William B Kurtz | Total Shoulder Replacement

Introduction

A shoulder replacement is a commonly preformed surgery for arthritis and joint disease that has been performed for about 30 years. The main indication for a shoulder replacement is pain relief. Occasionally, shoulder replacement surgery is needed for certain fractures around the shoulder, but most shoulder replacements occur after years of wear and tear on the shoulder.

There are 3 main types of shoulder replacement: hemi-arthroplasty, total shoulder arthroplasty, and a reverse shoulder arthroplasty. The indications for each type of replacement are discussed below.

The purpose of the following information is to explain to patients the major aspects of shoulder replacement surgery, inform them of its major risks, and hopefully help them make a well informed decision about their shoulder disease. My intention is not to frighten patients, but through education, to alleviate any fears patients might have. This information is not meant to be complete with regard to every detail of the surgery or its risks. If you would like more information, please schedule an appointment to see me.

History of Total Shoulder Replacement

The first shoulder replacement was performed in 1893 by a French surgeon, Pean, for a tuberculous infection. However, it was not until the 1970's that shoulder replacements were routinely performed. Initially, implant designs were highly constrained devices that did not accurately restore shoulder biomechanics and ultimately failed. Modern total shoulder implants allow for more motion and less constraint.

A shoulder replacement involves replacing the end of the arm bone (humerus) and the socket (glenoid) with metal and plastic parts that then act as a new shoulder joint. A plastic (polyethylene) glenoid component is cemented to the glenoid. The parts are made of cobalt chrome, titanium, and/or polyethylene. For a first time surgery, it is likely that your incision will be 10 cm of about 4 inches in length.

Surgical Approach

Shoulder replacements are preformed through a delto-pectorial approach in the front of the shoulder. The deltoid muscle is moved laterally and the pectorialis muscle is moved medially. The subscapularis tendon is transected to gain access to the shoulder joint and then repaired at the end of the case. Because the subscapularis tendon takes ~ 6 weeks to heal, Dr. Kurtz, and almost every surgeon in the United States, limits external rotation of the patient's arm for 6 weeks.

Types of Shoulder replacements

Hemi-arthroplasty

A hemi-arthroplasty involves replacing the humeral head and not replacing the glenoid (socket) which might be the best option if the glenoid does not have any arthritis or if there is some concern that the glenoid component might fail if it is replaced.

Total shoulder arthroplasty

A total shoulder involves replacing the humeral head and the glenoid. A total shoulder might be the best option if the glenoid is damaged but sufficient bone and rotator cuff remain to ensure that the glenoid component will last. A total shoulder is contra-indicated if the rotator cuff is not intacted.

Reverse shoulder arthroplasty

A reverse shoulder arthroplasty involves replacing both the humeral head and the glenoid, but the ball and socket are reversed to improve the muscle function. Because the center of rotation is translated medially, the deltoid muscle has a longer moment arm and can generate more force. The deleterious effect of translating the center of rotation is decreased range of motion and increased impingement. This increased impingement causes scapular notching and can undermine the glenoid component.

Medical Clearance

If you have not seen your medical doctor recently, you should make an appointment with him/her as soon as possible. Your surgery can then be performed once your medical doctor clears you for it.
If you have recently seen your medical doctor, you should have him/her send a note to my office stating that you are medically fit for your surgery.
If there is a question as to whether you have seen your medical doctor recently enough, call your medical doctor and ask him or her.
If you see a medical specialist (e.g., a heart or lung doctor), have him/her also send a note to my office stating that you are medically fit for your surgery.
If you have no medical doctor and no medical problems, let me know during your clinic visit.
If you have no medical doctor and you do have medical problems, I will refer you to a medical doctor prior to any surgery.
You must inform my office immediately about any infection anywhere on your body, especially in the skin over your hip. This can include a pimple or scratch, or infection in your fingernails, toenails, teeth, or urine.
If you have any ongoing dental problems or even old infections, you must see your dentist before the operation, and have him/her contact my office.

Medicines

You should stop all aspirin seven days before the surgery
Stop all “non-steroidal” anti-inflammatory drugs (such as Advil, Motrin, Alleve, Naprosyn, Celebrex etc.) three days prior to the operation.
If you take coumadin or other blood thinners (such as Plavix), please contact your medical doctor to find when it is safe to discontinue these drugs. If your medical doctor feels it is unsafe to stop these drugs, you must inform my office of this, preferably a week before your surgery.
If you are unsure whether any drugs you take fall in these categories, contact my office or your medical doctor.
All other medications should be continued unless your medical doctor instructs you otherwise. You should ensure that you bring a list of all your medications and their doses to the hospital with you for the pre-operative joint class and anesthesia visit.

Day of Surgery

Patients are asked not to eat anything for 8 hours before their surgery which typically means nothing after midnight..
Most of your normal medicines should be taken the morning of your surgery with a small sip of water. Please ask the anesthesiologist at your pre-operative visit which medicines you should take.
Patients report to the admission office on the first floor and will be taken up to the 5^th floor pre-admission floor.
Patients will see me, Dr. Kurtz, in the holding room prior to the operation.
Family members can wait in the family waiting room on the 4^th floor
After the surgery, Dr. Kurtz will update your family members about how the operation went and how you are doing.
The patient will typically spend ~ 2 hours in the recovery room before being taken to their hospital room on the 8th floor.
Once the patient has been assigned a room, family member can wait in the patient’s room for the patient to arrive.

Wound Closure

I feel strongly that the wound closure is as important as the insertion of the components..
I therefore close the surgical incision with both interrupted and running suture in order to help evenly distribute the force on the skin edges.
All of the sutures dissolve over the following 6 weeks.
I also apply Dermabond (similar to Super Glue) to the incision after it is closed.
The incisions typically do not bleed or drain after surgery.
The water-proof dressing that is applied in the operating room typically does not need to be changed, and most patients remove the dressing about a week after the operation.

During your hospital stay

Pain medicine is custom tailored to every patient's need..
Most patients received both a long acting oral pain medicine and additional short acting oral pain medicine as needed.
Patients will receive IV antibiotics for 24 hours after surgery.
Patients will receive a blood thinner for about 3 weeks.
Patients are encouraged to walk immediately after surgery.
Patients are encouraged to shower the day after surgery.
Physical therapists will work with each patient multiple times each day helping them learn how to safely walk and work on range of motion.
All IVs and catheters are removed once the patient is medically stabilized, usually 1-2 days after surgery.
I typically sees every patient at least once a day and often times twice a day. I also try to round on my patients over the weekend, but occasionally, weekend rounds maybe covered by one of my partners.
The hospital stay is usually about 2-3 days.

Leaving the hospital

A social worker will help determine how much help you need at home, and contact your insurance company to see what help is covered.
The physical therapist, social worker, and Dr. Kurtz will help determine whether you might be able to go home, to a rehabilitation facility, or a short-term nursing home.
Patients will receive a prescription for pain medication and a blood thinner.
If the patient is taking the blood thinner, coumadin, your blood will be drawn at home or at a lab every 3 to 4 days for the next 3 weeks. You must also make sure that Dr. Kurtz’s assistant receives the results of your blood tests, and changes the dose of coumadin as needed.

Follow up

Patients first follow up is between 2 and 4 weeks after surgery

Patients second follow up is ~6 weeks after the first visit.

Patients are then followed on a yearly basis for a 2-3 years.

Every joint replacement patient should have an x-ray of their replacement every 2-3 years regardless if they are having pain or not.

Knee replacements usually fail because the plastic bearing surface wears out, the components loosen, or the components get infected. Pain is often not present until significant destruction has taken place. Revision surgery can be made more difficult by waiting until after this destruction has occurred. Appropriate follow up can hopefully identify small problems before them become bigger problems. If you develop new knee pain, notify my office immediately.

Risks of a total shoulder replacement

Infection: Antibiotics are given before and after surgery to decrease the risk of infection, but an infection still can occur immediately or even years after the surgery. It is usually treated with another surgery to remove infected tissue and often the prosthesis as well. If the components are removed, a revision shoulder prosthesis can sometimes be inserted months later if the infection clears, but sometimes the patient is left without a shoulder joint. Although patients rarely have life threatening problems from their joint infection, an infection is a devastating complication.

Stiffness: Patients may experience stiffness in the shoulder joint after surgery. This stiffness usually resolves with time and physical therapy

Fracture: The humerus or glenoid can crack when preparing the bone for insertion of the components, actually inserting the components, or even years after the surgery. Fractures usually are treated with metal cables or a plate, and usually heal.

Component Loosening: Occasional the bone will not grow into the implanted components. The components may loosen and change position. Component loosening can occur years after the surgery from wear debris from the plastic liner. The motion of the loose component may cause pain and require another surgery to revise the components.
Nerve Injury: Although extremely rare, nerves to your shoulder, arm and hand can occasional be injuried. These nerves may or may not recover by themselves. If they do not, you may be left with a weak arm.
Bleeding: Rarely, the blood vessels around the shoulder are damaged by the surgery and excessive bleeding occurs after or during the surgery, requiring additional surgery. Occasionally, blood gathers in the shoulder even if no major blood vessel is damaged and further surgery (or observation) is required to correct the problem.
Blood Clots: Blood clots in your arm veins are possible after any surgery on the upper extremities. The occurrence of blood clots can be minimized with blood thinners and early mobilization. The main danger of blood clots is if they dislodge and travel to your veins in your lungs. This phenomenon is called a pulmonary embolus and can result in respiratory difficulty, chest pain, or even death. Blood clots may or may not hurt or cause swelling in your arm. If you have unexplained pain or swelling in your arm, let Dr. Kurtz know as he may order a duplex ultrasound to look for a blood clot. If you feel chest pain or breathing difficulties, you should call 911 and then call Dr. Kurtz. The risk of these clots causing death has been drastically reduced, and is less than 0.1%. The treatment for a proven blood clot is additional blood thinners, and occasionally a filter in your veins.
Osteolysis: Polyethylene bearings can wear over many years and cause osteolysis which is the body's response to the plastic wear debris from the shoulder replacement. The body tends to attack the tiny plastic particles and inadvertently causes the bone around the shoulder joint to weaken. The weakened bone can lead to fractures or component loosening.
Dislocation: The humeral head rarely can dislocate from the glenoid component. If your total shoulder dislocates, Dr. Kurtz will manipulate your leg under anesthesia or sedation to place the components back together. Occasionally, unstable shoulder replacements need to be revised to correct this condition if it keeps occurring.
Need for Further Surgery: Though uncommon, shoulder replacements occasionally fail sooner than expected. Some other problems can also make further surgery necessary, including: bone forming where it should not, breaking of the bone around the prosthesis (during or after surgery), and irritation of the soft tissues by wire or sutures.
Death: Though very rarely, patients have died following shoulder replacements. This can be due to underlying medical or heart problems that arise or worsen after the surgery. It can also be due to blood clots traveling to the lungs as mentioned above, or from the stress placed on the body by more than the usual amount of bleeding.
Other Problems: This list is meant to cover only the major problems most frequently encountered. Just as everyone is unique, so are many problems.

For a detail review article on total replacement complications click on the following article.

J Bone Joint Surg Am WIRTH and ROCKWOOD 78 (4): 603.

Measures that you can take to help prevent complications include:

Telling your doctor immediately of any possible infection anywhere on your body. Also let my office know.
Receiving antibiotics before any dental, urinary, or rectal procedure for two years. You will require pre-procedure antibiotics for a longer period if you have a disease that compromises your immune system. (Call my office if there are any questions.)
Always mention to any doctor performing an invasive procedure on you that you have a shoulder replacement.

Revision shoulder surgery

Replacing a previously inserted prosthesis is more difficult and less predictable than the first surgery. Each case has its own unique problems and risks. In all cases, the risks are much greater than the risks with first-time surgery. The recovery is often longer, and the results are less certain. The outcomes following revision surgery have greatly improved over the years.