Introduction
In this procedure, the shoulder joint (the glenohumeral joint) is either partially or totally replaced with implanted prosthetic components.
It is an option where either shoulder arthritis or shoulder trauma (injury) or another condition (for example osteonecrosis, where blood supply to the joint is limited or cut off entirely) has made movement very painful and / or has severely limited the range of motion of the joint.
In some cases, the surgery is necessary to revise (i.e. correct) a previous procedure, most frequently due to the original implant coming loose or moving out of position.
Preoperative Instructions
- Existing medication/s – some medications can impact surgery, especially any anti-coagulant medication and medicine for diabetes; we will advise if any of your medication needs to be stopped (and when) well ahead of the day of surgery. Any other medication should be taken the morning of surgery with a little water (half a cup maximum).
- You should not shave (or wax) skin near where any surgical incisions will be made.
- No solid foods (cow's milk and drinks containing cow's milk are considered food) should be consumed within 6 hours of surgery; clear fluids (e.g. water, cordial) may be consumed until 3 hours before surgery and then nil by mouth from that point.
- Please advise us if you have a cold or fever, a cough or any other injuries or infections (e.g. urinary tract infection or cuts/tears to the skin) – your procedure may need to be postponed as any of these may make anaesthesia or surgery unsafe.
- Please bring all imaging (e.g. x-rays / CT scans / MRI scans) with you to hospital.
- Please come to hospital at least one hour before your planned surgery, unless we advise you otherwise.
In very general terms make sure you follow a healthy and balanced diet before surgery and continue any regular physical activity up until the day of the procedure. If you smoke, you should ideally stop smoking at least four weeks before the procedure and otherwise as a minimum at least one week before.
Procedure
A total shoulder replacement procedure is carried out under general anaesthetic and normally takes around two hours to complete. A hospital stay of 1-3 days after surgery is generally necessary.
During the procedure itself Dr Moopanar accesses the shoulder joint via an incision to the front of the shoulder. The ball at the upper end of the humerus bone (called the 'head' of the humerus) is removed and – in some cases – the socket in the scapula (the 'glenoid') is also removed. A new prosthetic head is fixed into the humerus, and, if the socket has been removed as well, a new prosthetic socket is fitted. The replacement head is generally a metal component, while a replacement socket is often made of plastic. Once this is complete, the incision is closed with absorbable sutures.
Postoperative instructions
Once you have undergone a total shoulder replacement, the aim is to have the new shoulder fully functional as soon as possible and this is best achieved by a physical therapy schedule over the three-month period after surgery and avoiding any activities that will put the new joint under too much stress.
There will be some pain after the procedure, and this can be kept in check with regular pain medication. You will also be given a sling for the arm which should be worn at all times in the first 4 weeks, and only removed for showering and exercising.
During the first 2 weeks you should apply ice packs to the shoulder five times a day (for 10min each time) to help with the swelling.
You will be given a physical therapy program which will gradually increase over the initial 4 weeks. Strength exercises generally commence after 12 weeks. The strength and range of motion of the joint should progressively improve over the 3-6 months after surgery by following the physical therapy program.
At the 4-week mark most patients can resume normal day-to-day activities (but not lifting heavy weights or making any push-pull movements) and at the 6-8 week mark you will probably be able to start driving again as long as Dr Moopanar has confirmed good range of movement and lack of pain.
More details on the rehabilitation program will be given to you after surgery.
Risks
As with any surgery, there is always a risk of:
- Pain.
- Bleeding.
- Scarring.
- Infection (of the incision site, or in the chest).
- Blood clot (leg or lung).
- Stroke.
- Heart attack.
Some specific risks of a total shoulder replacement are:
- Nerve damage around the shoulder.
- Rotator cuff tears.
- Frozen shoulder.
- Loosening / dislocation of the shoulder replacement components.
- Wearing out of components over time.
Postop Physio Protocols
Patient will be placed in a sling from day 1 and will wean off on an individual basis. In some instances, where the rotator cuff muscles have been repaired (such as in a hemiarthroplasty), the sling may be required to be worn for a period of 6 weeks. Furthermore, the sling must be worn at night and when out and about for 3 to 4 weeks to protect the repair of the rotator cuff muscles performed during your surgery.
Immediate postop
- Cold packs will be applied 20 minutely initially to assist with swelling and inflammation. You will be positioned by nursing and allied staff in a comfortable position with pillows.
- Your shoulder immobiliser is to remain on at all times and is to be adjusted by the nursing staff or physiotherapists if ever uncomfortable.
- As soon as your anaesthetic block begins to wear out (you start feeling pins and needles in your arm and hand), please let nursing staff know such that they may commence oral pain relief to keep you feeling comfortable.
Day 1
Physiotherapists will commence elbow, wrist and finger range of motion exercises in order to prevent stiffness and loss of strength. The shoulder will be allowed to be moved passively in pendular movements depending on patient’s ability.
Day 2
Patient is to begin pulley exercises under the instruction of the physiotherapist. Exercises will be performed 5 times per day for up to 20 repetitions. External rotation will be limited to neutral in order to protect the subscapularis repair. Hot or cold packs are used sparingly for comfort prior to exercise.
Day 2-4
Patients has been discharged and will be instructed to follow-up in the rooms or at the hospital out-patient clinic at the 2-week mark for a wound check. Patients are to contact Dr Moopanar’s rooms if there are any issues including excessive pain or wound discharge.
Precautions at this stage include, no weight through the arm exceeding the weight of a cup of tea, no leaning on the arm for any reason and leaving the sling on at all times.
Week 2
Wound is checked by Dr Moopanar either at his specialist rooms or at the public out-patient clinic and dressing is removed. Passive flexion is increased to 100 degrees and external rotation to 10 degree.
Week 3
Flexion is commenced with rod. Gentle forward flexion, abduction and external rotation may also be commenced at this stage. Hand, wrist and elbow exercises are accompanied by gentle isometric exercises of the shoulder.
Weeks 5-6
Active flexion is commenced and if deltoid weakness is present, exercises may be graduated from a supine to a half sitting to a sitting position.
Weeks 6-12
Weights are commenced using a theraband at waist level as well as light deltoid exercises. Care is taken when active internal rotation is initiated to protect the subscapularis repair. The hand is only now permitted to gradually move to behind the back exercises.
Ongoing
The patient will continue to perform strengthening exercises for several months until goals of rehab are achieved.