Introduction
The most frequent source of debilitating pain and joint destruction is arthritis.
It is estimated that 36 million people in the United States have some form of arthritis.
That's one in seven people. Of the more than 100 types of arthritis,
the following three are the most common sources of joint damage:
- Osteoarthritis, sometimes called degenerative arthritis, is a disease which involves the breakdown of the tissue (cartilage) that normally allows the joint to move smoothly. When the gliding surface of the cartilage is gone, the bones grind against each other, creating popping sounds, pain and loss of normal movement. This condition occurs primarily in people over 50.
- Rheumatoid arthritis is considered a systemic disease because it can attack any or all joints of the body. It affects women more often than men, and can strike both young and old. Rheumatoid arthritis causes the body's immune system to produce a chemical that attacks and destroys the synovial lining covering the joint capsule, the protective cartilage and the joint surface, causing pain, swelling, joint damage and loss of mobility.
- Trauma-related arthritis results when a joint is injured, either by fracture, dislocation or damage to the ligaments surrounding the joint causing instability or damage to the joint surfaces.
When conservative methods of treatment fail to provide adequate relief, total shoulder replacement is considered. The development of total shoulder replacement began over 40 years ago, and over 15,000 people each year undergo this surgery to diminish pain and stiffness and restore mobility. If your X-rays show destruction of the joint, your surgeon will decide if your degree of pain and loss of use is severe enough to warrant the operation.
The primary purpose of the operation is to relieve your pain. The secondary purpose is to increase your range of motion. The extent of improvement in your range of motion will depend on the severity of your preoperative condition, the length of time you have had the problem, the range of motion of your shoulder before surgery and your commitment to the preoperative and postoperative rehabilitation programs. Total joint replacement is a remarkably successful operation that has transformed the lives of many people. Many of those who once suffered from severe pain and stiffness in a joint are again swimming, golfing, playing tennis and dancing.
The Shoulder Joint
 A joint is a junction where two or more bones meet. The shoulder joint is considered one of the most complex joints in the body, with three bones meeting there -- the scapula (shoulder blade socket), clavicle (collar bone) and humerus (upper arm bone). The shoulder joint is unique in that the ball of the upper arm bone is two times larger than the socket of the shoulder blade. This creates a very mobile joint, but demands an extensive array of ligaments and muscles to keep the joint together. The muscles and ligaments together allow the free and easy movement found in the healthy shoulder.
The muscles around the shoulder include the powerful and large deltoid muscle which forms the bulk of the shoulder muscle mass; four smaller and deep muscles that comprise the rotator cuff; and multiple large muscles of the back and neck that help to stabilize the shoulder joint.
Your Shoulder Evaluation
Your shoulder evaluation will begin with a detailed questionnaire. Your medical history is very important in determining whether surgery is necessary. It helps the surgeon understand your pain and the progression of your shoulder problem.
After your history is taken, a physical exam is performed. The range of motion of your shoulder is measured and your muscle strength is evaluated. A small amount of fluid may be taken from your shoulder joint to check for infection.
X-rays are then taken of your shoulder joint. Bring any X-rays that may have been taken of your shoulder in the past. These X-rays will help your surgeon plan the surgery and identify the correct size shoulder prosthesis, if necessary.
After your initial orthopaedic evaluation, the surgeon will discuss all possible alternatives to surgery. If the x-rays show severe joint damage and no other means of treatment has provided relief, total shoulder replacement may be recommended.
Total Shoulder Replacement
 Total shoulder replacement or shoulder arthroplasty is the replacement of the ball of the upper arm and socket of the shoulder blade with specially-designed artificial parts, called prostheses, made of metal and polyethylene (a medical-grade plastic).
The humeral (upper arm) prosthesis consists of a metal ball that replaces the head of the humerus, and a body and stem that is secured into the upper arm bone. The glenoid (shoulder blade socket) prosthesis is made of a special polyethylene, and is designed to replace the socket part of the joint. The metal ball and stem units are selected by your surgeon from multiple sizes to fit the contour and shape of your humerus. This two-piece construction is known as a modular prosthesis. This allows fitting of the ball and socket to your shoulder, which enhances the proper repair and tension of the muscles around the joint.
There are two types of shoulder replacement procedures. If the surgeon only uses the metal humeral (upper arm bone) components, the procedure is called a hemi-arthroplasty. If the surgeon uses both the humeral components and the glenoid (shoulder blade socket) prosthesis, then the procedure is called a total shoulder arthroplasty. The surgeon decides which procedure to use based on the extent of damage to your shoulder.
Before Surgery
You may be asked to see your family physician or an internist for a thorough medical evaluation one to two weeks prior to hospital admission. You may be asked to lose extra weight. If you smoke, it is important to stop two weeks before surgery. If you are taking any anti-inflammatory medications, your surgeon will probably advise you to stop taking them one week prior to surgery. This helps to minimize bleeding during your operation.
If Estrogen (Premarin) is being used, your surgeon will probably advise you to stop taking it one month before surgery. Your doctor may want you to donate your own blood ahead of time in the event that transfusions are needed during surgery.
You will probably be admitted to the hospital the morning of surgery. You cannot eat or drink anything after midnight the day of surgery.
In order to receive medications and blood transfusions during surgery, an intravenous (IV) line will be started. The anesthesiologist will speak to you before surgery and discuss the type of anesthetic to be used.
What to Expect After Surgery
You may have a drainage tube coming out through your surgical dressing, which will be attached to a portable drainage apparatus. This system provides continuous, gentle suction to remove any blood that may be accumulating in the surgical area. It is usually removed on the first or second day after surgery. Your dressing will probably be changed on the first or second postoperative day, and cold compresses may be applied for up to two days.
On the first postoperative day, you may begin drinking fluids and eating meals under the direction of your surgeon.
The IV will remain in your arm for one to two days to administer fluids and antibiotics. This helps prevent infection and gives you proper nourishment until you are eating and drinking comfortably. It is normal to feel pain and discomfort after surgery. Be sure to inform your nurse of your pain, and medication will be ordered.
To prevent fluids from building up in your lungs, you will receive an incentive spirometer to encourage you to cough and breathe deeply. This will be used every hour while you are awake.
Your arm will be in a shoulder immobilizer, which protects and positions your shoulder, or it may be placed in a shoulder splint. Keeping a small pillow or folded blanket under your elbow while sitting or lying down will prevent the arm from falling back and straining the area of your operation.
A trapeze bar attached to the bed will help you move about more easily. It is important that you use only your non-operative arm with the trapeze. You do not want to turn on or move your postoperative shoulder until instructed that it is alright to do so by your surgeon. The nurse will help you find comfortable positions.
On the first or second day after surgery, you will be encouraged to use your involved arm for some gentle living activities such as feeding yourself, brushing your teeth, shaving and drinking.
Physical Therapy
The postoperative rehabilitation program normally begins the day of surgery. It consists of stretching exercises and normal, gentle daily activities. The postoperative rehabilitation program is critical, and it is important that you cooperate, follow your surgeon's instructions and work hard.
Pain medication may be taken prior to your therapy as you request. The members of the surgical team or a physical therapist will gently move your arm and shoulder through various positions while you relax. These early movements and exercises will help prevent stiffness and will help you regain shoulder motion. You will also work on tightening the muscles of your hand and arm by flexing your hand, wrist and elbow.
Depending on your progress, you will gain independence about one week after surgery. You will continue strengthening yourself in preparation of your return home. It is important for you to adhere to precautions and proper positioning techniques throughout your rehabilitation. Your stitches will be removed seven to ten days after surgery.
Just before your discharge, you will receive instructions for your at-home recovery, including how and when to wear your shoulder sling, changing your bandage and bathing and showering. The surgical team will also give you directions and the necessary equipment to continue your rehabilitation program at home and a date for your return appointment.
It is normal for you to have some discomfort, but it will be unusual for you to use pain medication more than five to seven days after surgery. You will receive a prescription for pain medication before you leave the hospital. If a refill is needed, please call your surgeon's nurse at least five days before you run out of pills.
Preparing to Go Home
Until you see your surgeon for your follow-up visit, you must take certain activity precautions. Look for any changes around your incision. Contact your surgeon if you develop any of the following:
- Drainage and/or foul odor from the incision.
- Fever (100.4 degrees F or 38 degrees C) for two days.
- Increased swelling, tenderness, redness and/or pain.
Resuming Activities
You may return to work when authorized by your surgeon. Your surgeon will tell you when you can begin driving a car.
Take time to adjust to your home environment -- it is okay to take it easy. You may need help with your daily activities, so it is a good idea to have family and friends prepare to help you. It is normal to feel frustrated, but these frustrations will soon pass.
You are encouraged to return to your normal eating and sleeping patterns as soon as possible, and to be as active as possible in order to control your weight and muscle tone. But remember to increase your activity level or exercises only as your surgeon has directed. Increasing activity too quickly may cause injury and damage to the healing tissue. Avoid activities that could cause stress on your shoulder, especially those that may result in a collision or fall such as contact sports or skiing. During your follow-up visits, your surgeon will discuss your progress with you.
Special Instructions
You may be seen six weeks, five months and twelve months after your surgery. You may also see your surgeon once a year after the first year, even if you are not having any problems.
Any infection must be promptly treated with proper antibiotics because infection can spread from one area of the body to another through the blood stream. Every effort must be made to prevent infection in your artificial joint. You should always tell your dentist or physician that you have an artificial joint. If you are to have dental work performed, please call your surgeon prior to having this work done. Your surgeon will most likely prescribe an antibiotic for you. Antibiotics must be used before and after any medical or dental procedure. This precaution must be taken for the rest of your life.
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