Anatomic Shoulder Joint Replacement
The following information is a general overview of the process of a shoulder replacement. We hope you find this informative and educational, as the patient, about the process you are about to undergo. Shoulder Replacement surgery is not a “minor” surgery, and it is our belief the patient should be well educated and welcomed to ask questions. We hope this overview will help ease any anxiety in regards to surgery and serve as a guide to getting all your questions answered before and after surgery.
Remember, the following are only GENERAL guidelines and suggestions. Your surgeon will give you specific instructions that should be followed at all times.
“Total Shoulder Replacement”, also known as “Total Shoulder Arthroplasty” (TSA), has become a more common procedure over the past 15-20 years. TSA is most commonly performed for shoulder arthritis, but can also be used to assist with fracture (broken bone) fixation of the shoulder. During a TSA the “worn out” (or broken) parts are replaced with artificial parts, called components or prostheses. In a TSA the prosthesis is designed to match the normal shape of the parts being replaced. This is considered an “Anatomic TSA.”
THE NORMAL SHOULDER
The normal shoulder is made up of the humeral head (top part of the arm bone) and the glenoid (the socket part of the shoulder blade). In a normal shoulder, the humeral head and glenoid are covered with “articular cartilage” on the surface which allows for smooth gliding of the joint with motion. The cartilage creates the space between the bones seen on X-rays. The rotator cuff muscles connect to the humeral head and assist with motion. These muscles are usually fuly intact when an Anatomic TSA is performed.
THE ARTHRITIC SHOULDER
With normal aging, the cartilage surfaces of all joints wear out. Sometimes this happens to the point there is no cartilage remaining and causes pain, dysfunction, and possibly deformity. Other processes, including rheumatoid arthritis, osteonecrosis, and fractures, can cause this process to be accelerated. As the cartilage thins out, the joint space seen on radiographs decrease to the point of “bone on bone” (see pictures below). For some patients, arthritis is painful, and for others this does not cause too much of an issue. When your arthritic pain begins to cause a decrease in the “quality of life”, that is when it is time to consider shoulder replacement surgery and discuss it with your physician.
SHOULDER REPLACEMENT OPTIONS
There are three types of shoulder replacement.
- Hemiarthroplasty (partial shoulder replacement): with this procedure only the humeral head is replaced. This is commonly done for younger patients, and to treat fractures of the shoulder.
- Total Shoulder Arthroplasty (total shoulder replacement):with this procedure BOTH the humeral head and the glenoid (socket) are replaced
- Reverse Shoulder Arthroplasty (“reverse” arthroplasty):with this procedure the humeral head and socket are replaced, but reversed. This type of replacement is reserved for certain patients, and the details are beyond the scope of this handout. Your physician will give you a different handout if this prosthesis may be used for you.
During surgery, your surgeon will expose your shoulder very carefully. After the exposure, the rotator cuff muscles are inspected to ensure they are intact. The surgeon then must release the rotator cuff muscle in the front of the shoulder, called the subscapularis. This muscle will be repaired at the end of your replacement surgery. (see next section “Subscapularis Healing”).
At this time, the humeral head is removed, and the humerus (arm bone) is hollowed out to allow the prosthesis to fit inside your arm bone. The humeral component is made out of metal. This can either be held in place with or without bone cement. Your surgeon will decide this based on the “fit” of the prosthesis.
The bony socket is then smoothed out and a new socket made from “fancy” plastic, called polyethylene, is used to replace the diseased area. This is typically held in place with bone cement.
Next the ball is fitted with the socket to ensure a good fit and smooth motion. The Subscapularis muscle is then repaired with suture. Your skin incision is then sewn closed and a sterile dressing is placed. A shoulder immobilizer is applied and you are awoken from anesthesia and taken to the Recovery Room.
Xrays and diagram of a typical shoulder replacement
LENGTH OF SURGERY
The surgery usually lasts between 1 and 3 hours. This is a common question we are asked but every shoulder is different and your surgeon will take as long as needed to complete the surgery. The surgical nurse should keep your family informed of our overall progress during the surgery. Once the surgery is completed, your surgeon will find your family and discuss with them the results of surgery.
The subscapularis muscle is one of your very important rotator cuff tendons which allows you to move your shoulder. This muscle is the “door” to the shoulder during surgery and must be carefully released. This tendon is very meticulously repaired at the end of surgery.
For your TSA to function properly after surgery it is VERY IMPORTANT that the repaired subscapularis muscle heal. This is why you are placed in a shoulder immobilizer and gentle protective exercises are the only exercises allowed after surgery. It takes 6 weeks (or longer) for your subscapularis tendon to heal before it can be “tested”.
It has been shown smoking and uncontrolled diabetes can delay or inhibit healing. It is HIGHLY encouraged to stop smoking and control your blood sugars before AND after surgey.
RISKS OF SHOULDER REPLACEMENT SURGERY
As with anything, there are risks. Your surgeon will take precautions to attempt to prevent complications, but one still may occur.
- Fracture (broken bone)
- Continued pain
- Blood Vessel or Nerve injury
- Component Failure
- Tendon not healing
- Wound complications
**This is not a complete list of possible complications, but does list the some of the most common complications**
In addition, the prosthesis may come loose in the future and may need to be revised. Loosening can be caused by wear and tear on the prosthesis, or from a traumatic injury (ie: fall, car accident). This is most likely not due to your initial surgery.
PREPARING FOR YOUR SURGERY
There is a lot that both your surgeon, their office, and you need to complete prior to your surgery. All of this is done with your safety as the primary goal!
One of the main requirements, is all patients receive a medical evaluation by their primary care physician. In addition, you will have to have a blood draw to ensure your lab work is adequate. Your doctors’ office will assist you in scheduling your “clearance” appointments and lab work prior to surgery.
Before surgery we ask, in assistance/guidance with your primary care physician (or other specialist), certain medications be changed or stopped. These medications include (but are not limited to):
- Blood thinning medications: warfarin (Coumadin), clopidogrel (Plavix), Cilostazol (Pletal), Dabigatran (Pradaxa), Rivaroxaban (Xarelto), heparin, enoxaparin (lovenox), dalteparin (fragmin), fondaparinux (arixtra), asprin (asprin containing products), Aggrenox, Nonsteroidal Anti-inflammatory medications (NSAIDS), etc
- Rheumatoid Arthritis: minocycline, sulfasalazine, methotrexate, azathioprine, Imuran, chlorambucil, leflunomide, cellcept, etc
Your primary care provider who manages these medications will help you decide when to stop and restart these medications in regards to your surgical date.
A list of medications will be given to you as a reminder.
If you have diabetes: Before your procedure, the physician who manages your diabetic medication should be contacted and asked for specific instructions on adjusting, or stopping, your insulin or other diabetic medications for surgery.
If you develop an infection before surgery: If you develop an infection on any area of your body prior to surgery, please seek medical attention from your PCP as soon as possible. Please notify your surgeon as soon as possible also. Your surgery may be rescheduled to allow your infection to resolve completely.
This will help prevent an infection in your shoulder after surgery.
Find a “caregiver” to go with you: Find someone who will be able to take you to the hospital and can wait in the surgical waiting room for you during surgery. This person is usually a family member, spouse, friend or other loved one. They will not need to stay overnight in the hospital with you.
PREPARING FOR YOUR RECOVERY
Most patients return to their own home after shoulder surgery. Usually a “caregiver” is around during the day to assist with the needs of the patient.
Below are some things to think about, starting several weeks before surgery, to help with a comfortable transition home:
- Clean your home a week before surgery as it will be difficult to do so afterwards
- Remove clutter and loose rugs from the walkways to prevent falls
- Rearrange your bedroom (and other rooms) to allow extra room to maneuver as you will only have the use of one arm
- Anatomic Shoulder Joint Replacement
- Reverse Shoulder Replacement
- Revision Shoulder Replacement
- Shoulder Fracture
- Shoulder Arthroscopy
- Rotator Cuff Repair
- Instability Repair: Shoulder Labrum Reconstruction
- Distal Clavicle Excision
- Subacromial Decompression
- Scapula Fractures / ORIF
- Clavicle Fractures / ORIF
- AC Joint Injury Reconstruction
- SC Joint Injury Reconstruction
- Biceps Tenodesis/Tenotomy
- Pectorlis Major Tears Repair