Monday, March 21, 2011
TOPIC: Advances in Shoulder Surgery
Matthew Willis, MD: orthopaedic surgeon
news notes via www.webmd.com
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:
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:
Other causes of shoulder symptoms
Overuse and acute injuries are common causes of shoulder symptoms. Less common causes of shoulder symptoms include:
Treatment for a shoulder injury may include first aid measures, physical therapy, medicine, and in some cases surgery. Treatment depends on:
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.
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
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:
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 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.
The risks of shoulder replacement surgery include: