Reverse total shoulder replacement

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1 Patient information Reverse total shoulder replacement This leaflet has been designed to give you some more information about having a reverse shoulder replacement. Your surgeon believes you will benefit from this operation. The aim of the operation is to reduce your pain and so improve your function. Barts Health Therapies Department

2 Why do I need a shoulder replacement? The shoulder is a ball and socket joint and is made up of three bones; the humerus (arm bone), scapula (shoulder blade) and clavicle (collar bone). The main reason for having a shoulder replacement is painful arthritis in the ball and socket joint. Less frequently a replacement may be carried out to deal with a fracture close to the joint. If the shoulder joint is affected by arthritis it can become painful, swollen and difficult to move. Where pain and movement cannot be improved with medication, injections or physiotherapy, a joint replacement may be considered. What is a reverse shoulder replacement? The replacement of the shoulder joint is where the surfaces of the joint, normally made of bone covered with cartilage, are replaced with parts made of metal and plastic. The operation is sometimes called an arthroplasty. A reverse shoulder replacement is when the positioning of the ball and socket are reversed. This improves the biomechanics and function of the shoulder when damage has occurred to the small muscles around the shoulder called the rotator cuff. What are the risks of having this type of surgery? All operations involve an element of risk, these are very small but you need to be aware of them and can discuss them with your doctor at any time. The risks are: Complications relating to the anaesthetic Stiffness and or pain around the shoulder Damage to nerves or blood vessels around the shoulder Need to re-do the surgery. Dislocation of the prosthesis Infection - these are usually superficial wound problems (rare; less than 1%). 2

3 Questions that we are often asked about the operation What sort of anaesthetic will be given to me? You will be given a general anaesthetic. General anaesthesia is drug-induced unconsciousness: an anaesthetist, who is a doctor with specialist training, always provides it. Unfortunately, general anaesthesia can cause side effects and complications. Side effects are common, but are usually short-lived: they include nausea, confusion and pain. Complications are very rare, but can cause lasting injury: they can include paralysis and death. The risks of anaesthesia and surgery are lower for those who are undergoing minor surgery, and who are young, fit, active and well. You will be given an opportunity to discuss anaesthetic options and risks with your anaesthetist before your surgery. Often the general anaesthetic may be combined with a regional anaesthetic. This will be discussed with you pre-operatively, and involves the injection of local anaesthetic around the nerves at the base of the neck that supply the shoulder and arm. Depending on the type of local anaesthetic used, the effects may last hours or sometimes even days. The advantage of using this technique is that you are likely to be far more comfortable immediately post-operatively and therefore will require less strong pain killers and are less likely to feel sick following the surgery. For this reason patients recover usually far quicker immediately post-operatively. There is a risk of nerve injury or sensitisation following this procedure, but it is very rare. Getting ready for your operation The staff will ask routine questions about your health, the medicine you take at the moment and any allergies you may have. You will be given instructions on eating and drinking. You will be able to discuss the operation with a doctor. You will be asked to sign a consent form to say that you understand the procedure, and what the operation involves. What happens on the day of your operation? You will come into hospital on the day of your operation. Please make sure you contact the ward before you leave home to check bed availability. Please leave all cash and valuables at home. The Trust does not accept responsibility for items not handed in for safekeeping. There is a very small lockable cupboard by your bedside which will be used to store your medication and small amounts of petty cash. It cannot accommodate large items. You will be asked to remove jewellery - plain bands can be worn but they will be taped. 3

4 Please leave body piercings at home. Acrylic nails and nail polish will also need to be removed. If you are on regular medication, you will be told to take this if necessary. A bracelet with your personal details will be attached to your wrist. You may be prescribed some medication to take before your operation by the anaesthetist. A member of the nursing staff will give this to you. You will be given a gown to wear for your operation. A nurse and porter will accompany you to the operating theatre. Your dentures, glasses or hearing aid can stay with you on your journey to the operating theatre. When you arrive in the waiting area, a theatre nurse will check your details with you. The ward nurse will then leave you and you will then be taken to the anaesthetic room. What should I expect after the operation? After your operation you will be kept in the theatre recovery room before being transferred to the ward. A nurse will check your pulse, blood pressure, and breathing rate regularly. It is important that if you feel any pain you tell the nursing staff, who can give you painkillers to help. The first time you get out of bed, please make sure you ask a nurse to be with you. This is in case you feel dizzy. When will I go home? You will usually be kept in hospital overnight after your surgery. Occasionally you may be kept in hospital for a couple of days. During this time medical, nursing and physiotherapy staff will be involved in your care. Remember that you have just had an operation. It is normal to feel more tired than usual for a few days after having an operation. Your shoulder is likely to be uncomfortable in the first few days post- surgery. This is normal. You may not feel there is a significant improvement in your pre-operative pain until a few weeks after surgery. If you have had a regional nerve block, you are likely to feel little pain postoperatively. Sometimes the block can be very dense and also lead to weakness in the muscles of the arm and hand and well as numbness. Do not worry, the function does return when the anaesthetic wears off. It is important for you to be particularly careful with your arm and protect it in the sling initially as during this period it will be numb. It is also very important you start taking your painkillers regularly straight away, despite having little or no pain. 4

5 Discharge information Will I be in pain? It is normal to feel some pain following your operation. A number of methods will be available after your operation to help keep your arm as free from pain as possible. These may include local anaesthetic, patient controlled analgesia or PCA (a system where you can control your own supply of painkiller going into a vein by pressing a button), or other injections or tablets. You will be given some painkillers and/or antiinflammatory medication to take in the days following the operation. It is vital to begin the tablets prescribed by the surgeon immediately after the operation even if you are pain free because of a very effective nerve block. It is important that you have adequate pain relief for when the block eventually wears off. Using ice on your shoulder can be helpful in reducing pain. Wrap a bag of crushed ice, or frozen peas in a damp towel. Protect your dressings from getting wet with a layer of cling film, or a plastic bag, before applying the ice pack for minutes at a time. Posture can make a big difference to your pain after surgery. Avoid hitching your shoulder or holding it in an elevated position. Also try to avoid slumping or standing/sitting with round shoulders as this puts more stress onto your shoulder. What do I do about the wound? Your wound needs to stay clean and dry. If you have removable stitches they will be removed after days at an outpatient clinic appointment or by your GP. If dissolvable stitches are used, they will not need to be removed. How long do I need to wear the sling? Your arm is supported in a sling straight after your operation for comfort. You can remove the sling for showering (keep the wound covered to avoid it getting wet for the first 5-7 days. You can start to remove the sling during the day approximately a fortnight after your operation (your Physiotherapist will advise you). It is very important you remove the sling 3-4 times a day to carry out your exercises. However, you should wear the sling at night for 6 weeks. Are there things that I should avoid? Yes, it is important to avoid over using your arm in the first few weeks. You will be advised to wear a sling for the first 2 weeks. You will gradually be able to return to activity but your activity levels will be guided by pain and your physiotherapist. Do not use the un-operated arm for any heavy manual work whilst the operated arm is in the sling. 5

6 Do I need to do exercises? Yes (see at the end of this leaflet) you will be shown exercises by the physiotherapist and you will need to continue with the exercises once you go home. They aim to stop your shoulder, elbow and wrist getting stiff. Getting back to normal how you can help yourself to recover Sleeping can be uncomfortable if you try and lie on your operated arm. We would recommend that initially you lie on your back or on the opposite side. If you lie on your back support the operated arm with a folded pillow under your lower arm. Make sure that your elbow is above your shoulder (see picture on right). In the first few days after surgery you will find it helps to support your arm when you sit as well. Put some pillows behind you shoulder and elbow to prevent the arm from falling behind your trunk (see picture on left). How long will it take me to recover? It will take three to six months before you get the full benefit of the surgery. You should feel a noticeable improvement by six weeks from the operation, and further steady improvement from then on. The outcome of your shoulder operation is linked to the work you put in with your rehabilitation so it is vital you complete a regular exercise regime. What is the long-term prognosis? You will continue to improve up to two years following the operation, but from six months these improvements are usually much slower. Everybody is individual and makes progress at slightly different rates, but overall more than 85% of patients get a satisfactory result in the first six months. Returning to activities When can I drive? You should not drive until you have discussed your progress with your consultant / physiotherapist, which will not be until at least six weeks following your operation. You must be able to comfortably control your vehicle and perform emergency manoeuvres. 6

7 When can I return to work? The amount of time you have off work depends on your job. If you have a manual job, or one that involves lifting or overhead activities, you will not be able to do this for eight to 12 weeks. Please discuss this with your consultant or physiotherapist. When can I return to sports and leisure activities? The timescale for which you can go back to any previous sport or activity will depend on your movement and strength and the particular activity you have in mind. Please discuss returning to any activity or sport with your consultant or physiotherapist. Physiotherapy appointments - how often will I have to attend? You will be referred for outpatient physiotherapy and until you have that appointment you are expected to start the exercises on this sheet as soon as possible after the surgery. You have an important part to play in your own recovery and are expected to follow your home exercise programme as instructed. Further appointments when will you back to see the doctor? You will be seen in outpatient clinic approximately two weeks after your surgery. This appointment will be made and given to you before you are discharged from hospital. Further clinic appointments are made after this as necessary. What are the alternatives for treatments are available? You are having this surgery because other treatment options have been unsuccessful. You have probably tried most of the alternative solutions for your shoulder pain before considering surgery. Not all these options are appropriate for all people. They include: Modifying activity and sport to avoid the pain. Taking painkillers and/or anti-inflammatory tablets. Cortisone injections. Physiotherapy and other allied specialities such as acupuncture. Where can I get more information? - this is a very good site that has a lot of information written by Orthopaedic Surgeons specialising in the Upper Limb. Arthritis Research Campaign (ARC) leaflets shoulder and elbow joint replacements. 7

8 Important things to remember following your reverse shoulder replacement 1. Continue to wear your sling day and night as requested by your Consultant 2. Avoid putting your hand behind your back in the first few weeks 3. Do not use the un-operated arm for any heavy manual work whilst the operated are is in the sling These are important to allow for effective healing after your operation. Notes 8

9 Exercises Day one after the operation: Use painkillers and/or ice packs to reduce the pain before you exercise, if necessary. Do short, frequent sessions (e.g. five to10 minutes, five times a day) rather than one long session. It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, intense and lasting pain (e.g. for more than 30 minutes) is an indication to change the exercise by doing it less forcefully or often. When you are not doing your exercises ensure your shoulder is supported by pillows or your sling as described earlier in this leaflet, to assist with pain relief. Ensure you keep your neck, elbow, wrist and hand moving after the operation. These exercises can be started straight after the operation: 1. It is important to set the shoulder blades in a good position before commencing with these exercises. In order to do this you need to sit up straight with elbows by your sides, gently lift the tips of your shoulders very slowly upwards about two centimetres. The base of your shoulder blades will lift up and outwards very slightly. Hold for five seconds Repeat 10 times In lying position 2. Lying or sitting. Slowly take your operated arm up towards the line of your shoulder (90 degrees) using your un-operated arm. Take it no higher than shown in the picture. Repeat 10 times 9

10 3. Lying on your back. Hold your elbow bent at a right angle close to your body while it rests on your stomach. Hold onto your wrist with the un-operated hand. Try to move your hand outwards to in line with your shoulder. Do not go past the movement shown in the picture. Repeat 10 times In standing position 4. Take your arm out of the sling and straighten your elbow. Movement should only occur at the elbow not the shoulder. Hold for 10 seconds Repeat 10 times Day 14 + You will begin a course of physiotherapy to check your recovery after surgery and your exercise regime will start to include strengthening exercises 10

11 Patient Advice and Liaison Service (PALS) If you need general information or advice about Trust services, please contact the Patient Advice and Liaison Service (PALS) on or visit Alternatively please contact staff who are providing your care if you require clinical advice. Your health records To enable us to improve the quality of the care that we provide, your health records are kept by the Trust and may be used for teaching, training, audit and research. Further information on how the Trust uses your information can be found on our website at Contact information Barts Health Therapies Department The Royal London Hospital Telephone No: Mile End Hospital Telephone No: Authors: Jenny Harper, extended scope physiotherapist Mr Ali Noorani and Mr Livio Di Mascio, consultants in trauma and orthopaedic surgery. Large print and other languages For this leaflet in large print, please ring or For help interpreting this leaflet in other languages, please ring Reference: BH/PIN/179 Publication date: January 2014 All our patient information leaflets are reviewed every three years. Barts Health NHS Trust Switchboard:

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