Reverse Total Shoulder Replacement

Reverse Total Shoulder Replacement

The following information is a general overview of the process of a reverse total shoulder replacement. We hope you find this information educational for you, as the patient, about the process you are about to undergo. Reverse total shoulder replacement surgery is not a “minor” surgery. We believe each patient should be well-educated and welcomed to ask questions about the process and specifics. We hope this guide will help ease any anxiety with regard to your surgery and will be a start to getting all your questions answered before and after surgery.

Don’t forget that the following overview contains only GENERAL guidelines and suggestions. Your surgeon and primary care physician (PCP) will give you specific instructions that should be followed at all times. Never hesitate to ask questions if you have them.

Introduction to the Procedure

A “Shoulder Replacement” has become a more common procedure over the past 15-20 years. During a shoulder replacement surgery the “worn out” parts are replaced with artificial parts, called components or prostheses.

Most of the time, the prostheses are designed to match the shape of the area being replaced (called an anatomic replacement), but sometimes the shoulder is damaged in such a way that this is not possible. To help patients that are not able to have an “anatomic replacement,” a special prosthesis is used. This prosthesis reverses the shoulder parts, and is called a REVERSE TOTAL SHOULDER ARTHROPLASTY (RTSA). The reversed parts allow you to use the large muscles around the shoulder and hopefully decrease your pain and increase your function.

Anatomy of the Normal Shoulder

A normal shoulder is made up of the humeral head, which is the top part of the arm bone, and the glenoid, which is the socket part of the shoulder blade. In a normal shoulder, both of those parts are covered with “articular cartilage” on the surface, allowing for smooth gliding of the joint with motion. This cartilage creates the space between the bones seen on radiographs. The rotator cuff muscles also connect to the humeral head and assist with motion. These muscles are usually not intact or functioning when a RTSA is performed.

The Arthritic Shoulder and Need for a Reverse Total Shoulder Replacement

The cartilage surfaces of all joints wear out eventually with aging; sometimes this happens to a point when there is no cartilage left, which causes pain and possibly deformity. Other processes, including rheumatoid arthritis, osteonecrosis, and fractures, can accelerate this process. As the cartilage thins out, the joint space seen on radiographs decreases to the point of “bone on bone.”

In addition to the shoulder joint’s cartilage being worn out, sometimes the rotator cuff muscles are damaged and cannot be repaired. This causes even more limitations and pain. Over time, the humeral head gradually moves out of the socket and is in an elevated position.

For some patients, this process can be functionally limiting and painful, and for others it does not cause too much of an issue. When your pain and function begin to cause a decrease in your “quality of life,” that is when it is time to consider this shoulder replacement surgery and discuss it with your physician.

Shoulder Replacement Options

There are three types of shoulder replacement surgeries:
  • Hemiarthroplasty (partial shoulder replacement): Only the humeral head is replaced in this procedure. This one is commonly done for younger patients, as well as to treat shoulder fractures.
  • Total Shoulder Arthroplasty (total shoulder replacement): With this procedure, BOTH the humeral head and the glenoid (socket) are replaced. This type of replacement is beyond the scope of this overview. We do have a different page describing total shoulder replacement, which you should read if your physician says this prosthesis may be used for you.
  • Reverse Shoulder Arthroplasty (“reverse” arthroplasty): This procedure involves the humeral head and glenoid (socket) being replaced, but reversed.

About the Surgery

During surgery, your surgeon will expose your shoulder very carefully. After the exposure, 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 and contains a “socket.” The original bony socket is then smoothed out, a plate with screws is put on the socket, and a metal ball is then attached to the new socket. This is how the shoulder is “reversed.”

A drain is usually placed to help decrease a hematoma from collecting (this will be removed before you go home). The incision in your skin is then sewn shut and a sterile dressing is placed. Following that, a simple sling is applied and you are awoken from anesthesia to be taken to the Post-Anesthesia Care Unit (PACU or Recovery Room).

Surgery Length

This is a common question. The surgery usually lasts between 1 and 3 hours, 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.

Subscapularis Healing

The subscapularis muscle is an important rotator cuff tendon that allows you to move your shoulder. This muscle serves as the “door” to the shoulder during surgery. If this muscle is still intact, it must be carefully released for your surgery to be performed. This tendon is very meticulously repaired by your surgeon at the end of the surgery.

For your RTSA to function properly after surgery, it is VERY IMPORTANT that the repaired subscapularis muscle heal. This is why you are placed in a sling and why 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 that smoking and uncontrolled diabetes can delay or inhibit healing of this tendon. It is HIGHLY encouraged that you stop smoking and control your blood sugars before AND after surgery to prevent this delay.

The surgery varies, from a simple liner exchange to changing one or all of the components. Extra bone (cadaver bone) may need to be used to make up for any bone loss during the surgery.

Possible Risks

As with anything, there are risks. Your surgeon will take precautions to attempt to prevent complications, but one still may occur. Please let your surgeon know if you have any questions.

Common risks of shoulder surgery include:

  • Infection
  • Dislocation
  • Fracture (broken bone)
  • Blood Vessel or nerve injury
  • Tendon not healing
  • Wound complications
  • Stiffness
  • Weakness
  • Continued pain

This is of course not a complete list of possible complications, but it does list some of the most common complications stemming from this procedure

In addition, your prosthesis may come loose in the future and may need to be revised. Loosening can be caused by wear and tear on the prosthesis from it being used, or from a traumatic injury (e.g., a fall, a car accident). This is most likely not going to happen due to your initial surgery.

Preparing for Your Shoulder Surgery

There is a lot that your surgeon, their office, and you need to complete prior to your surgery. This is all done with your safety as the primary goal.

One of the main requirements for all patients is to receive a medical evaluation by both their primary care physician and anesthesiologist. A dental clearance is also required. 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, but please ask questions if you have them.

Before surgery, we ask, in assistance/guidance with your primary care physician (or other specialist), that certain medications be changed or stopped. These medications include, but are not limited to, the following:

  • Blood thinning medications: warfarin (Coumadin), clopidogrel (Plavix), Cilostazol (Pletal), Dabigatran (Pradaxa), Rivaroxaban (Xarelto), heparin, enoxaparin (lovenox), dalteparin (fragmin), fondaparinux (arixtra), aspirin (aspirin-containing products), Aggrenox, non-steroidal anti-inflammatory medications (NSAIDS), etc.
  • Rheumatoid Arthritis medications: 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 when to restart these medications with regard to your surgery date.

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 in any part of your body prior to surgery, please seek medical attention from your PCP or local ER as soon as possible, and notify your surgeon. 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 Period

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, from bathing to getting dressed to eating.

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
  • If your bedroom is on a second story, consider moving a bed to the first floor for easy access
  • Place your remotes, magazines, books, computer, telephone, and other items in an easily accessible location
  • Prepare and freeze meals which can be easily reheated
  • If you wish, contact your religious or spiritual leader to visit you during your recovery

Many patients find it helpful to “practice” only having the use of one arm to assist with their understanding of the limitations after surgery. This can easily be done by placing the arm that will undergo surgery in a sling for a day or two.

The Day Before Surgery

EAT AND DRINK AS YOU HAVE BEEN INSTRUCTED

It is imperative that your stomach be empty before you receive anesthesia. This helps decrease the chances that any nausea, vomiting, and other anesthesia-related problems arise.

This typically means NOTHING TO EAT OR DRINK FOR 8 HOURS PRIOR TO YOUR SURGERY. It is typically asked that you stop eating and drinking at midnight the night before your surgery, even if your surgery is not planned until the afternoon. This may seem harsh, but it allows the surgeon to do your surgery earlier if there is a cancellation before your scheduled surgery time. We understand that this is not a pleasant experience, but we appreciate your understanding.

Take a shower or bath the night before AND the morning of surgery

Bathing will help decrease the bacteria on your skin and helps reduce the chance of infections.

PACK FOR SURGERY

Some items you may find useful while you are in the hospital are:

  • Comfortable, non-skid shoes
  • Loose-fitting clothing with pockets
  • Button-down shirts
  • Toiletries
  • Books, magazines, cell phone chargers
  • A list of prescription meds, over-the-counter meds, vitamins and/or herbal meds you take; be sure to include the entire dosage and times you take them
  • Money, credit cards
  • ID cards, drivers license
  • Continues Positive Airway Pressure (CPAP) machine or other special equipment

The Morning of Your Surgery

  • Take a shower/bath
  • Do NOT apply lotion, makeup, deodorant, or perfumes after taking your shower/bath
  • Do NOT shave your armpit or any hair on your shoulder
  • Remove all nail polish if possible
  • Do NOT bring jewelry to the hospital
  • Give your wallet/purse to your caregiver who is with you at the hospital
  • Wear eyeglasses instead of contacts
  • Take ONLY the meds your PCP instructed you to before surgery
  • Arrive at the hospital ON TIME!
  • Remember: you should be arriving 2-3 hours before your scheduled surgery time, so that the hospital and surgical staff can get you checked in and ready for your surgery

After You Return To Your Hospital Room

After your surgery is complete and you have recovered, you will be transferred to your hospital room. This may be a private, semi-private, or shared room (this is usually not the surgeons’ decision, but based upon what is available at the time).

We ask that you refrain from getting out of bed on your own the day of surgery. This helps reduce your risk of falling and sustaining an injury to your shoulder, head, or other areas. When your surgeon, nurse, or therapist gives permission to get out of bed, you will be shown the proper way to do so using only your unaffected arm and other assisting devices.

Below is a list of things that may occur/be in place when you are in your hospital room:

  • The bed rails may be up to prevent you from rolling off the bed while asleep
  • Your heart rate, blood pressure, and operative side will be checked frequently
  • You will be given fluids through your IV until you are able to eat a full meal
  • Antibiotics will be given through your IV for 24-48 hours to reduce the risk of infection
  • Pain meds may be given through your IV until you can take meds by mouth
  • A drain may be in place around the surgical site, and a nurse may need to empty the collected fluid periodically
  • You will be encouraged to drink fluids slowly, then progress to more solid foods as you are able to tolerate them
  • You may or may not have a bladder catheter in place. If one is in place, it will most likely be removed that day after surgery. After it is removed, your bladder may be checked (“scanned”) to make sure you are emptying your bladder fully when you urinate. Completely emptying your bladder helps prevent infections
  • You may continue to get oxygen through a tube around your nose for 1-2 days
  • You will be instructed on exercises that also help promote circulation (ankle pumps and fist squeezes)
  • Your caregiver will help with your personal care while in the hospital. This includes brushing your teeth, bathing, clothing changes, etc. The nursing staff will help teach them proper care techniques.
  • You will be encouraged to cough and take deep breaths. This helps keep your lungs open and clear to prevent pneumonia.
  • An “incentive spirometer” (breathing machine) will be at your bedside to help you keep your lungs clear
  • Support stockings (hose) and/or Sequential Compression Devices (SCDs or squeezers) will be placed on your legs to help with circulation and reduce your risk of blood clots

Your Sling/Immobilizer

When you wake up, your shoulder will be in a sling; sometimes this is called an immobilizer. The sling helps protect your arm following surgery and helps prevent movement that can damage your new shoulder joint and the repaired subscapularis. You should use the sling, NOT your own muscles, to support the weight of your arm. The sling will be worn DAY AND NIGHT for at least 6 weeks to allow your wound to heal.

Your Hospital Stay

Most reverse total shoulder replacement patients stay in the hospital 1-2 nights. Each person is different and your needs are assessed daily by your surgeon and nurses.

The day after surgery is a big day! Today you will most likely begin your shoulder exercises under the direction of the medical team and therapist. It is nice to have a family member or other caregiver with you when you return home to watch and assist with the exercises. You will be given handouts about the exercises along with a “kit.” Even though the kit may contain different instructions and/or extra equipment, ONLY DO THE EXERCISES YOUR PHYSICIAN AND/OR THERAPIST SHOWED YOU!!!!! As you progress, more exercises will be added and the “extra” equipment will be utilized. It may be helpful to take a dose of pain medication right before the therapist comes, to help with some discomfort which may occur.

Most likely, your bladder catheter will be removed on the first day by the nursing staff. Your IV lines and oxygen tubes may be removed if they are no longer needed. Blood may be drawn to be checked by the laboratory and physicians, so you can be managed appropriately. Usually your drain remains in place until the 2nd day after surgery. Once the drainage has decreased, your drain is removed and your dressing is changed to a smaller dressing.

Once your catheter and drain are removed and your pain is under control, you are ready for discharge from the hospital. Make sure you have learned how to get in and out of beds, chairs, and cars, as well as on and off toilets, before you leave. Make sure you have learned the exercises from your physician and therapist and take your handouts as reminders.

Make sure you continue to take a stool softener and drink plenty of water after surgery. The meds given to help with pain control may cause constipation. It is normal not to have bowel movements for a few days.

Being Back Home

Activity and Physical Therapy: Remember, everyone is different and the following are just guidelines. Make sure to follow the more specific instructions given to you by your physician, nurses, and therapists.
  • Use your shoulder sling at all times – DAY AND NIGHT – until told not to. The only time it may be removed is for exercises and for hygiene purposes (shower/bath, changing clothes, etc.)
  • Set aside time to do your exercises
  • Exercises should be done 3-4 times per day. Each individual exercise should be done 10 times.
  • Active movement of your elbow, wrist and hand are safe as long as your shoulder is not moving. It is important to move your elbow, wrist and hand to prevent stiffness in these joints.
  • DO NOT LIFT OR HOLD HEAVY OBJECTS UNTIL YOU ARE GIVEN PERMISSION TO DO SO.
  • Examples of approved objects to hold are:
  • Coffee cup
  • Dinner plate
  • AVOID HEAVY HOUSEWORK WHILE RECOVERING (light housework may be okay, depending on the activity)

Antibiotics: Now that your shoulder has been replaced, it needs to be protected. For the rest of your life, any time you need any of the following procedures, you need to take antibiotics before and after the procedure. The Orthopaedic Clinic will be happy to prescribe these to you if you give advanced warning. Please ask your surgeon and PCP if you have questions or need specifics.

  • At Risk Procedures:
  • Dental work (except cleaning)
  • Colonoscopy
  • Pelvic exams
  • Urinary catheterization
  • Any other procedure where a tube or instrument is inserted into your body
  • It is advised that any of these procedures be delayed for at least 3 months AFTER your surgery, if medically possible.

Bathing/showering: You may shower once your wound has stopped draining for 24 hours. This usually occurs by the 5th day after your surgery. Your surgeons will give you more specific information in your discharge paperwork on this item. When you do shower, DO NOT scrub the wound!! Only allow soapy water to run over the wound and gently clean it this way. Then GENTLY pat the wound dry and recover with a DRY gauze. NEVER PUT ANY LOTIONS OR OINTMENTS ON THE WOUND!!!!

DO NOT SOAK YOUR WOUNDS FOR 6 WEEKS AFTER SURGERY!!! This means no baths, hottubs, or swimming! If your wound is submerged, this may increase your chances of obtaining an infection. You may need assistance getting in/out of the shower, in addition to showering, drying off, and getting dressed afterwards. Remember: this is what your caregiver is there for!

ONLY USE STICK OR ROLL-ON DEODORANT! Spray deodorants, powders, and perfumes may get into the incision by accident and slow the healing process!

Driving After Surgery

  • IF YOU ARE USING NARCOTIC MEDICATIONS YOU MAY NOT DRIVE AT ALL!!!
  • YOU MAY BEGIN TO DRIVE WHEN YOU NO LONGER NEED YOUR SHOULDER IMMOBILIZER
  • YOUR SURGEON WILL HELP YOU WITH THIS TIMING
  • IN GENERAL:
  • YOUR VEHICLE MUST HAVE AUTOMATIC TRANSMISSION
  • DO NOT START TO DRIVE UNTIL 2 WEEKS AFTER YOUR SLING IS DISCONTINUED
  • START SLOW! DO NOT START ON HIGHWAYS AND DURING RUSH HOUR!!!

YOU SHOULD DISCUSS DRIVING WITH YOUR PHYSICIAN BEFORE YOU RETURN TO DRIVING

Sexual Activity

  • You may be sexually active when you are comfortable to do so
  • Your shoulder immobilizer should be used during sexual activity
  • Care should be taken to protect your surgical repair

Call Your Surgeon Or Health Care Provider If Any Of The Following Occur:

  • Fever (temperature above 101.5 for 2 days)
  • Increasing pain that does not improve after taking meds
  • Drainage with pus, odor, redness, swelling, heat or opening of the incision
  • Urinary/bladder infection
  • Lung infection
  • Change in motion ability or arm length
  • Calf/thigh pain, tenderness or swelling in either leg
  • Shortness of breath
  • Chest pain
  • New/increased numbness or tingling in your arm
  • A fall or injury

Conclusion

Congratulations on your new reverse total shoulder replacement! As you can tell, it isn’t an overnight process. A good outcome involves cooperation between the entire healthcare team and YOU!! We hope you find this overview informative and useful. Please feel free to ask more questions of your healthcare team before and after your surgery. The more informed you are, the more likely you are to have a better result!!!
  • References:
  • Mayo Clinic. Shoulder Replacement Surgery. Reverse Prosthesis. 2010.
  • Google images
  • AAOS
  • Personal experience
  • Patient input