Orthopaedic surgery is a team effort

Guest post by Jessica Scott, PA-C, OU Medical Center Edmond

A surgical procedure, whether an outpatient surgery such as rotator cuff repair or a larger procedure such as total shoulder replacement, is very much a team effort. Here are a few of the key players in surgery, some of whom patients will meet and others whom they will not.

Pre-Operative Nurse

When a patient arrives at the hospital, a pre-op nurse will ensure they are checked in and prepared for surgery. This includes placing an IV, asking questions about health history and current medications, and other steps to prepare the patient for their procedure.

Circulator Nurse

The circulator nurse is in the operating room to document what happens during surgery, including what time the patient entered the room, when the incision was made, and any other details. The circulator nurse is not sterile, so if the surgical team needs something from outside the sterile field or outside the operating room, the circulating nurse can go get it. This is also the nurse who updates the patient’s friends or family in the waiting room about how surgery is going.

Anesthesiologist

The anesthesiologist is responsible for putting the patient to sleep and controlling their pain for the procedure. They are in the room throughout the procedure to monitor the patient’s vitals, ensure they stay asleep, and help control any pain during the procedure. If the procedure is being done with a regional block, the anesthesiologist places the block prior to the procedure.

Primary Surgeon

For patients of the Oklahoma Shoulder Center, Dr. Betsy Nolan is the primary surgeon. The primary surgeon is responsible for the majority of the surgical procedure.

First Assist

The first assist is usually a resident surgeon or a physician’s assistant. Their role in surgery is to provide support in whatever way the surgeon requests support, such as holding retractors or doing suction so the surgeon can see better. The first assist also acts as another set of eyes and ears for the surgeon. They play an important role in positioning of the patient. As the surgeon focuses on a particular task, it is the first assist’s job to survey everything else happening and do what’s necessary to support the surgeon.

In many cases, the PA and/or resident also assists with taking care of the patient postoperatively if a stay in the hospital is necessary.

Scrub Techs

Scrub techs are another part of the surgeon’s support team. They assist with retraction, handing instruments to the surgeon, or anything else needed during the procedure.

Device Company Representative

For surgeries that will use an implant of some kind, a representative from the device company is also present. The representative will unpack the boxes to ensure everything meets the company’s specifications and be available to answer any specific questions related to the company’s implant or instruments.

Post-Operative Nurses & Techs

After surgery, a team of nurses and techs will care for the patient on the floor. Nurses will administer meds and monitor pain levels, nausea, and other postoperative symptoms to ensure the patient stays comfortable while recovering. Techs assist with activities like toileting and bathing, as well as checking vital signs.

X-Ray Tech

For some procedures, x-ray is required during the procedure in order to check, for instance, fracture alignment or hardware placement. An x-ray tech with a mobile x-ray machine called a c-arm comes into the operating room to take x-rays when requested by the surgeon.

Additional Support Roles

Aside from the team members directly involved in surgery and pre/post-operative care, there are additional support staff members often working behind the scenes. This category includes schedulers, medical coders, billing department staff, and hospital administrators, all of whom help ensure a smooth process for patients.

While a patient will mostly see their surgeon and pre/post-op nurses, it takes the entire team to ensure a successful surgery.

Treatment for scapular instability

Abnormal scapular (shoulder blade) motion most often occurs when compensating for another injury or pain in the shoulder area. Individuals may compensate for pain in the ball and socket joint by trying to get more motion through the scapulothoracic joint (the joint between the shoulder blade and the chest wall), which results in overuse injury to the muscles that stabilize that joint. Scapular instability can cause pain in the back of the shoulder, upper back, or even pain in the neck area that comes from the scapular stabilizing muscles, including the trapezius muscle, among others.

The most common visible sign of fatigue or imbalance of the scapular stabilizing muscles is called winging, where the shoulder blade looks like it pops out when raising the arms overhead. This typically occurs because of weakness in the muscles surrounding the shoulder blade, although it can also occur due to a nerve deficit.

Physical therapy is the most common treatment for pain or winging due to scapular instability, as it helps strengthen the specific muscles that stabilize the scapula. Many shoulder surgery post-operative physical therapy plans include exercises for scapular stabilization, since many patients will use the scapulothoracic joint more in order to compensate for pain and limited motion following surgery. Physical therapy to strengthen the surrounding muscles is important to address this secondary problem, which often occurs after surgery. The link below demonstrates some of the exercises that may be helpful.

When recovering from surgery or healing from a fracture, scapular instability can be a frustrating hurdle to overcome in the healing process. It can also be confusing for patients, as the pain may occur in a different location than where the issue actually occurs, as in patients who experience neck pain or upper back pain.

When an underlying issue, such as arthritis, contributes to scapular instability, it’s important to see a specialist who can treat the primary problem and reduce the need for compensation when rotating the shoulder. A combination of treating the primary problem and working with a physical therapist to strengthen the surrounding muscles can help reduce pain and improve overall shoulder function.

If you experience pain in the back of the shoulder or uncomfortable popping of the shoulder blade, contact the Oklahoma Shoulder Center for an appointment.

Fractures of the elbow and shoulder

There are many types of fractures that can occur to the shoulder or elbow, all of which differ in terms of severity, treatment, and recovery. Lots of fractures occur in older patients who have osteoporosis, but patients of any age can suffer a fracture in the right circumstances.

Orthopaedic surgeons classify fractures based on the number of parts fractured, the direction of displacement, whether or not there is an associated open skin injury, whether or not the fracture line extends into the joint itself, and more. Shoulder and elbow fractures can be evaluated through x-rays and sometimes a CT scan, if needed.

 

For a typical patient, it’s not important to understand the classification systems, but they help physicians be able to better discuss the injury with other doctors and the other members of your care team. It also helps with providing diagnostic and treatment-related information, as not all fractures are created equal.  

In general, treatment of fractures depends on bone quality overall, how well the bone is expected to heal, and potential future repercussions of that injury, such as risk of future arthritis when a fracture goes into a joint and makes the joint incongruent. Many fractures heal on their own with immobilization, while others can be repaired through surgical use of plates and screws, pins, or wires. In some cases, replacement of a portion of the joint or the entire joint may be required.

Fractures of the elbow

Distal humerus humerus fractures most often occur from a fall from standing or a slight elevation, such as a step or two. This often occurs in patients with osteoporosis and results in lots of fragments. Treatment usually requires surgery and the use of pre-contoured plates attached with screws that hold the fragments in correct alignment in order to allow the arm to heal in correct alignment. This is especially helpful in allowing motion earlier to avoid stiffness in the elbow.

Radial head fractures are common and often occur when falling, such as off a bike, onto an outstretched hand. If the injury results in only two fragments and minimal displacement, treatment is to immobilize the elbow in a sling for a week or two and then start early physical therapy. If there are more fragments or greater displacement, surgery to repair the fracture with screws or a radial head replacement (different than a total elbow replacement) may be required.

Olecranon fracture occurs in the bony tip of the elbow and typically needs to be repaired with screws, pins, or wires. Because the triceps attaches to the point of the elbow, it can create a gap that doesn’t allow new bone to form, thus the need for surgical treatment.

Coronoid fracture can occur alone or in combination with elbow dislocation and/or ligament injury. A simple tip of the coronoid fracture may not require treatment beyond temporary immobilization, but more complex coronoid injuries that include ligament injury will likely require surgery. The terrible triad of the elbow is a coronoid fracture combined with radial head fracture and dislocation.

Fractures of the shoulder

Proximal humerus fracture is a fracture of the upper part of the arm bone, the third most common joint fracture after wrist and hip. Most can be treated non-operatively, although it depends on the fracture pattern.

Scapula fractures can occur in the blade part of the shoulder. Most are non-operative, but some may require surgery if they extend into the socket part of the shoulder joint or if they cause instability of the shoulder. Scapular fractures are not common and require a significant amount of trauma to occur, such as a motorcycle accident.  

Glenoid fractures (the socket part of the shoulder joint) can cause the joint to be uneven, can lead to arthritis, and can cause the ball to fall out of the socket. Surgical treatment is generally recommended if they are displaced to prevent long-term consequences.

Clavicle fractures are relatively common and treatment depends on age, activity demands, and how displaced they are. The clavicle remodels well even up to the early 20s, and many heal on their own in older patients as well. For patients who do manual labor or lots of overhead work, repairing the clavicle surgically may be recommended.

A type of fracture that occurs between the shoulder and elbow is a humorus fracture, which is the shaft part of the arm. It can be associated with radial nerve injury, especially if the fracture occurs in a spiral pattern at the groove where the nerve is normally located and traps the nerve. Most humorus fractures only require a sling and physical therapy.

If you experience pain in your shoulder or elbow that may be the result of a fracture, contact the Oklahoma Shoulder Center today to schedule an appointment.

Dislocations of the shoulder and elbow

The shoulder is the most commonly dislocated joint in the body. The shoulder joint has the most motion of any joint, which also means it has the least inherent natural stability of any joint. Joints like the hips and knees are more about supporting body weight rather than performing the range of activities that utilize the arm and shoulder, so they have less motion overall than the shoulder.

For most patients, shoulder dislocations occur through some type of trauma—a fall, car accident, or sports injury—where the arm is in a vulnerable position and then an applied force pops the shoulder out of place. More than 90% of dislocations are anterior, meaning the ball comes out to the front of the socket. Such injuries usually occur when the arm is in a position of abduction and external rotation, such as throwing a ball overhead.

The second most common type is posterior dislocation, or to the back of the socket. This type accounts for about 9% of dislocations and is frequently associated with seizure disorders where the patient’s muscles tighten during a seizure and push the shoulder to the back.

Less than 1% of shoulder dislocations are inferior dislocations that occur when the patient’s arm is straight up overhead with force applied. This type of injury might occur in surfers hit by a wave or if someone’s arms were up and pinned against a wall. It’s an uncommon but dangerous injury because a nerve or vascular injury can occur along with this particular type of dislocation.

Once a dislocation has occurred with trauma once, it can become a recurring problem that happens with a lesser amount of trauma in the future. In some patients with multiple dislocations, the shoulder can begin to dislocate during their sleep without any trauma.

In most cases, a first-time shoulder dislocation is treated non-operatively by immobilizing the shoulder in a sling for a week or two followed by physical therapy to restore motion and help balance the muscles for better stability. Therapy is also commonly used to treat partial dislocations, called subluxations, where the joint feels like it might come out but doesn’t go all the way.

Once a dislocation becomes recurrent, surgery is generally required. Although the specific type of surgery will vary depending on the type of dislocation and which structures have been torn or damaged, most can be done arthroscopically. Some patients have inherent hyperlaxity of their tissues, where joints naturally move farther than they should. If it becomes symptomatic, it usually responds to physical therapy. A small number of these patients may require stabilization by surgically tightening the capsule around the joint.

Elbow dislocations are much less common than shoulder dislocations, but the elbow can go out any direction. The most common type of dislocation, a posterior dislocation, is caused by a fall on outstretched hands. Typical treatment for elbow dislocation is immobilization in a sling for a week or two. Because elbows are not as prone to recurrent dislocation or instability as shoulders are, no further treatment is generally needed. In cases where an elbow dislocation is accompanied by certain types of fractures and/or ligament injuries, however, urgent surgery may be needed to stabilize the elbow.

It’s also possible to dislocate either end of the clavicle, commonly called the collarbone. At the sternoclavicular joint (the end of the collarbone in the center of your chest), it can dislocate to the front or the back. If the collarbone comes out to the front when dislocated, it generally doesn’t require surgery. However, if it dislocates to the back, which is much less common, it can be stuck under the sternum and pointing into the trachea, esophagus, and vessels as they come out of the heart to supply blood to the rest of the body and return blood from the rest of the body to the heart. When a clavicle dislocation to the back occurs, surgery is generally required to decrease risk to these vital structures.

The distal clavicle area of the shoulder typically separates, rather than dislocates. A distal clavicle separation is common in sports that may involve a direct hit on the top of the shoulder, such as football or soccer. While it can result in a cosmetic deformity from one end of the collarbone appearing more prominent, most of these injuries don’t require surgery and don’t cause any particular disability.

If you have experienced one-time or recurrent dislocation of the shoulder or elbow, contact the Oklahoma Shoulder Center today for more information and to schedule an appointment.

Can I go hunting after a shoulder replacement?

When working with patients who need a total shoulder replacement or reverse shoulder replacement, many patients ask if they will be able to hunt following their surgery. Other patients ask about returning to golf or other physically active hobbies. Still others have more questions about their ability to continue in a job that requires physical labor. Not many patients ask us whether they can return to riding a motorcycle, although we have an answer for that as well.

So what activities can you do (and not do) after a shoulder replacement?

When it comes to hunting, we advise patients to proceed with caution following their surgery but that they can still hunt. Certain types of guns can have a pretty decent kick, and the shoulder takes most of that impact. At this point in time, there’s no specific research to measure how that impact affects a replacement shoulder joint over time though. Dr. Nolan hopes to do a future study on the impact of hunting on shoulder replacement to fill that research gap, but for now, we simply don’t know what the impact is.

In the absence of research showing negative impact on shoulder implants, there’s no specific reason to avoid hunting once fully healed from surgery. Dr. Nolan has seen many patients who returned to hunting following their shoulder surgery, and these patients have not developed any implant-related issues over time.

Potential risk doesn’t just come from shotguns, as some handguns still kick and create pressure on the shoulder. Yet some professions, such as police officers, must regularly pass shooting qualifications and meet certain physical standards to continue in their job.

Other jobs that could be impacted by a shoulder replacement include those that require heavy lifting, especially overhead lifting. Some patients with physically demanding jobs choose to take a non-operative treatment approach to manage shoulder pain until they reach retirement age and can pursue replacement. Others who can’t avoid shoulder replacement any longer may need to change positions or request accommodations following surgery.

For golfers, there are no restrictions on returning to regular activity once fully recovered from surgery. However, most patients can expect full recovery to take about six months. There’s no research addressing whether tennis has an impact on replacement shoulder joints. If you played tennis prior to your surgery, you are likely fine to return to playing after recovery. But if you are picking up a new sport after surgery, it’s best to stick with lower impact sports overall that put less stress on your shoulder.

One category of activities we advise against following shoulder replacement surgery is any hobby or activity that could result in falling, such as riding a motorcycle, horseback riding, skiing, or even climbing ladders. Any fall can result in a significant injury, such as dislocating the shoulder, fracturing the area around the implant, or even breaking the implant. Revision surgeries to repair a damaged joint that has already been replaced are harder on the patient than the original surgery, and the outcomes are often not as good as the primary surgery. Thus, we advise people to avoid any activities that could result in a fall or accident that may cause damage to the shoulder.

Ultimately, all joint replacements surgeries are designed to help the individual with activities of daily living, or ADLs. More research is needed to determine how well joint replacements hold up to higher levels of activity over time, but until that research can be completed, remaining active while exercising reasonable caution is the best approach.

Restoring Shoulder Motion Through Tendon Transfer

Tendon transfers can be a great option for many patients who have significant injury to the rotator cuff but may want to avoid reverse shoulder replacement. Tendon transfers may be less invasive than replacement surgery and are a permanent repair with fewer restrictions on future activity. There is also less risk of additional surgeries in the future, such as with patients who undergo joint replacement at a young age.

Tendon transfers can help restore motion to the shoulder, but they don’t resolve any pain associated with arthritis. Thus, tendon transfers are typically done for patients with minimal or no arthritis. For patients with arthritis and an irreparable rotator cuff tear, reverse shoulder replacement surgery is usually the better option.

Here we review three major tendon transfers for the shoulder: latissimus dorsi, pectoralis major, and lower trapezius. In these procedures, the tendon is detached from its regular location and moved to a new location, which changes the force vector to allow it to move the shoulder in a different way. Tendon transfers can be particularly useful for patients who are younger or have a job that requires heavy labor and hope to avoid reverse shoulder replacement.

In some cases, a tendon transfer is done along with a shoulder replacement surgery. For example, a latissimus dorsi tendon transfer can be done alongside or in combination with teres major transfer (called a modified L’Episcopo procedure) while doing a reverse shoulder replacement in a patient with profound weakness that limits external rotation.

A latissimus dorsi transfer is used in patients whose rotator cuff tear is irreparable and located in the posterosuperior position of the rotator cuff, which results in pain and weakness in external rotation. One quick test for this type of injury is the hornblower sign, during which the arm is lifted with the elbow at 90 degrees and the hand pointed up. If the hand falls in the fashion of a hornblower, that can signal that the part of the rotator cuff responsible for external rotation is too weak and the patient might be a candidate for tendon transfer.

The latissimus dorsi transfer was first developed by Dr. Christian Gerber in Switzerland, whom Dr. Betsy Nolan studied under during her first shoulder and elbow fellowship. The procedure requires incisions in the front and back of the shoulder and generally requires three to six months of specialized physical therapy afterward to train the muscles to work in a new way.  

A lower trapezius tendon transfer can be done arthroscopically but works similarly to a latissiumus dorsi transfer. Both eliminate the restrictions required with joint replacement.

The pectoralis major transfer treats a different type of rotator cuff tear, a tear of the subscapularis tendon in the front. The procedure helps restore internal rotation to the shoulder, which impacts daily activities like tucking in a shirt or getting a wallet out of a back pocket. If the tendon can be repaired, then a primary repair is done. In patients whose subscapularis tendon is not repairable, a pectoralis major tendon transfer may be an option.

It is common that a surgeon may offer some, but not all, of these treatment options, depending on their skill set. If you have an irreparable rotator cuff tear and want to be able to consider all of your treatment options, contact us today at the Oklahoma Shoulder Center to schedule a consultation.  

Women in Orthopaedics: Dr. Jacquelin Perry

According to a 2014 survey by the American Academy of Orthopaedic Surgeons, women represent only 6.1% of practicing, while medical school enrollment tends to be evenly split between men and women.

Orthopaedic surgery is not a required rotation at most medical schools, and therefore exposure to the field before a career path is chosen is limited. The Perry Initiative seeks to provide early exposure to the field in order to build the pipeline of future female leaders in orthopaedic surgery and engineering.  

Its namesake Dr. Jacquelin Perry, a significant pioneer for women in orthopaedics, was among the first women to practice orthopaedic surgery in the United States. Her career in orthopaedics spanned more than 60 years, and she continued to practice part time until her death in 2013 at the age of 94. Prior to attending medical school, she was a physical therapist in the Army.

She was a professor of surgery at the University of Southern California medical school from the early 1970s to late 1990s, where Dr. Betsy Nolan completed her residency. Dr. Nolan remembers Dr. Perry as sharp, detail-oriented, committed to her work and her patients, and a mentor to both women and men in orthopaedics.

Dr. Perry’s work focused on treating post-polio syndrome patients through gait analysis and spinal surgery to restore mobility. Even when she retired from surgery, she continued to treat patients at her specialized gait analysis clinic. Together with Dr. Vernon Nickel, she developed the halo, a metal ring attached to the skull that is still used today to immobilize the neck and spine.

The Perry Outreach Program offered through The Perry Initiative offers hands-on programs for women in high school, college, and medical school. Their dual focus on orthpaedics and engineering recognizes that a strong partnership between the two fields is critical for the future development of orthopaedic implants and other solutions for patient needs.

For more information about The Perry Initiative and their programs, visit their website.

Reverse Total Shoulder Replacements

In a reverse total shoulder replacement, the normal anatomic configuration of the shoulder is reversed to put the ball where the socket was and socket where the ball was. These procedures are most often done for patients whose rotator cuffs are damaged beyond repair and/or are unable lift their arm overhead due to rotator cuff deficiency. Reversing the ball and socket changes the center of rotation for the shoulder, which allows the deltoid muscle to play a bigger role in moving the arm.

The Food and Drug Administration (FDA) approved the procedure in the United States in 2004, although it had been used in Europe for approximately 20 years prior. When Dr. Betsy Nolan completed her shoulder and elbow fellowship in Switzerland under Dr. Christian Gerber, her training included hundreds of reverse total shoulder replacements with one of the early adopters and design surgeons for the reverse (also called inverse) shoulder replacement.

Dr. Nolan calls the reverse total shoulder replacement the single biggest technological advance in shoulder surgery in her lifetime. The procedure is now done for many patients who previously would have been told that nothing else could be done. While it is a newer procedure than the total anatomic shoulder replacement, it is not a better treatment — the two are simply different procedures used in different situations. In recent years, new convertible implants are available which make it easier to convert an anatomic total shoulder to a reverse total shoulder at a later date, if further injury or passage of time results in new rotator cuff pathology, which requires revision.  

Many patients who need a reverse total shoulder replacement will have pseudo-paralysis of the shoulder that prevents them from lifting their shoulder above 90 degrees. This means they can’t reach the top of their head to wash or groom their hair or their mouth to feed themselves, for example. Not all patients experience shoulder pain, so the issue may be written off as a nerve injury or simply old age, when in fact it’s due to a massive rotator cuff tear that occurred over time. Patients may have adjusted to limited shoulder function on one side, and it’s not until the second shoulder begins bothering them that they seek treatment. A reverse total shoulder replacement is also done for patients with arthritis when the rotator cuff is not intact and for many patients who need a revision (repeat surgery) who have undergone a prior anatomic total shoulder replacement.

Compared to anatomic total shoulder replacement surgery, the reverse total shoulder replacement is similar in terms of size of incision, length of surgery, and timeframe for recovery. The primary difference between the two are precautions to avoid dislocating the joint following surgery. An anatomic shoulder replacement can dislocate in abduction and external rotation (the position of throwing a ball overhead, for example). A reverse total shoulder replacement is most likely to dislocate in adduction and internal rotation, such as if reaching for a wallet in the back pocket.

The goal for any shoulder replacement surgery is to allow the patient to perform activities of daily life. Shoulder replacements are not designed for heavy lifting or competitive athletics, as doctors do not know how long the replacement joints will last with that level of activity. Any patient with a shoulder replacement should avoid activities with a high risk of falling, such as riding a horse, riding a motorcycle, or working on a roof.

If your shoulder motion, strength, or pain limit you from doing your normal daily activities or you have other shoulder or elbow concerns, call the Oklahoma Shoulder Center today at 405.278.8006 to schedule an appointment.

Should I Get a Second Opinion?

At the Oklahoma Shoulder Center, we regularly see patients who want a second opinion regarding their shoulder or elbow problem. Some patients may be hesitant to seek a second opinion because they are unsure of the cost or they don’t want to offend their original surgeon or referring doctor. However, when it comes to surgery, a second opinion can be beneficial whether it confirms the course of treatment or provides an alternative option. For most patients, the cost for a second opinion is simply an office visit co-pay. Here are a few reasons to consider getting a second opinion:

  • You don’t feel completely comfortable with your doctor. Doctors have different personalities, just like patients do. If you don’t feel like a doctor is the right fit for you in terms of personality, find someone who is.
  • You have unanswered questions after your consultation. It’s important to find a doctor who will answer all of your questions prior to surgery and not make you feel rushed.
  • The first doctor you see doesn’t do this procedure very often. Be sure to ask how many procedures like yours the doctor has done in the past year, or when they last did a surgery like yours. It’s also important how much experience the team (nurses, anesthesiologist, and office staff) have with your specific procedure.
  • You wonder if there might be another option besides surgery or other types of surgery that were not offered. A surgeon often won’t recommend a procedure they’re unfamiliar with, but there may be more than one surgical approach to your injury. A shoulder and elbow specialist should be able to explain the full spectrum of nonsurgical and surgical options. For example, some types of rotator cuff tears can be treated with tendon transfer instead of a reverse total shoulder replacement when they cannot be repaired.  

Many patients who come to the Oklahoma Shoulder Center for a second opinion come to us from out of town, either from other places in Oklahoma or from surrounding states. If you are scheduling an appointment from out of town, our staff will be happy to help with recommendations for nearby restaurants and attractions. We also have group rates available at some nearby hotels if you need lodging.

Whether coming to see us for a second opinion from out of town or locally, here are some important items to bring to your appointment:

    • Previous x-rays, MRIs, or other images, especially any images taken within the past six months. Please bring the actual images as either prints or electronic files, in addition to the written report from the radiologist.   
    • Prior operative reports and implant logs, if you have had a previous surgery. Be sure to request these in advance from your previous physician and bring them with you or ask that they fax them to us in advance. 
    • Any medical records from recent visits to other orthopaedic surgeons.

If you are considering a second opinion about your shoulder or elbow issue, we invite you to contact us at the Oklahoma Shoulder Center. Call 405.278.8006 today to schedule an appointment with Dr. Betsy Nolan.

An Overview of Anatomic Total Shoulder Replacements

There are four basic types of shoulder replacements: hemiarthroplasty (also known as a partial shoulder replacement); resurfacing arthroplasty; traditional, or anatomic, total shoulder replacements; and reverse total shoulder replacements.  Hemiarthroplasty and resurfacing arthroplasty are used in specific, limited circumstances. Reverse shoulder arthroplasty is used mostly in patient with arthritis when the rotator cuff is not intact, patients with massive irreparable rotator cuff tears with pseudo-paralysis (inability to lift the arm above 90 degrees), and many revision and deformity situations. This post will specifically address anatomic total shoulder replacements, with a post about reverse shoulder replacements to come later.

Most shoulder replacements are done when arthritis of some kind — rheumatoid, osteoarthritis, psoriatic, or post-traumatic — causes significant pain or limitations in shoulder function. Before shoulder replacement surgery, Dr. Nolan will usually recommend more conservative treatment options, including activity modification, anti-inflammatory medications or steroid injections, physical therapy, and other non-invasive treatment options. Some patients may not find relief with any of the non-invasive treatments, however, and will then proceed to total shoulder replacement surgery.

The rotator cuff, or the muscles and tendons that keep the ball-and-socket joint between your arm and shoulder blade functioning, must be intact for an anatomic total shoulder replacement to function correctly and to avoid early loosening. The shoulder replacement surgery is typically a one- to two-hour procedure, but it could be longer in some circumstances if there is additional work required, such as bone grafting. During the procedure, a prosthesis is used to replace the head of the humerus bone (ball portion of the ball-and-socket joint) and the socket (glenoid) of the shoulder joint. The ball is typically made of cobalt chrome, while a medical-grade plastic (polyethylene) is used for the glenoid portion. Most total shoulder replacements can be done with an approximately five-inch scar on the front area of the shoulder.

Most patients stay in the hospital for one night following surgery, but some patients may stay longer. Before being discharged from the hospital, you will see a physical therapist to learn how to take your sling on and off and learn tips for getting dressed and doing daily tasks without injuring your shoulder as it heals. Upon going home, you will be able to do things with your hand on the operative arm like talking on your phone and feeding yourself, but may need someone available to help you with getting dressed, showering, cooking, and other daily tasks, typically for a week or two following surgery.

About two weeks after surgery, you will have a post-operative appointment with Dr. Nolan. If everything looks good in terms of the incision healing, most patients will start a three-month course of physical therapy two or three times per week. Some patients may continue physical therapy for up to an additional three months. We can help you locate a physical therapist near home or work so that you can make it to therapy appointments frequently, as regular therapy is essential for full recovery from total shoulder replacement.

Many patients want to know when they can return to work or other activities following surgery. For patients who work desk jobs, we recommend taking a full two weeks off to recover, make sure the incision is healing properly, and get scheduled for physical therapy. You will be in a sling for approximately six weeks after surgery. For patients who work manual labor jobs, additional time off work will likely be required to allow your shoulder to fully heal. For those who do heavy lifting at work, expect to take at least three months off work. Sports activities should generally wait for three to six months after surgery, depending on your progress in physical therapy and the type of activity you want to do. We recommend avoiding contact sports and activities where you risk falling from a height, such as riding a horse or working on roofs indefinitely following shoulder replacement surgery.

Some individuals are not good candidates for total shoulder replacement surgery, including anyone with an active infection, those who are too weak or ill for anesthesia, diabetics with A1c levels that are not well controlled, individuals who do a lot of heavy lifting that may compromise the implant, and individuals who work at high elevations (such as roofers), and those who are at high risk of falls (such as people with Parkinson’s disease). Heavy lifting and falling from a high elevation or falling shortly after surgery create risk of breaking the implant, breaking the surrounding bones, or injuring the muscles and tendons. If any of those occur, surgery may be required to repair the shoulder, and each additional surgery has a lower success rate. Dr. Nolan will discuss all of these factors with you to determine whether or not you are a good candidate for a total shoulder replacement.

If you are experiencing significant pain or limited function of your shoulder and wonder if you might be a candidate for a total shoulder replacement, call the Oklahoma Shoulder Center today to schedule a consultation appointment.