Evidence
Alert

Most shoulder replacements last longer than a decade: patients can be reassured by new research

Most shoulder replacements last longer than 10 years. A new study – one of the most complete reports to date – found that patients can expect large and long-lasting improvements in pain, strength, range of movement, and their ability to complete everyday tasks.

Before surgery, patients want to know how they will benefit from surgery and what they can expect in the long term; they want to know how long their replacement will last. But data on the lifetime of shoulder replacements and how they affect patients remains limited.

The new findings could help surgeons explain the likely outcomes of surgery to patients and may increase their confidence in recommending the procedure. In turn, this may reassure patients and help them decide whether to go ahead with a shoulder replacement.

What’s the issue?

The shoulder is a complex joint with a wide range of movement. The ball at the top of the upper arm should move smoothly in the socket of the shoulder blade. A lining on the surface of the bones prevents them from rubbing together. But arthritis, severe fractures, disrupted blood supply and tears to muscles and tendons can make the shoulder joint stiff and painful.

A replacement shoulder joint can reduce pain and improve function. The average age for people having a shoulder replacement is around 70. The National Joint Registry recorded 7,294 shoulder replacements in 2019. The number of shoulder replacements carried out each year is increasing.

There are three types of replacements:

  • Total shoulder replacement. The ball at the top of the upper arm bone is replaced by a metal ball and a new socket is inserted into the shoulder blade.
  • Reverse total shoulder replacement. The relationship between ball and socket is reversed so that a metal ball is attached to the shoulder blade to replace the original socket, and a new socket is attached to the top of the upper arm to replace the ball.
  • Partial shoulder replacement (humeral hemiarthroplasty). Only the ball at the top of the upper arm is replaced.

All replacements carry risks such as implant failure and infection. Patients may need further surgery or may continue to experience pain and disability. As with any joint replacements, implants are more likely to fail as time goes on.

Specialist centres carry out the most long-term follow-up, but data on shoulder replacements outcomes are limited.  Many national joint registries have only recently started collecting data on shoulder replacements.

Patients and doctors need to know how long shoulder replacements last, and the extent to which they reduce pain and improve function. This study aimed to provide answers.

What’s new?

Researchers searched for global data about the three types of shoulder replacements. They selected data that followed patients for at least 10 years after their surgery. 

They drew out information about how long the artificial shoulder had lasted. They also looked at the success of the surgery as reported by patients. In most of the studies, this included pain, impact on everyday activities, strength, and range of motion in the shoulder, arm, and hand. 

The analysis was based on nine studies (including 529 total and 364 partial shoulder replacements); plus six articles about patient-reported outcomes (of 530 shoulder replacements). An Australian national joint registry which provided 10-year follow up (on 7,651 total, 7,953 reverse total and 1,395 partial shoulder replacements) was also included. 

The findings reveal that nine out of ten shoulder replacements last for at least a decade. The patient-reported outcomes showed a large, long-lasting, and positive effect up to 10 years after surgery. It included reduction in pain and a greater ability to complete everyday tasks. 

Ten-year survival for the different types of shoulder replacements was around:

  • 92-95% for total shoulder replacements
  • 94% for reverse total shoulder replacements
  • 86-90% for partial shoulder replacements. 

Why is this important?

This research could help surgeons and patients decide whether to proceed with a shoulder replacement. The findings may reassure patients that their new joint is likely to last more than 10 years, with good outcomes.

The data may also help healthcare commissioners plan future joint replacement services.

What’s next?

This research provides support for shoulder replacements. Emerging technologies are improving replacement joints, for example by fixing the implant into the existing bone more tightly, or by carrying out more detailed scans of the joint before surgery. Most national joint registries are now including shoulder replacements in their data. These changes mean that data about this type of surgery is likely to grow and improve. 

In future, all studies should ensure they gather information about how long shoulder replacements last alongside patient-reported outcomes. This will help draw clearer links between the long-term survival of shoulder replacements and issues such as pain, function, and quality of life. 

You may be interested to read

The full paper: Evans JP, and others. How long does a shoulder replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 10 years of follow-up. The Lancet Rheumatology. 2020;2:e539-48. 

Commentary on the research published in The Lancet Rheumatology: Sodhi N and Mont MA. Shoulder replacement survivorship. The Lancet Rheumatology. 2020;2:e513-4. 

Commentary on the research published by the Rheumatology Network: How long does a shoulder replacement last?

Paper regarding the 'Can Shoulder Arthroscopy Work?’ (CSAW) trial: Beard DJ and others. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet. 2018;391:329-38. 

 

Funding: This research was supported by the NIHR Applied Research Collaboration South West Peninsula; NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust; the NIHR Oxford Biomedical Research Centre and an NIHR Clinical Lectureship.

Conflicts of Interest: Several authors have received grants from medical device companies outside of the submitted work.  

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Commentaries

Study author

We were reassured by the findings. There has been a perception that shoulder replacements are not as reliable, and do not last as long, as hip and knee replacements. This may be putting patients and surgeons off from proceeding to surgery. Our study has highlighted that this may not be the case, and that the survival of shoulder replacements is actually quite similar to hips and knees. And I am pleased that we put a particular emphasis on the patient-focused outcomes, which were excellent.

One of the disappointing findings was the lack of extended follow-up data. By this I mean, what happens beyond 15 or 20 years after shoulder replacement? Our future work will try and answer this question, with a particular focus on the emergence of registry data. We would also encourage the reporting of well-conducted long-term cohort analysis of shoulder replacements, which will help inform future meta-analysis.

Jon Evans, NIHR Academic Clinical Lecturer & Trauma and Orthopaedic Registrar, Health Services and Policy Research Group, University of Exeter 

Surgeon 

This research highlights the long-term benefits of shoulder replacements. The implants are long-lasting, and patients report the benefits 10 years after surgery. The robust evidence provided by this paper will help surgeons and patients in shared decision-making.

The research will also help inform commissioners about the high potential value that should be attached to shoulder replacements. The ‘Can Shoulder Arthroscopy Work?’ (CSAW) trial into a different procedure has been misinterpreted by commissioners in some parts of the country to suggest that shoulder surgery in general is not effective. This research is reassuring about the effectiveness of shoulder replacements and is important at a time of increasing competition for sparse resources.

Patients can be somewhat apprehensive in discussions about shoulder replacements. In my experience, the key to informed decision-making is listening to the patient to find out what their concerns are, as this varies from patient to patient.  You need to take the time to explain in simple English what the procedure involves and the impact it will have on them, especially in the first two to three months after surgery.

Steve Drew, Consultant Shoulder Surgeon, University Hospitals Coventry and Warwickshire NHS Trust