Injuries in many industries remain at high levels worldwide. A large percentage of injuries involve damage to the shoulder joint. However, in addition to injuries, the shoulder joint can be affected by various diseases, arthritis, osteoarthritis and others. Shoulder joint replacement surgery is often the only method to preserve a patient’s quality of life. The amount of shoulder joint replacement surgery required depends on many factors. Therefore, preparation for such surgery is extremely important.
Preparing for shoulder replacement surgery
Before surgery, the doctor will ask the patient to take several medications to ensure a successful surgery and recovery. Preparation should begin while still at home. The patient should see if various objects will interfere with the rehabilitation activities after surgery to minimize the likelihood of lifting the injured arm or accidentally hitting the corners of furniture.
Some changes to consider include:
Prepare your spouse, friend, or other relative for the initial need to help with meal preparation and housekeeping. Pre-prepared meals, canned goods, and toiletries should be stocked to avoid having to run errands after surgery. Transportation needs to be arranged, as most patients cannot drive for the first 4-6 weeks after surgery.
Requires moving commonly used foods, dishes, pots and pans and appliances from high shelves to a more acceptable level. After surgery, you need cold packs to reduce swelling and heating pads to warm up the joint. In addition, traveling and falls should be avoided. A fall can jeopardize the shoulder implant.
If there are no relatives or helpers, the patient can be discharged from the hospital and admitted to a rehabilitation center. These centers provide nursing care and physical therapy until the patient is able to live independently at home.
Medicines
Medications help reduce the risk of complications during and after surgery. The patient should report any medications he or she is taking, including homeopathic medicines and supplements, and make sure they are safe to take before and after surgery.
Two weeks before surgery, the patient may be asked to stop taking certain medications such as:
-aspirin, nonsteroidal inflammatory drugs (NSAIDs), and other drugs that make it harder for the blood to clot.
-steroids and other drugs that suppress the immune system and therefore may increase the likelihood of postoperative infection
The patient may also be encouraged to eliminate or reduce the use of tobacco products, including cigarettes. Nicotine interferes with soft tissue and bone healing and increases the risk of postoperative deep vein thrombosis, a potentially fatal complication.
If a patient has diabetes, heart disease, or another medical condition, he or she may need to see a specialist to help determine the appropriate dosage of medications to take before, during, and after surgery.
Patients should report consumption of more than 1 or 2 alcoholic beverages per day because heavy alcohol consumption affects the effects of anesthesia.
Patients who become ill (cold, flu, fever, herpes, etc.) in the days leading up to surgery should inform their physicians.
The surgeon and hospital should clearly communicate any necessary medications well in advance of surgery.
Total shoulder replacement
In a total shoulder replacement, the doctor replaces the original hinged shoulder joint with a similarly shaped prosthesis. At the end of the recovery period, patients typically experience less pain, increased shoulder strength, and better range of motion. Traditional shoulder arthroplasty, total shoulder replacement is considered the gold standard for the surgical treatment of severe shoulder osteoarthritis.
Of course, as with any joint replacement surgery, there are risks, and recovery requires several months of physical therapy. Patients are given possible medication before surgery is scheduled. If it is not effective, then surgery is considered.
Why is a total shoulder replacement necessary? Most candidates for traditional shoulder replacement have osteoarthritis or rheumatoid arthritis, with moderate to severe degeneration of the joint confirmed on x-rays and other imaging.
Such patients often report the following:
the onset of pain,
— which ranges from moderate to severe,
— that affects sleep
— which appears when you raise your arm to perform everyday tasks, such as grabbing things from overhead shelves or even washing your hair.
In addition, the pain does not go away when taking various medications such as, non-steroidal anti-inflammatory drugs (NSAIDs), steroid injections, and doing physical therapy.
Some patients have already undergone minimally invasive treatment such as arthroscopy but have not had adequate benefit. Other reasons for total shoulder replacement surgery include a compound fracture of the bone(s) or a tumor.
Complete shoulder replacement and reverse shoulder replacement.
Reverse shoulder replacement is becoming an increasingly common operation worldwide. There are two main differences between total shoulder replacement and reverse shoulder replacement: the position of the new joint and the socket for it, and the muscle groups on which they are located.
According to the anatomy, the joint is supported by the muscles and tendon of the shoulder cuff for joint strength and function. In reverse shoulder replacement, the position of the joint and socket is switched and it rests on the deltoid muscle of the shoulder. In shoulder arthritis caused by rotator cuff tears, this lesion is called rotator cuff tear arthropathy. The reverse shoulder replacement was developed to address the problem of cuff tissue arthropathy.
Delayed surgery can lead to more damage to the shoulder joint. In patients with shoulder arthritis, in whom the rotator cuff is intact, delaying surgery too long can cause irreparable damage to the rotator cuff. This makes total shoulder replacement surgery unacceptable. Reverse shoulder replacement is often a reasonable surgical alternative for these patients. However, shoulder replacement surgery cannot restore rotator cuff function, and although most surgeries are successful, reverse shoulder replacement has more limitations than total shoulder replacement.
Before scheduling surgery, the doctor will explain the patient’s future lifestyle, hopes and expectations. In addition, the doctor will explain the potential risks of the surgery. With this information, the patient will also determine the future tactics and type of surgery.
If the patient does not want surgery, the doctor may suggest exercises as well as other activities to avoid it and help preserve the existing rotator cuff and other supporting soft tissues around the shoulder joint.
Weight and age do not affect the indications for surgery. However, older age and increased weight (obesity) may increase the risk of infectious complications in the postoperative period. If you are overweight, your doctor may recommend reducing your weight through diet and exercise.
Not everyone with shoulder arthritis is a candidate for a total shoulder replacement.
Factors that may affect this include:
— Nicotine use. Patients who smoke or use other tobacco products face higher post-surgical complications. Tobacco users can reduce their postoperative risks by avoiding or reducing tobacco use prior to surgery. In a total shoulder replacement, a specialist cuts the rotator cuff tendon and reconstructs it after the main stage of surgery. Nicotine use has been shown to interfere with healing after rotator cuff repair.
Infection. Doctors consider infection a serious complication. A patient may need to postpone surgery if they have a systemic infection, a predisposition to infection, skin problems that may limit wound healing or increase the risk of infection.
Osteoporosis. Severe osteoporosis can lead to brittle bones that cannot support the prosthesis properly. On the other hand, the degree of osteoporosis, mild to moderate, may simply affect how the surgeon plans the surgery. For example: the surgeon may decide to use a fast-acting bone cement to attach the new socket to the natural bone instead of using the cement fixation method. The surgeon may ask the patient to take steps to improve bone density before and after surgery to improve the longevity of the shoulder joint.
Damage to the rotator cuff. Rotator cuff damage and shoulder arthritis often go hand in hand, a condition called rotator cuff tear arthropathy. If the rotator cuff is severely and irreparably damaged, total shoulder replacement is not recommended. Reverse shoulder replacement may be possible in this situation.
Irreparably damaged deltoid muscle. Damage to the large deltoid muscle of the shoulder limits the chances of successful rehabilitation and recovery in any shoulder replacement.
Nerve damage.
Other factors. Patients who are unable to follow pre- and post-operative instructions may not be suitable for surgery. For example, people with dementia or alcoholism are more prone to dangerous falls, putting them at higher risk for complications such as bone fractures and shoulder dislocations.
Total shoulder replacement.
The goal of a total shoulder replacement is to relieve shoulder pain and increase shoulder function by resurfacing the bone surfaces that meet at the hinge joint of the shoulder joint. The surgeon removes the humeral head at the top of the humerus, re-shapes the shoulder socket and then attaches prosthetic components to both bones. The surgery usually lasts 1 to 3 hours.
Stages of total shoulder replacement surgery.
The course of surgery may vary depending on the patient’s needs and the surgeon’s preference, but generally includes the following steps. Prior to surgery, the physician measures blood pressure, heart rate, body temperature, and oxygenation level. To avoid error, the physician makes a mark with a marker on the patient’s affected shoulder before surgery. Once the patient is admitted to surgery, the anesthesiologist connects the patient in the tracking equipment and administers the necessary drugs for anesthesia. The surgery is usually performed under general anesthesia. In addition, it may be necessary to perform regional anesthesia, which is a blockade of the nerve plexuses in the shoulder area. The type of anesthesia the patient will receive is decided long before the surgery.
After treating the operative field, the surgeon makes an incision about 15 cm long, starting at the top and front of the shoulder and continuing along the deltoid muscle. The surgeon then cuts through deeper tissue, including one of the rotator cuff tendons, to reach the capsule of the shoulder joint. Next, the upper part of the humerus, called the head, is removed from the socket of the scapula. Next, the surgeon examines the neck of the humerus, which is the area just below the head of the humerus.
The surgeon uses an instrument called an osteotome to remove any bony protrusions that may have developed on the neck of the humerus as a result of arthritis. The surgeon uses a special saw to remove the humeral head. The surgeon prepares the humerus bone for the prosthesis. The shoulder prosthesis is a narrow, tapered metal shaft that is placed a few centimeters inside the humerus. The top of this prosthesis is designed to hold the prosthetic ball that will replace the natural humeral head. The surgeon uses a special tool called a reamer to flatten and shape the humeral head and prepare it for the prosthesis. The artificial socket is usually made of polyethylene and has a smooth, slightly concave design to facilitate movement with the prosthetic humeral head. The new prosthesis is usually supported by either a few short pins or a flat, straight edge called a keel (which is shaped like a boat keel). The pegs or keel are attached to the natural bone. The prosthesis may be attached to the natural bone with bone cement, or it may have cementless (sometimes called «clip-on») components. Fast-acting bone cement sets in as little as 10 minutes.
Once the shoulder prosthesis is secured in place, a temporary prosthetic ball is attached to the top of the prosthesis. Different sizes of the temporary ball will be used to test the stability of the new joint before the final size is determined. The artificial humeral head is shaped and sized to fit the patient’s specific anatomy. The exact model chosen is based on pre-surgical planning and observation during surgery. The surgeon inserts the temporary ball into the new socket and moves the shoulder in a circular motion, making sure that the shoulder joint can move with ease and cannot dislocate from the joint. The surgeon will then remove the joint, remove the temporary or trial component, and attach the final prosthesis. The surgeon inserts the ball into the new socket, again checking for movement and the likelihood of dislocation. The muscles and other soft tissues that were cut away are stitched together.
After the operation, the patient is taken to the intensive care unit, where he or she is monitored by an anesthesiologist and other medical personnel. After a few days, depending on the course of the anesthesia and surgery, the patient is transferred to a regular trauma unit. Many patients spend one or two nights in the hospital before discharge, although this figure can vary depending on the circumstances.
Common risks and complications of surgery.
The vast majority of shoulder replacement surgeries are successful. However, complications can occur even if the surgery is performed correctly and goes smoothly. In rare cases, some complications are life-threatening. A small percentage of patients may need a second or revision surgery.
Complications related to the administration of anesthesia can occur. Any major surgery involving general anesthesia has a risk of strokes, heart attacks, pneumonia, and blood clots. Blood clots that occur in the deep veins, called deep vein thrombosis (DVT), are of particular concern after major joint replacement surgery, but this complication is more common in lower extremity joint replacement. If this condition is not corrected, a blood clot can break free from the vein, leading to a life-threatening condition known as pulmonary embolism. Blood thinning medications are used to rule out this complication. One comprehensive study found that among 42,261 shoulder replacement surgeries, about 0.52% of patients (or about 220 people) had bleeding after surgery.
Infection. Antibiotics are routinely given during surgery to reduce the risk of infection. Despite this precaution and other measures, superficial and deep wound infections affect a small percentage of shoulder replacement patients. Most of these patients can be treated with antibiotics. In rare cases, infection can lead to removal of the artificial shoulder joint and may even be life-threatening. Once the infection has resolved, it may be possible to have a second surgery to insert a new prosthesis.
Other complications. In addition to the risks associated with anesthesia and infection, there are potential complications common to traditional shoulder replacement surgery: rotator cuff injury. Rotator cuff sleeves are more susceptible to injury after surgery.
To reduce the risk of cuff problems you need to:
— Prior to surgery, the surgeon will carefully evaluate the rotator cuff muscles for damage that may be exacerbated by a traditional shoulder replacement.
— During surgery, the surgeon will make every effort to minimize damage to soft tissues
— After surgery, the patient must learn how and when to hold the shoulder.
— The patient should also learn which movements are safe and which movements are dangerous for the injured shoulder.
Shoulder replacement surgery — is a complex operation to remove a patient’s bone and further prosthetics. If the prosthesis is not sufficiently anchored in the natural bone or if it is not well aligned with other parts of the shoulder, problems can arise. Loosening and socket alignment problems are of particular concern. Patients with loosening of the prosthesis do not always feel any impairment. Some feel shoulder pain and/or stiffness with movement. Loosening of the prosthesis can lead to other problems such as joint instability that can affect range of motion and shoulder function. Bone fracture. A patient’s bone may break during or after surgery. A patient’s risk of fracture can be affected by the patient’s anatomy and bone density, as well as the surgical placement of the prosthesis. A postoperative fracture may require a second surgery.
Dislocation and malalignment of the prosthesis.
The new shoulder may dislocate from its new socket. This risk decreases as the muscles around the shoulder joint are strengthened through physical therapy. Vascular damage or nerve damage. The surrounding nerves and blood vessels can be damaged during surgery, although this risk is low. Experts estimate that 0.6 to 4.3% of patients experience some nerve damage after shoulder replacement surgery, although 80 to 85% of these cases resolve on their own.
Response in general.
In rare cases, the patient has an allergic reaction to the bone cement or combined prostheses. In these cases, the bone cement and prostheses must be removed. Surgery accompanied by complications can be considered successful if pain is relieved and function improves over the long term. Patients can reduce the risk of complications by working with an experienced surgeon. Some studies have shown that complication rates are lower for surgeons and hospitals that perform many of these types of surgeries. If the artificial shoulder joint wears out or otherwise deteriorates, the surgeon may recommend revision surgery to remove and replace the prosthesis. Revision surgeries are often elective, meaning that the patient has time to decide whether to have another surgery. Rare but notable exceptions are infections and dislocations.
Revision surgeries are more complex than initial joint replacement surgeries and carry a higher level of risk and side effects.
If a patient suffering from chronic joint pain due to arthritis prefers joint replacement surgery, the orthopedic surgeon will replace the existing joint surfaces with artificial joint prostheses. These prostheses or prosthetic components must adhere to the patient’s natural bone. How this adhesion is achieved depends on the type of prosthesis used: a cemented denture uses quick-drying bone cement to help attach it to the bone.
Cementless prosthesis, sometimes called a clip-on prosthesis, is specially textured so that bone can grow into it and be supported over time.
Shoulder replacement surgery begins with the surgeon talking to the patient and then deciding whether to use cemented prostheses, cementless prostheses, or a combination of the two. The type of components used may depend on the patient’s physiology, the type of surgery being performed, and the surgeon’s preference.
The cement denture is attached within 10 minutes of application, so the surgeon and patient can be confident that the denture is firmly in place. The disadvantage of using bone cement is that it can deteriorate over time and pieces of cement can enter the bloodstream, causing many complications. It can also break down, which will require a second surgery. Cement debris can irritate the surrounding soft tissue and cause inflammation. In rare cases, patients have an allergic reaction to bone cement and must undergo a second surgery to remove the glue and dentures.
A cementless denture, also called a press-on denture, has a rough surface or porous coating that encourages bone to grow into the denture. Some prosthetic components have screws or pins that help hold the bone and prosthesis in place until new bone is present. Many surgeons prefer cementless dentures because: they believe that cementless components provide a better long-term bond between the dentures and bone. However, cementless prostheses require healthy bones. It can take up to three months for bone material to turn into a new joint component.
Patients are advised to avoid full loading of the cemented prosthesis from 4 to 12 weeks after surgery. Limited partial loading is allowed. This cautious approach lengthens the patient’s rehabilitation schedule, but protects against stress or weakening of the new joint.
Researchers are constantly striving to improve existing prosthetic designs as well as methods of attaching prostheses to natural bone. For example, recent research has been conducted with components made from highly porous metals such as tantalum. Initial studies indicate that tantalum can promote a strong bond between the bone and the prosthesis in a relatively short period of time.
Во время частичной замены плеча или плечевой гемартропластики плечевая головка удаляется и заменяется протезным шариком, но сохраняется естественная плечевая кость.
«Grinding and Finishing»
During this version of partial shoulder replacement surgery , the natural joint bed is preserved; however, the surgeon may use special tools to smooth and reshape this socket to facilitate movement of the shoulder joint. This process is called hemiarthroplasty without prosthetics or, more informally, «resurfacing and finishing.»
Shoulder resurfacing. During this surgery, the damaged humeral head is covered with a smooth, rounded cap to facilitate joint motion. Unlike previous methods, shoulder resurfacing does not require the complete removal of the natural humeral head or the insertion of a prosthesis into the humerus canal. Which type of surgery the doctor recommends depends on the problem being corrected, as well as other factors such as the patient’s age, health, and activity level. While shoulder replacement surgery can relieve shoulder pain and increase shoulder function in the long term, it is an extensive surgery that requires several months of recovery and physical therapy.
Before surgery, the doctor will order x-rays and possibly more detailed imaging, such as a CT scan, to evaluate the humerus. A patient who understands all the options available can make an informed decision with their doctor about the best course of treatment.
Shoulder surgery techniques are constantly improving, giving many patients the chance to get the best possible treatment option, reduce pain and increase range of motion.
The success of shoulder replacement surgery is largely determined by the qualifications of the orthopaedic surgeon and the availability of the necessary modern high-tech equipment. We provide our patients with these important prerequisites for a positive surgical outcome at our Munich clinics.
Contact «Clinics of Germany». Our specialists will ensure that you are treated by a leading specialist highly specialized in shoulder surgery.