Total Shoulder Replacement
The following information is a general overview of the process of a total shoulder replacement. We hope you find this informative and helps educate you, as a patient, about the process you are about to undergo. Total shoulder replacement surgery is not a “minor” surgery, and it is our belief the patient should be well-educated and welcome 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.
A “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 prosthesis. 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 radiographs. The rotator cuff muscles connect to the humeral head and assist with motion. These muscles are usually 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 that there is no cartilage left, which causes pain 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 decreases to the point of “bone on bone.” For some patients, arthritis is painful; for others this does not cause too much of an issue. When your arthritic pain begins to cause a decrease in your “quality of life,” that is when it is time to consider total shoulder replacement surgery and discuss it with your physician.
Shoulder Replacement Options
There are three types of shoulder replacement.
During surgery, your surgeon will expose your shoulder very carefully. After the exposure, your rotator cuff muscles are inspected to ensure they are intact. Your 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 have to decide this intraoperatively based on the “fit” of the prosthesis.
The bony socket is then smoothed out and a new socket is 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. A drain is usually placed to help decrease a hematoma from collecting (this will be removed before you go home). Your skin incision is then sewn closed and a sterile dressing is placed. A simple sling is applied and you are awoken from anesthesia and taken to the Post-Anesthesia Care Unit (PACU or Recovery Room).
Length of Surgery
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 surgery usually lasts between 1 and 3 hours. The surgical nurse should keep your family informed of our overall progress during the 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. If this muscle is still intact, it must be carefully released for your surgery to be performed. 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 sling 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 that smoking and uncontrolled diabetes can delay or inhibit healing. It is HIGHLY encouraged to stop smoking and control your blood sugars before AND after surgery.
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.
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.
Common Risks of Shoulder Surgery are:
In addition, the prosthesis may come loose in the future and may need to be revised. Loosening is caused by wear and tear on the prosthesis from it being used, or from a traumatic injury (e.g., a fall or a car accident). This is most likely not due to your initial surgery.
Preparing for Your Surgery
There is a lot that 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 for all patients to receive a medical evaluation by their primary care physician and anesthesiologist, along with getting a dental clearance. In addition, you will have to have blood drawn 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):
The primary care provider who manages these medications for you will help you decide when to stop and restart these medications with regard to your surgical date.
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 back home:
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 have surgery in a sling for a day or two.
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 seems harsh, but allows the surgeon to perform your surgery earlier if there is a cancellation before you. We understand that this is not a pleasant experience, but we appreciate your understanding.
Bathing will help decrease the bacteria on your skin and helps reduce the chance of infections.
Some items you may find useful while you are in the hospital are:
After You Return To Your Hospital Room
After your surgery is completed 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).
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 this using only your unaffected arm and other assistive devices.
Below is a list of items that may occur when you return to your room:
Your Hospital Stay
Most total shoulder replacement patients stay in the hospital 1-2 nights. Each person is different, and your needs will be assessed daily.
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, who will be with your 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. Also, your IV lines and oxygen tubes may be removed when they are no longer needed. Blood may be drawn to have 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. Make sure you have learned how to get in and out of the bed/chair/toilet/car before you leave. Make sure you have learned the exercises and take your handouts as reminders.
One thing to consider is 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 movement for a few days.
When you wake up, your shoulder will be in a sling; sometimes this is called an immobilizer. The sling helps protect your arm and helps prevent movement that can damage your new shoulder joint and the repaired subscapularis. You should use the sling to support the weight of your arm, and NOT your own muscles. The sling will be worn DAY AND NIGHT for 6 weeks to allow your shoulder to heal.
Now You Are Home
Activity and Physical Therapy:
Remember: everyone is different and the following are just guidelines. Make sure to follow the instructions given to you by your physician, nurses, and therapists.
Antibiotics: Your shoulder has now been replaced and 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.
Bathing/showering: You may shower once your wound has stopped draining for 24 hours. This usually occurs by the 5th day. 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 re-cover 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 for!
ONLY USE STICK OR ROLL-ON DEODORANT! Spray deodorants, powders, and perfumes may get into the incision by accident and slow the healing!
Call Your Surgeon Or Health Care Provider If Any Of The Following Occur:
Congratulations on your new shoulder replacement! As you can tell, it is not an overnight process, and a good outcome involves cooperation between the entire healthcare team and YOU! We hope you find this guide informative and useful. Please feel free to ask more questions of your healthcare team as they occur to you. The more informed you are, the more likely to have a better result!