your shoulder

Introduction

The shoulder, the knee and the hip joint are some of the most important joints in the human body. Quality of daily living depend on painfree and good range of motion of these joints. As a joint pain sufferer, you’re undoubtedly used to making decisions dictated by limitations. Osteoarthritis, inflammatory arthritis and other debilitating joint conditions can interfere with just about every aspect of your life – from walking, to exercising, working, enjoying time with family and friends, to getting a full night of sleep. But any surgical treatment is a big step. Before doing surgery on one of these joints, we believe that knowledge and preparation as to what to expect pre- and post- operatively will make your recovery easier. Medical professionals expect you to have questions, concerns, hopes and expectations.

Please note that Limacorporate S.p.A. is a manufacturer of medical devices and does not practice medicine. The purpose of this guide is to provide you with more information so that you can proceed with confidence as to what to expect along the road to recovery, and what you can do to maximize your outcomes. Make sure to go over pertinent information with your care team as well. The more you know, the better prepared you’ll be to take charge of your comfort and mobility again.

Anatomy

The shoulder is basically a ball and socket joint; on one side there is the humerus with its humeral head, on the other side the scapula with the glenoid bone; in the healthy state, both are covered by cartilage and articulate with each other. The joint capsule, ligaments, and shoulder muscles with their tendons stabilize the joint. The main moving forces are provided by the deltoid muscle and the rotator cuff, four muscles centralizing with their combined forces on the humeral head in the glenoid cavity.

Joint Pathologies

There are differences between degenerative (age-related, wear), inflammatory (joint degeneration by inflammatory arthritic desease, see below), traumatic (fracture, muscle or legement rupture) and posttraumatic disorders (joint incongruencies after healed fractures or bone necrosis, see below) of a joint. They all end in a joint incongruency, affecting daily painfree use.

OSTEOARTHRITIS:

This is an age-related “wear and tear” type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones wears away and the bones then rub against each other. Over time, the joint slowly becomes stiff and painful. Unfortunately, there is no way today to prevent the development of osteoarthritis. It is a common reason people undergo joint replacement surgery. Osteoarthritis may also be caused or accelerated by subtle irregularities in how the joint developed in childhood.

RHEUMATOID ARTHRITIS:

This is a disease in which the synovial membrane that surrounds the joint becomes inflammated and thickened. This is an autoimmune process that can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed “inflammatory arthritis”.

POST-TRAUMATIC ARTHRITIS:

This can follow a serious joint injury like fractures and / or muscle/legamentous tears. Fractures of the bones that make up the joints may damage the articular cartilage over time resulting in joint incongruency followed by degeneration of the cartilage because of eccentric wear. This can causes pain and limited joint function.

Special shoulder joint pathologies

ROTATOR CUFF TEAR ARTHROPATHY:

This is a disease in which the synovial membrane that surrounds the joint becomes inflammated and thickened. This is an autoimmune process that can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed “inflammatory arthritis”.

AVASCULAR NECROSIS (OSTEONECROSIS):

Avascular necrosis is a painful condition that occurs when the blood supply to the bone is disrupted. Because bone cells die without sufficient blood supply, osteonecrosis can ultimately cause destruction of the shoulder joint and lead to arthritis. Chronic steroid use, deep sea diving, severe fracture of the shoulder, sickle cell disease, and heavy alcohol use are risk factors for avascular necrosis.

Symptoms

The decision to have joint replacement surgery should be a cooperative one between you, your family, your family physician, and your orthopaedic surgeon. There are several reasons why your doctor may recommend joint replacement surgery. People who benefit from surgery often have:

-Severe joint pain that interferes with everyday activities, such as walking, running, reaching into a cabinet, dressing, toileting, washing or being limited in sports activities.

-Moderate to severe pain while resting. This pain may be severe enough to prevent a good night’s sleep.

-Loss of range of motion of the joint and/or weakness in movement.

-Failure to substantially improve with other treatments such as anti-inflammatory medications, injections, physical therapy or perhaps arthroscopical treatment.

Generally, the pain associated with osteoarthritis develops gradually, although sudden onset is also possible. The joint may become stiff and swollen, making it difficult to bend or straighten the hip or the knee or raise the arm. Pain and swelling can be worse in the morning or after a period of inactivity. Pain may also increase after activities such as walking, stair climbing, or kneeling for hip and knee and overhead activities in shoulder joint degeneration. The pain can cause a feeling of weakness in the limb. Many people report that changes in the weather also affect the degree of pain from osteoarthritis.

Prosthetic Implants

SHOULDER JOINT RECONTRUCTION (ARTHROPLASTY)

Advanced arthritis of the glenohumeral joint can be treated with shoulder replacement surgery, in which the damaged parts (humeral head and glenoid) of the shoulder are partially removed and replaced with artificial components, called “prostheses”.

There are several possibilities for shoulder reconstruction surgery :

-Hemiarthroplasty: Just the head of the humerus is replaced by an artificial component.

-Total shoulder arthroplasty: Both the head of the humerus and the glenoid are replaced. A polyethylene “cup” or a metal back component with a polyethylene liner is placed into the glenoid and a metal “head” is attached to the top of the humerus. A functional deltoid muscle and functional rotator cuff are required for this type of shoulder replacment.

-Reverse total shoulder arthroplasty: In a reverse total shoulder reconstruction, the materials of the socket and ball are “reversed” compared to a conventional total shoulder arthroplasty. The metal “head” is fixed to the glenoid and a polyethylene cup is fixed to the upper end of the humerus.A reverse total shoulder replacement works for people with rotator cuff tears, cuff tear arthropathy and osteoarthritic joints. The more recent designs inverted materials, so polyethylene glenosphere will meet a metal humerus liner. A functional Deltoid muscle is needed for a reverse shoulder replacement. Range of motion and stability also depend on the remaining anterior and posterior parts of the rotator cuff muscles.Depending on bone quality and the diagnosis, all these types of prothesis are possible to implant with or without (“stemless”) a humeral stem.

-Resurfacing Shoulder Arthroplasty: The damaged surface of the humeral head is replaced with a smooth, perfectly round metal cap. Many replacements now can be achieved with a “resurfacing” which allows more of your own bone to be maintained.

All above mentioned shoulder prosthesis can fail for many different reasons, such as trauma, infection, aseptic loosening, rotator cuff failure in Hemi and Total Shoulder Arthroplasty, component dislocation and wear. When this occurs, further surgery, called “revision prosthetic surgery” with the implantation of a new prosthetic implant could be necessary.

About Surgery

MEDICATION:

Check with your surgeon about whether or not you should take your daily medications before surgery. Before surgery, it is common for you to receive an injection of medicine by your anesthesiologist that will help relax; this medicine may make your mouth feel dry. After receiving the medicine, you will probably be asked to remain in bed.

WAITING AREA:

Your family and friends will be told where to wait while you are in surgery. After surgery, your shoulder surgeon will talk to your family and let them know how you are doing. Family and friends are usually able to see you when you have returned to your room after a short stay in the recovery room.

OPERATING ROOM:

Please discuss the anesthesia procedure with your anestheologist . You will stay in a pre-surgery area before going to the operating room where you may have an intravenous (IV) line placed in a vein so you can receive fluids and medications during the surgery. When the operating room is ready, you will be taken to the operting room and helped onto the operating room table. Your blood pressure may be taken and you may have an oxygen mask placed over your face.

There will be many people around helping to prepare you for the surgery. If you are receiving general anesthesia, you will fall asleep so that you will not feel any pain or be aware of anything during the surgery. Other types of anesthesia will numb only the area of surgery, so you will not feel pain. You may also receive medicine that will allow you to drift in and out of sleep.

Ongoing Surgery

You will need a local or regional or general anesthesia for shoulder replacement surgery. Your anesthesiologist will discuss the options before surgery. Feel free to ask questions for any concerns that you may have.

Local or regional anesthesis numbs the shoulder area while general anesthesia puts you to sleep. You will be placed on the operating table in what is often called a “beach-chair” position with your chest in 30 to 45° of inclination.

Shoulder replacement surgery is often done through an incision on the front of your shoulder, which is called an anterior approach. The surgeon cuts through the skin and then isolates the nerves and blood vessels and moves them to the side to protect them. The muscles are also moved to the side to give a complete view to the joint and allow the surgeon to replace the damaged parts of your shoulder joint. Your surgeon will discuss alternative surgical approaches, depending on your diagnosis, physical condition and lifestyle. Feel free to ask for more information on any concerns or questions you might have.

Recovery after Surgery

The following contains only a general description of the post-operative activities that are usually suggested by health care professionals . Please do not use this information as a medical prescription of postoperative care; always refer to your surgeon’s directions for adequate post-operative therapy.

 

As time passes, you have the potential to experience a reduction in joint pain and a significant improvement in your ability to participate in daily activities.

When will I be able to return to work?

Returning to work can be as soon as 2 weeks or as long as 3 months, but your specifi c timetable will depend on your job and your surgeon’s recommendation. Your surgeon will determine when you will be able to return to work based on your job responsibilities. Returning to work will also depend on your commitment to rehabilitation.

What will my recovery be like after surgery?

Therapy is crucial to proper rehabilitation of your shoulder. Your surgeon along with a team of therapists will work to design a rehabilitation program specifi c to you. Therapy may begin as soon as the day of surgery and, subject to your surgeon’s recommendation, can last several months post-surgery. Your commitment to following your therapy program will determine how well you recover.

Will I be able to care for myself after surgery?

It is good to have someone help you with daily activities the fi rst few days or weeks after surgery. You should be able to return to normal activities such as dressing and grooming within a few weeks.

When will I be able to shower?

In most cases your surgical incision will be closed with absorbable sutures and covered with surgical glue or staples. Most of the time, you will be able to shower in about 2-3 days after surgery, but you will not be allowed to submerge your incision in water. A bandage should cover the incision until the 2 week follow-up appointment with your surgeon. Your surgeon will advise you of exactly when you will be able to shower based on the type of closure performed.

When will I be able to drive again?

While on any type of narcotic pain medication, you will not be able to drive. You will also be required to wear a sling and there are different state laws that allow you to drive or not with a sling. Your surgeon will advise you when you will be able to drive again, most likely in 4-6 weeks approximately.

How long is the recovery period after a shoulder replacement?

You will generally be in the hospital for 1-3 days. When you leave the hospital, you will be in a shoulder sling and your arm will be sore for several weeks. Your surgeon along with the rehabilitation team will work with you to start your rehabilitation. They will work with you on exercises that you will do at home as well as in the clinic that will help you recover. Total recovery is patient specifi c, but generally ranges from three to six months.

What is the physical therapy process after shoulder replacement?

Working with a physical therapist will be critical in your total recovery from shoulder replacement surgery. Your rehabilitation schedule may start as soon as the day of surgery while you are in the hospital. You will continue to work with a physical therapy team once you leave the hospital. Your surgeon’s offi ce will set this up for you. You will be given exercises to perform at home, which are designed to increase your range of motion, mobility and strength. Your surgeon will provide you with a list of “do’s and don’ts” after surgery and your rehabilitation team will work with you to design a specifi c program based on your individual situation.

Your New Joint

In the days following surgery, your orthopaedic surgeon, nurse practitioners, physician assistants, nurses and physical and occupational therapists will closely monitor your condition and progress. You’ll spend a great deal of time exercising your new joint. Gradually you will become increasingly mobile and confident in your new joint. When you get home, keep up the exercise program you learned in the hospital according to the directions from your surgeon and physical therapist. You may see your physical therapist for several in-home treatments. Your physical therapist will also make recommendations about your safety, review your exercise program and continue working with you on range of motion.

It is recommended to expect to regain strength and endurance as you begin to take on more of your normal daily routine. However, your orthopaedic surgeon and physical therapist will outline a specific plan that you should follow. Your post-surgical pain should be temporary.. Most patients with artificial joints are able to enjoy many activities, though some should be avoided. In general, high impact exercises, such as running, jumping, heavyweight lifting, or contact sports, are not recommended. Participating in these activities, or activities like them, may damage your joint or cause it to wear down much more quickly. Please always ask your surgeon because you have to remember that some activities are not adviseable after you have been prosthesized. Low impact activities such as swimming and walking are encouraged, subject to your surgeon’s recommendation.

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