Total Shoulder Replacement Arthroplasty is a very well established surgical procedure for restoring comfort & function in patients with arthritic shoulders. Arthritic ball is replaced by a smooth metallic ball which is fixed to humerus (arm bone) by a stem which fits in it during this procedure. Arthritic glenoid (socket) is also resurfaced as part of this procedure with high-density polyethylene prosthesis. Among different types of surgical options which are available for arthritis shoulders, this procedure seems to provide the most rapid & complete improvement & which is comfortable & functional for patients with arthritis in shoulders. Success will however require technical excellence of surgery & patient's commitment to exercise program until desired range of motion can be comfortably achieved.
Humeral head or the ball fits within the socket called glenoid & which is held there by the rotator cuff.
Arthritis of the shoulder is a condition where previous surgery, inflammation, injury or degeneration destroys the normally smooth cartilage lining the ball (humeral head) & the socket (glenoid).
Carefully standardized x-rays generally reveal loss of space between glenoid & the humeral head, which is normally occupied by cartilage, leaving bone upon bone contact.
In a total shoulder replacement arthroplasty procedure, the arthritic ball is replaced with a metal ball along with a stem which is press fit inside the humerus or arm bone so that only the smooth surface is extending from the bone. The socket which takes in this ball is also resurfaced with high density polyethylene component. This operation is usually performed under influence of a regional or general anesthetic. Approach to the joint is made possible through an incision made between the pectoralis major muscles & deltoid on the front of the shoulder. This also includes release of contractures & adhesions along with removal of bone spurs which may be blocking range of motion. For this operation, services of an operating team are required, which includes anesthesiologists, orthopedic surgeons & surgical assistants who normally perform this operation in less than two hours of time.
While there are some surgeons who prefer cementing the humeral component, others use implants which foster bone growth along the stem. Both these approaches can eventually stiffen the bone in order to make it more likely to fracture in a fall & also greatly complicating revision surgery in case that may become necessary in future. In order to overcome these issues, some surgeons prefer fixing the component by impaction grafting inside humerus by using healthy bone, which is recently harvested during the procedure from humeral head which was removed, until a tight press fit of implant is achieved.
Bone of glenoid is precisely shaped with glenoid reamer & then the glenoid component is secured with a combination of cementing & press fitting. Patients must however maintain range of motion achieved during surgery with simple & frequent stretching exercises in order to promote proper healing of the replaced shoulder joint. Exercises for rehabilitation are started immediately following surgery by using continuous stretching & passive motion by the patient. Attaining & maintaining a minimum of 150 degrees of forward elevation is critical to success of total shoulder replacement surgery. Supine stretch & forward lean can be very helpful in attaining these results & maintaining the range of motion which is attained.
Total shoulder replacement surgery for shoulder arthritis should only be considered when arthritis is drastically limiting the quality life of the patient even after mild analgesics & physical therapy have been tried. Severe shoulder arthritis is normally best managed either by a partial or total joint replacement surgery. Moreover, total shoulder replacement arthroplasty, which involves replacing both surfaces of the socket & ball, is commonly considered by patients who are expecting the best chance of rapid recovery of shoulder comfort along with ability to perform daily routine activities.
Since this procedure is less likely to be successful among patients with conditions like Parkinson's Disease, diabetes, obesity, depression, severely altered shoulder anatomy, rotator cuff deficiency, shoulder joint infections & multiple previous shoulder surgeries, it would be sensible to avoid total shoulder replacement arthroplasty in the first place.
Success for total shoulder replacement arthroplasty requires technical excellence of the surgical procedure & participation of patients in simple exercise programs until they are able to comfortably achieve the desired range of motion.
Like it is for all elective surgical interventions, patients should be in the best possible mental & physical health at the time of total shoulder replacement surgical procedure. Any tooth or gum, bladder, kidney, lung or heart problems should be managed prior to surgery. Any type of infection can also prove to be a valid reason for delaying the operation. Skin problems on arm or shoulder including burns, blisters, rashes, scratches or acne should also be resolved prior to surgery. The operating surgeon also needs to be aware of any health issue which the patient is having including allergies & all prescription & non-prescription drugs the patient is taking. Like for instance, aspirin & anti-inflammatory medications can affect blood clotting. Some of these medications may either be required to be modified or stopped by the patient before undergoing surgery.
Total shoulder replacement arthroplasty is a major surgical intervention which involve cutting of bone, tendons & skin. Pain during this surgical procedure is effectively managed by anesthesia & pain medications. Strong medications like morphine or Demerol are quite often injected immediately after surgery. Following which oral medications like Tylenol with codeine or hydrocodone are usually started within a day or so. Shoulder rehabilitation programs generally start on the day of surgery. Patients are also encouraged to be up & out of bed, soon after the operation is over. Moreover, pain medications are also progressively removed.
Discharge from hospital usually takes place on the second or third day following surgery. Patients are also asked to avoid lifting more than one pound of weight. Pushing & pulling for 6 weeks is also restricted after surgery. Driving is permitted only after the shoulder regains comfort & strength along with requisite range of motion. This may sometimes take several weeks following total shoulder replacement surgery. Therefore, patients must stay prepared & make arrangements as they will typically have less function for the arm for the first month or so after surgery, than immediately before surgery. In such a scenario, patients will require assistance with self-care, shopping, daily living activities & driving for at least 6 weeks after total shoulder replacement surgery. Managing these limitations would require advance planning for patients to accomplish these activities of daily living during recovery period following total shoulder replacement surgery.
Early motion following total shoulder replacement surgery is critical for achieving optimal function of the shoulder since arthritic shoulders are often stiff. Even though major goal of this surgical intervention is to relieve stiffness by releasing scar tissue, stiffness may however recur during the process of recovery, in case range-of-motion exercises are not immediately accomplished. Therefore, focus of rehabilitation should be on maintaining motion which was recovered at surgery for the first 6 weeks of the recovery phase. Strengthening exercises are specifically avoided during the first 6 weeks in order to not stress tendon repair before it can heal back to the bone. Only when the shoulder is comfortable & flexible, additional activities & strengthening exercises are started. There are some total shoulder replacement surgery patients who prefer to carry out the rehabilitation program by themselves, while other prefer to work with physical therapists who understand total shoulder rehabilitation programs much better.
Most patients are generally able to perform gentle activities involving daily chores using the operated arm from 2 - 6 weeks after surgery. Walking is strongly encouraged following total shoulder replacement surgery. Driving will however need to wait until the patient can comfortably & confidently perform necessary functions. Recovery of driving ability may take about 6 weeks of time in case surgery was performed on the right shoulder, simply because the right shoulder has to take increased demands for shifting gears. However, with consent of the surgeon, most patients can often return to activities like golf & swimming at 6 months following surgery. This is often when the shoulder with total shoulder replacement surgery has successfully completed the rehabilitation program.
Once the patient's shoulder has gained comfort, strength & full range of motion, doctors usually recommend that the shoulder be protected from impacts & lifting heavy loads. Activities like vigorous hammering, training with heavy weights, chopping wood & recreational activities which subject the shoulder to impact loading are normally discouraged.
Like with all types of surgeries, total shoulder replacement arthroplasty operation can also be complicated by anesthesia, infection, instability, nerve or blood vessel injury, fracture & loosening of implant components. Moreover, this is a technically exacting procedure which requires a highly experienced surgeon in order to optimize this complex of a bony, prosthetic & soft tissue anatomy after the primary operation procedure. The entire operation can fail when reconstruction is too loose, too tight, insecurely fixed or improperly aligned, or when bone-to-bone contact is found to occur. However, most common cause of failure in short-term is the patient's inability to maintain range of motion which was achieved at the time of surgery, but could not be brought back during the recovery period which generally lasts for up to 6 months following the surgical procedure. Most common long term problem associated with total shoulder replacement arthroplasty is loosening or wearing out of the glenoid component.
Total shoulder replacement arthroplasty is a highly established surgical procedure designed for restoring comfort & function to shoulders which have been damaged by arthritis. When surgery is performed in hands of an experienced surgeon, total shoulder replacement surgery can be a very effective technique in treatment of shoulders with damaged joint surfaces in healthy & motivated patients.
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