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“A tremendously successful procedure for treating the severe pain and stiffness that often result at the end stage of various forms of arthritis or degenerative joint disease of the shoulder joint."

Information by Dr Mark Ferguson
Edited for the website by Lorraine Melvill

TOTAL SHOULDER REPLACEMENT (Shoulder Arthroplasty – TSA)

Patient Information Sheet

Total shoulder replacement, is a tremendously successful procedure for treating the severe pain and stiffness that often result at the end stage of various forms of arthritis or degenerative joint disease of the shoulder joint. The primary goal of shoulder replacement surgery is pain relief, with a secondary benefit of restoring motion, strength, and function.

The surgery involves replacing the humeral head (or joint “ball”) and the glenoid (called the “socket”). Partial shoulder replacement (or hemi-replacement) may also be indicated with certain severe shoulder fractures of the humeral head. This technique requires the replacement of that component only.

Shoulder replacement was first performed in the U.S. in 1953. Since that time, the procedure has been refined with the use of new implant materials and design, as well as improved surgical, anesthetic, and rehabilitation techniques.

Treatment Options

Nonsurgical Treatment

Treatment of an arthritic shoulder starts with rest, exercise and taking arthritis medications. Resting the shoulder and applying moist heat can ease mild pain. After strenuous activity, an ice pack may be more effective at decreasing pain and swelling.

Physical therapy may be helpful when arthritis is in early stages. It helps maintain joint motion and strengthen the shoulder muscles. Physical therapy is less effective when the arthritis has advanced to the point that bone rubs on bone. When this is the case, physical therapy may make the shoulder hurt more.

Arthritis medications, called nonsteroidal anti-inflammatories (NSAIDs), can control arthritis pain. Certain NSAIDs may be purchased over-the-counter, while others require a prescription. Periodic cortisone injections into the shoulder joint can provide temporary pain relief. Excessive cortisone shots can have adverse effects, however.

Surgical Treatment

Shoulder joint replacement.

Shoulder ReplacementIf nonoperative treatments fail, shoulder replacement surgery may be needed. Shoulder replacements are usually done to relieve pain. There are several different types of shoulder replacements. The usual total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket.

The components come in various sizes. If the bone is of good quality, your surgeon may choose to use a non-cemented or press-fit humeral component. If the bone is soft, the humeral component may be implanted with bone cement. In most cases, an all-plastic glenoid component is implanted with bone cement. Implantation of a glenoid component is not advised if:

The glenoid has good cartilage. The glenoid bone is severely deficient. The rotator cuff tendons are irreparably torn.

Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.

Depending on the condition of the shoulder, your surgeon may replace only the ball. Sometimes, this decision is made in the operating room at the time of the surgery. Some surgeons replace the ball when it is severely fractured and the socket is normal.

Reverse total shoulder replacement components

Another type of shoulder replacement is called reverse total shoulder replacement. This surgery was developed in Europe in the 1980s. It was approved by the Food and Drug Administration (FDA) for use in the United States in 2004. Reverse total shoulder replacement is used for people who have:

For these individuals, a conventional total shoulder replacement can still leave them with pain. They may also be unable to lift their arm up past a 90-degree angle. Not being unable to lift one's arm away from the side can be severely debilitating. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder bone and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm.

Shoulder replacement surgery is highly technical. It should be performed by a surgical team with experience in this procedure. Each case is individual. Your surgeon will evaluate your situation carefully before making any decisions. Do not hesitate to ask what type of implant will be used in your situation. Ask why that choice is right for you.

Before surgery, patients see their internist or family practice physician for a preoperative medical evaluation. Cardiac patients should see their cardiologist as well. Two weeks before surgery, you should stop taking the following medications that thin the blood and can lead to excessive bleeding during surgery:

Nonsteroidal anti-inflammatory medications (aspirin and ibuprofen such as Motrin and Advil) Most arthritis medications The surgery is performed on an inpatient basis. Most patients are discharged from the hospital on the second or third day after the operation.

Implant Materials

There are many different types of implants that are used for shoulder replacement. They all, however, share the same basic components: a metal ball that rests against a plastic (polyethylene) socket. The goal of shoulder replacement is to remove the patient’s arthritic humeral head, replace it with the metal “ball” component with a stem that extends down inside the patient’s humerus (upper arm bone), and then place a plastic socket over the surface of the patient’s own glenoid.

While the new polyethylene socket is always cemented to the bone surrounding it, the new ball has a stem that is cemented in place only when the fitting is not exact. In most cases, new prostheses feature stems that actually promote natural bone growth into the material.

Dr. Craig and two of his colleagues at HSS, Russell F. Warren, MD, and David M. Dines, MD, have created and recently marketed a new implant with a ball made of cobalt chrome and a stem made of titanium metal, featuring modular (separate) components; the ball, stem, and socket all fit together to provide a more customized fit. The ball component features Versadial®, which allows for the new humeral head to be “dialed in” to conform to the patient’s exact anatomy, and the stem was designed to be cementless, providing the opportunity for the ingrowth of bone into the prosthesis.

The Procedure

The surgeon begins by separating the deltoid and pectoral muscles, accessing the shoulder in a largely nerve-free area to minimize nerve damage. The shoulder is covered by the rotator cuff, which must be opened by cutting one of the anterior (front) rotator cuff muscles. This “opens the door,” allowing the surgeon to view and manipulate the arthritic sections of the shoulder.

After the arthritic sections have been removed, the surgeon inserts the implant socket, ball, and stem components; closes and stitches the rotator cuff muscle; and stitches and cleans the incision.

Recovery/ Rehabilitation

After leaving the operating room with the arm immobilized at the side, the patient will wake up in the recovery room.

“Normally,” notes Dr. Craig, “patients will wake up from surgery with pain due to surgery, but not the same type of pain they have experienced due to their arthritis. Arthritic pain is largely absent from that point forward.”

Based on the range of motion and stability of the implant, physical therapy begins on the first postoperative day, following x-rays documenting that the implant is properly postioned. Sling immobilization in enforced during the early rehabilitation phase.

“As patients begin the physical therapy program, they notice that shoulder mobility is easier,” Dr. Craig explains, “and the hard grating and grinding so typical of an arthritic shoulder is no longer there.”

The patient is permitted to use the arm for light activity beginning at approximately four weeks after surgery and unrestricted, active use of the arm may begin as early as eight weeks after surgery.

“I do tell patients that they can usually return to desk work within two to three weeks from the time of surgery,” says Dr. Craig, “but that heavier work is forbidden for four months or more and depends greatly on the motion and strength of the shoulder and how they are progressing.”

The pre-surgical condition of the shoulder muscles and tendons play the biggest role in the patient’s outcome. “If their muscles and tendons are in good shape, rehab will be minimal, as post-surgical rehabilitation of the shoulder depends on the patient’s own muscles and tendons.” Dr. Craig notes. “That’s the critical difference between shoulder replacement vs. hip and knee replacement.”

Patients can expect the following after surgery:

• At about three months after surgery, most patients are reasonably comfortable, have motion about half normal, but do notice some weakness. • At six months, most patients are pain-free (although weather does have an effect), and have motion and strength about two-thirds normal. • At one year, approximately 95% of TSA patients will be pain-free, and the remaining will usually have no more than a weather ache or an occasional ache with excessive activity. Likewise, there will probably not be significant strength limitations, depending on the condition of the deltoid and rotator cuff.

Possible Complications

The most common complications involved in TSA, which occur only rarely, include shoulder stiffness, instability, infection, nerve damage, and glenoid loosening.

An arthritic shoulder is often very tight to begin with, however if post-operative stiffness is a problem in a shoulder in which motion was restored during surgery, the stiffness is usually a result of incomplete rehabilitation. Continued rehabilitative efforts are usually effective in restoring shoulder motion and strength.

Conclusion

Total shoulder arthroplasty is a highly beneficial surgical procedure intended to reduce pain and restore mobility in patients with end stage shoulder arthritis, and occasionally after certain severe shoulder fractures. In most cases, non-operative measures such as medication, injections, and gentle physical therapy are considered prior to deciding on surgery.

It is important to understand that proper and extensive post-operative rehabilitation is a key factor in achieving the maximum benefit of shoulder replacement surgery. With this in mind, TSA is generally considered to be as successful in relieving pain as total hip or knee replacement.

After one year, 95% of TSA patients enjoy pain-free function, which enables them to exercise the shoulder area sufficiently to promote restoration of strength and motion, making the procedure a highly valued choice for a wide variety of patients suffering from significant shoulder pain.

 

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