Thinking About Shoulder Replacement? Watch This First

Hi, I'm Dr. Patrick Denard. I'm a shoulder specialist at the Oregon Shoulder Institute. So I do 100% shoulder in my practice as an orthopedic surgeon. I've published multiple articles and done over 10,000 surgeries. And here I want to talk about commonly asked questions for shoulder replacement. Because if somebody's going to go into shoulder replacement, they really need to understand their condition, understand what all the options are, what's involved. So first off, what is the anatomy of the shoulder? What's actually being replaced with a shoulder replacement? And here we're talking about the glenohumeral joint. Now the glenohumeral joint is the ball and socket joint of the shoulder. The shoulder is the most mobile joint in the body, which is really, really cool because it allows us to put our hand in space all over, reach things, and do a variety of functions. But unfortunately, due to arthritis most commonly, you can get breakdown in the cartilage. That leads to loss of range of motion and pain. And when we do a shoulder replacement, we do that through an incision in the front of the shoulder that works on the ball and socket joint itself. There are other joints in the shoulder that are not affected. For instance, there's your acromioclavicular joint, which is a very immobile joint that helps position your shoulder in space. There's also the scapulothoracic joint, which is the shoulder, uh, joint between your shoulder blade and your rib cage. It's not a true joint, but it is a mobile structure. So when is a shoulder replacement needed? Well, it's an individualized decision, but generally speaking, the number one driver for people to see me for shoulder conditions in general is lack of sleep. As you know, lack of sleep affects your mood, it leads to fatigue, and importantly, it affects your recovery and also your overall health. It's increasingly recognized that if you're not getting good sleep, this has a really big detriment on your overall health. So when is a shoulder replacement needed? Well, when conservative measures have not worked, things like anti, anti-inflammatories, activity modifications, and physical therapy. We can also consider injections, but essentially it comes down to a decision where somebody is having a daily impact on their quality of life with limited range of motion and pain that is limiting their ability to either work or take care of themselves or do the things that they love. So what are the types of shoulder replacements? Well, the most common shoulder replacements are two broad categories. There's anatomic and there's reverse shoulder replacement. An anatomic replacement most commonly is total shoulder. We're working on both sides of the joint. As the name sounds, the goal there is to restore the anatomy of the shoulder. What I mean by that is removing the diseased cartilage, by replacing the ball with a metal ball most commonly, and on the socket side, placing a high-strength plastic most commonly that restores the joint, that limits pain or reduces it by eliminating the arthritis, and then improves range of motion because there's improved gliding of the joint itself. In some scenarios under the anatomic category, there's what's called a hemiarthroplasty. Now the goal there is to simply replace the ball side and let the socket be alone. That is a consideration in people who have a socket that we are worried about placing a total shoulder replacement. In particular, that is a long-term sort of consideration. That's typically a consideration somebody who's very young where we're worried about the impact of an implant for decades to come in the future. However, there are limitations with a partial replacement or a hemi shoulder arthroplasty. And that is simply the lack of pain improvement. You can get improvement in pain, but it is not as high as you get when you replace both sides of the joint. Additionally, with a hemiarthroplasty or partial shoulder replacement, you see that the recovery is much longer. So for instance, on average with a shoulder replacement, you're doing both sides of the joint, that's going to be on the order of several months. But with a hemiarthroplasty, it is many, many months. One study, for instance, showed that it was 18 months on average. So it's a consideration in some people. In particular cases, particularly the young heavy lifter, but it's much less common. Now the second category of shoulder replacements, it's actually about 70% of the shoulder replacements done in the United States at this point in time, is reverse shoulder replacement. With a reverse shoulder replacement, we put a ball on the socket side and a similar cup on the arm bone side. The goal here is also to remove arthritis, but additionally it provides stability to the joint because normally the rotator cuff provides stability to the joint. However, there are some situations where the rotator cuff is compromised or the socket cannot accommodate a plastic socket. And in those cases, a reverse shoulder replacement restores stability and provides pain relief. And the reason it's become so common is there's many reasons to do that. Rotator cuff problems in association with arthritis, particularly where there's an irreparable rotator cuff tear. You'll see this in people who break their shoulder, reverse shoulder replacement for proximal humerus fracture, it's called, or in some cases what's called primary arthritis with problems with the bone itself. And in those cases, reverse shoulder replacement is the most reliable solution. So how successful is shoulder replacement? Well, you think about this in a couple of ways. Number one is patient satisfaction. If you just look at satisfaction or pain relief, it's a very successful procedure. Over 90% of people are going to be happy having relief of pain in their shoulder and improved range of motion. Now the range of motion that one achieves after a reverse shoulder replacement is different than that after an anatomic replacement. The best anatomic replacement will provide better range of motion than the best reverse shoulder replacement if you look head to head. However, those differences are pretty small. If you look at forward elevation or the ability to reach up, it's a very small difference. The biggest difference comes in the ability to reach behind the back. That has gotten better and better as reverse shoulder replacement has become more and more sort of anatomic in the design. But nonetheless, with reverse shoulder replacement, I commonly tell my patients that to expect slight limitation of rotation behind the back compared to that with an anatomic replacement. Now, the other way we look at this or talk about the success of a shoulder replacement is survival. And what we mean there is survival of the implant, not survival of the patient. So somebody who has a shoulder replacement, if you just look at 10 years later and say, what are the odds they're still gonna have that shoulder replacement in? It's about 90% at 10 years. If you go out 20 years, it's 70 to 80%, meaning that the probability that the implant has not been revised is very, very high. So very successful in those terms. But when it comes to an individual, you have to think about this not just in broad strokes of population, but what are the demands of the individual person? So if somebody is 75 undergoing a shoulder replacement, it is very unlikely that they're going to need a shoulder replacement again in their lifetime. However, if somebody is 55 years, for instance, the odds that they need another shoulder replacement in the future is quite high based on their life expectancy and a higher activity level. So what we do is think about that in advance. So I'm always thinking about, okay, how are we going to solve the person's problem now, but also how are we going to set ourselves up in the future if something else needs to be done? And that comes down to making decisions about the type of replacement, but also using implants that are bone-preserving. Another question is, how do the results of a complete shoulder replacement compare to a partial replacement? I kind of spoke about this earlier, but the bottom line is you see that both types of replacements work. But with a partial replacement, you don't get as good of pain relief. So when you look at head-to-head, a partial replacement versus a total shoulder replacement working on both sides of the joint, you actually see better survival of the implant, better outcomes, and long-term follow-up. The additional thing you see is that with a partial replacement, because you're just working on one side of the joint, it's a slower recovery compared to a total shoulder or complete shoulder replacement, meaning working on both sides of the joint. So for instance, 18 months on average for full recovery with a partial replacement. When you're talking about a complete shoulder replacement, you're really talking about complete pain relief in 3 to 4 months, maximal recovery at 6 months. How common is shoulder replacement? Well, it's much less common than the hip or knee replacement. Most common joint replacement in the United States is knee replacement. After that is hip replacement, and then shoulder follows after that. There's a pretty big drop-off, but I would say that's really been increasing in recent years as more people become shoulder specialized and have the ability to treat shoulder conditions. And quite honestly, one of the big things has been that the implants or ability to treat people has just become much better. That said, the majority of shoulder replacements are still done by people who do very, very few. So if you look at high-volume surgeons, I do 300 shoulder replacements a year. A high-volume surgeon varies on the study. One study says 120 a year. Only about 30% of shoulder replacements in the United States are done by high-volume surgeons. Now, is that important? I believe it's actually very important. The data shows when you look at shoulder replacement, as well as across other specialties, that somebody who is specialized and has a higher volume of a procedure has lower complications. Really what it means is that you can just get into the nuance. Somebody who's just specialized in the shoulder is going to really be paying attention to all the nuances and literature in that area. And then of course have the experience of not only be able to, uh, address things in an efficient manner, but with experience comes the ability to avoid complication, which is very, very important for a patient. And getting through the surgery in a good manner, in a quick manner. So what are the complications of shoulder replacement? Well, one of the devastating complications that can occur that people want to look out for is infection. If you actually look at the data on shoulder replacement, it's somewhere between 2% and 4%. Now there are steps that can be taken to reduce this. Our infection rate in my practice is less than 1%. There's several reasons for this. Number one is we take many steps to prevent infection ahead of time. One is optimizing nutrition. Two is thinking about the bacteria around the skin by doing a prep around the skin with benzoyl peroxide. Three are the steps I take during the surgery to limit the risk of infection. That goes into preparation, how we prep the skin, how we drape everything out in a sterile field, the antibiotics we give prior to the procedure, the irrigation and antibiotics I give during the procedure. And then also important is surgical speed. There's clear data that shows that if people are slower in their surgery, the infection rate goes up. And that's because really what happens is over time inflammation goes up. The longer you are asleep and having a surgery, it creates more trauma. And it's not about moving fast, it's really about eliminating wasted movement. And if you have a team and a system and do it on a regular basis, you can make it an efficient procedure for somebody and reduce the risk of infection. Other complications that occur are much more rare. Things like bleeding, blood transfusion for me is something I never had to, have had to give to a person after a primary shoulder replacement. Only very rarely in a revision shoulder replacement setting. There's steps that we take to prevent that. But things can occur like hematoma. With reverse shoulder replacement, there's a unique complication which is acromial stress fracture. And that's because the arm is placed under the ball. That can lead to stress on the acromion bone on the top of the shoulder leading to a stress fracture. That occurs in about 4% of people. We also take steps to try to prevent that. And all that information is in my surgical packet and preparation for shoulder replacement in another video. So when it comes to surgery, what's involved in this surgery? How long does it take? Well, first off, it's an outpatient procedure, meaning you go home the same day. Over 90% of the shoulder replacements I do, people go home the same day. They recover in their own bed that night. And that's really nice because you have a lower risk of complication with that approach. Really the only reason that somebody has to stay in the hospital, or the most common reason somebody has to stay in the hospital, is if they simply have have no home support, that rare individual who does not have friends or family that can help take care of them, or they have significant limitations such as the need for a walker or the need for a wheelchair. The actual procedure takes about 45 minutes from beginning to end to perform the shoulder replacement. I make an incision in the front of the shoulder in a diagonal manner, go between the muscles, and then go inside of the shoulder and do the shoulder replacement. So after surgery, people are really worried about their self-care. They ask, say, will I be able to care for myself? And the answer there is yes. Right away after surgery, you can walk immediately. I want patients actually walking the day of surgery. They can shower 2 days after surgery. And yes, there's use of a sling, but even during that time, you can use your hand, wrist, and elbow freely, going arm up and down. That allows you to do things like type, write, drink a glass of water, feed yourself, etc. How long do you wear a sling after shoulder surgery? For me, for an anatomic shoulder replacement, it's 4 weeks. That's based on a study we did where we found that those people who were in a sling for 4 weeks had higher healing than those who did not remain in the sling and started doing early range of motion. And that's because with an anatomic shoulder replacement, you're relying on the rotator cuff. And when you go into the shoulder, you typically take down the subscapularis, which is is a rotator cuff muscle in the front of the shoulder. I take that off with a fleck of bone called an osteotomy to get inside of the shoulder. That allows you to see very clearly, but you need to repair that back down and have that heal. So by being asleep for 4 weeks, you protect that healing from occurring. Now, there are people who are also looking at subscapularis sparing approaches. I think that's a future thing, but right now I don't feel that's mainstream because the techniques that are being really used are inadequate in my view to sufficiently restore the anatomy in the vast majority cases. So while it's appealing, it's not yet a mainstream procedure. I think that will change in the future with more technology coming on board. With a reverse shoulder replacement, for me, I put people in a sling for 2 weeks. Now, with a reverse shoulder replacement, because stability is provided by the joint itself, less needed or less dependent upon the subscapularis for healing. So we can do some early range of motion right out of the gate, doing table slides, in front of you and passive external rotation out to the side. That allows you to get some early motion going and prevent disuse osteopenia that may be associated with that stress fracture phenomenon I talked about earlier. So what we're seeing actually with this approach is people that reverse shoulder replacement are getting their function back very quickly, even raising their arm overhead within a few weeks. When can I shower after shoulder replacement? Well, in most cases, we close the skin with absorbable sutures in a running manner with glue that goes over the top of the incision site. So the dressing is taken off 2 days after the procedure. You can then shower at that point in time, let water run over it and pat it dry. When it comes to actually submersing yourself in water, I typically advise waiting a couple of weeks to get in things like a hot tub or pool. When can I drive after a shoulder replacement? Well, 2 things to consider here. Number 1, there's a study that shows that people can safely drive with a sling on 2 weeks after shoulder surgery. Now, I have people drive sooner than that. That's just what the data shows, that you're safe at the 2-week point. The second requirement is that you're off narcotic pain medication because that of course is gonna impair you just like any other substance. Fortunately, that's usually not the case at a couple weeks. Most of my patients are off of narcotic pain medication within a couple of days. In fact, 30% of them don't take a single narcotic after a shoulder replacement. When can I return to work? Well, this really depends on the type of work you do. This is an individual discussion. If somebody's doing desk work, it is possible for them to go back to surgery within a week. Now, I usually advise at least taking a week off just to kind of get your bearings back. Focus on healing first. A little bit of work or effort in the beginning will benefit you in the long term. If you're talking about heavy, heavy activity, somebody's doing manual labor activity, this may be several months down the line. Full restriction or full, you know, release to activities is typically at 6 months, but we can do that in a gradually progressive manner that allows you to get back. And what we try to do is just work with everybody on an individual basis to meet their needs and get them back as quickly as possible. What about return to your normal activities like sports, et cetera? This really can happen typically around the 4-month point, certainly by the 6-month point. Again, recognize that early on people are doing a lot. They're gradually working themselves up. One of the questions that comes up a lot for people is golf. I typically advise putting at 3 months, chipping at 4 months, full swing at 5 to 6 months. Sometimes that's a little accelerated. For instance, with reverse shoulder replacement that may be even quicker than that. But I think it's better to count on that longer period and then be able to return earlier than be disappointed with the lack of return because you think you can get back within a couple of months. How do I improve my chances of good outcome or speed up my recovery? The single biggest thing you can do is lean into nutrition. Of all the factors for your ability to influence your outcome, it really is nutrition. And this is not just eating well, this is supplementing. The data is very clear. Your protein requirements double after surgery, so you want to increase your protein by supplementing between meals. It's also been shown that things like vitamin C and vitamin D can improve surgical recovery after orthopedic surgery. Some people are also interested in peptides. I think there's a potential there, although it's not yet proven that that's going to make an impact, but that can be an option to consider in some cases for those people who are interested. Will I set off a metal detector? Well, this really varies based on the sensitivity of metal detector. How much metal you have on your body otherwise, and if you have other joint replacements inside your body. So not everybody who has a shoulder replacement is going to set off a metal detector if they go to the airport. There's no card that can be provided that's going to make that process easier. You simply just have to deal with TSA. If you are stopped, you can tell somebody you have a shoulder replacement. You may get scanned, but it's not going to prevent you from traveling. What about dental work? Do I need antibiotics if I have dental work? This is a common thing. Dentists will often say, hey, you gotta talk to your orthopedic surgeon if you have a joint replacement. The American Academy of Orthopedic Surgery and American Dental Association have a joint statement that say that you do not need to do antibiotics in the vast majority of cases prior to dental work. Some exceptions to that may be if you're immunocompromised. So in general, the bacteria in the mouth are not what cause infection in the shoulder And there's no need to do antibiotics around your dental work. One of the most important questions is, how well will I function after a shoulder replacement? I would encourage you to really take a look at my social media page. You can see examples of people getting back to high-level activities, but generally speaking, we're going to be able to achieve the ability to get your arm overhead again, get out to the side. And my goal is always to try to meet the individual needs of my patients. So if that's lifting weights, we're going to shoot for that ability. If that's playing golf or tennis or swimming, we're going to shoot for that ability. And we've looked closely at my patients in particular and done several studies in these categories and found very high return of function of things like golf, tennis, swimming, yoga, shooting, etc. So all these things are possible. I don't think it's good to tell people they cannot get back to their activities if they have a shoulder replacement. For instance, I do not provide lifting restrictions after a shoulder replacement. Some surgeons will do this, but there's actually no evidence to say that a certain lifting restriction is necessary after a shoulder replacement.