Shoulder Replacement

Introduction

Shoulder Replacement is a surgical procedure in which all or part of the glenohumeral joint is replaced by a prosthetic implant. Such joint replacement surgery generally is conducted to relieve arthritis pain or fix severe physical joint damage.

Shoulder replacement surgery is an option for treatment of severe arthritis of the shoulder joint. Arthritis is a condition that affects the cartilage of the joints. As the cartilage lining wears away, the protective lining between the bones is lost. When this happens, painful bone-on-bone arthritis develops. Severe shoulder arthritis is quite painful, and can cause restriction of motion. While this may be tolerated with some medications and lifestyle adjustments, there may come a time when surgical treatment is necessary.

When is Shoulder Replacement Surgery recommended?

Common symptoms of shoulder arthritis include:

  • Pain with activities

  • Limited range of motion

  • Stiffness of the shoulder

  • Swelling of the joint

  • Tenderness around the joint

  • A feeling of grinding or catching within the joint 

What are the causes?

Shoulder replacement surgery is usually done when you have severe pain in the shoulder area, which limits your ability to move your arm. Causes of shoulder pain include:

Your doctor may not recommend this surgery if you have:

  • History of infection, which can spread to the replaced joint

  • Severe mental dysfunction

  • Unhealthy skin around the shoulder area

  • Very weak (rotator cuff) muscles around the shoulder that cannot be fixed during surgery

How is Shoulder Replacement Surgery diagnosed?

The most common indication for TSA is shoulder pain due to arthritis that cannot be controlled with non-operative treatment such as anti-inflammatory medications and rest. Accompanying the pain is a progressive stiffness and loss of motion, with the patient often experiencing a grinding or grating sensation within the shoulder joint that is disturbing and painful.

A series of standard x-rays are taken to determine the condition of the shoulder joint. A CT scan and Magnetic Resonance Imaging (MRI) may also be necessary to evaluate bone quality as well as the condition of important surrounding structures such as the rotator cuff tendon. Those with possible nerve damage may also undergo an EMG test.

In some chronic arthritic conditions such as ankylosing spondylitis, which may be associated with a stiff elbow and a stiff shoulder, TSA may be considered to improve overall function in the shoulder and arm, regardless of the pain level experienced by the patient.

Steroid injections are sometimes recommended prior to a TSA procedure. Most candidates, however, will not experience lasting relief from these injections, making TSA a necessary next step if pain is uncontrolled. Likewise, some patients experiencing early osteoarthritis may consider more conservative management (such as physical therapy, medication, cortisone injections, or even shoulder arthroscopy) before TSA is deemed a necessary measure.

In addition, there are certain patients who are contraindicated (are not good candidates) for TSA. These include:

  • patients whose symptoms are not sufficiently disabling

  • patients experiencing loss or paralysis of both rotator cuff and deltoid muscles

  • patients with active infection

  • in most cases, patients with a disease of the nervous system that has affected the joint

What are the treatment options for Shoulder Replacement Surgery?

Always tell your doctor or nurse what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

  • Two weeks before surgery you may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), naproxen (Naprosyn, Aleve), and other drugs.

  • Ask your doctor which drugs you should still take on the day of your surgery.

  • If you have diabetes, heart disease, or other medical conditions, your surgeon will ask you to see your doctor who treats you for these conditions.

  • Tell your doctor if you have been drinking a lot of alcohol, more than 1 or 2 drinks a day.

  • If you smoke, try to stop. Ask your doctor or nurse for help. Smoking can slow down wound and bone healing.

  • Always let your doctor know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

On the day of your surgery:

  • You will usually be asked not to drink or eat anything for 6 - 12 hours before the procedure.

  • Take your drugs your doctor told you to take with a small sip of water.

  • Your doctor or nurse will tell you when to arrive at the hospital.

After the Procedure:

You may stay in the hospital for 1 - 3 days after your surgery. While there, you may receive physical therapy to help keep the muscles around your shoulder from getting stiff. Before you go home, the physical therapist will teach you how to move your arm around by using your other (good) arm.

What are the risk factors for Shoulder Replacement Surgery?

Risks of shoulder replacement surgery are:

  • Allergic reaction to the artificial joint

  • Blood vessel damage during surgery

  • Bone break during surgery

  • Nerve damage during surgery

  • Dislocation of the artificial joint

  • Loosening of the implant over time

Can Shoulder Replacement Surgery be prevented?

To be shared by the Doctor

How fast can you recover?

After leaving the operating room with the arm immobilized at the side, the patient will wake up in the recovery room.

Normally, patients will wake up from surgery with pain due to surgery, but not the same type of pain they have experienced due to their arthritis. Arthritic pain is largely absent from that point forward.

Based on the range of motion and stability of the implant, physical therapy begins on the first postoperative day, following x-rays documenting that the implant is properly positioned. Sling immobilization in enforced during the early rehabilitation phase.

As patients begin the physical therapy program, your doctor notice that shoulder mobility is easier, and the hard grating and grinding so typical of an arthritic shoulder is no longer there.”

The patient is permitted to use the arm for light activity beginning at approximately four weeks after surgery and unrestricted, active use of the arm may begin as early as eight weeks after surgery.

Patients can usually return to desk work within two to three weeks from the time of surgery, but that heavier work is forbidden for four months or more and depends greatly on the motion and strength of the shoulder and how they are progressing.

The pre-surgical condition of the shoulder muscles and tendons play the biggest role in the patient’s outcome. If their muscles and tendons are in good shape, rehab will be minimal, as post-surgical rehabilitation of the shoulder depends on the patient’s own muscles and tendons.. That’s the critical difference between shoulder replacement vs. hip and knee replacement.”

Expect the following after surgery:

  • At about three months after surgery, most patients are reasonably comfortable, have motion about half normal, but do notice some weakness.

  • At six months, most patients are pain-free (although weather does have an effect), and have motion and strength about two-thirds normal.

  • At one year, approximately 95% of TSA patients will be pain-free, and the remaining will usually have no more than a weather ache or an occasional ache with excessive activity. Likewise, there will probably not be significant strength limitations, depending on the condition of the deltoid and rotator cuff.

After Discharge?

You will be discharged from the hospital on the second or third day following your surgery depending on your recovery. Once you have returned home, it is very important to follow your orthopedic surgeon's instructions during the first few weeks after surgery.

Medications

You will be given prescriptions for pain medication, anti-inflammatory medicine and aspirin, which helps to prevent blood clots. Use the pain medication only if you are experiencing pain. Take the anti-inflammatory as prescribed.

Caring for Your Incision

You will have stitches running along your wound on the front of your shoulder. These will be removed one week after your surgery, at your first follow-up appointment. Call your surgeon immediately if your incision swells, drains, becomes red or painful, or if you develop a temperature over 101 degrees Fahrenheit.

Before leaving the hospital, your incision will be covered with a dry bandage. Please do not get the incision wet or dirty. The dressing can be changed daily and it is not uncommon to have a small amount of blood on the dressing. Do not shower or go in the bath until you return for your follow-up appointment. The incision has not healed yet and getting the incision wet puts the shoulder at risk of infection. After the stitches are removed and if the doctor allows you to, you can take a shower and let the water run over the wound. Do not go into a tub or Jacuzzi to soak the wound. Pat the wound dry after you finish showering.

Physical Activity

Being physically active is an essential part of recovery. Continue to perform the exercises you learned in the hospital. Before leaving the hospital, you will be given a physical therapy exercise plan to follow. Within the next three to six weeks, you need to protect the shoulder so that the muscles can heal. You should have an appointment to see a therapist within the first or second week after you are discharged from the hospital. During the first few weeks of recovery, the physical therapist may teach or help you perform specific exercises to strengthen your arm and shoulder.

You may experience swelling and bruising of the hand and arm. This is normal and results from the swelling and bruising from your shoulder, which travels down the arm. Unfortunately, there is no treatment for this, but it is recommended that you bend and straighten your elbow frequently and make a fist to help keep your circulation flowing.

Your arm will still be in a sling and it is recommended that you wear it when you are in public or moving around. If you are reading, watching television or working at a desk, you may loosen it. When you are getting dressed, it is easiest to put your operated arm through the shirt-sleeve first, then put your sling on. You may use your arm to perform normal daily activities, such as eating, writing or shaving, but you may not lift any items or reach out suddenly until you are instructed that it is OK to do so.

Six weeks after surgery, when you regain full shoulder movement, you can probably resume driving. At this time, your surgeon also may allow you to return to work, depending on how much physical activity is involved in your occupation. You will also start to strengthen your shoulder up with physical therapy.

Follow-Up

Please schedule your first post-operative appointment prior to surgery. When you come for your first appointment, you will have an X-ray, so please make sure to come 30 minutes before your appointment time.

During the first year following your surgery, routine follow-up visits will be scheduled with your orthopedic surgeon at one week, two weeks, six weeks, three months, six months and 12 months after your surgery. You will be asked to return for annual visits thereafter to assess the status and function of your implant.

What are the results of the surgery?

Shoulder replacement surgery relieves pain and stiffness for most people. You should be able to do most of your normal daily activities without much problem. Many people are able to return to sports such as golf, swimming, gardening, bowling, and others.

Your new shoulder joint will last longer if less stress is placed on it. With normal use, most people’s new shoulders last for at least 10 years.

What are the complications?

Total shoulder replacement is a very successful operation and the 10 year survival rate is up to 90 percent. Many patients end up with extremely functional shoulders and are able to return to the activities of daily living and low impact sports without pain. The operation may have some complications, although they are very rare. Complications may include infection, bleeding, shoulder instability, tearing of the rotator cuff, fracture and loosening of the prosthesis.

Cost of Surgery?

The cost of surgery for Shoulder Replacement depends on many factors. They include the cost of being in the hospital for several days. Unexpected events that result in an extended hospital stay will also increase the overall cost.

Costs also vary depending on the type of insurance coverage you have. Many insurance companies cover the cost of the surgery, the hospital stay, and the instruments to straighten the spine. You may owe a co-payment or you may be billed the balance of what your insurance does not cover.

Be sure to contact your insurance provider prior to surgery to discuss the extent of your coverage. Discuss with your surgeon, as well as the hospital billing department to make sure you understand all the costs involved.

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