Shoulder Replacement Surgery
Reverse Shoulder Arthroplasty
Reverse shoulder replacement is performed for specialized arthritis or certain fractures of the shoulder when other treatments have failed. Those “other treatments” can include physical therapy, medications, injections, debridement type (i.e. cleanout) procedures, or activity modifications. The number one reason for a shoulder replacement is to relieve your pain, and in this case also to control stability. Motion and strength are secondary goals.
The Reverse Shoulder Replacement is typically done for people who do not have a repairable rotator cuff and have developed arthritis. We cannot do a standard shoulder replacement because without a functioning rotator cuff, the regular shoulder replacement loosens very quickly. So, in this case we take advantage of your deltoid muscle as a lever arm to help move the shoulder. The Reverse Shoulder Replacement has been approved in the United States since approximately 2004 and has opened up a whole new realm of options for patients with arthritis and lack of a rotator cuff. We can also use it for shoulder fractures. We call it the reverse because the ball goes on the socket and the socket goes on the ball – hence the name Reverse.
Shoulder replacement surgery does have its risks. These risks include but are not limited to bleeding, infection, neurovascular damage (i.e. axillary nerve palsy), component breakage, intra-operative or post-operative fractures, component loosening, component wear and tear, glenoid component loosening, dislocations, glenoshpere dislodgement, need for further revision surgeries, incomplete pain relief, deep venous thrombosis (i.e. blood clots), and general risks from anesthesia. These risks will be discussed with you during your office visit if we are setting up your surgery.
Reverse Shoulder Arthroplasty is an elective surgery and also a major surgery. In this light, we will send you for a medical clearance by your primary physician. Depending on your other medical history, you may also have to see a cardiologist or other subspecialist to make sure you are fit for surgery. The office staff at Performance Orthopedics will walk you through the process and be there for any questions you may have. In a routine surgery, there is typically no need for blood transfusions.
The surgery is typically a one to two day hospitalization procedure. If your pain is well controlled, you are eating a general diet, and there are no other medical issues going on, there is a possibility that you may leave the day after surgery. Most people stay in the hospital for two days.
You will receive a general anesthetic, in addition to a nerve block to your operative side. The nerve block is placed by the anesthesia service and allows you to wake up relatively pain-free. The block lasts for approximately 12-18 hours, after which you can start easing into your pain medication.
You are positioned into a “beach chair” position, with all of your extremities carefully padded. Your head is also supported in a padded head holder. After performing a “time out”, where we verify the operative site, your arm is cleaned and sterilely draped. Typically we make an incision in the front of the shoulder from the end of the clavicle bone down to the bottom of your pectoralis tendon (basically just above the arm pit area). Most of the tissues we just spread out of the way, but in order to get into the shoulder, we must take down the subscapularis tendon, which is a tendon on the front of the shoulder. The takedown of this tendon is why we need to have some of the precautions after surgery.
Once inside the shoulder, we remove all the bone spurs and take off the arthritic ball (i.e. humeral head) of the shoulder. Then we prepare your arm bone to receive the prosthetic stem. Most of the time we do not cement the humeral stem in place, but depending on the quality of your bone we might use cement for stability. Once the arm bone is prepared, we then start looking at the socket (i.e. glenoid). Again, we remove the bone spurs and through a series of steps with guides and reamers, we implant your new socket, which because of the Reverse nature of the implant is really the new ball (called the glenosphere). We then go back to the stem piece in your arm and place the new cartilage socket. Your arm is then reduced in place and we check your motion while you are asleep.
Once all the components are in place, we close the tissues, including the subscapularis tendon, and a sterile dressing is applied. A drain is placed to help remove some of the post-operative swelling. The drain is typically removed the next day. Your arm is placed in a sling and pillow device for immobilization. It is very important that you stay in the sling and pillow and adhere to the rehabilitation protocol.
Typically after surgery, we do not start much physical therapy for the first 6 weeks. Unlike a regular shoulder replacement, we need to let the tissues heal and sometimes avoid any instability. Once you start to recover from the initial surgical incision, you will see that your arm will be easier to move. In order to avoid any dislocations, we ask that you avoid extending the arm, much like if you were to get up from a chair and push backwards.
Once your pain is under control, you are eating and keeping food down, and you are medically stable, you can be discharged home. You will get a full set of instructions of Do’s and Don’ts. Basically make sure to keep your incision clean and dry. No showering until your postoperative visit. If you have any questions on what you should be doing or not doing to your shoulder, make sure to ask your surgeon or the nurses/residents. You will be seen in the office for a check up and to remove any staples or sutures in 7 – 10 days after surgery. You will also be given a pain medication prescription. Please take the pain medication as directed. Eat a healthy diet and get plenty of rest. Also remember that ICE is a form of pain relief, and you should ice the shoulder regularly.
You are in the sling for 6 weeks after surgery but are coming out of the sling for showering and hygiene type activities. After 6 weeks, we discontinue the sling, and we will start physical therapy. Physical therapy will consist of lifting the arm up and down, in addition to rotating the arm in and out. We will teach you those exercises. There is still no heavy lifting. After 3 months from surgery, we start a light strengthening program if you wish, but most people are happy just to have the arthritis gone and a pain free shoulder. Full healing is about 4 – 5 months after surgery, and you can continue to see gains in your motion and strength for up to a year after surgery. Regular x-rays will be needed on a yearly basis to make sure that the components are in the proper position and there is no loosening.
Just like any mechanical piece of equipment, you will need to take care of your shoulder. Typically there is a 30 – 40 lb weight restriction at all times. Remember that the metal and plastic cannot repair themselves, so be gentle. In addition, there are certain requirements for taking antibiotics if you have certain other procedures, such as a colonoscopy or any dental work. Please call our office for any questions regarding this. Also, please see our article “Joint Replacement: Prophylactic Antibiotics for Life” for further information on this.