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Mr Apurv Sinha
Consultant Trauma and orthopaedics
REVERSE SHOULDER REPLACEMENT
What is a Reverse or ‘Delta’ shoulder replacement?
This type of shoulder replacement involves reversing the mechanics of the shoulder joint. This means that the ball component of the humerus (arm bone) is replaced with a socket, and the socket component (called the glenoid) is replaced with a ball.
What are the benefits of having a shoulder replacement?
A shoulder replacement is often advised when there are severe degenerative changes in the shoulder joint, such as arthritis, causing pain and reduced movement, in conjunction with an irreparable rotator cuff muscle tear.
Occasionally, it can also be used for:
Broken shoulder (‘proximal humerus fracture’).
Osteoarthritis is “wear and tear” arthritis, which can damage the joint surfaces.
Rheumatoid arthritis is another type of arthritis, which can affect many joints in the body including the shoulder, resulting in pain and reduced movement.
This type of shoulder replacement is used when the muscles surrounding the shoulder joint (the ‘rotator cuff’) are damaged beyond repair. This type of tear alters the biomechanics of the shoulder which creates pain and disability. Reverse shoulder replacement compensates for the absence of these muscles to reduce pain and improve movement by altering the biomechanics of the shoulder.
What are the benefits?
Reverse shoulder replacement can relieve a lot of the pain previously experienced in an arthritic shoulder.
In addition, there is improvement in the range of movement of your shoulder, but this largely depends upon the condition and strength of your shoulder muscles (Deltoid) before surgery.
You will not get as much movement as in a normal shoulder, but due to the decreased pain, you may be able to carry out functional activities more easily. It can take up to 12-18 months to get the full benefit from a shoulder replacement.
Are there any complications in having a shoulder replacement?
As with most types of surgery there are risks involved and complications can occur which are unrelated to the shoulder replacement and can be discussed further with your anaesthetist.
• anaesthetic risks (such as sickness, nausea or rarely cardiac, respiratory or neurological (less than 1%)
• chest infections,
• blood clots in the legs (DVT/deep vein thrombosis) or in the lungs (PE/pulmonary embolus).
• Nerve damage from the ‘nerve block’ in your neck used to numb the arm.
Some of the complications which can occur rarely with a shoulder replacement are:
2. the new joint becoming loose
3. damage to the nerves and blood vessels (less than 1%)
6. residual pain and stiffness in the shoulder (up to 20%).
These risks are very small but if any occur, further treatment or an operation may be necessary.
1. Infection can be a very serious complication - it is thought that the risk of developing an infection is about 1%. Some infections show up immediately whilst you are still on the ward, others are not apparent for months. Due to this risk, your surgeon may recommend you take antibiotics, if you have dental work or other surgery, to prevent any infection from spreading to your new joint.
If your wound changes in appearance, weeps fluid or pus or you feel unwell with a high temperature it could be a sign of infection. Contact your surgeon, our team or your GP immediately.
2. Loosening is the main reason why joint replacements can eventually fail. It is a process that occurs where the metal or cement meets the bone. Most will eventually loosen and require revision, as loosened joints are painful.
3. Nerve damage can occur during the surgery as many of the large nerves and blood vessels that enter the arm pass very close to the site of the operation. Damage can be temporary if retractors holding them out the way stretch them; it is rare that permanent damage can occur, but is possible.
4. Dislocation of the new shoulder joint is a possibility after surgery before the tissues holding the joint in place have healed fully. Your therapist will show you which positions to avoid in order to minimise the risk.
5. Fracture during surgery is very rare, but if this happens, you may require additional surgery or a slightly different prosthesis. There is a small risk of a periprosthetic (below the metalwork) fracture after surgery, which is most likely following a fall.
6. Bleeding. Excess bleeding after surgery may need blood transfusion or a further visit to the operating theatre.
What happens if I agree to a shoulder replacement?
If you and your surgeon agree that a shoulder replacement is necessary, you will be given an appointment for a pre-operative assessment clinic to ensure you are fit for the operation and to record some baseline information. You will see your consultant, or a member of the team, to discuss your surgery and to sign a consent form. You will have the opportunity at this appointment to discuss any concerns you may have and ask any questions. We must seek your consent for any procedure or treatment beforehand. Staff will explain the risks, benefits and alternatives where relevant before they ask for your consent.
If you are unsure about any aspect of the procedure or treatment proposed, please do not hesitate to ask for more information during your clinic appointment the nurse will discuss your stay in the hospital and organise any other necessary tests.
These may include a blood test, urine test and an ECG (heart tracing). If you have any concerns about how you will manage at home after your operation, please mention this to the consultant at your preoperative assessment clinic appointment who may be able to arrange for extra support or assistance following your operation.
How long will I be in the hospital?
The actual operation will last about 2-3 hours, and you will generally be expected to remain in the hospital for a further 2-3 days. This is to ensure you are well enough to manage at home and to start your post-operative rehabilitation.
Will it be painful?
The anaesthetist will put an injection into the side of your neck (called an ‘interscalene block’) to numb your shoulder prior to the surgery. This may last for up to 24 hours and is very useful in providing adequate pain relief following surgery. Prior to the operation, you will be given the opportunity to speak to the anaesthetist with regards to this.
Although the operation is to relieve pain it may be several weeks until you feel the benefit. You will be given painkillers whilst in hospital and a prescription for pain medication for your discharge home. Please visit your GP if you require further medication. You will have some bruising around the shoulder/upper arm and it may be swollen. This will settle after a few weeks.
Will I have to wear a sling? Your arm will be supported in a sling immediately after the operation. This needs to be worn continuously for six weeks, apart from when you remove it to do the exercises taught to you by your physiotherapist. The occupational therapist will also show you how to remove the sling carefully to wash and dress.
How will I sleep?
Sleep may be uncomfortable if you try and sleep on your affected side, as you will need to continue to wear the sling whilst in bed. We recommend that you lie on your back or on the opposite side, as you prefer. Pillows can be used to give you comfort and support (feather pillows are easier to mould than foam ones).
What clothes should I wear with the sling?
Most people find it difficult to manage ordinary clothes immediately after surgery due to the limitation of shoulder movements; therefore we advise you to wear a loose-fitting button-through shirt or blouse, and comfortable trousers/skirt. A bra may be uncomfortable in the early days so it would be advisable to bring an under slip or loose-fitting underwear.
When can I drive again? You should not drive for at least six weeks after your operation. After this point, you should return to driving only after a discussion with your therapist or surgeon. You should also inform your insurance company and the DVLA as your operation may affect your insurance.
What exercises will I need to do after the operation?
The day after your shoulder replacement, the ward physiotherapist and occupational therapist will begin your rehabilitation. You will only be able to move your elbow, wrist and hand for the first four weeks following your operation. At four weeks following your operation, you will see the physiotherapists who will advise you on how to progress your exercises.
What happens when I leave the hospital?
When you leave the hospital, we will make you an appointment to attend the outpatient physiotherapy department within the following 4 weeks to check on and continue your exercises. You will need to have physiotherapy to ensure your new shoulder doesn’t become stiff and also to get the muscles working. You may also need to attend occupational therapy. You will be seen in the clinic by the surgeon or a member of his team two weeks after your operation, then again at about 3 months after surgery.
When will my stitches be removed?
Generally, the stitches we use are dissolvable, so you do not need a separate appointment to remove them. Any protruding ends of stitches will be checked at your clinic appointment at 2 weeks and trimmed if necessary. Keep the wound dry until it is healed. This is normally 10-14 days. Avoid using deodorant, talcum powder or perfumes near or on the scar.
When can I resume normal activities?
This depends on your symptoms. Most people find they are comfortable within three months after their surgery, but that they continue to improve for up to 12-18 months afterwards. Light activities such as sewing, knitting and computer work are best avoided until 6 to 8 weeks after your operation. Avoid taking your arm out to the side and twisting it backwards. Avoid leaning with all your body weight on your arm with your hand behind you. Tasks such as ironing should be avoided for the 8 weeks and following this only for short periods of time, such as 15 minutes in any one session. Heavier work above shoulder level and tasks such as mowing the lawn should be avoided until at least 12 weeks after the operation. Bowls after three to six months.
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