Shoulder replacement

Overview

Shoulder replacement, also known as shoulder arthroplasty, is a surgical procedure that involves replacing damaged areas of the shoulder joint with artificial components made of metal and plastic implants. The shoulder joint is a ball-and-socket joint, with the round head of the upper arm bone fitting into a shallow socket in the shoulder. When this joint is damaged, it can lead to pain, weakness, and stiffness. Shoulder implants come in various shapes and sizes, offering options such as partial or total replacement with either anatomic or reverse implants.

The common reason for a shoulder replacement surgery is to alleviate pain and improve the function of the shoulder. This is achieved by replacing the damaged parts of the shoulder joint with prostheses. Common reasons for undergoing shoulder replacement surgery include conditions like osteoarthritis, rotator cuff tear arthropathy, avascular necrosis, or rheumatoid arthritis. The procedure aims to relieve pain, enhance strength, increase the range of motion, and restore the ability to use the shoulder and arm effectively.

Types of procedure

The choice of shoulder replacement procedure recommended by your doctor depends on the specific type of joint damage you have. The options include:

• Hemiarthroplasty: This procedure involves replacing only the ball and stem of the shoulder joint. The stem is connected to the ball and fits into your natural socket.
• Resurfacing hemiarthroplasty: In this approach, the joint surface of the humeral head is replaced with a cap-like prosthesis, without the use of a stem.
• Anatomic total shoulder replacement: This surgery replaces the arthritic joint with a highly polished metal ball attached to a stem on the humeral side, along with a plastic cup on the glenoid socket.
• Stemless total shoulder arthroplasty: This method is a bone-preserving variation of total shoulder arthroplasty. It involves attaching the metallic ball directly to the upper arm without using a stem.
• Reverse total shoulder replacement: In a reverse total shoulder replacement, the joint is fundamentally reconfigured. The metal ball is placed where the glenoid socket used to be, and a plastic cup is attached to the stem, which is then relocated to the upper arm bone (humerus).

Reasons for undergoing the procedure.

Surgery to replace the shoulder joint is performed to treat pain and other side effects brought on by shoulder joint damage.

The following conditions may damage the joint:

• Osteoarthritis: Osteoarthritis, also referred to as wear-and-tear arthritis, affects the cartilage that protects the ends of bones and facilitates joint motion.
• Rotator cuff injuries: The shoulder joint is surrounded by the rotator cuff, a group of muscles and tendons. There is a chance that cartilage and bone in the shoulder joint will be damaged as a result of rotator cuff injury.
• Fractures: When the previous surgery to treat a fracture failed, or when the injury caused the fracture, the upper end of the humerus may need to be replaced.
• Inflammatory disorders (rheumatoid arthritis or others): The inflammation associated with rheumatoid arthritis, which is brought on by an overactive immune system, can harm the cartilage and, on rare occasions, the underlying bone in the joint.
• Osteonecrosis: The humerus’s ability to receive blood might be affected by specific shoulder disorders. A bone that is blood-starved may collapse.

Risks

Although uncommon, it is important to acknowledge that shoulder replacement surgery may not always provide complete pain relief or fully restore the joint’s range of motion and strength, potentially necessitating a follow-up procedure. These subsequent surgeries should be approached with caution due to potential complications, including the need for additional interventions, as all surgeries inherently carry some level of risk.

• Implant dislocation: With reverse total shoulder replacement, there is a risk of the implant dislocating, which may necessitate either a non-invasive realignment or surgical intervention to correct or revise the implant’s positioning.
• Fractures: During or after surgery, fractures can occur in the humerus bone, scapula, or glenoid bone, potentially requiring further medical attention and treatment.
• Implant loosening: While shoulder replacement components are designed for durability, there is a possibility of them gradually loosening or wearing out over time. In some instances, a follow-up surgery may be required to replace these components.
• Rotator cuff failure: In cases of partial or total anatomic shoulder replacement, the surrounding group of muscles and tendons known as the rotator cuff can deteriorate or become less effective.
• Nerve damage: The nerves near the implant site can be damaged, potentially leading to numbness, weakness, or pain.
• Blood clots: Surgery can increase the risk of blood clots forming in the veins of the arm or leg. This is concerning because a clot fragment can break off and travel to the lungs, heart, or, rarely, the brain.
• Infection: Infections can occur, with minor ones often treatable with antibiotics, while more severe cases may require additional surgical interventions.

Before the procedure

Your surgery will be scheduled in advance unless there is an emergency. This will give you enough time to prepare and plan for any assistance you might need once you leave the hospital. It’s important to have a partner or someone to help you with your home exercises after your discharge. Before your surgery, you’ll have a series of tests scheduled about one to two weeks in advance.

• Symptom overview: When discussing your shoulder issues with the surgeon, it’s important to provide a comprehensive history. This should include details about the level of pain you experience during activities, any limitations in shoulder use, any restrictions in your range of motion, and any pain experienced at rest. Additionally, you should mention any prior treatments you’ve undergone, such as medications, injections, physical therapy, or previous surgeries.
• Physical examination: The surgeon will conduct a physical examination to pinpoint the source of your pain and assess any reductions in your shoulder’s range of motion.
• Imaging: Various imaging techniques will be employed, including X-rays to identify bone spurs, damaged joint surfaces, and joint space narrowing. If your shoulder issue stems from trauma or injury, X-rays will help determine whether a fracture can be repaired or if a shoulder replacement is necessary. Computerized tomography (CT) scans may also be used for more detailed evaluation.
• Medical evaluation: You will undergo essential blood tests to assess your overall health and suitability for surgery.
• Cardiac assessment: An electrocardiogram (EKG) will be conducted to evaluate your heart’s electrical activity. Additionally, you will have a consultation with a healthcare provider to ensure your medical fitness for the upcoming surgery.
• Medication management: A thorough review of your current medications will be conducted. Certain medications may need to be discontinued due to potential complications during surgery, while others will be continued as necessary.
• Anti-inflammatory medications: Unless otherwise instructed by your healthcare team, it is advisable to discontinue the use of any anti-inflammatory medications, including aspirin, one week prior to the scheduled surgery.
• Medication guidance: Detailed instructions regarding the management of your daily medications will be provided during your pre-surgery consultation.
• Anesthesia options: Your attending physician and the anesthesiologist will engage in a discussion with you concerning the most appropriate anesthesia approach. The primary method is general anesthesia, delivered intravenously to induce relaxation, comfort, and sedation. You will also have the opportunity to explore supplementary options, such as regional or block anesthesia, aimed at minimizing postoperative discomfort.
• Fasting protocol: As of midnight on the day before your surgery, you should abstain from all food and beverages.

During the procedure

When you’re in the operating room, you’ll encounter a team consisting of nurses, doctors, technicians, and anesthesiologists. The anesthesiologist will be stationed near your head, continuously monitoring your well-being throughout the surgical procedure. Typically, the surgery lasts for a duration of 1 to 2 hours.

After the procedure

After your shoulder surgery, you’ll be taken to the Post Anesthesia Recovery Unit (PACU). There, they’ll closely monitor your vital signs like blood pressure, pulse, and breathing as you recover from anesthesia. You’ll wake up with a dressing on your shoulder, and they’ll also perform an X-ray during your stay in the recovery room. Typically, you’ll spend at least an hour in the PACU while your medical team assesses your condition and decides when it’s best to transfer you to a hospital room. Once in your room, your nurse will check your vital signs, the dressing on your shoulder, and assess the movement and sensation in your hand. You may also wear a sling on your arm for the first day.

Dealing with pain is essential after shoulder surgery. While a regional nerve block should help manage most of the pain, there might be moments when it doesn’t work entirely, and you may need oral pain medication for comfort. During your hospital stay, they’ll encourage you to get out of bed and move around. It’s a good idea to bring loose-fitting clothing to make dressing easier. You’ll be able to take a shower after 48 hours.

A crucial aspect of your recovery is the physical therapy. A physical therapist will guide you through specific exercises and restrictions that will be important for your healing process. They will provide written instructions for you to follow at home, and these exercises are typically straightforward and don’t take up too much of your time. In most cases, you won’t need formal outpatient physical therapy after leaving the hospital, but your surgeon will evaluate your progress during follow-up visits to determine if it’s necessary. The goal of these exercises is to ensure the optimal functioning of your new shoulder joint over the course of a year.

Outcome

• Recovery time: Expect your recovery to take anywhere from six months to one year for you to experience the full benefits of the surgery. It’s important to remember that progress may not always be quick or constant, so patience is key.
• Daily exercises: Dedicate five to 10 minutes several times a day to perform your prescribed exercises as part of your therapy program.
• Early post-surgery: For the first month after surgery, avoid lifting anything heavier than five pounds. Also, refrain from using your arm for activities like lifting, reaching, pushing, or pulling above waist level for six weeks.
• Physical therapy: Around six weeks post-surgery, you’ll begin physical therapy. You’ll work with gym-type equipment to strengthen your shoulder muscles.
• Follow-up visits: Your healthcare provider will monitor your progress through regular visits, typically every six weeks for the first four to five months, and less frequently for the following year.
• Returning to work: When you can return to work depends on your therapy progress and the demands of your job. If your job isn’t physically demanding, you can often go back after two months. However, if your work involves heavy lifting or repetitive overhead tasks, you may need to adjust your work environment. For highly demanding jobs, work closely with your surgeon and therapist to decide on the best time to return.
• Participation in sports: After a shoulder replacement, you can eventually participate in sports like golf, swimming, and tennis. Before resuming sports, discuss your goals with your surgeon and therapist to plan your rehabilitation and sports activities accordingly.