Total Shoulder Replacement

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.

Introduction

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.

  • 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 beyond the scope of this guide, but we do have a page about RTSA if your surgeon says that it may be the right procedure for you.

The Surgery

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.

Subscapularis Healing

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:

  • 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

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):

  • Rheumatoid Arthritis: minocycline, sulfasalazine, methotrexate, azathioprine, Imuran, chlorambucil, leflunomide, cellcept, etc
  • 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, Nonsteroidal Anti-inflammatory medications (NSAIDS), etc

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:

  • 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 for meals
  • 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 have 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 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.

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 clothes with pockets
  • Button-down shirts
  • Toiletries
  • Books, magazines, cell phone chargers
  • A list of prescription meds and over-the-counter meds, including vitamins or herbal meds you take. Include the entire dose 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 Surgery

  • Shower/bathe
  • 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 are arriving 2-3 hours before your scheduled surgery time so that the hospital and surgical staff can get you checked in and ready for surgery

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:

  • 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 tolerate
  • 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 a day or two
  • You will be instructed on exercises that also help promote circulation (ankle pumps and fist squeezes)
  • A family member (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
  • 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 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.

Your Sling

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.

  • 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 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: 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.

  • 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. 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!

Driving

  • 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:
  • MUST HAVE AUTOMATIC TRANSMISSION
  • DO NOT START TO DRIVE UNTIL 2 WEEKS AFTER 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 of either leg
  • Shortness of breath
  • Chest pain
  • New/increased numbness or tingling in your arm
  • A fall or injury

Conclusion

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!
  • References:
  • Mayo Clinic. Shoulder Replacement Surgery. Reverse Prosthesis. 2010.
  • Google images
  • AAOS
  • Personal experience
  • Patient input