Shoulder Replacement Surgery
Shoulder replacement surgery is recommended for the treatment of shoulder problems which have failed to improved with non-operative treatments. Shoulder replacement is an option for the treatment of severe shoulder arthritis caused by osteoarthritis, avascular necrosis, capsulorraphy arthropathy, dislocation arthropathy, shoulder fractures (proximal humerus fracture), severe rotator cuff tears and rheumatoid arthritis.
The Normal Shoulder
The shoulder joint is complex and involves the clavicle (collar bone), the scapula (shoulder blade),
and the humerus (arm bone). There are numerous muscles, ligaments, and tendons
in the shoulder. The upper end of the arm bone (humerus) and a portion of the scapula bone (glenoid) form a “ball-and-socket joint”. This is the area affected in shoulder arthritis.
Who Needs Shoulder Replacement Surgery?
When the smooth, gliding surfaces (cartilage) of the ball and socket wear out the bone grinds against the bone. This causes pain, stiffness, swelling and often a ratcheting sensation. Arthritis pain in the shoulder is often constant and limits a persons daily activities, as well as interferes with their sleep. Shoulder replacement surgery is performed to alleviate this severe shoulder pain. It often improves the range of motion of your shoulder joint as well. The decision to have a shoulder replacement is a personal one that is different for each individual. When the pain and limited use of the shoulder affects a persons quality of life, it is time to talk to your shoulder surgeon and consider shoulder replacement.
Total shoulder replacement
During shoulder replacement surgery the damaged, worn out cartilage is removed and replaced with
a shoulder prosthesis (artificial joint). The shoulder joint is reached by making an incision on the front of the shoulder. The arthritic ends of the bone (humerus and glenoid) are removed. The bone is prepared for the shoulder replacement. The artificial joint is made of metal (titanium or a cobalt-chrome alloy) and a special plastic (polyethylene). The stem is placed inside the humerus bone and glenoid surface is replaced with the special plastic. Bone cement may be used to secure the components.
Reverse Shoulder Replacement
Reverse shoulder replacement is done is a similar fashion as Total shoulder replacement except the components of the reverse shoulder replacement are reversed. The glenoid component is shaped like a ball (called the glenosphere) and is anchored to the scapula with screws. The humeral component is now the socket that attaches to the upper end of the humerus. Reverse shoulder replacement is generally reserved for patients with severe osteoarthritis combined with a torn or poorly functioning
rotator cuff or patients with fractures involving the shoulder joint with poorly functions rotator cuff tendons.
The Risks of Surgery
All surgeries have potential risks and adverse outcomes. These risks differ for each person depending
on the person’s age, health, and the type of surgery performed. The risks of shoulder replacement surgery include but are not limited to infection, periprosthetic fracture, Instability, Hematoma, Loosening, Polyethylene wear, Osteolysis, Heterotopic Ossification, Neurovascular Injury, Hardware failure, Incomplete relief of pain, Incomplete return of function, Stiffness, Incisional scar (cosmesis), CRPS, and numbness surrounding the incision, and the Need for further surgery. General risks of anesthesia and surgery include blood clots, pulmonary embolus, heart attack, stroke and death. Although complications can occur, most patients are happy with their surgical outcomes. To decrease the risk of complications ensure that your surgeon is experienced in shoulder surgery and total shoulder arthroplasty. You should always discuss any concerns that you have about surgery with your surgeon and ensure that you have a surgeon that you trust and are confident in.
Preparing for Your Hospital Admission
Shoulder replacement patients are admitted to the hospital on the morning of surgery. Patients generally arrive at least two hours before the actual time of the surgery. Most patients go home on the first day after surgery in the afternoon. Patients with several other medical problems occasionally stay 2 days after surgery. Patients are typically discharged home. If you feel that you will not be able to return home because of the anticipated limited use of your arm, please notify Dr. Grutter and his staff prior to surgery so they can best assess and help you with your needs following surgery.
Ten days Prior to Surgery
If you take anti-inflammatory medications such as aspirin, Motrin, ibuprofen, Naprosyn, Lodine, Voltaren, DayPro, etc., you should stop taking these medications ten days prior to your surgery.
If you are taking blood thinners for a medical condition (heart disease, arrythmias, history of blood clots), you will need to stop these medications prior to surgery. This must be discussed with and approved by your primary care physician or cardiologist. Please notify your primary care physician and get their approval prior to scheduling your surgery.
Stop smoking. Smoking increases your surgical risks, especially the risk of infection. You should refrain from smoking for 10 days prior to surgery and for 3 months after surgery.
If there is any change in your physical condition, such as a fever, flu, diarrhea, skin rash or cold, please call your personal physician and your surgeon’s staff as soon as possible.
The Night Before Your Procedure
Bathe or shower the night before or the morning of your surgery. Scrub your shoulder and arm pit with antibacterial soap. Do not eat or drink anything after midnight before the surgery. This includes drinking water, chewing gum, or sucking hard candy. An empty stomach helps to avoid possible anesthesia complications during your surgery. Failure to follow this instruction may result in the cancellation of your surgery.
Day of Surgery
If you have been instructed to take medication by mouth on the morning of the surgery, you may take that medication with a sip of water. You may brush your teeth and rinse your mouth, but do not swallow any water.
Do not wear any jewelry, facial makeup or nail polish to the hospital.
Do not bring valuables with you to the hospital. Leave all money, jewelry (including wedding rings) and credit cards at home.
Please bring a form of photo identification (e.g. driver’s license) and insurance cards to present to the registration and admitting department. If your insurance carrier requires that you submit a claim form at the time of admission, please remember to bring a completed claim form with you.
Be sure to keep all cards and forms in a safe place in your hospital room.
Eyeglasses, contact lenses, hearing aids and dentures must be removed prior to your surgery. Please bring a container to protect these items.
Please inform the anesthesiologist and the nursing staff of any allergies or medications that have caused problems for you in the past. It is also important to discuss any problems that you may have had with anesthesia during a previous surgery. It is essential that you let us know whether you have any allergies to antibiotics.
In the Same Day Surgery area, you will change into a hospital gown and the nurse will begin to prepare you for the surgical procedure. When it is time you be taken to the preoperative holding area and your family will go the surgery waiting area. You will meet the anesthesia personnel, and undergo additional preparations by the nursing staff in the preoperative holding area. While awaiting your surgical procedure, your nurse may give you an injection (shot) or pill that can help with any nervousness or anxiety that you may have.
Recovery Room
After your surgery, you will be placed on a hospital bed and taken to the postanesthesia care unit (PACU/ “Recovery Room”). Your vital signs (heart rate, blood pressure, temperature and breathing), IV, shoulder dressing and level of comfort will be checked frequently. Your arm will be in a sling or arm immobilizer and supported on a pillow. Once you are awake and your vital signs are stable, you will be discharged from the post-anesthesia care unit and brought to your hospital room. Dr. Grutter will talk with your family following the surgery. Your family members should be aware that after they leave you, it may take a number of hours before they will see you again. Much of this time is getting ready for the surgery and the time in the postanesthesia care unit.
POSTOPERATIVE CARE
Respiratory Care
Following surgery your lungs might have become “lazy” causing congestion. Coughing and breathing exercises help to loosen the mucus in your lungs and prevent pneumonia. Keeping your lungs clear is very important. The following activities will help you avoid complications:
• Turn – from side-to-side to loosen secretions and allow them to drain
• Cough – one or two deep coughs as needed will help to keep your lungs clear
• Deep breathing – 10-20 deep breaths per hour will help to promote normal function of your lungs In addition to these key steps, your nurse may instruct you on special breathing exercises.
Circulation and Sensation
Increasing the amount of fluid you drink and exercising your legs help prevent blood from becoming “sluggish” in your blood vessels. Following your surgery, sequential compression stockings may be applied to your legs to help prevent blood clots from forming in your legs. Once you are up and walking around consistently, the compression stockings can be discontinued per your physician’s instructions
Exercise
During the first day of your surgery, it is not unusual to feel weak, light headed and drowsy. Within 24 hours, these effects will wear off and you will be able to gradually increase your activity level. You can start with short trips to the bathroom and gradually increase your walking as tolerated. Increasing your activity will help to promote good circulation and decrease the risks of developing blood clots. Furthermore, walking will help to avoid problems with your lungs. Please ask your nurse to assist you whenever you get out of bed.
Ankle pumps – Push your foot down as if you were pushing a gas pedal all the way to the floor. Hold it down for a count of five (5), then bring your foot up again as far as possible. Make little circles with your foot. Do this exercise every hour while awake. This exercise promotes good circulation and decreases the risk of developing blood clots.
Incision Care
You will leave the hospital with a special bandage covering your incision. As long as this bandage is clean and dry it is to remain in place for the first 7 days after surgery. The special bandage is water proof and you may take a brief shower 3 days after surgery. The special bandage can remain in place provided the incision does not get wet. Seven days after surgery or if the bandage appears wet or damaged you may change the dressing. The incision must stay clean and dry until you see Dr. Grutter in the office. The incision is typically closed with an absorbable suture and small pieces of paper tape, called steri-strips. Do not remove the steri-strips which are directly on the skin over the incision. These strips will fall off by themselves. Do not pull them off since this could disrupt your incision. There typically are no staples or sutures to remove. Do not scratch, cleanse or apply any creams, lotions or other treatments to the incision. You should not swim or get in a hot tub for 6 weeks.
Bowel Management
Some patients become constipated because of pain medications as well as being inactive. It is important that you drink plenty of fluids, as well as eat foods that are high in fiber. Increasing your activity level, such as walking, will also help to avoid this problem. If necessary, you may be given a laxative or stool softener.
Physical Therapy
The day after surgery your physical/occupational therapist will work with you to plan your therapy program. He/she will begin exercises for your shoulder, elbow and wrist the morning after the surgical procedure. While you are in the hospital, the physical therapist will work with you one to two times per day. To help maximize your efforts with your therapy program we encourage you to take your pain medication approximately 30 minutes before your therapy session. While the therapy sessions on the first day are uncomfortable, it is important to start your range of motion program as soon as possible to avoid stiffness.
Outpatient Physical Therapy
Following surgery you will have outpatient therapy or a home exercise program to do on your own.
To receive supervised physical therapy outside your home, you must travel to therapy office. You will be
expected to attend supervised therapy sessions two to three times a week. Eventually, you will learn your exercise program and be able to continue with your exercises at home without supervision. Please understand that you are the most important therapist for your shoulder. On those days that you do not have supervised physical therapy, it is essential for you to continue the exercise program at home. The best results of shoulder replacement surgery occur in those patients who independently perform their exercise on a daily basis.
Help at Home
Many patients will require help from their family and friends for the first few weeks. You may be able to care for yourself, including bathing, dressing and personal grooming. However, it is beneficial to have your family and friends help you with preparing meals, shopping, laundry and other responsibilities that require driving.
Restrictions/Precautions
- It is strongly recommended that you do not drive while in your sling. Once out of your sling, you may resume driving after you can comfortably use your arm for all of your activities of daily living. This goal is generally achieved by six weeks following your surgery.
- Although you should progress with your exercises, do not force any shoulder motions. Most importantly, do not let anyone (family members, etc.) force your arm into uncomfortable positions.
- Do not use your arm to pull yourself out of bed or out of a chair for six weeks.
- It is necessary to wear a sling or arm immobilizer for six weeks to protect your shoulder from any unexpected movements unless indicated otherwise by your surgeon. Wearing the sling also alerts others around you to avoid accidentally striking your arm.
- Do not bear weight on your shoulder for the first six weeks.
Returning to Work
Returning to work depends on the demands of your work responsibilities. Return to work can be as early as early as 2 to 6 weeks for sedentary type jobs. Returning to a job that requires significant use of the arm can take three months. Office workers often return in two weeks while patients with more strenuous jobs require more time away from work. Dr. Grutter recommends that patients do not return to jobs involving heavy physical-demand responsibilities, especially activities over shoulder level. The timing of your return to work depends considerably upon your commitment to your physical therapy and overall recovery. Please discuss you goals for returning to work with Dr. Grutter to determine a realistic goal.
Driving
When a person can return to driving varies from person to person. You may not drive if you have any disability in your arm, if you are wearing a sling or protective device which limits your mobility, or if you are taking narcotic pain medication or medications which cause drowsiness. If you have questions or concerns about driving please discuss them with Dr. Grutter. Physicians can recommend when driving is unsafe, but can not make a legal determination of when it is safe to drive. The legal determination of who is safe to drive is made by the Department of Motor Vehicles.
Medications
You will be provided with a prescription for pain medication. If you have problems with your medication or you run out of medication, please call Dr. Grutter’s office during normal business hours. Narcotic pain medications can not be refilled on evenings or weekends. Please plan ahead and request these medications during normal office hours.
Please call your surgeon’s office if….
- You develop a fever greater than 101 degrees Fahrenheit
- Persistent warmth, redness or drainage from the site of your incisionYour shoulder becomes more swollen, tender and painful with increased difficulty performing your exercises
- Calf pain, chest pain or shortness of breath are signs of a possible blood clot. Notify your doctor immediately if you notice any of these symptoms.
- If you develop severe pain, chest pain or difficulty breathing, report immediately to your local emergency room.
Please call during normal office hours. Calls at night or on weekends will be taken by the answering service and passed to your surgeon or other staff members.
Follow-Up Visits (typical schedule)
Ten to 14 day follow-up appointment:
X-rays
Check the site of surgery
Review exercise program progress
Evaluate comfort level
Six week evaluation:
X-rays
Check the site of surgery
Check range of motion
Review ability to begin a strengthening program
Evaluate ability to perform activities of daily living and personal care
Discuss return-to-work responsibilities
Twelve week (three month) evaluation:
X-rays
Check range of motion
Review strengthening program progress
Evaluate activities of daily living and personal care progress
Discuss return-to-work responsibilities
Annual checkup
Dr. Grutter will follow your shoulder replacement on an annual basis to check your range of motion and strength, as well as obtain new radiographs (X-rays) to look at the relationship between the shoulder prosthesis (replacement) and the bones. Follow-up examinations are important to provide you with advice regarding your shoulder replacement, as well as to minimize the risk of a problems related to your shoulder replacement.
Life-Long Prevention of Infection
Infection prevention is very important for the rest of your life. Your new joint is artificial and does not have your body’s “natural” protection against infection. Bacteria from a variety of sources can enter your blood stream and cause infection in the artificial joint. This can eventually cause it to become loose and painful. If you have any invasive procedure (e.g. dental cleaning, proctoscopy, cytoscopy, endoscopy, interventional radiology) inform your doctor or dentist that you have an artificial joint and need to be given antibiotics to protect it during these procedures. If you have any signs of infection in you body, such as pain with urination, call your doctor. Do not wait to see if these problems go away on their own. You should see your doctor immediately so they can evaluate and treat the problem.