This booklet has been designed to answer your questions about what to expect if you will need surgery. I truly hope that this will make your surgery an easier and more understandable experience for you. If you have any questions or suggestions about the information in this booklet, please share them with me. I am always interested in improving the care I provide for my patients. Your input can help me to provide even better care for those who come after you. Please note that this booklet is not intended as a substitute for professional medical care, but as an aid to provide additional information for my patients.
ABOUT DR. BURNS
Dr. Burns is a board certified orthopedic surgeon with additional subspecialty training in sports medicine and shoulder surgery. Her practice focuses primarily on diseases of the shoulder, including degenerative arthritis, rotator cuff problems, and shoulder problems in the athlete. Currently Dr. Burns is a member of several societies, including the American Academy of Orthopedic Surgeons, the Arthroscopic Association of North America, the American Orthopedic Society for Sports Medicine, and the Ruth Jackson Orthopedic Society. She is also a member of several state and local associations as well. She was awarded a Ruth Jackson Orthopedic Society traveling fellowship in 2005 for additional study in shoulder surgery, and traveled in the United States and Europe. For additional information about Dr. Burns, her practice, and common shoulder problems, please visit her website at www.kburnsmd.com.
ABOUT YOUR SURGERY
Reverse shoulder replacement (also known as reverse shoulder arthroplasty) is a surgical procedure designed for patients who have non-repairable damage to their rotator cuff in conjunction with arthritis. This condition is commonly termed “cuff tear arthropathy.” Reverse shoulder replacement can also be used to treat shoulder fractures in older patients. Reverse shoulder replacement still replaces the ball and socket of the shoulder joint with new metal and plastic parts. A reverse is similar to a traditional or primary shoulder replacement because both involve “replacing” the arthritic or “worn out” shoulder joint. However, a reverse places the rounded “ball” part on the socket and the hollowed out socket on the arm bone, or humerus.
A total shoulder replacement has a metal ball on the humerus (arm) and a plastic socket placed on the native socket.
A reverse shoulder replacement has the metal ball screwed into the socket and the plastic socket placed into the humerus (arm).
The main reason to have a shoulder replacement, whether a primary total shoulder placement or a reverse, is to relieve pain. Dr. Burns has recommended a reverse shoulder to you based on your personal health history. A reverse shoulder replacement is typically done on patients who have arthritis and damage to their rotator cuff. Arthritis is damage to the shiny white articular cartilage (joint) surfaces of the bone. The rotator cuff is a group of tendons/muscles that help lift the arm over the head. The rotator cuff also helps hold the ball (humeral head) in the socket (glenoid) of the shoulder.
Reverse shoulder replacement is done through an incision on the front part of your shoulder. Dr. Burns uses the delto-pectoral approach. This approach is between the deltoid and the pectoral muscles on the front of your shoulder. You are usually positioned in a reclined position on your back, as if you were sitting in a beach chair. That’s why this is called the beach chair position. During the surgery, the arthritis is removed and replaced with specially designed artificial parts called the prostheses, described above. The rotator cuff is not repaired, but any remaining cuff tissue is preserved and closed around the prosthesis. In a reverse shoulder replacement, the parts are snugly fit together like a true ball and socket. The surgery generally takes 1 to 2 hours. Some of this time is used to put you to sleep and properly position you in the beach chair position.
There are risks associated with everything we do in life. Surgery is no exception. The risks of surgery include, but are not limited to, the following:
- Bleeding. Bleeding is common with shoulder replacement. However, very rarely do you need a blood transfusion.
- Infection. This is uncommon. You will receive antibiotics through your IV on the day of surgery and after the surgery to minimize this risk.
- Nerve, blood vessel, or tendon injury. Anything important that goes by the shoulder can be injured at the time of surgery. The most common thing is skin numbness, but even that is not all that common.
- Medical problems. This includes blood clot, stroke, heart attack, pneumonia, and even death related to the procedure or a complication of the procedure. This is exceedingly rare. Your surgeon will work in conjunction with your regular medical doctor to minimize this risk and ensure that you are healthy enough to undergo a surgery.
- No or incomplete relief of pain, or other failure of the surgery. There are no guarantees in life, and that includes surgery. Most people do experience relief of pain and improvement of their symptoms. However, the results are often not 100 percent.
- Need for further surgery. You are receiving artificial parts, and these parts can and do eventually wear out. They will typically last 10 years or more, but are not guaranteed to last any amount of time. The prosthesis may loosen or otherwise fail and require additional surgery at some point in the future.
- Dislocation. Because the reverse parts fit together, they can come apart or dislocate. This is rare.
- Limitation of motion. The reverse is designed to relieve pain and can restore elevation (motion above the head). Because rotation is powered by the rotator cuff, and many patients have torn and damaged rotator cuffs, the reverse replacement is not designed to restore rotation.
PREPARING FOR SURGERY
In the 7 to 10 days before surgery, you should stop taking aspirin and ibuprofen or other anti-inflammatory medications, as this can increase your tendency for bleeding. Tylenol is safe to take as an alternative pain medicine prior to surgery. Your surgeon may order preoperative blood work, EKG, or chest x-ray if necessary, depending on your age and medical history. Your primary care doctor may also be required to evaluate you and determine if you can safely undergo surgery.
At your pre-operative visit in the office, you will be given this book, which includes your post surgery exercise program. You should be prepared to stay overnight in the hospital for 1 – 3 days. You will perform these exercises at the hospital, at home, and with your physical therapist.
DAY BEFORE SURGERY
Do not eat or drink anything after midnight on the night before surgery. If you have a fever or a cough before surgery, please call my medical assistant at the office 314-291-7900. If you have any other questions or concerns, please don’t hesitate to call the office.
DAY OF SURGERY
You will be asked to check in at the hospital 1 and1/2 to 2 hours prior to your scheduled surgery time. You will have an IV placed, as well as a shoulder block, also known as an interscalene block. A shoulder block is placed by using a needle to inject numbing medicine around your shoulder. This will make your shoulder and arm numb and weak. This is the same type of medication that is used at the dentist. Most people cannot lift or move their arm while the block is working. The shoulder block usually lasts around eight hours. This will decrease your anesthesia requirements, which reduces postoperative nausea and vomiting. The block will also provide good post-operative pain relief.
You will spend approximately 1-2 hours in the operating room. After the surgery, expect to have your shoulder bandaged and elevated. The incision will be stitched and taped with steri-strips. Pain medication will be given orally or through your IV. You will be given a shoulder sling and ice, which will help to minimize post-operative pain.
After your surgery is over, you will spend about 1-2 hours in the recovery room, where your blood pressure, pulse, respirations, and temperature will be closely monitored. When you are stable and comfortable, you will be taken to the joint replacement floor of the hospital. You will remain on the joint replacement floor for about 2 days. While in the hospital, you will start your post surgery exercises. A physical therapist will help you with your exercises. Your dressing will be removed 24 hours after surgery. You may also shower 24 hours after surgery if there is no drainage from your incision.
Your arm will be placed in a sling after surgery. You will also be given pain medication to take at home. The goal of pain management is to prevent the pain from occurring rather than to control the pain once it occurs. We use several types of medication to prevent and control pain.
Vicodin (hydrocodone) is a strong narcotic pain medication. Common side effects include nausea and upset stomach, as well as itching. You can take 1-2 tablets every 4-6 hours as needed for pain.
Aspirin is an anti-inflammatory and anti-platelet medication. You will be instructed to take 325 mg twice a day. This medication will keep your blood slightly thin and has been shown to reduce the risk of mortality compared to stronger blood thinners, while having lower risk of bleeding complications.
A list of recommended exercises will be reviewed with the therapist. You will begin exercises the next day after surgery. By leaning over and allowing the arm to hang, you can use this motion to wash under your arm and to pull on a shirtsleeve.
Call your surgeon’s office if you have excessive bleeding, pain uncontrolled by the medication prescribed, fever (>101 degrees), severe nausea or vomiting, or shortness of breath. The office number is 314-291-7900 and the exchange (for after hours calls) is (314) 865-6015.
FREQUENTLY ASKED QUESTIONS
- How long does the surgery take? The surgery usually takes about 1-2 hours.
- How long will I be in the hospital? Patients usually stay 2 days in the hospital.
- How long do I have to wear a sling? Most patients use a sling on a fairly regular basis for the first 3 weeks. After 3 weeks, you can just use the sling as needed for comfort.
- Do I need to sleep in my sling? Most patients will find it more comfortable to sleep in a sling for the first few weeks, and some prefer to sleep propped up in a recliner. However, we do not require that you sleep in a sling.
- When can I drive? I will allow patients to drive 3 weeks after surgery. After 3 weeks, you can drive as soon as you feel comfortable controlling a car. For most patients this is between 3 and 6 weeks.
- When can I take a shower? Most patients take a shower 2 days after their surgery.
- Will I need therapy after surgery? Yes, a physical therapist will see you in the hospital and get you started on your exercises. When you go home, a different physical therapist will come to your house and help you with the exercises for the first 3 weeks. After 3 weeks, most patients go to an outpatient physical therapy clinic.
- When will I return to the office after surgery? You should make a post op appointment for 3 weeks after surgery to see Dr. Burns.
- What if I live alone, or don’t feel able to go home after the surgery? Most patients, even those who live alone, will be able to function at home after shoulder replacement. If you believe you will need additional care at a rehab center or a skilled facility, you can let Dr. Burns know but these arrangements cannot be made ahead of time. Once you are admitted to the hospital, the team of social workers, nurses, and Dr. Burns will work to ensure you are appropriately placed.
- Can I still have a shoulder replacement if I use my arms to weight bear on a walker, cane or other supportive device? Yes, you can still have a shoulder replacement but it is important to protect your new shoulder from weightbearing for 4 weeks after it is replaced. This allows the new parts time to heal, and your muscles and tendons around the shoulder some time to regain strength and function. The physical therapists will work with you to try alternative devices to support yourself. In some cases, a stay in rehabilitation or a skilled nursing facility is necessary to protect your new shoulder for 4 weeks.