Background
Shoulder (glenohumeral) arthritis is a common source of pain and disability that affects up to 20% of the older population
Damage to the cartilage surfaces of the glenohumeral joint (the shoulder’s “ball-and-socket” structure) is the primary cause of shoulder arthritis
There are many treatment options for shoulder arthritis, ranging from anti-inflammatory medications and exercises for mild cases, to surgical procedures for severe cases
Treatment decisions are based upon the cause, the symptoms and the severity of the patient’s disease
Shoulder replacement is a safe and effective treatment option in patients with end stage shoulder arthritis that have failed conservative management
Each year, over 120,000 shoulder replacement surgeries are performed in the United States to relieve pain and improve function for shoulders that are severely damaged by glenohumeral arthritis
Figure 1. Utilizing Computer navigation technology and 3D printed guides to plan shoulder replacements
Surgical Procedure
The goal of the total shoulder replacement procedure of the shoulder is to remove the arthritic humeral head (ball) and glenoid (socket) and replacing with alloy metal and highly crosslinked polyethylene (plastic) components with the goal of decreasing pain and improving function
Dr. Kandil performs the total shoulder replacement through an open technique between two muscle planes (the deltopectoral approach) to minimize damage to muscle and expedite the healing and recovery process
Dr. Kandil utilizes computer navigation technology and 3D printed guides to plan all of his shoulder replacements. This can help with component positioning
Most total shoulder replacements can be done as outpatient procedures which generally takes about an hour and a half to complete
Most patients receive a regional nerve block prior to surgery to decrease amount of anesthesia and pain medications during and after surgery
Meticulous care and attention is taken during the procedure to ensure the highest likelihood of a successful total shoulder replacement
Figure 2. This is an example of a stemless total shoulder replacement where much of the bone around the shoulder is preserved
What To Expect After Surgery
After your surgery, you will have prosthetic components which are susceptible to mechanical loosening or dislocation
Therefore, it is important to adhere to post operative instructions and to return to the clinic at the designated time points
These follow-ups are usually at 2 weeks, 6 weeks, 3 months, 6 months, and one year after surgery
Also, we would like to see you every year for routine surveillance of the prosthesis
What should I know about my incision/dressing/showering?
Sutures are removed at the first post-op appointment two weeks after surgery after which you may shower and have running water over incisions
You should not remove the Steri-Strips that cover the surgical incisions
To shower you should remove the sling and leave arm hanging down, and then bend forward to clean under the arm with the opposite hand
How long do I have to wear the sling?
You should wear the sling at all times for the first 6 weeks after surgery to protect the deep muscle layer repair, except for the exceptions below. This is critical for healing and this protects against dislocation of the prosthesis
You should also be sleeping in the sling for the first 6 weeks after surgery
During the first 6 weeks, you can come out of the sling to do pendulum exercises, type on a computer, turning the pages of a book to read and feed yourself
However, no active motion of the shoulder, such as reaching outwards or upwards is allowed. For example: no motion as in washing her hair, doing laundry, washing dishes, lifting pots to cook or cleaning a window with the arm is allowed for 6 weeks
You should not drive a car while wearing the sling
Rehab and Physical Therapy
During the first 4-6 weeks after surgery, the shoulder is usually immobilized with a sling.
During this time, the therapist will move the shoulder through passive range of motion exercises to prevent stiffness. This will allow the patient to maintain functional motion in the shoulder while protecting the soft tissue repair.
After soft tissues are adequately healed (about 6 weeks) an active range of motion exercise program can begin.
Soon after adequate active range of motion is achieved, a strengthening program begins, concentrating on the rotator cuff muscles, and those that stabilize the scapula.
Once appropriate levels of motion and strength are reached, a maintenance program of shoulder exercises, as part of a whole-body fitness regimen, is recommended. The patient who commits to a lifetime physical therapy program will maximize the success of the surgical procedure
Return to full activity is highly variable among patients. Generally, complete recovery takes 4-6 months.
Expected Recovery Time
Time to return to work usually is between 2 weeks to 4 months, depending on the nature of your job
No heavy lifting of more than 15 pounds is allowed in the first 4 months after surgery
It is not recommended to lift greater than 15-20 pounds overhead permanently
Generally, pain should be resolved by 3-6 months after surgery, and your ability to reach vertically overhead is usually achieved by 6 months after surgery
Patients should expect to continue to improve steadily with regards to motion, strength and overall comfort up to one year after surgery
What types of complications may occur?
Even with the closest attention to detail, surgical complications may occur. These include but are not limited to the following
Infection – Perioperative antibiotics (given before and after surgery) and current intraoperative procedures have reduced infection rates in arthroplasty to less than 1%. If the infection is caught early, aggressive antibiotic treatment may save the components. A chronic infection that has been present for more than 6-12 weeks generally requires removal of the infected implant.
Blood loss – Although not usually considered a complication, blood loss can occur during shoulder replacement surgery and a transfusion may be required. This is very rare. Even though there are legitimate concerns about banked blood, the current blood available is extremely safe with very low incidences of disease transmission.
Nerve injury – Nerve injuries that occur during shoulder replacement surgery are usually temporary, with near normal function returning over time.
Component failure – This problem is more common with the glenoid component of a total shoulder arthroplasty. Usually, but not always, the loose glenoid component requires surgical removal or revision.
How painful is shoulder replacement surgery?
Shoulder arthroplasty is a complex procedure, which requires a great amount of cutting of deep tissues and bone. The surgeon takes great care to eliminate pain with appropriate analgesia both immediately after surgery and during the rehabilitation process
A long acting local anesthetic infused around the nerves of the joint is often used with general anesthesia during surgery. This is placed by anesthesiologists prior to surgery, either as an injection or as an indwelling catheter. These regional “interscalene” blocks will provide several hours of pain relief even after a patient has emerged from general anesthesia.
By the first day after surgery, oral pain relief medication is usually adequate for pain control and may be used through the early rehabilitation period (4-6 weeks)
With many of these advancements, the level of pain following shoulder surgery has been dramatically reduced compared to even 10 years ago
Most patients are able to return home the day of, or at the latest, the day after surgery.
How long before I can return to my normal activities after shoulder arthroplasty?
The time it takes to return to normal activity varies greatly from patient to patient
Most individuals have less pain at night or at rest in the first 2-4 weeks after surgery
Pain with activity persists longer, but generally decreases as the strength and function of the shoulder muscles improve
Full recovery usually takes 4-6 months.
What activities can I safely do after shoulder replacement?
The goal of shoulder arthroplasty is to relieve the pain from glenohumeral arthritis. It is unrealistic to expect to return to repetitive, heavy, or overhead activities, which would put the replacement components at risk
According to the American Shoulder and Elbow Society, the acceptable activities after a shoulder arthroplasty are:
Bowling, doubles tennis, cross-country skiing, swimming, canoeing, and shuffleboard
For those with previous experience in the activity: golf, ice skating, shooting, and downhill skiing
Unacceptable activities are:
Football, hockey, rock climbing
Bench press, pushups, contact sports
Yoga positions (downward dog) where excessive weight is placed through the shoulders.
You should not engage in heavy manual labor for the lifetime of the prosthesis, and do not lift more than 15-20 pounds overhead
I’ve heard that joint replacement sometimes “wear out” and need to be redone. What are the chances I may require a second shoulder arthroplasty?
Long-term studies show that 90% of total shoulder replacements are functioning well ten years after implantation, and 85% are doing well fifteen years after surgery
Over time, current advances in materials and techniques should improve these percentages even more.
For more information, please refer to Dr. Kandil’s website: www.rahmankandilmd.com
[Adapted from John Costouros from Stanford University]