A Patient S Guide To Reverse Shoulder Replacement
A Patient’s Guide toReverse Shoulder ReplacementSterling Ridge Orthopaedics & Sports Medicine6767 Lake Woodlands Drive, Suite F, The Woodlands, TX7738220639 Kuykendahl Road, Suite 200, Spring, TX 77379The Woodlands & Spring, TX .Sterling Ridge Orthopaedics & Sports Medicine
DISCLAIMER: The information in this booklet is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases,physical conditions,ailments or treatments.shouldNOT be used inplace of a visit with your health care provider, nor should you disregardA Patient'sGuide Theto informationReverseShoulderReplacementthe advice of your health care provider because of any information you read in this booklet.Sterling Ridge Orthopaedics & Sports MedicineIf you are experiencing pain, feel symptoms of an orthopedic condition or you've just beendiagnosed, we encourage you to use our online patient education library to learn about thecondition and what can be done. This can help you prepare for an appointment and serve as areview of the information your physician shares. Feel free to read the information online ordownload a PDF to print or share.At Sterling Ridge Orthopaedics & Sports Medicine we provide each patient with the highestlevel of care by board certified physicians. Please schedule an appointment with one of ourspecialists if you have any questions or concerns about symptoms you may be experiencing.Two convenient locations:THE WOODLANDS281-364-11226767 Lake Woodlands Drive, Suite FThe Woodlands, TX 77382SPRING832-698-011120639 Kuykendahl Road, Suite 200Spring, TX 77379Sterling Ridge Orthopaedics & Sports Medicine6767 Lake Woodlands Drive, Suite F, The Woodlands, TX7738220639 Kuykendahl Road, Suite 200, Spring, TX 77379The Woodlands & Spring, TX .Phone: 281-364-1122 832-698-011All materials within these pages are the sole property of Medical Multimedia Group, LLC and are used herein by permission. eOrthopod is aregistered trademark of Medical Multimedia Group, LLC.Compliments of: Sterling Ridge Orthopaedics & Sports Medicine2
A Patient's Guide to Reverse Shoulder ReplacementIntroductionShoulder joint replacement surgery (alsocalled shoulder arthroplasty) can effectivelyease pain from shoulder arthritis. Most peopleexperience improved shoulder functionafter this surgery. But, certain patients arenot candidates for joint replacement ofthe shoulder because they lack the musclefunction necessary to stabilize the joint. Adifferent type of shoulder replacement, calledreverse shoulder replacement, may be available for many of these patients and providepain relief as well as a stable functioningshoulder.This guide will help you understand how the shoulder works what parts of the shoulder are replacedin reverse shoulder replacement how reverse shoulder replacementdiffers from shoulder replacement what to expect after surgeryThe rotator cuff connects the humerus to thescapula. The rotator cuff is formed by thetendons of four muscles: the supraspinatus,infraspinatus, teres minor, and subscapularis.Muscles move bones by pulling on thetendons. The rotator cuff helps raise and rotatethe arm. As the arm is raised, the rotator cuffalso keeps the humerus tightly in the socket. Apart of the scapula, called the glenoid, makesup the socket of the shoulder. The glenoid isvery shallow and flat.AnatomyWhat parts make up the shoulder?The shoulder is made up of three bones: thescapula (shoulder blade), the humerus (upperarm bone), and the clavicle (collarbone).Compliments of: Sterling Ridge Orthopaedics & Sports Medicine3
A Patient's Guide to Reverse Shoulder ReplacementThe shoulder joint is surrounded by a watertight sac called the joint capsule. The jointcapsule holds fluids that lubricate the joint.The walls of the joint capsule are made up ofligaments. Ligaments are connective tissuesthat attach bones to bones. The joint capsulehas a considerable amount of slack, loosetissue, so that the shoulder is unrestricted as itmoves through its large range of motion.The part of the scapula that connects to theshoulder is called the acromion. A bursa islocated between the acromion and the rotatorcuff tendons. A bursa is a lubricated sac oftissue that cuts down on the friction betweentwo moving parts. Bursae are located allover the body where tissues must rub againsteach other. In this case, the bursa protects theacromion and the rotator cuff from grindingagainst each other.The humeral head of the shoulder is the ballportion of the joint. The humeral head hasseveral blood vessels, which enter at the baseof the articular cartilage. Articular cartilageis the smooth, white material that covers theends of bones in most joints. Articular cartilage provides a slick, rubbery surface thatallows the bones to glide over each other asthey move. Cartilage also functions as sort of ashock absorber.RationaleWhat conditions lead to a reverse shoulderjoint replacement?The most common reason for undergoingshoulder replacement surgery is osteoarthritis.Osteoarthritis is caused by the degenerationof the joint over time, through wear and tear.Osteoarthritis can occur without any injury tothe shoulder, but that is uncommon. Becausethe shoulder is not a weight-bearing joint, itdoes not suffer as much wear and tear as otherjoints. Osteoarthritis is more common in thehip and knee.Rotator cuff problems are a common conditionin the shoulder, especially as we grow older.Degeneration or wear and tear of the rotatorcuff tendons occurs as we age. Over time thiscan lead to weakening of the tendons and mayresult in a rotator cuff tear. Surgery to repaira rotator cuff tear is fairly common in peopleCompliments of: Sterling Ridge Orthopaedics & Sports Medicine4
A Patient's Guide to Reverse Shoulder Replacementwho are middle aged and older. Most rotatorcuff repairs are successful, but in a portion ofpatients, the tendon has become so degeneratedthat the tendon can simply not be repaired.Small, medium and many large tears can berepaired either through arthroscopic or opensurgical procedures. Unfortunately, many largetears that are untreated for a long time mayretract and become un-fixable.Cuff tear arthropathy is difficult to treat. Theshoulder is weak and painful. Patients may notbe able to raise the arm above shoulder level.Patients with this type of arthritis would seemto be good candidates for a shoulder replacement, but replacing the shoulder in the typicalfashion has not been successful.A shoulder joint without an intact rotatorcuff may still function relatively well. Somepatients will have weakness, some pain andmay not be able to completely raise the arm.But, they get by without their rotator cuff fairlywell. There are many people who choose notto have surgery to repair a rotator cuff tear andwill simply live with the limitations. Patientswith massive rotator cuff tears may not be ableto lift the arm without significant pain andweakness. When the arm cannot be lifted, thisis called a pseudoparalytic shoulder.The shoulder needs a functioning rotator cuffto remain stable as well as to create a jointcapsule to hold the joint fluid that lubricatesthe joint. Over time, a shoulder without anintact rotator cuff becomes arthritic - theshoulder joint wears out due to the abnormalmotion, the instability, and lack of lubricationfrom the joint fluid. This type of wear andtear arthritis in the shoulder is called cuff teararthropathy.The "normal" artificial shoulder was designedto copy our real shoulder. The glenoid component (the socket) was designed to replace ournormal shoulder socket with a thin, shallowplastic cup. The humeral head component wasdesigned to replace the ball of the humeruswith a metal ball that sits on top of the glenoid.This situation has been compared to placing aball on a shallow saucer. Without somethingto hold it in place, the metal ball simply slidesaround on the saucer. In the shoulder thatsomething is the rotator cuff and the musclesCompliments of: Sterling Ridge Orthopaedics & Sports Medicine5
A Patient's Guide to Reverse Shoulder Replacementthat attach to the tendons. Without a rotatorcuff to hold the metal ball centered in theplastic socket, the metal quickly wore out theplastic socket and the joint became painfulonce again.The answer to this dilemma was to rethink themechanics of the shoulder joint and design anartificial shoulder that worked differently thanthe real shoulder joint. The solution was toreverse the socket and the ball, placing the ballportion of the shoulder where the socket useto be and the socket where the ball or humeralhead use to be. This new design led to a muchmore stable shoulder joint that could functionwithout a rotator cuff. The artificial joint itselfprovided more stability by creating a deepersocket that prevented the ball from slidingup and down as the shoulder was raised. Thelarge deltoid muscle that covers the shouldercould be used to more effectively lift the arm,providing better function of the shoulder. Thefinal result is a shoulder that functions better,is less painful and can last for years withoutloosening.Other reasons to consider a reverse shoulderreplacement include failed rotator cuff surgeryleading to a pseudoparalytic shoulder evenwithout arthritis. A pseudoparalytic shoulderrefers to a situation where you can not raisethe shoulder. Pseudo means false and paralysisusually means that the nerves that control themuscle no longer control the muscles. A pseudoparalytic shoulder appears paralyzed, butthe reason that you cannot raise the shoulderis because the rotator cuff tendons that attachthe muscles (that raise the shoulder) to thehumerus bone are torn. The power of themuscles cannot be transmitted to the humerusto raise the shoulder.Older patients with very severe fractures of thehead of the humerus appear to do very wellwith reverse shoulder replacements as opposedto a standard shoulder replacement. Patientswho have had previous shoulder replacementsthat have failed of become loose will alsorequire a reverse shoulder replacement to fixthe loose or painful prosthesis.In most cases, doctors see a shoulder replacement as the last option. Sometimes there isa benefit to delaying shoulder replacementsurgery as long as possible. Your doctor willprobably want you to try nonsurgical measuresto control your pain and improve your shouldermovement, including medications and physicalor occupational therapy.Like any arthritic condition, cuff teararthropathy of the shoulder may respond toanti-inflammatory medications such as aspirinor ibuprofen. Acetaminophen (Tylenol ) mayalso be prescribed to ease the pain. Some ofthe newer medications such as glucosamineand chondroitin sulfate are more commonlyprescribed today. They seem to be effective inhelping reduce the pain of arthritis in all joints.There are also new injectable medications thatlubricate the arthritic joint. These medicationshave been studied mainly in the knee. It isunclear if they will help the arthritic shoulder.These lubrication injections are presently beingstudied in the shoulder. Although they are safein the knee, they are not presently approved foruse in the shoulder.Physical or occupational therapy may besuggested to help you regain as much ofthe motion and strength in your shoulder aspossible before you undergo surgery. In manycases, however, therapy may not be indicatedfor severe shoulder arthritis since it may aggravate the pain. This is a matter to be discussedwith your orthopedic surgeon.An injection of cortisone into the shoulderjoint may give temporary relief. Cortisoneis a powerful anti-inflammatory medicationthat can ease inflammation and reduce pain,possibly for several months. Most surgeonsonly allow two or three cortisone shots intoany joint. If the shots don't provide you withlasting relief, your doctor may suggest surgery.Compliments of: Sterling Ridge Orthopaedics & Sports Medicine6
A Patient's Guide to Reverse Shoulder ReplacementPreparationWhat do I need to do to get ready for surgery?When cuff tear arthropathy of the shoulderrequires replacement of the painful shoulderwith an artificial shoulder joint, a reverseshoulder replacement may be recommended.You and your surgeon should make thedecision to proceed with surgery together.You need to understand as much about theprocedure as possible. If you have concerns orquestions, you should talk to your surgeon.Once you decide on surgery, you need to takeseveral steps. Your surgeon may suggest acomplete physical examination by your regulardoctor. This exam helps ensure that you arein the best possible condition to undergo theoperation.Special x-rays will be needed. Plain x-raysof the shoulder will allow your surgeon toevaluate the severity of arthritis and the statusof the rotator cuff. A CT scan is alwaysrequired before any kind of shoulder replacement to determine the degree of damage to thebones (glenoid and humeral head) for surgicalplanning.You may also need to spend time with thephysical or occupational therapist who willbe managing your rehabilitation after surgery.This allows you to get a head start on yourrecovery. One purpose of this pre-operativevisit is to record a baseline of information.Your therapist will check your current painlevels, ability to do your activities, and themovement and strength of each shoulder.A second purpose of the pre-operative visitis to prepare you for surgery. You'll beginlearning some of the exercises you will useduring your recovery. Your therapist can helpyou anticipate any special needs or problemsyou might have at home, once you're releasedfrom the hospital.On the day of your surgery, you will probablybe admitted to the hospital early in themorning. You shouldn't eat or drink anythingafter midnight the night before. Come preparedto stay in the hospital for several nights. Thelength of time you will spend in the hospitaldepends a lot on you.Surgical ProcedureWhat happens during shoulder replacementsurgery?Before we describe the procedure, let's lookfirst at the reverse artificial shoulder itself.The Reverse Artificial ShoulderThe reverse shoulder prosthesis (artificialjoint) is made up of two parts. The humeralcomponent replaces the humeral head, orthe ball of the joint. The glenoid componentreplaces the socket of the shoulder, which isactually part of the scapula.In the normal artificial shoulder prosthesis, theglenoid prosthesis is a shallow socket madeof plastic and the humeral component is ametal stem attached to a metal ball that nearlymatches the anatomy of the normal shoulder.In the reverse shoulder replacement, the balland the socket are reversed.The humeral component is combination of ametal stem that fits into the marrow cavity ofthe upper humerus and, on top of the metalstem, a plastic socket. This plastic socket fitsonto the humeral component to create a balland socket type bearing. The glenoid component is usually made of two parts. A metal trayCompliments of: Sterling Ridge Orthopaedics & Sports Medicine7
A Patient's Guide to Reverse Shoulder Replacement(base plate) attaches directly to the bone. Theglenoid base plate is inserted into a small peghole drilled into the bone and is secured withspecial screws through the base plate into thebone. Attached to that metal tray, a metal ballis attached that will fit into the plastic socketattached to the humeral component. The plasticis very tough and very slick, much like thearticular cartilage it is replacing. In fact, youcan ice skate on a sheet of this plastic withoutcausing it much damage.vessels and moves them to the side. Themuscles are also moved to the side.The surgeon enters the shoulder joint itselfby cutting into the joint capsule. This allowsthe surgeon to see the joint. In more advancedcases of cuff tear arthropathy, and in patientswith previous surgery, there may be no capsuleand rotator cuff remaining.The OperationThe reverse shoulder replacement surgery isperformed almost identically to the normalshoulder replacement - except different artificial parts are inserted.You will most likely need general anesthesiafor shoulder replacement surgery. Generalanesthesia puts you to sleep. It is difficult tonumb only the shoulder and arm in a way thatmakes such a major surgery possible. Whilenerve blocks can be helpful with postoperative pain control, they are not usually effectiveenough to be used as the only anesthetic forthis kind of operation.Shoulder replacement surgery is done throughan incision on the front of your shoulder. Thisis called an anterior (deltopectoral) approach.For reverse shoulder replacements, especiallyfor patients with multiple previous surgeries, asuperior approach through the deltoid musclemay be used. The surgeon cuts through theskin and then isolates the nerves and bloodAt this point, the surgeon can prepare the bonefor attaching the replacement parts. The ballportion of the humeral head is removed witha bone saw. The hollow inside of the upperhumerus is prepared using a rasp. This letsyour surgeon mold the space to anchor themetal stem of the humeral component insidethe bone.The glenoid will be replaced with a ball ofmetal. The arthritic glenoid surface is preparedby grinding away any remaining cartilageand flattening the surface. This is done withan instrument called a reamer. The surgeonCompliments of: Sterling Ridge Orthopaedics & Sports Medicine8
A Patient's Guide to Reverse Shoulder Replacementusually uses the reamer to drill holes into thebone of the scapula and to flatten the deformedglenoid surface so the base plate rests on asmooth, flat surface. This is where the stem ofthe glenoid component is anchored.Finally, the humeral component and theglenoid component are inserted.Once the joint is anchored, the surgeon testsfor proper fit. When the surgeon is satisfied with the fit, the joint capsule is stitchedtogether. The muscles are then returned to theircorrect positions, and the skin is also sutured.Your incision will be covered with a bandage,and your arm will be placed in a sling. Youwill then be woken up and taken to therecovery room.ComplicationsWhat might go wrong?As with all major surgical procedures, complications can occur. This document doesn'tprovide a complete list of the possible complications, but it does highlight some of the mostcommon problems. Some of the most commoncomplications following reverse artificialshoulder replacement are anesthesia infection fracture dislocation loosening nerve or blood vessel injuryAnesthesiaMost surgical procedures require that sometype of anesthesia be done before surgery. Avery small number of patients have problemswith anesthesia. These problems can be reactions to the drugs used, problems related toother medical complications, and problems dueto the anesthesia. Be sure to discuss the risksand your concerns with your anesthesiologist.InfectionInfection following reverse joint replacementsurgery can be very serious. The chances ofdeveloping an infection following artificialjoint replacement, however, are low (aboutone percent). Sometimes infections show upvery early, before you leave the hospital. Othertimes infections may not show up for months,or even years, after the operation.Infection can also spread into the artificial jointfrom other infected areas. Once an infectionlodges in your joint, it is almost impossiblefor your immune system to clear it. You mayneed to take antibiotics when you have dentalwork or surgical procedures on your bladderand colon. The antibiotics reduce the risk ofspreading germs to the artificial joint.FractureDuring the surgery, the humerus is preparedby cutting off the deformed humeral headand reaming the canal to allow for insertionof the humeral stem. The glenoid is reamedto create a bone tunnel, and flattened to seatthe glenoid base plate. In patients with weakbone, fractures can occur during this part of theprocedure that may require restricted activityafter the surgery while the fracture heals.DislocationJust like your real shoulder,
called shoulder arthroplasty) can effectively ease pain from shoulder arthritis. Most people experience improved shoulder function after this surgery. But, certain patients are not candidates for joint replacement of the shoulder because they lack the muscle
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