Patient Guide To Total Shoulder Replacement

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Patient Guide toTotal Shoulder Replacement

About this guideContentsThis booklet provides valuable information for you and yourfamily regarding your shoulder replacement surgery.Preparing for your surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4You can expect the best results if you read and discuss this guidewith your family before your surgery. The goals of our staff areto restore your shoulder to a painless, functional status and tomake your hospital stay as beneficial, informative, and comfortable as possible. Please feel free to ask questions or share concerns with any of your caregivers.The day of your surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7The day before your surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Getting the most out of your surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Resuming your normal activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Risk factors and complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Special topicsAbout blood transfusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Readying your home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Planning ahead for your discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Getting to the hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8What and what not to bring to the hospital . . . . . . . . . . . . . . . . . . . . . . . . 9Surgery preparation checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Arthritis of the shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Pain management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Your care team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Exercises after surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Taking care of your surgical incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172Patient Guide to Total Shoulder ReplacementJointReplacementCenterNYC.com3

Preparing for your surgeryPreparation for your shoulder replacement surgery begins several weeksbefore the date of the surgery itself. To begin with, you will be asked tokeep the following appointments: Pre-Admission Testing: This is a physical examination and a series oftests (x-rays, blood work, etc.) in preparation for your surgery. DuringPre-Admission Testing you will also meet with an anesthesiology staffmember to discuss the type of anesthesia you will undergo. Medical Clearance for Surgery: Approval for you to undergo surgery isrequired from your primary doctor—or we can arrange for you to be examined by one of our doctors. This examination, along with Pre-Admission Testing, is necessary to review your overall health and identify anymedical condition that could interfere with your surgery or recovery.In the weeks before your surgery you may also be asked to: Have a dental examination: Although infections in joint replacementsare not common, one can occur if bacteria enter the bloodstreamsomewhere else in your body. Therefore, you should plan to have dental procedures such as extractions and periodontal work done beforeyour surgery. Stop taking certain medications: Your surgeon can advise you whichmedications to stop taking before your surgery. Be certain to tell yourphysician all the medications that you are taking, including over-thecounter medications, because some of these may increase your bleeding during surgery. Stop smoking: This is a good idea at any time, but particularly beforemajor surgery in order to help reduce the risk of postoperative lungproblems and improve healing.About blood transfusionsUnlike other joint replacement surgery, most patients who undergoshoulder replacement do not require a blood transfusion. For mostpatients, then, donating blood before surgery will not be necessary.In patients with certain risk factors for bleeding or whose surgeryis more complicated, additional blood loss may be anticipated. Inthese special circumstances, your surgeon will discuss the possibility of blood transfusion before the surgery.4Patient Guide to Total Shoulder Replacement Evaluate your needs for at-home care after discharge from the hospital: Most shoulder replacement patients will need help at home for thefirst few weeks, including assistance with preparing meals and transportation. Tell your surgeon about your current support services/devices: If youare now using a home service, bring the name and phone number ofthe service to the hospital. If you have medical equipment such as awheelchair, crutches, or walker at home, ask your surgeon if you shouldmake arrangements to have the equipment brought to the hospital forthe physical therapist to make adjustments. Review your insurance: Contact your insurance company well ahead oftime to familiarize yourself with the benefits available to you. For example, different insurance providers have different rules for determining the medical necessity of rehabilitation, and most do not provide abenefit for your transportation home. Also be aware that you will bebilled separately by the hospital, your surgeon, and your anesthesiologist and that different insurance plans have different formulas fordetermining payments for these services.Readying your homeThere are several things that you (or a friend or family member) cando before entering the hospital to make your home safer and morecomfortable upon your return: In the kitchen and elsewhere, place items that you use regularly atarm level so you do not have to reach up or bend down. As you will be wearing a sling, rearrange furniture if necessary togive yourself enough room to maneuver. Get a good, firm chair, preferably one that allows you to recline. Remove loose carpets and rearrange electrical cords in the areaswhere you will be walking. Set up a “recovery center” in your home, with the phone, television remote control, radio, facial tissues, wastebasket, pitcher andglass, reading materials, and medications within reach.JointReplacementCenterNYC.com5

Keeping track of all this information can be overwhelming. Please feelfree to ask questions or share concerns with any of your caregivers at anytime. You can contact your surgeon or your surgeon’s office manager atany time.The day before your surgeryYou will receive a telephone call from the hospital after 5:00 PM on theweekday before your surgery telling you when to come to the hospitaland exactly where to go. For example, if your surgery is on Tuesday, thehospital will call you on Monday night; if your surgery is on Monday, thecall will be on Friday night. Your arrival may be scheduled for as earlyas 6:00 AM, so be sure to get a good night’s sleep. It is important thatyou arrive on time because if you are late, your surgery will have to berescheduled.Planning ahead for your dischargeWhether or not you require “rehab” following your surgery dependson several factors, including your general state of health. Most patients can be safely discharged directly home. If your surgeon determines otherwise, a member of our Social Service Department willvisit you a day or two after your surgery to give advice and help prepare the necessary paperwork for entry into a rehabilitation facility.Every patient is visited by a case manager who works with you,your surgeon, and your insurance provider to make your dischargefrom the hospital is as smooth as possible. Patients who are admitted to acute (in-house) rehabilitation will additionally be helped bya discharge planner. If you have any concerns about your ability tomanage your personal care, mobility, medications, or other recoveryneeds once you return home, bring them up with your case managerand/or discharge planner: they are trained to help you in these matters.Please note that discharge time is 11:00 AM.Once you are home, we continue to provide care. Depending on yourneeds, a member of our Social Service Department can arrange fora visiting nurse, a home therapist, or in some cases a home healthaide to check on you several times during the week for the first fewweeks after your surgery.6Patient Guide to Total Shoulder ReplacementAbout diet: You may eat normally on the day before your surgery, but donot drink alcohol. DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT.This is important so that it will not interfere with your anesthesia. Theonly exception is if your doctor specifically instructs you to take medication with a sip of water. Shower and shampoo either the night before orthe morning of your surgery.The day of your surgeryOn the day of surgery: You may brush your teeth and rinse your mouth—without swallowingany water. Wear comfortable, loose-fitting clothing and flat, non-slip, walking orathletic shoes. Leave valuable possessions at home or give them to a family memberfor safekeeping. (See “What and what not to bring to the hospital,”page 9.)Once you arrive at the hospital: You will be provided with a gown and disposable undergarments foryour comfort. Your own clothing and personal belongings will be safely stored. You will be asked to fill out an operative consent form, to review it,and to sign it along with your surgeon and a third-party witness. (Ifthis was done previously, your surgeon will review the form with youagain.) Your surgeon will also place his/her initials on the shoulder tobe replaced as an extra precaution.Getting to the hospitalIf your surgery is at the NYU Hospital for Joint Diseases:Go to the NYU Hospital for Joint Diseases at 301 East 17th Street,which is on the corner of Second Avenue, and proceed to the locationyou were told the night before.If your surgery is at Tisch Hospital–NYU Langone Medical Center:Go to Tisch Hospital at 530 First Avenue, which is between East 30thand 31st Streets, and proceed to the location you were told the nightbefore.JointReplacementCenterNYC.com7

Your anesthesiologist will go over with you the type of anesthesia tobe used for your surgery. After that explanation, you will be asked tocomplete, review, and sign a consent form specifically for the anesthesia. When the operating room is ready, you will be escorted there by anurse.During your surgery, your family and friends may wait in any of severalcomfortable hospital locations, including the NYU Hospital for Joint Diseases’ waiting room (C1 level), Tisch Hospital’s solarium (15th floor), andthe cafeteria (13th floor at NYU HJD, ground floor at Tisch). With yourpermission, your surgeon will speak with them after your surgery.AnesthesiaAnesthesia is the process of inducing a pain-free, tranquil, sleeplike state for your surgery. Your anesthesiologist has several techniques to carry you through surgery comfortably and without pain.Some medical conditions may make one technique preferable. Youshould discuss this with both your surgeon and your anesthesiologist. Whichever technique is chosen, be assured that your operatingroom experience will be a painless and tranquil one.General anesthesia. First you are given medication to induce a sleeplike state, followed by a gas anesthetic agent administered via amask into your lungs. Throughout the operation you will be attachedto monitors that display information on your heart rhythm and rate,oxygen level in your bloodstream, body temperature, and bloodpressure. Your anesthesiologist continually checks these monitors.Regional Anesthesia. Some patients reject regional anesthesia because they think that they will be awake during the procedure. Thisis not true. In regional anesthesia, you also receive medications thatallow you to sleep peacefully throughout the operation. Unlike general anesthesia, when regional anesthesia is discontinued you willawaken almost immediately and without pain (because the anesthesia is still working). Most often for shoulder surgery an intrascaleneblock is used in combination with light sedation. When this type ofanesthesia is used, you are monitored as described above for general anesthesia.What and what not to bring to the hospitalDO bring to the hospitalDO NOT bring to the hospital Toiletries (toothbrush etc.) Your cane or crutches,if needed Eyeglasses—not contact lenses Dentures/hearing aid.A container will be providedfor these, which you shouldkeep on your bedside table orin a drawer—not on the bed ora food tray. A list of your medications,including the ones you haverecently stopped taking at yoursurgeon’s request Important telephone numbers Small amount of cash—fornewspapers, etc. Credit card or 2-3 checks—forTV and telephone services A book, magazine, or hobbyitem for relaxation This Guide. Medications—unless asked byyour surgeon Valuables—jewelry, largeamounts of cash, credit cards(other than for the TV etc.—seeother column), wallet, watchAll hospital staff membersrespect your property rights,but we cannot guarantee security for your personal property.Surgery preparation checklistThe night before your surgery:The day of your surgery:o Shower (may be done day ofo Take routine medications withsurgery if time permits).o Nothing to eat or drink aftermidnight.o Review this Guide.o Get a good night’s rest.only a sip of water—as instructed by your doctor.o Brush your teeth and rinse—without swallowing.o Wear comfortable clothing.o Leave valuables at home orwith a family member.8Patient Guide to Total Shoulder ReplacementJointReplacementCenterNYC.com9

Arthritis of the shoulderIn a normal shoulder, the humeralhead (“ball”) at the top of the armbone rotates smoothly inside the glenoid cavity (“socket”). Arthritis of theshoulder develops when the normallysmooth, gliding surfaces of the balland socket are damaged.The most common form of shoulderarthritis, osteoarthritis, typically develops in older patients after a lifetimeof wear and tear. Less common formsof arthritis include post traumatic arthritis (arthritis that occurs after abroken bone or other injury) and inflammatory arthritis (an autoimmunedisease that destroys the joint). If themuscles surrounding the shoulderare severely damaged, the alteredshoulder motion can wear out thegliding surfaces and lead to anotherform of arthritis called rotator cuffarthropathy.In shoulder replacement surgery, thedamaged joint is replaced with bio com patible devices that provide asmooth and painless range of motion.Your surgeon will make every effort torestore your shoulder to a conditionthat resembles its previous healthystatus. You should discuss what realistic outcome to expect with your surgeon.10Arthritic shoulderThere is no space between thisshoulder’s ball and socket, indicating that the normal surfaces are likely destroyed. Also, the large bonespur (arrow) extending from the ballis probably causing additional painand stiffness.Total shoulder replacementIn a standard total shoulder replacement, the ball and socket of the jointare replaced by implants. Placementof the components insures that thesmooth gliding surfaces are recreated and normal shoulder functionrestored.Arthritic shoulderwith damaged musclesIn some cases the ball is not evenlocated next to the socket. This x-rayshows that the humeral head (ball)has moved up and away from itsnormal position. It is highly likelythat the muscles surrounding theshoulder joint have been destroyed.Reverse total shoulder replacementIn this type of total shoulder replacement surgery, the ball is placedwhere the socket used to be and viceversa. This reverse total shoulder replacement compensates for the lossof shoulder muscles and makes itpossible for the arm to be raised.Normal shoulderOn an x-ray of a normalshoulder, a slight spacecan be seen between thehumeral head (ball) andthe glenoid cavity (socket).This indicates a smooth,gliding joint surface.Patient Guide to Total Shoulder ReplacementJointReplacementCenterNYC.com11

Getting the most out ofyour surgeryWhen your surgery is complete you will be taken to a recovery room,where you will wake to find your operated arm protected in a sling. Nursing staff in the recovery room will make sure that you are comfortableand get you ready for your recovery.Your care team Your surgeon Nurses Nurse practitioners Physical therapist or occupational therapistAfter surgery, you will be admitted into the hospital for in-patient monitoring. Most patients require about two days of hospital stay, but this willultimately depend on how fast you are recovering from the surgery. Whileyou are in the hospital, you will receive medication to control your pain,and your health will be carefully monitored. In addition, you will likelybegin exercises to regain shoulder motion with the help of our therapists. Fellows and residents: licensed physicians undergoingspecialized postgraduate training in orthopaedic surgeryOnce you are home, contact your surgeon’s office to make a follow-upappointment (usually about 1-2 weeks after surgery). At this visit, yoursurgeon will check your surgical incision and plan your continued rehabilitation, including beginning shoulder exercises if you have not alreadyinstructed to do so. Shoulder exercises can be performed at home or onan outpatient basis at the hospital with supervised therapy. The specificsof your rehabilitation will be determined by your surgeon based on yourcondition. Rehabilitation specialist: a physician trained to determine thelevel of care you will require once you leave the hospitalPain managementMany patients are understandably concerned about postoperativepain. Pain control has become very sophisticated. Usually the levelof discomfort is easily manageable with oral or injected pain medication.Some patients receive IV-PCA—intravenous patient-controlled analgesia—for a day or two following surgery: this allows the patientto self-administer a safe and effective amount of pain medicationthrough an IV tube by pressing a button.12Patient Guide to Total Shoulder Replacement Internist: a specialized physician selected by your surgeon to assist in the medical management of your postoperative care Pain specialists: a physician and a nurse practitioner whospecialize in pain managementOne or more of the above care team physicians, depending on yourneeds, will visit you “on rounds” every day that you are in the hospital.Exercise is crucial for proper rehabilitation (see pages 14-15). Therapymay continue for four to six months after your surgery. Proper rehabilitation under your surgeon’s guidance will result in a more successful recovery. Most patients are able to resume waist-level activities—actions,such as typing and writing, that do not require you to raise your arm—inthe first week following surgery. Driving may begin three to four weeksafter the surgery depending on your condition. Activities such as golfcan usually be eventually resumed, but only after a thorough evaluationby your surgeon. It is important to remember that recovery time variesfor each patient.After recovery, your surgeon will likely continue to evaluate your progress on a yearly basis. These evaluations may or may not require x-rays.In order to prevent catastrophic complications, it is important to seeyour surgeon if you notice any unusual changes associated with yournew joint.JointReplacementCenterNYC.com13

Exercises after surgeryPassive external rotation exerciseMost patients will begin exercising in the hospital shortly after surgery,under the supervision of our therapists. A few patients will be asked towait until the surgeon gives them the go-ahead, usually after the firstoffice visit following surgery. In either case, it is important that you con

2 Patient Guide to Total Shoulder Replacement JointReplacementCenterNYC.com 3 About this guide This booklet provides valuable information for you and your family regarding your shoulder replacement surgery. You can expect the best results if you read and discuss this guide with your family before your surgery. The goals of our staff are

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