Total Shoulder Replacement

Replacement

Total Shoulder Replacement

In a complete shoulder replacement surgery, the arthritic surface of the ball joint is substituted with a metal ball attached to a stem, which is securely fitted into the interior of the upper arm bone (humerus). Additionally, the socket is renewed with a high-density polyethylene component.

This procedure is carried out under either general or regional anesthesia, with an incision made between the deltoid and pectoralis major muscles at the front of the shoulder. It involves releasing adhesions and contractures, as well as removing bone spurs that could hinder the joint’s range of motion.

How Is The Humeral Component Fixed In The Humerus?

While certain surgeons opt for cementing the humeral component and others utilize implants promoting bone ingrowth, we've observed that these methods tend to stiffen the bone, increasing the risk of fracture during a fall and significantly complicating any potential future revision surgeries. Instead, our preference lies in fixing the component through impaction grafting of the humerus interior, using bone harvested from the removed humeral head, until a snug press fit of the implant is attained.

How Is The Glenoid Component Fixed To The Glenoid Bone?

The glenoid bone undergoes precise shaping using a glenoid reamer, followed by securing the glenoid component through a combination of press-fitting and cementing.

To ensure proper healing, it's essential for the patient to maintain the range of motion achieved during surgery through regular, gentle stretching exercises.

Rehabilitation exercises commence immediately post-surgery, incorporating continuous passive motion and stretching techniques performed by the patient.

Achieving and preserving a forward elevation of at least 150 degrees is crucial for the success of this procedure. Techniques such as forward lean and supine stretches can aid in reaching and sustaining this range of motion.

Who Should Consider A Total Shoulder?

Surgery for shoulder arthritis should be considered only if the arthritis significantly affects the patient's quality of life, following a period of trying physical therapy and mild pain relievers. In cases of severe arthritis, the preferred approach is often a partial or complete joint replacement. Total shoulder arthroplasty, involving the replacement of both the ball and socket surfaces, is typically recommended for individuals seeking a swift recovery of shoulder comfort and the ability to perform daily activities with ease.

Who Should Probably Not Consider A Total Shoulder Replacement?

Individuals with depression, obesity, diabetes, Parkinson’s disease, multiple prior shoulder surgeries, shoulder joint infections, rotator cuff deficiency, and significantly altered shoulder anatomy are less likely to experience success with this procedure.

What Happens After Surgery?

Total shoulder arthroplasty represents a significant surgical intervention involving incisions through the skin, tendons, and bone. Postoperative pain is addressed through anesthesia and pain-relieving medications. Initially, potent medications like morphine or Demerol are administered via injection, with a transition to oral pain relief within a day or two. Rehabilitation commences on the day of surgery, encouraging early mobilization and a gradual reduction in pain medication usage. Typically, patients are discharged from the hospital on the second or third day post-surgery.

Following discharge, patients are advised against lifting objects heavier than one pound, as well as pushing and pulling activities for six weeks. Driving is recommended only once comfort, range of motion, and strength in the shoulder have sufficiently recovered, which may take several weeks. Consequently, patients should anticipate reduced arm function during the initial month after surgery compared to preoperative levels. As a result, assistance with self-care, daily activities, shopping, and driving is often necessary for approximately six weeks post-surgery. Planning is essential to manage these limitations and ensure the accomplishment of daily tasks during the recovery period.

What About Rehabilitation?

Early mobilization following a total shoulder replacement is crucial for optimizing shoulder functionality. Arthritic shoulders tend to be rigid, and while the primary aim of surgery is to alleviate this rigidity by releasing scar tissue, there's a risk of it returning if range of motion exercises aren't initiated promptly during recovery. During the initial six weeks post-surgery, the rehabilitation focus is primarily on preserving the range of motion achieved through surgery. Strength-building exercises are postponed during this period to allow for proper healing of the tendon repair to the bone. Subsequently, once the shoulder gains comfort and flexibility, strength training and additional activities are gradually introduced. Some patients opt for self-guided rehabilitation, while others prefer working with a physical therapist experienced in total shoulder programs.

When Can Ordinary Daily Activities Be Resumed?

Typically, patients can resume gentle daily tasks with the operated arm within two to six weeks post-surgery. Walking is highly recommended during this time. Driving should be postponed until the patient feels comfortable and confident in performing essential functions. Regaining driving ability might take up to six weeks after surgery, especially if it involves using the left shoulder extensively for gear shifting. With approval from their surgeon, patients can usually reintegrate activities like swimming and golf into their routine around six months after surgery.

Once A Shoulder With A Total Shoulder Procedure Has Successfully Completed The Rehabilitation Program, What Activities Are Permissible?

After achieving almost full range of motion, strength, and comfort in the shoulder, it's advisable to shield it from heavy lifting and impact. Therefore, we advise against activities such as chopping wood, lifting heavy weights, vigorous hammering, and engaging in recreational activities that put strain on the shoulder.

What Problems Can Complicate A Total Shoulder And How Can They Be Avoided?

Similar to all surgical interventions, the total shoulder operation carries risks such as infection, nerve or blood vessel damage, fractures, instability, component loosening, and anesthesia-related complications. Moreover, this procedure demands precision and expertise, necessitating an experienced surgeon to ensure optimal alignment of bones, prosthetics, and soft tissues post-surgery. Failure may result from overly tight or loose reconstruction, misalignment, insecure fixation, or unwanted bone-to-bone contact. Short-term failure often stems from the patient's inability to maintain postoperative range of motion during the healing period, which can extend up to six months. In the long term, the most common issue is the wearing or loosening of the glenoid component.

Replacement

Reverse shoulder arthroplasty

A traditional shoulder replacement device follows the natural structure of the shoulder: a plastic “cup” is inserted into the shoulder socket (glenoid), while a metal “ball” is affixed to the upper arm bone (humerus). However, in a reverse total shoulder replacement, this configuration is flipped. Here, the metal ball is anchored to the socket, and the plastic cup is attached to the upper end of the humerus.

This reversal is particularly advantageous for individuals with cuff tear arthropathy because it relies on different muscle groups to facilitate arm movement. In a healthy shoulder, the rotator cuff muscles play a crucial role in positioning and powering the arm through its range of motion. In contrast, a conventional replacement device depends on the rotator cuff muscles for its functionality. Yet, when a patient experiences a significant rotator cuff tear and cuff tear arthropathy, these muscles cease to function effectively. Consequently, the reverse total shoulder replacement entrusts the task of powering and positioning the arm to the deltoid muscle instead of relying on the compromised rotator cuff.

Reverse total shoulder replacement may be recommended if you have

A rotator cuff tear so severe that it cannot be surgically repaired.

Cuff tear arthropathy, a condition resulting from a tear in the rotator cuff.

An unsuccessful prior shoulder replacement surgery.

A complex fracture involving the shoulder joint.

Persistent shoulder dislocation over an extended period.

Presence of a tumor affecting the shoulder joint.