Shoulder replacement surgery for arthritis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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From the American Academy of Orthopedic Surgeons

Patients who have arthritis of the shoulder often respond to conservative treatment. This includes limiting certain activities. Shoulder exercises are excellent for most patients with shoulder disorders requiring surgery.

Stretching and strengthening of the muscles around the shoulder joint may help decrease the stress on the shoulder. Preventing atrophy of the muscles is an important part of maintaining functional use of the shoulder. Physical therapists are helpful resources.

Non-steroidal anti-inflammatory drugs (NSAIDs) are prescription and nonprescription medications that help treat pain and inflammation.

Corticosteroid injections may help decrease inflammation and reduce pain within a joint.

Nutritional supplements such as glucosamine and chondroitin appear to be safe and might be effective for treatment of arthritis.

If a patient fails these measures, they may be candidates for shoulder replacement surgery.

In this procedure the arthritic cartilage is removed and a metal andf plastic implant is placed in the shoulder.

The shoulder joint is a ball-and-socket joint, similar to the hip joint. The ball is the top of the arm bone (the humerus), and the socket is within the shoulder blade (scapula).

When shoulder replacement surgery is performed, the ball is removed from the top of the humerus and replaced with a metal implant. This is shaped like a half-moon and attached to a stem inserted down the center of the arm bone. The socket portion of the joint is shaved and replaced with a plastic socket that is cemented into the scapula.

Shoulder replacement surgery is a highly technical procedure.

After the anesthetic has been administered and the shoulder is prepared, an incision is made across the front of the shoulder from the middle of the collarbone to the middle of the arm bone. This incision allows access to the joint without damaging the important deltoid or pectoralis muscles that are responsible for a significant portion of the shoulder's power.

The muscles and other tissues near the shoulder are mobilized by removing any scar tissue that may restrict their motion. The tendon of the subscapularis muscle is cut to gain access to the joint and released to restore its length and mobility. The arthritic humeral head (ball of the joint) is removed. The bone spurs are removed to prepare the bone for the humeral prosthesis.

If the glenoid socket is unaffected or in other selected conditions, a hemiarthroplasty may be performed (replacing the ball only). For example in cuff tear arthropathy, a hemiarthroplasty (replacing the humeral joint surface only) is usually selected because the anatomy does not favor the use of a glenoid prosthesis. The humeral component is made of metal and is usually press fit, but sometimes cemented, into the shaft of the bone of the humerus.

If the glenoid is affected, but conditions do not favor the insertion of a glenoid component, a non-prosthetic glenoid arthroplasty may be performed along with a humeral hemiarthroplasty. In this procedure, the glenoid shape and orientation are corrected, but a glenoid prosthesis is not inserted. The reshaping of the socket using a spherical reamer is next. The prosthetic ball of the humeral component articulates with the reshaped bony socket of the glenoid.

In a total shoulder joint replacement, the glenoid bone is shaped and oriented as in the non-prosthetic glenoid arthroplasty and then covered with a polyethylene glenoid component, as seen in the figure. A small amount of bone cement is used to hold the artificial glenoid socket in place.

At the conclusion of any of these procedures, the subscapularis tendon is securely repaired to the bone. This repair requires protection from active use for at least 6 weeks while it is healing.

Shoulder joint replacement surgery may be performed under a general anesthetic or under a brachial plexus nerve block.

The procedure usually takes approximately two hours, however the preoperative preparation and the postoperative recovery may add several hours to this time. Patients often spend two hours in the recovery room and two to four days in the hospital after surgery.

The patient will be sent home wearing a sling and should not attempt to use the arm except as specifically instructed by the doctor.

Most physicians will begin some motion immediately following surgery, but this may not be true in every case. Usually within two to three months, patients are able to return to most normal activities and place an emphasis on strengthening the muscles around the shoulder and maintaining range of motion.

As always, risks of surgery include risks of general anesthesia which tend to be dependent on other medical issues you may have. Some specific risks of shoulder replacement surgery include:

• Infection around an implanted joint is a very serious complication and therefore there are significant measures taken to avoid this complication. If an infection develops, the entire implanted joint may need to be removed in order to eradicate the infection.
• Dislocation/Instability. Because of the ball-and-socket design of the implanted joint, it is important that the surgeon balance the soft-tissues around the shoulder to ensure it is not pulled out of position.
• Loosening of the Implant. Over time, implanted joints may loosen. Developments are constantly being made to produce longer-lasting implanted joints, but this has not been perfected. If an implant loosens to the point where patients are having significant problems, a revision surgery may need to be performed (a replacement of a joint replacement).
• Damage to Nerves or Blood Vessels. The shoulder is a tight space, and many important structures pass just next to the shoulder joint. The nerves that send and receive messages to and from your hand and arm, as well as the blood vessels that provide circulation, sit very close to the shoulder joint. One complication of this surgery is damage to a blood vessel or nerve.

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