Advances in Shoulder Surgery -- March 21, 2011 -- Dr. Matthew Wi - NewsChannel5.com | Nashville News, Weather & Sports

Monday, March 21, 2011
TOPIC: Advances in Shoulder Surgery
Matthew Willis, MD: orthopaedic surgeon

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Advances in Shoulder Surgery

Shoulder Problems & Injuries: Topic Overview

Minor shoulder problems, such as sore muscles and aches and pains, are common. Shoulder problems develop from everyday wear and tear, overuse, or an injury. They can also be caused by the natural process of aging.

Your shoulder joints move every time you move your arms. To better understand shoulder problems and injuries, you may want to review the anatomy and function of the shoulder . The shoulder is a ball-and-socket joint with three main bones: the upper arm bone (humerus), collarbone (clavicle), and shoulder blade (scapula). These bones are held together by muscles, tendons, and ligaments. The shoulder joint has the greatest range of motion of any joint in the body. Because of this mobility, the shoulder is more likely to be injured or cause problems. The acromioclavicular (AC) joint, which lays over the top of the shoulder, is also easily injured.

Shoulder problems can be minor or serious. Symptoms may include pain, swelling, numbness, tingling, weakness, changes in temperature or color, or changes in your range of motion. Shoulder injuries most commonly occur during sports activities, work-related tasks, projects around the home, or falls. Home treatment often can help relieve minor aches and pains.

Sudden (acute) injury

Injuries are the most common cause of shoulder pain.

A sudden (acute) injury may occur from a fall on an outstretched arm, a direct blow to the shoulder, or abnormal twisting or bending of the shoulder. Pain may be sudden and severe. Bruising and swelling may develop soon after the injury. If nerves or blood vessels have been injured or pinched during the injury, the shoulder, arm, or hand may feel numb, tingly, weak, or cold, or may look pale or blue. Acute injuries include:

• Bruises (contusions ), which occur when small blood vessels under the skin tear or rupture, often from a twist, bump, or fall. Blood leaks into tissues under the skin and causes a black-and-blue color that often turns purple, red, yellow, and green as the bruise heals.
• Injuries to the tough, ropelike fibers (ligaments) that connect bone to bone and help stabilize the shoulder joints (sprains).
• Injuries to the tough, ropelike fibers that connect muscle to bone (tendons).
• Pulled muscles (strains).
• Injuries to nerves, such as brachial plexus neuropathy.
• Separation of the shoulder, which occurs when the outer end of the collarbone (clavicle) separates from the end (acromion) of the shoulder blade because of torn ligaments. This injury occurs most often from a blow to a shoulder or a fall onto a shoulder or outstretched hand or arm.
• Damage to one or more of the four tendons that cover the shoulder joint (torn rotator cuff), which may occur from a direct blow to or overstretching of the tendon.
• Broken bones (fractures). A break may occur when a bone is twisted, struck directly, or used to brace against a fall.
• Pulling or pushing bones out of their normal relationship to the other bones that make up the shoulder joint (subluxation or dislocation).

Overuse injuries

You may not recall having a specific injury, especially if symptoms began gradually or during everyday activities. Overuse injuries occur when too much stress is placed on a joint or other tissue, often by overdoing an activity or through repetition of an activity. Overuse injuries include:

• Inflammation of the sac of fluid that cushions and lubricates the joint area between one bone and another bone, a tendon, or the skin (bursitis).
• Inflammation of the tough, ropelike fibers that connect muscles to bones (tendinitis). Bicipital tendinitis is an inflammation of one of the tendons that attach the muscle (biceps) on the front of the upper arm bone (humerus) to the shoulder joint. The inflammation usually occurs along the groove (bicipital groove) where the tendon passes over the humerus to attach just above the shoulder joint.
• Muscle strain.
• A frozen shoulder, which is a condition that limits shoulder movement and may follow an injury.
• Overhead arm movements, which may cause tendons to rub or scrape against a part of the shoulder blade called the acromion. This rubbing or scraping may lead to abrasion or inflammation of the rotator cuff tendons (also called impingement syndrome).

Other causes of shoulder symptoms

Overuse and acute injuries are common causes of shoulder symptoms. Less common causes of shoulder symptoms include:

• Muscle tension or poor posture.
• Pain that is coming from somewhere else in your body (referred shoulder pain).
• Breakdown of the cartilage that protects and cushions the shoulder joints (osteoarthritis).
• Calcium buildup in the tendons of the shoulder.
• An irritated or pinched nerve or a herniated disc in the neck.
• Infection in the skin (cellulitis), joint (infectious arthritis), bursa (septic bursitis), or bone (osteomyelitis).
• Invasive cancer that has spread to the bones of the shoulder or spine.
• Abuse. Any shoulder injury (especially a dislocated shoulder) that cannot be explained, does not match the explanation, or occurs repeatedly may be caused by abuse.

Treatment

Treatment for a shoulder injury may include first aid measures, physical therapy, medicine, and in some cases surgery. Treatment depends on:

• The location, type, and severity of the injury.
• How long ago the injury occurred.
• Your age, health condition, and activities, such as work, sports, or hobbies.

Shoulder replacement surgery

Joint replacement involves surgery to replace the ends of bones in a damaged joint. This surgery creates new joint surfaces.

In shoulder replacement surgery, doctors replace the ends of the damaged upper arm bone (humerus) and usually the shoulder bone (scapula) or cap them with artificial surfaces lined with plastic or metal and plastic. Shoulder joint components may be held in place with cement. Or they may be made with material that allows new bone to grow into the joint component over time to hold it in place without cement.

The top end of your upper arm bone is shaped like a ball. Muscles and ligaments hold this ball against a cup-shaped part of the shoulder bone. Surgeons usually replace the top of the upper arm bone with a long metal piece, inserted into your upper arm bone, that has a rounded head. If the cup-shaped surface of your shoulder bone that cradles your upper arm bone is also damaged, doctors smooth it and then cap it with a plastic or metal and plastic piece.

Surgeons are now trying a newer procedure called a reverse total shoulder replacement for people who have painful arthritis in their shoulder and also have damage to the muscles around the shoulder. In this procedure, after the surgeon removes the damaged bone and smoothes the ends, he or she attaches the rounded joint piece to the shoulder bone and uses the cup-shaped piece to replace the top of the upper arm bone. Early results are encouraging.¹

Doctors often use general anesthesia for joint replacement surgeries, which means you'll be unconscious during surgery. But sometimes they use regional anesthesia, which means you can't feel the area of the surgery and you are sleepy, but you are awake. The choice of anesthesia depends on your doctor, on your overall health, and, to some degree, on what you prefer.

Your doctor may recommend that you take antibiotics before and after the surgery to reduce the risk of infection. If you need any major dental work, your doctor may recommend that you have it done before the surgery. Infections can spread from other parts of the body, such as the mouth, to the artificial joint and cause a serious problem.

What To Expect After Surgery

Right after surgery

You will have intravenous (IV) antibiotics for about a day after surgery. You will also receive medicines to control pain, and perhaps medicines to prevent blood clots (anticoagulants). It is not unusual to have an upset stomach or feel constipated after surgery. Talk with your doctor or nurse if you don't feel well.

When you wake up from surgery, you will have a bandage on your shoulder and probably a drain to collect fluid and keep it from building up around your joint. You may have a catheter, which is a small tube connected to your bladder, so you don't have to get out of bed to urinate. You may also have a compression sleeve on your arm, which squeezes your arm to keep the blood circulating and to help prevent blood clots.

A physical therapist may begin gentle exercises of your shoulder on the day of surgery or the day after. These exercises are just passive motion, which means you relax and let the therapist move your arm for you.

Most people who have shoulder replacement surgery are able to sit up and get out of bed with some help later on the day of surgery.

Your doctor may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is decreased.

The first few days

You will probably still be taking some medicine. You will gradually take less and less pain medicine. You may continue anticoagulant medicines for several weeks after surgery.

A physical therapist will move your arm for you to keep your shoulder loose as it heals. The therapist will also show you how to use a pulley device so you can move your arm when you go home from the hospital. Your therapist may also begin some simple exercises to keep the muscles of your other arm and your legs strong.

Rehabilitation (rehab) after a shoulder replacement starts right away. It is not too demanding early on, but it is very important that you do it. Most doctors will not allow you to use the shoulder muscles for several weeks after surgery. The main goal of rehab is to allow you to move your shoulder as far as possible so it's easier for you to do daily activities, such as dressing, cooking, and driving. Most people eventually regain about two-thirds of normal shoulder motion after surgery. But other things that affect how much movement you get after surgery are how much movement you had before surgery and whether the soft tissues around your shoulder were also damaged. It is very important that you take part in physical therapy both while you are in the hospital and after you are released from the hospital to get the most benefit from your surgery.

Most people go home 1 to 3 days after surgery. Some people who need more extensive rehab or those who don't have someone who can help at home go to a specialized rehab center for more treatment.

Continued recovery

After you go home, monitor the surgery site and your general health. If you notice any redness or drainage from the wound, notify your surgeon. You may also be advised to take your temperature twice each day and to let your surgeon know if you have a fever over 100.5F.

You will have an exercise program to follow when you go home, even if you are still having physical therapy. You should use the pulley to move your arm 4 to 5 times each day. If you notice any soreness, try a cold pack on your shoulder and perhaps decrease your activity a bit, but don't stop completely. Staying on your exercise program will help speed your recovery.

Rehab generally continues after you leave the hospital until you are able to function more independently and you have recovered as much strength, endurance, and mobility in your shoulder as you can. Total rehab after surgery will take several months.

An example of a typical rehab schedule is:¹

• 6 weeks of very limited activity. No movement of the shoulder using the shoulder muscles is permitted. You will use the pulley to help lift your arm and keep your shoulder flexible. Your physical therapist may also show a family member how to do some other exercises for you, such as rotating your arm to the outside and elevating your shoulder. You will have a sling to wear at night. And it's a good idea to also put a small stack of folded sheets or towels under your upper arm while you are in bed to keep your arm from dropping too far back. Your arm should stay next to your body or in front of it for several weeks, both while you are up and during sleep. Don't lift anything heavier than a cup of coffee during this time.
• Exercises and stretching, starting 6 weeks after surgery. This stage usually lasts until 3 months after surgery and includes active use of the shoulder muscles to do exercises. The therapist will also begin more vigorous stretching of the soft tissues around the shoulder.
• More intensive strength training starting 3 months after surgery.

Living with a shoulder replacement

Your doctor may want to see you periodically for several months or more to monitor your shoulder replacement. Gradually, you will return to many of your presurgery activities.

Stay active to help keep your strength, flexibility, and endurance. Your activities might include light yard work, walking, swimming (after your wound is completely healed and your doctor has approved), dancing, and golf. Your doctor may recommend that you avoid heavy lifting and repetitive activities.

For at least 2 years after your surgery, your doctor may want you to take antibiotics before dental work or any invasive medical procedure. This is to help prevent infection around your shoulder replacement. After 2 years, your doctor and dentist will decide whether you still need to take antibiotics. Your general health and the state of your other health conditions will help them decide.

Why It Is Done

Doctors recommend joint replacement surgery when shoulder pain and loss of function become severe and when medicines and other treatments no longer relieve pain. Your doctor will use X-rays to look at the bones and cartilage in your shoulder to see whether they are damaged and to make sure that the pain isn't coming from somewhere else.

Shoulder replacement may not be recommended for people who:

• Have poor general health and may not tolerate anesthesia and surgery well.
• Have an active infection or are at risk for infection.
• Have osteoporosis (significant thinning of the bones).
• Have severe weakness of or damage to the muscles around the shoulder.

Some doctors will recommend other types of surgery if possible for younger people and especially for those who do strenuous work. A younger or more active person is more likely than an older or less active person to have an artificial shoulder joint wear out.

Doctors usually do not recommend shoulder replacement surgery for people who have very high expectations for how much they will be able to do with the artificial joint (for example, people who expect to be able to play competitive tennis, paint ceilings, or do other activities that stress the shoulder joint). The artificial shoulder allows a person to do ordinary daily activities with less pain. It does not restore the same level of function that the person had before the damage to the shoulder joint began.

How Well It Works

Most people have much less pain after shoulder replacement surgery and are able to do many of their daily activities more easily.

• The shoulder will not move as far as it did before you started having shoulder problems. But the surgery will allow you to do more of your normal activities without pain.
• After surgery, you may be allowed to resume activities such as golfing, riding a bike, swimming, walking for exercise, dancing, or cross-country skiing (if you did these activities before).
• Your doctor may discourage you from doing things that put a lot of stress on the joint.

The younger you are when you have the surgery, and the more stress you put on the joint, the more likely it is that you will eventually need a second surgery to replace the first artificial joint. Over time, the components wear down or may loosen and need to be replaced.

Your artificial joint should last longer if you do not do hard physical work or play sports that stress the joint. If you are older than 60 when you have joint replacement surgery, the artificial joint will probably last the rest of your life.

Risks

The risks of shoulder replacement surgery include:

• Blood clots. People can develop a blood clot in a leg vein after shoulder joint replacement surgery but usually only if they are inactive. Blood clots can be dangerous if they block blood flow from the leg back to the heart or move to the lungs. Blood clots occur more commonly in older people, people who are very overweight, people who have had blood clots before, and those who have cancer.
• Infection in the surgical wound or in the joint. Infection is rare in people who are otherwise healthy. People who have other health problems, such as diabetes, rheumatoid arthritis, or chronic liver disease, or those who are taking corticosteroids are at higher risk of infection after any surgery. Infections in the wound usually are treated with antibiotics. Infections deep in the joint may require more surgery. And in some cases the artificial joint must be removed.
• Nerve injury. In rare cases, a nerve may be injured around the site of the surgery. It is more common (but still unusual) if the surgeon is also correcting deformities in the joint. A nerve injury may cause tingling, numbness, or difficulty moving a muscle. These injuries usually get better over time and in some cases may go away completely.
• Problems with wound healing. Wound healing problems are more common in people who take corticosteroids or who have diseases that affect the immune system, such as rheumatoid arthritis and diabetes.
• Lack of good range of motion. How far you can move your shoulder after surgery depends a lot on how far you could move your shoulder before surgery. Some people are not able to move their shoulder far enough to allow them to do their regular daily activities, even after several weeks of recovery. If this happens, the doctor may give you a medicine to relax your muscles and will gently force the shoulder to move farther. This may loosen tissues around the joint that are preventing you from bending it.
• Dislocation of the upper arm bone (humerus). This usually only happens if the soft tissues around the shoulder are stretched too soon after surgery. To help prevent dislocation, do not allow your elbow to move past your body toward your back.
• Fracture of the upper arm bone. This is an unusual complication, but it may happen either during or after surgery.
• Instability in the joint. This can be the result of either the soft tissues being stretched too soon after surgery, or the new joint pieces loosening.
• The usual risks of general anesthesia. Risks of any surgery are higher in people who have had a recent heart attack and those who have long-term (chronic) lung, liver, kidney, or heart disease.