Although less common than hip or knee replacement, Shoulder Joint Replacement Surgery is just as successful for relieving pain in joints. Originally this procedure was performed to treat severe shoulder-fractures; shoulder joint replacement surgery is now used for treating many painful conditions of shoulders including different forms of arthritis. Most people considering shoulder joint replacement surgery are those who have earlier tried nonsurgical treatments like activity changes & medications which have failed to relieve pain.
Anatomy of the Shoulder
The shoulder joint is basically made up of 3 bones; Humerus or the upper arm bone, Scapula or the shoulder blade & Clavicle or the collarbone. These form a ball & socket joint where the ball or head of the upper arm bone fits into a shallow socket in the shoulder blade. This socket is clinically known as the glenoid. Surfaces of bones where they come together are covered with articular cartilage, which is a smooth substance protecting bones & enabling them to move easily, while smooth & thin synovial tissue covers remaining surfaces located inside shoulder joint. This synovial membrane also makes a small amount of fluid which lubricates the cartilage while eliminating any friction caused by movement in the shoulder. Muscles & tendons which surround the shoulder also provide support &stability to the shoulder joint while allowing the shoulder to rotate through a greater range of motion than any other joint within the body.
What is Shoulder Joint Replacement Surgery?
Shoulder joint replacement is normally performed to remove & replace damaged parts of the shoulder with artificial components called prosthesis. Treatment options for this procedure include either replacing just the head or ball of humerus bone or replacement of both the ball & glenoid socket.
Causes for Shoulder Pain & Disability
Shoulder pain & disability leading patients to consider shoulder joint replacement surgery is caused by several conditions including some of these listed below.
- Degenerative Joint Disease called Osteoarthritis – This is basically age-related wear & tear kind of arthritis which usually occurs in people above 60 years of age, although younger people are also sometimes found to suffer. Cartilage, which cushion bone of the shoulder soften & wear out while exposing bones that rub against each other. Therefore, shoulder joint slowly becomes painful & stiff over time. However, there is no known way to prevent the development of osteoarthritis which is one of the most common reasons for people to undergo shoulder joint replacement surgery.
- Rheumatoid Arthritis – It is a disease where the synovial membrane surrounding the shoulder joint becomes thickened & inflamed. This kind of chronic inflammation often damages cartilage & causes pain, stiffness & loss of cartilage. This most common type of group of disorders is also termed ‘inflammatory arthritis’.
- Post-Traumatic Arthritis – This condition usually follows a serious injury to shoulders. Fractured bones making up the shoulder joint or tears of tendons or ligaments within the region may damage articular cartilage over time causing severe shoulder pain & limiting functions of the shoulder joint.
- Rotator Cuff Tear Arthropathy – Patients with large & long-standing rotator cuff tear may often develop rotator cuff tear arthropathy. This is a condition where changes in shoulder joint caused due to rotator cuff tear may eventually lead to destruction & arthritis of the shoulder joint cartilage.
- Avascular Necrosis called Osteonecrosis – This is a painful condition which occurs when the blood supply to shoulder bone is disrupted. Since bone cells will eventually die due to lack of blood supply, osteonecrosis will ultimately destroy shoulder joint & lead to arthritis. Deep sea diving, chronic use of steroids, sickle cell disease, severe fractures of shoulders & heavy consumption of alcohol are some of the risk factors for the development of avascular necrosis.
- Severe Fractures in Shoulder – This is another common reason for people undergoing shoulder joint replacement surgery. It may often be very difficult for surgeons to put together pieces of bone when the head of upper arm bone is shattered. Blood supply to pieces of bone can additionally be interrupted. Surgeons in this type of scenario often recommend shoulder joint replacement surgery. Moreover, older patients with Osteoporosis are mostly at risk for developing severe shoulder fractures.
- Revision Shoulder Joint Replacement Surgery – Although chances are rare, some shoulder joint replacements may at times fail mainly because of dislocation, infection, wearing out or due to loosening of implant mechanics. Therefore, a revision shoulder joint replacement surgery may be necessary for a failed previous shoulder replacement surgery.
Good Candidates for Shoulder Replacement Surgery
There are many reasons why surgeons recommend shoulder joint replacement surgery. Some of these are listed below.
- People suffering from severe shoulder pain which interferes with normal everyday activities like washing, dressing, toileting & reaching into a cabinet.
- Having mild to severe shoulder pain while resting. This pain may at times also be severe enough so as to prevent good sleep at night.
- Weakness and/or loss of motion in the shoulder.
- Substantial failure to improve shoulder pain with other treatments like physical therapy, cortisone injections and/or anti-inflammatory medications.
Orthopedic Evaluation of the Shoulder Joint
When medications fail to yield positive results, physicians may often refer patients to orthopedic surgeons for thorough evaluation so as to determine if they can benefit from shoulder joint replacement surgery. Evaluation by orthopedic surgeons consists of several components including the following.
- Medical History – Orthopedic surgeons will gather all information regarding the general health of patients including asking questions about the extent of shoulder pain & ability to function.
- Physical Examination – This is usually done so as to assess strength, stability & motion of the shoulder joint.
- X-rays – These images are taken so as to help determine the extent of damage in shoulders. They will also be able to show bone spurs, loss of normal joint space between bones, irregularity or flattening in shape of bone & loose piece of bone or cartilage which may be floating inside shoulder joints.
- Other Tests – Magnetic resonance imaging (MRI), blood tests, and/or bone scans are occasionally done in order to determine the condition of soft tissues & bone of shoulder in patients.
Orthopedic surgeons will review these results with patients so as to evaluate & discuss if shoulder joint replacement surgery is the best option to relieve pain & improvement of function. Other shoulder joint treatment options including physical therapy, medications, injections and/or other types of surgical interventions may also be discussed & considered by orthopedic surgeons.
Preparing for Shoulder Replacement Surgery
- Medical Evaluation – Orthopedic surgeons will ask patients to schedule a complete physical examination several weeks before surgery after making a decision to undergo shoulder joint replacement surgery. This is essentially required so as to make sure that patients are healthy enough for surgery & for the complete process of recovery. Patients with chronic medical conditions like heart disease should also be evaluated by cardiology specialists prior to shoulder joint replacement surgery.
- Safe Medications – Patients should talk to orthopedic surgeons about the medications they are currently taking. Doctors may ask them to stop certain medications before surgery like some over-the-counter medicines causing excessive bleeding, which should be stopped at least 2 weeks before surgery. Other medications which should be discontinued prior to surgery include most arthritis medications & non-steroidal anti-inflammatory medications like aspirin, ibuprofen & naproxen sodium.
- Planning at Home – Simple changes should also be done at home prior to surgery & which can help make recovery period easier since it will be hard for patients to reach high shelves & cupboards for the first several weeks following surgery. Therefore, be sure to go through arrangements at home & place items which can later be needed on lower shelves. When patients return home from the hospital after shoulder joint replacement surgery, they will invariably require help for few weeks with daily tasks like laundry, cooking, bathing & dressing. In case they do not have any support at home after surgery, it is advisable that they seek short-stay in a rehabilitation facility until they feel more independent.
Shoulder Replacement Surgery Options
Shoulder joint replacement surgery is a highly technical procedure which is performed by a well experienced surgical team. Since there are different types of shoulder joint replacement procedures, surgeons will carefully evaluate the situation before making any decisions. They will make it a point to also discuss this issue with the patients. Patients should also feel free to ask surgeons as to the type of implant which will be used in the procedure & why this choice is best suited for them.
- Total Shoulder Joint Replacement – This surgery typically involves replacing the arthritic joint surfaces with highly polished metal ball attached to a stem & plastic socket. These components which come in various sizes may either be cemented or pressed-fit into bone. Surgeons tend to use non-cemented & pressed-fit humeral component in case quality of bone is good. In cases where bone quality is soft, the humeral component is most likely to be implanted using bone cement. However, the all-plastic glenoid socket component in most cases is implanted using bone cement. Patients with intact rotator cuff tendons& bone-on-bone osteoarthritis are normally good candidates for conventional total shoulder joint replacement surgery. Moreover, implantation of the glenoid component is generally avoided when glenoid cartilage is good, glenoid bone is severely deficient or when rotator cuff tendons are irreparably torn.
- Stemmed Hemiarthroplasty – Surgeons may only replace the ball at times depending upon the condition of the shoulder. Called hemiarthroplasty, the traditional approach involves replacing the head of the humerus with metal ball & stem which is similar to the component used in total shoulder joint replacement procedure. Stemmed hemiarthroplasty is generally recommended by surgeons when the humoral head is severely fractured while the socket remains normal. Other indications calling for hemiarthroplasty include the following.
- Shoulder condition with severely weakened bone in the glenoid region.
- Shoulders with arthritis & severely torn rotator cuff tendons.
- Arthritis which only involves the head of the humerus where glenoid features intact & healthy cartilage surface.
Quite often, surgeons will have to choose between hemiarthroplasty or total shoulder joint replacement surgery in the operation theater. Studies have revealed that most patients with osteoarthritis get better pain relief from total shoulder joint replacement than from hemiarthroplasty.
- Resurfacing Hemiarthroplasty – This procedure involves replacing just the joint surface of the humeral head with a cap-like prosthesis minus the stem. Resurfacing Hemiarthroplasty offers a bone preserving alternative to standard stemmed shoulder replacement for patients with arthritis. Resurfacing hemiarthroplasty is an ideal option in the following conditions.
- When glenoid still has intact cartilage surface.
- No fresh fracture of humeral head or neck is detected.
- When there is a desire to preserve humeral bone.
Resurfacing hemiarthroplasty avoids the risk of component wear & loosening which may occur with conventional total shoulder joint replacement among young patients who are very active. Moreover, it is also easier to convert to total shoulder joint replacement if necessary at a later stage due to its more conservative nature.
- Reverse Total Shoulder Replacement – This is another type of total shoulder joint replacement which is used for people having the following conditions.
- Rotator cuffs are completely torn with severe arm weakness.
- Cuff Tear Arthropathy – includes effects of rotator cuff tearing & severe arthritis.
- Patients with a failed previous shoulder joint replacement.
Conventional total shoulder joint replacement can still leave these patients with pain & they may also be unable to lift arms past 90-degree angle which can be severely debilitating. Reverse total shoulder joint replacement surgery is designed to switch the socket & metal ball where the metal ball is attached to shoulder bone & plastic socket is attached to upper arm bone. This procedure allows patients use deltoid muscle instead of torn rotator cuff to lift arms.
Shoulder Replacement Surgery Procedure
It would be sensible for patients to wear loose-fitting clothes & button-front shirts when going to the hospital for shoulder joint replacement surgery. Patients will also be wearing a sling & will have limited use of an arm after surgery. Admitted to hospital on the day of surgery, patients will most likely be taken to preoperative preparation area where they will meet a doctor from anesthesia department who will discuss the type of anesthesia to be used during operation. General anesthesia or regional anesthesia or a combination of both is normally used for shoulder joint replacement surgery. Procedure to replace shoulder joint with an artificial device normally takes about 2 hours of time. Patients will be moved to the recovery room after surgery where they will remain for several hours & closely monitored. Once awake, they will be shifted to a regular hospital room. The surgical team will give several doses of antibiotics so as to prevent infection. Most patients undergoing shoulder joint replacement surgeries are able to eat solid food & come out of bed on the day following surgery. They are also most likely to go home on the 1st, 2nd or 3rd day after shoulder joint replacement surgery.
Recovery Following Shoulder Replacement Surgery
- Pain Management – Patients will feel some pain following shoulder joint replacement surgery for which nurses will provide medication so as to make them feel comfortable. Pain management in this procedure is important of the recovery process. Physical therapy will also begin soon after the procedure & which will also make patients feel lesser pain so that they can start moving sooner while regaining strength. Patients should talk to the surgeon in case postoperative pain is causing problems.
- Rehabilitation – Carefully well-planned rehabilitation program is critical to the success of shoulder joint replacement surgery. This usually begins with gentle physical therapy after the operation. Physical therapists or surgeons will also provide a simple home exercise program which is meant to strengthen shoulders & improve flexibility.
- Activity – Exercise, particularly during the first few weeks following shoulder joint replacement is a critical component of care at home. Patients should, therefore, follow the home exercise plan suggested by the surgeon in order to regain strength. Most patients are also able to perform simple daily activities like grooming, dressing & eating within 2 weeks following shoulder replacement surgery. While mild pain at night & with activity is quite common for several weeks after surgery, driving a car is restricted for 2 – 4 weeks after shoulder joint replacement surgery.
- Wound Care – Patients will either have staples running along incision or sutures beneath skin following operation. While staples are normally removed several weeks after shoulder joint replacement surgery, sutures beneath the skin will not require anything to be done. It would, however, be sensible for patients to avoid soaking the wound in water until it has thoroughly sealed & dried over time. Bandaging over wound may, however, continue so as to prevent irritation from clothing.
- Recovery at Home – Arm undergone shoulder joint replacement surgery will be in a sling while leaving the hospital. Patients will need a sling to support & protect the shoulder for the first 2 – 4 weeks post surgery.
Risks & Complications of Shoulder Replacement Surgery
Orthopedic surgeons invariably explain potential risks & complications of shoulder joint replacement surgery to patients, including those generally related to surgery & specific ones which can occur over time following this procedure. However, most complications are successfully treated when they occur. Some possible complications of shoulder joint replacement surgery include the following.
- Infection – Generally a complication with all types of surgeries, the infection can occur within a wound or deep around prosthesis in shoulder joint replacement surgery. This may happen while the patient is in the hospital or after he has gone home, or years later in some cases. While minor infections in incision area are treated with antibiotics, deeper or major infections require additional surgery including removal of the prosthesis in few cases. Moreover, any infection within the patient’s body can also spread to the shoulder joint replacement site.
- Nerve Injury – Although prosthesis materials & designs including surgical techniques continue to advance, the prosthesis may at times wear down & components may eventually loosen. Components of shoulder joint replacement may also at times dislocate. Loosening, dislocation or excessive wear may sometimes require additional revision shoulder joint replacement surgery.
- Problems with Prosthesis – Nerves within the vicinity of shoulder joint replacement procedure may get damaged during surgical intervention. Although these types of injuries are infrequent, nerve injuries over time are often found to improve & completely recover.
Low-Cost Shoulder Replacement Surgery in India
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