only those orthopedic surgeons who are specially-trained in the appropriate indications, preparation, and injection of these therapeutics offer them to their patients. 

PRP therapy is a procedure that is done in the office. The procedure starts with a blood draw from the arm, just as with blood drawn for laboratory studies. The blood is specially processed and spun at a high velocity to separate it into layers. The concentrated platelet layer, PRP, is extracted and transferred to a syringe. The PRP is then injected under ultrasound guidance at the shoulder directly into the partially torn rotator cuff tendon. The patient leaves with a band-aid and post-procedure instructions. Sometimes there is an initial achy pain felt at the injection site for a few days, which is thought to be a positive indicator that the tissue repair process has been ignited and is under way. 

After the procedure, the patient will work on gentle stretching and range of motion exercises initially. Weight lifting should be restricted for about 4 weeks. The patient will be re-evaluated in the weeks following the injection to make a decision on whether another PRP injection should be given to further aid in the recovery process. 

Michael A. Cohn, M.D. 
Orthopedic Surgeon 
Shoulder to Hand Surgery 
Orthopedic Center of Palm Beach County 
(561) 967-6500