TOTAL SHOULDER REPLACEMENT

Overview:
If the shoulder joint is worn leading on to severe pain, an artificial joint can be implanted and this is called Total shoulder replacement.  A satisfying function and good pain relief can be achieved after performing total shoulder replacement.  If no complications occur, more than 95% of the time a shoulder replacement can last for more than 10-15 years.

The procedure is done for those suffering from advanced arthritis of the shoulder joint.  Total shoulder replacements are also performed for fractures of the upper end of arm bone. In fractures, usually it is such a situation that the fixation is not possible as the fracture is complex.

TYPES OF TOTAL SHOULDER REPLACEMENT:

• Anatomic Total Shoulder Replacement
• Reverse Polarity Total Shoulder Replacement
• Resurfacing arthroplasty of the shoulder joint.

The choice of procedure depends on number of factors.

A severely destroyed humeral head and glenoid surface with well working rotator cuff muscles would require a Anatomic Total Shoulder Replacement.

If the rotator cuff muscles are not functioning and a person has got severely damaged shoulder joint, then Reverse polarity Total Shoulder Replacement will be the correct option.  In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder blade bone and a plastic socket is attached to the upper arm bone. This gives a biomechanical advantage by changing the centre of the rotation of the shoulder joint and also tensions the arm muscle called deltoid.  These factors allow using the deltoid muscle instead of the torn rotator cuff to lift the arm thus facilitating to regain the lost movement.

If the destruction of the humeral head is not severe and hence if adequate bone stock is available, then Resurfacing arthroplasty of the shoulder joint will be the option.

The above description gives a general outline. Shoulder replacement surgery is highly technical.  Each case is individual. The situation will be carefully evaluated before making any decisions. The correct nature of procedure will be determined after physical examination and performing radiological investigations such as X ray and CT Scan.

Preoperative workup:

You will be anaesthetized for the surgery.  Hence you would have some blood tests and routine check up by an anesthetist for the surgery. The intensity of the pain in first 24 hours is high. Hence during the surgery you will also have an injection to block the nerve supply of the arm.  This block helps to get the whole arm numb and you feel a very little pain after the surgery.

A physiotherapist will see you before the surgery and teach you on the exercises that you will have to carry on after the surgery.

Operation:

The operation is performed in a position as if you are sitting in a beach chair.  The Key surgical steps are as follows

• Access into the shoulder joint is performed through an incision of about 10cm from the front of the upper end of arm.
• The gap between the arm muscle called deltoid and chest muscle called pectoralis major is explored and kept apart to have deeper access.
• Deeper to that is Rotator cuff muscle called subscapularis and lining of the shoulder joint called capsule.  Both are divided and the shoulder joint will be accessed.
• The humeral head and the glenoid are prepared and correct size implant is fixed in. Stability of the joint is restored to the satisfactory extent
• The fixation of the implant can be achieved by bone cement or with implants that have facility for bone growth. This will be determined on the individual case basis depending on the condition of the bone and the disease pathology.
• All the layers of the wound that are opened for the access are securely closed.

Postoperative Stage:

An inpatient stay in the ward for 2-3 days may be essential to optimize pain and train for getting range of motion before discharge. An adequate pain relief will be provided, wound will be checked, and an X ray of the shoulder joint will be taken.  A physiotherapist will teach the exercises that need to be carried on to get satisfactory function. When discharged, a plan of home exercise programme will be taught.

The Success Rates and the Outcomes:

The success of the surgery is very high.  It is in the order of 90-95%.  Most of the patients are satisfied with pain relief and gain of mobility.

Complications:

The complications after the surgery are minimal.  Infection, Nerve injury, Dislocation and Fracture are the important complications to think about, but fortunately the incidence of these problems is low.

Rehabilitation Post surgery:

A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement.   A sling will be given for comfort during the first four weeks.  Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery.

Here are some "do's and don'ts" for when you return home:

• Don't use the arm to push yourself up in bed or from a chair because this requires forceful contraction of muscles.
• Do follow the program of home exercises prescribed for you. You may need to do the exercises 4 to 5 times a day for a month or more.
• Don't lift anything heavier than a glass of water for the first 6 weeks after surgery.
• Don't participate in any repetitive heavy lifting after your shoulder replacement.
• Do avoid placing your arm in any extreme position, such as straight out to the side or behind your body for the first 6 weeks after surgery.

Many thousands of patients have experienced an improved quality of life after shoulder joint replacement surgery. They experience less pain, improved motion and strength, and better function.