Shoulder Replacement Surgery — What You Need to Know Before Your Appointment

Hi, I'm Patrick Denard from the Oregon Shoulder Institute in Medford, Oregon. The goal of this presentation is to really explain in simple terms what's involved in a shoulder replacement. What's the normal anatomy of the shoulder? What is a shoulder replacement required for? How do we do it? And what does the recovery look like? So let's start with the anatomy. So rotator cuff is one of the most common things that's affected in the shoulder. We have 4 rotator cuff muscles, the infraspinatus and teres minor in the back, subscapularis in the front and the supraspinatus tendon on the front. Most commonly, the rotator cuff tear, just the supraspinatus is torn, but that can progress and involve other areas. Underneath that, we have the normal bony architecture of the shoulder. On the ball side, we have the humeral head, and then on the socket side, we have the glenoid. The glenoid, or the socket side, comes off the shoulder blade. Now with arthritis, what happens is we have the cartilage that is the top of the ball and on the lining of the socket side. And as arthritis happens, that lining or padding wears away. So you get joint space loss. So the space between the two bones becomes smaller. That can lead to pain. It also leads to stiffness. As that arthritis progresses, the muscles around and the capsule around the shoulder get very tight. Typically what you'll see on x-rays, you'll see cysts. You'll see the space between the ball and the socket narrowed, and then you often see bone spurs, particularly on the ball side, but sometimes on the socket side as well. If that gets very severe, the ball can erode into the socket where you get bone loss, and that can be quite severe and even have to be addressed with more complex solutions such as augmented implants or even bone graft. There's two major reasons for which we do a shoulder replacement. The first reason is primary glenohumeral arthritis. This is arthritis that is related to age and genetics. What you see here on the left is you see a normal X-ray of the ball and the socket. And note there's a clear space between the ball and the socket. That's because X-ray goes through cartilage. It's not picked up in the X-ray, whereas the bone is. On the right side, you see a classic example of primary arthritis. So we don't have necessarily change in the architecture of the ball, but the space between the ball and the socket is narrowed and there's a really large bone spur on the undersurface here. And that'll typically limit motion, especially behind the back, but even out to the side and overhead. It especially will limit motion behind the back because that bone spur forms first on the back typically and will catch as somebody tries to rotate behind their back. One of the other common reasons for which we do a rotator cuff, a replacement that is, is for rotator cuff arthropathy. I mentioned that the rotator cuff normally keeps the ball in the socket. If the rotator cuff is torn for a long time, especially if you have a massive tear involving 2 or 3 tendons, the ball is not as stable. So the ball wants to ride up, and that's pulled up by the large deltoid muscle on the side of the shoulder. Over time, that changes the mechanics of the shoulder, and then there you therefore get arthritis. And it's classically seen in this X-ray here. The ball's sitting up. You see a little bit of a bone spur, not as severe as we saw before. Still some joint space remaining, but you start to see rounding off of the ball. And on the, the acromion bone, which is the bone on the top, we start to see that it gets worn as well. So there's two major types of shoulder replacement. On the left is what I call an anatomical shoulder replacement, and on the right is what I call a reverse shoulder replacement. Anatomical shoulder replacement we do when the rotator cuff is intact. We replace a metal ball and then typically a plastic socket, although there are some alternatives, but typically it's a plastic socket. The idea there is you're restoring the anatomy. Important thing there is you have to have a good rotator cuff and you have to have enough bone support on the socket side to support that implant. A reverse implant, we put a ball on the socket side and a stem with a cup on the arm bone side. I use that when there's a rotator cuff problem Sometimes when there's a fracture, when somebody breaks the bone and things aren't as stable, or in cases, as I mentioned, where the socket is really worn so there's effectively a stability issue. Okay, now let's go over this again. Let's watch some animations about what's involved in a shoulder replacement. So this is a schematic video or an illustrative video that give you a better idea of what's involved in a shoulder replacement. We talked about how in the shoulder joint, You get the ball side and the socket side, so you have the humerus and the glenoid, and again, the cartilage becomes diseased. That leads to joint space narrowing in the typical case of primary glenohumeral arthritis. So as you can imagine, the goal is to replace those surfaces only and to preserve the remaining bone. So we make an incision in front of the shoulder about 4 inches long, go between the muscles, First thing we do after we get inside the shoulder is we remove the diseased ball side. That gives us access to the socket. We try to remove as minimal as bone as possible. Then typically we'll place a plastic socket, which is made of what's typically a polyethylene component, and then go back to the ball side, put on a metal ball. Now typically these contain nickel. There are titanium options if somebody has allergies to this. But again, the goal here is to restore the anatomy, to simply put it back as close as we can to what it was many years ago. This typically leads to significant improvement in pain and improvement in function. You note there, you see that tissue repaired in the front, that's a subscapularis tendon. We have to take that down to get inside of the joint to really see. So that's why you're in a sling afterwards, partially for the components themselves, but primarily it's for that tendon to heal so you can have good long-term function because that's the rotator cuff in the front of the shoulder. Okay, now that we understand what's involved in an anatomic shoulder replacement, let's talk about what's involved in a reverse shoulder replacement. So similar type of video illustration I'm going to give you here to help explain it. Again, same incision right in front of the shoulder. Procedure takes about the same time. Uh, actually reverse shoulder replacement takes a little bit less time than an anatomical shoulder replacement because it's— there's a little bit less soft tissue balancing that has to occur. So typically this takes about 45 minutes whereas a An anatomic shoulder replacement will take something more like an hour. Again, 4-inch incision in front of the shoulder. We can use a cut guide, uh, if needed to remove the diseased cartilage. Uh, that gives us better access into the joint. But then rather than putting a plastic socket onto the, uh, glenoid side and cementing that into place, we will put what's called a base plate. That base plate is typically secured into the bone with screws. This really provides really robust fixation and stability. And then onto that base plate, we can put the ball. And that is called, also called a glenosphere. That's really the, where the ball becomes fixed now, rather than having the ball move around inside the joint, because the ball is fixed and then you have the cup side, that's how you get the stability back in the shoulder. And that's why it can compensate for a rotator cuff problem. Once that ball is on, we then go back and prep the humeral side, which is the cup side. We use, we basically size based on the individual person. And then a stem, once it's prepped, is press fit into the bone, meaning that no cement is typically required, or at least in over 95% of the cases, no cement is required. We use patient-specific sizes. And then once all the components are dialed in, we place the final components, placing the glenosphere on the socket side and the stem with a cup on the arm bone side, again, in a press-fit manner. There's a plastic liner that goes between, so it's not metal on metal, and we can adjust and fine-tune and use spacers if needed. But again, the stability is really restored to the joint in this manner. Now that we understand what's involved in the procedure, let's talk a little bit more about prepping for the procedure and the actual logistics. So I think success really depends on preparation, so I really advocate that people think about the, the procedure ahead of time. That starts with things like nutrition, taking vitamin D, multivitamin, et cetera. I have a long list of checklists in my packet that everybody should go over prior to procedure that really tries to outline thinking about this procedure really a month in advance. We do a preoperative visit typically within a week or two prior to the procedure. That's an opportunity to go over any additional questions or clarifications. We also, at that time, give you your prescriptions to go home with so you're prepared in advance, get you fit for a sling, and then ideally we like to do a physical therapy visit at that time so that you can kind of understand some of the exercises afterwards. It's important to try to minimize the risk of infection. I take several steps on my end with antibiotics and several things we do based on all the evidence out there at the time of the procedure One thing I ask all my patients to do is to put benzoyl peroxide on the skin for 3 days prior. The reason for that is that benzoyl peroxide is effective against the most common cause of shoulder infection. That helps get rid of a bug that lives in the skin called C. acnes, also associated with acne. Uh, so you can imagine it's more common in men and particularly high testosterone levels, but all people are, are at risk. And this is one step we can really take to eliminate the amount of this bacteria that lives in the skin. And with all the steps we take, our infection rate is less than 1%. The night prior to the procedure, you don't want to eat or drink anything. You take your normal medications. The only exception to that would be lisinopril or losartan because those can drop your blood pressure. So if you take that in the evening or the morning, you don't want to take that in the evening or the morning, uh, of surgery. Now the day of surgery, you typically are gonna have to check in 2 hours prior to the procedure. That'll be outlined in the packet. Again, you can take your morning meds except lisinopril. Most of my patients go home the same day. We've looked at our data really closely and actually 87% of our patients were able to have, or able to go home the same day. And we tracked our complications and they're very low compared to national rates. So we have a high success rate with that. Now the location, whether it's at a surgery center or at the hospital, really depends on insurance restrictions more than anything. But in either case, somebody should most commonly be prepared to go home the same day. Reasons to not be able to go home the same day, if somebody has no help at home, they live alone, or if somebody is wheelchair-bound, for instance, or if they have severe medical problems. Most people have some degree of medical issues that they're dealing with chronically, but we're talking severe problems such as really bad heart problems or really bad kidney problems. And with all that, again, 87% of people go home the same day. What are the risks? Okay, so infection, as I mentioned, our infection rate is less than 1%. We take several steps to eliminate that. I can— I'm happy to go into detail with that with anybody, but suffice it to say, I've reviewed all the literature and, and use a really, uh, uh, multi-step process to, uh, review that. And our infection rate is really low compared to what's published out there. Generally, if you look at studies, it'll be between 2 and 4%, and our infection rate is less than 1%. You can have bleeding or hematoma after the procedure. That's something that is uncommon, but sometimes we'll see people get some swelling around the incision with some blood underneath. The need to go back for the procedure, that typically only ha— that is back in and wash it out again, I'll typically see that maybe 1 or 2 times a year, so less than 1%. Blood clots are rare after a shoulder procedure. They're much more common after lower extremity procedures like a total hip or a total knee. But they can occur. What do we do to risk— reduce the risk of that? First of all, I have people wear TED hose, which is a compressive stocking around the legs for 2 days. During the procedure, we use sequential compression devices, which are essentially a device that squeezes on the calves. I ask you to be moving right away, so walking even the day of the procedure is a goal. And then lastly, I have people take aspirin for a couple of weeks. Nerve injury is reported after a shoulder replacement, but is generally very low in our practice. Let's talk about some specific risks. So the risks of an anatomical prosthesis, as I mentioned, the anatomical prosthesis relies on the rotator cuff. So if you look at the rotator cuff, it can sometimes fail to heal. Literature and our patients, that's about 5% of the time that that subscapularis in the front does not heal. Now, that doesn't necessarily mean somebody's gonna go on to another procedure, but it can happen. Again, that rate is low, but if it does happen, people cannot always, they will not always have as good a function, and occasionally their stability will be compromised and they'll have to go on to what's called a reverse shoulder replacement. The long-term complication of an anatomical shoulder prosthesis is that the components loosen. That's typically the socket side loosening over time. Sometimes the rotator cuff can also fail over time if it develops a tear later down the line. Aligned through natural degenerative process. If you look at the overall amount of, or percentage of patients who still have a shoulder replacement in 10 years later, that's 90%. If you look at 20 years, it's about 70, 80%. In other words, these are risks, but 90% of the time the implant will still be in 10 years later, and 70, 80% of the time it'll be in 20 years later, so track record is very good. Now let's talk about risks that are specific to a reverse shoulder replacement. Dislocation is reported in literature. As you can imagine, because you now have a ball that's, that's very fixed in the cup, that prosthesis could become disengaged due to somebody falling or because of soft tissue problems. Overall in the studies, that's about 3 to 4%. Again, our rate is very low here. We take a lot of steps to reduce this, and our risk of dislocation after shoulder replacement is less than 1%. Acromial stress fracture. This is a problem that, that is, that does occur in people, and this is about 3 to 4% in the literature. Our rate is consistent with what's in the literature. What happens here is that the bone above, the acromion bone, undergoes stress because with the shoulder replacement, the reverse, you're actually lengthening the arm because you're bringing the arm down around that ball. So that puts some stress on the acromion bone. I liken it to a runner. If you just go out and run right away, all of a sudden you're gonna get stress in the bone and people can develop a stress fracture. Now if that happens after this procedure, it can be quite painful. Typically this will happen 3 to 4 months after procedure, but it can even occur way down the line. How can you prevent this one? Well, there's some risk factors we can't control. Uh, osteoporosis or bone, poor bone quality is one. There are things that I do to reduce that risk by where I put the implants. I can't prove, but I believe that early motion, really aggressively early, can raise the risk of this. Another thing that I do is I try to advocate that people start doing some strengthening in advance of the procedure. Much like we talked about the runner, if you kind of gradually move into it, you can simulate the bone, right? And so what I'll try to tell people is oftentimes they're in pain and they can't raise their arm, but if you can just get against a wall and push against that wall and hold it 10 seconds with your elbow out to the side and mimic like you're pushing against that wall really forcefully. If you can do that a couple of times a day for the month prior, perhaps that'll help kind of activate that muscle and that bone to lower the risk of fracture afterwards. Can't be proven, but again, I think it's a good step to take. What happens if you get a stress fracture? We typically manage that without surgery. It usually is a setback. Sometimes people won't do quite as well. They will generally still get above shoulder level, but they may only get up to here. They may not get quite as high as they would otherwise. Generally with a reverse shoulder replacement as well, people don't do as well behind the back compared to an anatomical. That's because you have the rotational effect because you're kind of fixed around that ball. Our data, 50% of people will get to their belt line. 50% of people will be below. It typically also relates to where you start. So if you start really high, you can reach all the midline of your back, you're typically gonna have a better chance. So that's something you should definitely know about with a reverse compared to an anatomical. You look at the two, pain relief is very similar, overhead function and out to the side is very similar, but you typically don't do as well behind the back. And you typically, you have the risk of stress fracture, but the converse is you don't have the risk of the rotator cuff problem. And you don't have the risk of the socket loosening as much. Long-term complication, the most common complication is component loosening. That is also rare. If you look at the data, 90% of these implants are also in 10 years later. And there's data from Australia that compares an anatomical to reverse. They're very comparable, how many are, are both in at like, say, 7 years after the procedure. It's actually slightly higher with the reverse, but again, very similar. Alternatives to shoulder replacement. Hopefully you've talked about these or considered these prior to watching this, but these are the basic orthopedic principles: anti-inflammatories, injections, and rehab. Injections will typically consist of cortisone. Sometimes you can try platelet-rich plasma for arthritis, particularly if it's mild arthritis. That's where you take blood off your own body, spin it down, get the growth factor-rich area, and inject it back in the shoulder. That's a low-risk, thing to do, but it is not covered by insurance in 2022, so it's an out-of-pocket expense. And again, it's typically better for milder to maybe some moderate arthritis, but severe arthritis, it's not likely to help. Rehab after shoulder replacement, whether it's an anatomic or reverse, it's 4 weeks in the sling for me. Again, that's to protect that subscapularis muscle in the front. People can move their hand, their wrist, but their elbow right away so they can go up and down. They're just not moving their shoulder overhead. Typically, I'll tell people they can take the sling off and rest their arm at the side, like in an armchair, mimicking the position of the sling just like you see in the picture here, but picture that sling not being there. I think that's nice because you oftentimes get a little bit of pressure from that sling on the inside of the arm, so that gives you a little bit of break from that. But if you're up moving around or sleeping, sling needs to be on. That's probably the worst part of the recovery is sleeping with a sling. And then range of motion really progresses when you come out of the sling at 4 weeks. How do we do with pain after procedure? The good news is that we do a pretty good job controlling pain after a shoulder replacement. Many people think, okay, this is a big invasive procedure, make an incision, this can be very painful. Actually, people often find the recovery from a shoulder replacement easier than a rotator cuff repair because now instead of trying to pull a tendon over and get to heal, which causes some stretch and pain. We're taking out the arthritis and there's, you're just, you're removing the pain generator. I do use a multimodal approach to pain, so we use several different medications that hit pain from different pathways. By doing that, we're able to have very few of our patients need an extended amount of narcotics, and actually 30% of those will take no narcotics after a shoulder replacement. So if you're looking for a narcotic-free surgery, this is actually possible with the approach that we use, and that includes medications prior to the procedure, uh, what we do during, and then medications after the procedure. Decisions at the time of the procedure is whether to have a nerve block or local anesthetic prior to the procedure. And what is that? People ask about this all the time. So nerve block, picture on the left, what you're doing is you're injecting a numbing medication or an anesthetic up at the neck where the brachial plexus comes off. The brachial plexus are the nerves that come down the neck and they run down to the shoulder. As you can imagine, if you inject local anesthetic there, or numbing agent, you're going to have complete blockade. And many times you'll have loss of motor function, meaning that the arm will feel kind of floppy afterwards. Positive side of that, complete pain control. How long does that last? 12, 18 hours, sometimes a little bit more, but generally in the 12 to 18 hours. If you look at the studies. Downsides of this, there is a risk of nerve injury 'cause you're injecting that around the neck. Now, it's generally pretty safe because it's done with an ultrasound machine, so the nerves are visualized. If you look at studies though, a couple of percent of people will have some degree of symptoms, that is persistent numbness in their hands for a few months after procedure. That generally will go away over time. The risk of a permanent or severe injury is low, it's less than 1%. Other option is to do local anesthetic. Similar, you still take a numbing medication, but rather than putting the neck, you put it around the shoulder. One example is putting around the suprascapular nerve, which is right up here, right next to the shoulder itself, and then injecting around the skin to surround the shoulder. Now, if you look at that, you won't have risk of nerve injury, but because you're not providing as complete of a blockade, your pain afterwards will generally be a little bit higher. So people who have the local injection typically or often will require more pain medication afterwards. Now, if you go out to say 24 or definitely 36 hours, there's no difference between the two. So what I'll typically tell people is a lot of this comes down to your philosophy. If you're really worried about the experience of pain afterwards, if you feel like you got a low pain tolerance, if you got a long way to travel, I think doing the nerve block is probably the best way to go. Or also if you're just really sensitive to narcotics, if you get nauseated really easy with narcotics. If your mindset is that, you know, you feel like, I really wanna, I'm really just gonna try to get through this with minimal risk as possible, and you have the attitude that pain will pass, so to speak, then I think in that case perhaps a local is the best for you. So it's an individual choice. I think the important thing is that somebody's informed about what the options are. What does the recovery look like? Typically, uh, the, the maximum recovery, as you can see in the graph here, will actually be reached by 6 months. This is an interesting graph here. What you'll see is that people, once they hit about 6 months, that's pretty close to where they are long-term. You might see a slight improvement beyond that, but most of the recovery is by 6 months. Now you got to ignore the 3 months here on this graph because there's very few patients we had numbers on, so because I think it's falsely elevated. Really kind of picture that line going up from pre to 6 months. And if you kind of draw that line out, what you'll notice is that from a recovery perspective, about 70 to 80% of that recovery is in the first 3 months. So 6 months is generally maximal, but most of it occurs in the first 3 months. That also is the same with pain. This graph here, this is after reverse shoulder replacement. You can see on average people have about a 6 out of 10 pain, and that will reduce down to a 2 or less, and that'll typically occur within the first 3 months with regard to pain, but most of that's even occurring in the first couple of weeks. If you look at data, there's actually— the studies say that if somebody's saying it's a 1 or 2 pain, they're really— that's really not pain that bothers them with their activities at all. So most of these people are doing very, very well. Self-care. People are worried about, "How am I going to take care of myself after a shoulder replacement?" Well, remember, you can move the hand, wrist, and elbow right away. That allows you to do things like drink a glass of water. You can type. You can write. I talked to you earlier about taking the sling off when you're on the couch so you can rest it there. And then you can shower 2 days after procedure. At that time, you let water run over the bandage, take the bandage off. There's absorbable sutures underneath the skin with glue over the top. So what I'm trying to say there is you can do most of your activities of daily living right after the procedure. So return to activities, I really advocate walking right after, even the day of the procedure and the day after. I want you moving around. That really helps encourage blood flow, kind of just get your general health back in line. For activities of the shoulder, it's going to be a gradual advancement. We mentioned sling for 4 weeks, then you're typically doing motion and progressing up on strengthening. If you look at sport-specific activities, this is going to vary depending on the sport. It can be anywhere from 4 to 6 months. A typical timeline for golf would be putting at 3 months, chipping at 4 months. Full swing is going to be 5 to 6 months after shoulder replacement, maybe a little bit earlier than a rotator cuff repair. Tennis, very similar. You can do volleying in about 3 months, do some light swinging at about 4 months, but really full swing or overhead serve is gonna be 6 months. Now overhead serve, something like this is much more motion required for something like that, so that's harder to get back to after reverse shoulder replacement in particular, but we do have many patients that can get back and still do that. Most patients will be able to return to golf, general activities, fishing, swimming, et cetera. So I hope this gives you some good information to think about and be prepared for your shoulder replacement. So thank you for listening, and I wish you a speedy recovery, and please contact me at any time if you have any other additional questions.