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The shoulder is a ball and socket joint. The rotator cuff muscles of the shoulder are responsible for rotating, lifting, and stabilizing the arm. The four rotator cuff tendons converge and insert on the head of the humerus or arm bone. Injury, overuse, or age can tear the tendons and limit a patient’s ability to properly use their arm. A massive rotator cuff tear is a severe tear that is usually experienced by patients over 50. After a massive rotator cuff tear, the shoulder is not stable and the head of the humerus rubs against the glenoid cavity of the scapula (the socket of the shoulder joint). Arthritis develops and worsens over time when left untreated.
Reverse Total Shoulder Arthroplasty (RTSA)
A reverse total shoulder arthroplasty is a relatively new (the first procedure was performed in 2003) procedure used to treat the above-mentioned condition. The procedure is similar to a total shoulder arthroplasty; however, the ball and socket are swapped to compensate for the irreparable rotator cuff tendons. Following surgery, patients move their arm using the large deltoid or shoulder muscles rather than the rotator cuff ones. This limits movement—patients can move their shoulder to about 90 degrees—but drastically improves arthritic pain.
The procedure starts by the surgeon making an incision over the front or top of the shoulder. Through the incision, the surgeon visualized the shoulder joint. Arthritic bone is removed and replaced with metal and plastic prostheses. Once the prostheses are stabilized using a special cement, the incision is closed. Typical procedure time is approximately two hours.
Recovery and Rehabilitation
Patients are generally required to stay at least 2-3 nights in the hospital. During this time, post-surgical pain and swelling are managed and infection precautions are taken. When patients are sent home, they are given instructions regarding how to manage their pain and remain comfortable. The first post surgery appointment occurs after two weeks. At this time, physical therapy is prescribed. Physical therapy is an important part of recovery and rehabilitation because it helps patients regain shoulder strength and flexibility. Total recovery time varies. Generally, short term recovery occurs at the 4-6-week. Long term recovery may take 6-12-months.
Despite the shoulder not moving like it did prior to the injury, patient satisfaction following a reverse total shoulder arthroplasty is high. Pain is decreased or eliminated and shoulder function is improved.
A Total Shoulder Replacement is a type of joint replacement surgery used to alleviate pain and restore the anatomy of a shoulder that has been severely damaged by arthritis or severely injured.
The shoulder joint is made up of the following:
- Humerus (arm bone)
- Clavicle (collar bone)
- Scapula (shoulder blade)
In a healthy shoulder joint, the head of the humerus rests perfectly in its socket, which is the glenoid cavity of the scapula.
Any of the following injuries/conditions can affect the integrity of the shoulder joint and be the reason why a total shoulder replacement is performed:
- Osteoarthritis (OA). The wear and tear of the body’s cartilage, soft tissues, and bone with age and/or injury.
- Rheumatoid arthritis (RA). An autoimmune disease in which the body attacks its own cartilage.
- Post-traumatic arthritis. Arthritis that presents following a traumatic, joint damaging injury.
- A severe rotator cuff tear. The tearing of the tendons that move and stabilize the shoulder.
- Avascular Necrosis (AVN). A condition characterized by bone damage/loss due to a lack of blood supply.
- Severe fractures. A fracture that occurs across the head of the humerus or glenoid cavity.
These injuries/conditions can cause a great deal of pain and limit shoulder function, sometimes to the degree that patients can not move their arm.
An orthopedic surgeon makes an incision over the front or top of the shoulder to view the joint. Arthritic or damaged bone is removed and replaced with metal and plastic prostheses. The prostheses are cemented in place using a special biological cement. The surgeon checks to make sure the prostheses fit perfectly and the joint moves properly. The incision is then closed and the procedure is complete. Typical procedure time is approximately two hours.
Recovery and Rehabilitation
A total shoulder replacement is an inpatient procedure. After surgical anesthesia and pain medications have worn off, patients are brought to their comfortable hospital room where their pain is kept under control. Antibiotics are given to prevent infection. Patients typically stay 2-3-nights in the hospital and are then allowed to return home.
The first post operative appointment occurs at the two-week mark. After this appointment, physical therapy starts. Physical therapy is an important part of recovery because, during physical therapy sessions, shoulder strength and flexibility is regained.
Following a successful total shoulder replacement, patients experience less pain. Joint motion, strength, and function are restored and quality of life improves.
Total Hip Replacement surgery has helped countless patients experience less pain and live functional lives. Thanks to the new minimally invasive surgical techniques, hip replacement surgery is more advanced than ever. This is advantageous to patients because they experience less post-surgical pain, recover faster, and have a smaller, less noticeable scar.
Minimally invasive total hip replacement may be performed using one or two incisions. One incision surgery uses a 3-6-inch incision on the outside of the hip. Two incision surgery uses a 2-3-inch incision over the groin and a 1-2-inch incision over the buttocks.
The following steps occur after the incision(s) is made and the joint is visualized:
- Muscles and tendons are retracted
- The hip is dislocated
- Arthritic tissue and bone spurs are removed
- The head and neck of the femur (leg bone) are cut and replaced using a metal femoral stem
- A metal or ceramic ball is placed over the femoral stem and serves as the new femoral head
- The acetabulum (hip socket) is smoothed out and deepened
- A new, metal socket is inserted
- A plastic spacer is placed and secured into the socket so the femoral head ball component can move properly and smoothly
The surgeon takes x-rays to make sure the components are perfectly in place. The range of motion is checked. The incision is then closed. Typical surgical time is approximately two hours.
Recovery and Rehabilitation
Minimally invasive hip surgery is an inpatient procedure. During a 1-4-night stay in a comfortable hospital room, pain is controlled and antibiotics are given to prevent infection. Physical therapy starts during the hospital stay and continues throughout recovery. Physical therapy is an important part of a successful recovery because it helps patients learn how to stand, balance, and walk. It also helps patients regain strength and range of motion. Patients typically fully recover from surgery in 6-12-months.
Minimally invasive total hip replacement is one of the most successful orthopedic surgeries. Following surgery, patients are able to walk better and perform day-to-day activities without experiencing pain. Patients interested in minimally invasive total hip replacement are encouraged to make an appointment with an orthopedic surgeon who specializes in the procedure.
A Total Knee Replacement is a procedure used to treat severe arthritis. During the procedure, an orthopedic surgeon removes arthritic bone and replaces it with artificial components known as implants. Following surgery, properly positioned and secured implants allow the knee joint to function properly without producing pain.
Three implants components are used.
- A distal femur component. The distal femur or end of the leg bone is shaved during surgery. A smooth, metal component is placed over the shaved bone. The component curves around the bone to restore distal femur anatomy.
- A proximal tibial component. The proximal tibia or top of the shinbone is cut during surgery. A flat metal platform is placed over the area and secured. A plastic insert made of poly ethylene attaches to the platform and serves as a cushion between the femur and tibia.
- A patellar component. The patella is shaved and smoothened during surgery. Small holes are drilled in the bone and a plastic, dome-shaped component is placed into them and secured. This component serves as the new patella or kneecap.
The implants work in harmony to move the knee. Metal always moves against plastic to ensure smooth movement and reduce wear and tear of the implant.
Implants can be fixated using the following:
- Biological cement. A special type of fast-acting cement.
- Press-fit fixation. Press-fit components are made out of a special material that promotes bone growth. Implants are fixated as new bone grows around them.
- Hybrid fixation. Cement is used on the tibia and patella components but not the femur.
The type of fixation used depends on the preference of the orthopedic surgeon and the patient’s condition.
There are many manufacturers of total knee implants. The choice of which one to use depends on a variety of factors, including but not limited to: the cost of the implant, the preference of the surgeon, and the age and weight of the patient. Patients who are thinking of having a total knee operation and would like to learn more about knee implants should talk to their orthopedic surgeon. Most will gladly discuss the topic and answer any questions and address any concerns interested patients have.
Over half a million total knee replacement surgeries are performed in the United States every year. Quality of life improves for patients who undergo a successful knee replacement because they are able to perform everyday movements and activities easily and without pain. Advancements in surgery have led to total knee replacements being performed minimally invasively. Patients can now recover faster, experience less post surgical pain, and have a less noticeable scar.
A minimally invasive approach uses a 4-6-inch incision (rather than an 8-10-inch one) that allows surgeons to avoid the quadriceps muscle and tendon. Once an incision is made, the joint is visualized and the procedure is performed through the following steps:
- Damaged bone and cartilage are removed
- The femur (leg bone), tibia (shin bone), and patella (knee cap) are cut and smoothed
- Metal and plastic components are perfectly placed over the bone and fixated
- The surgeon examines the knee and makes sure it moves properly
- The incision is closed
The procedure typically takes 1-2-hours.
Recovery and Rehabilitation
Minimally invasive total knee replacement is an inpatient procedure. Patients typically spend 1-4-nights in the hospital while their pain is controlled. Antibiotics are taken to prevent infection. Physical therapy is started the day of surgery. After patients are discharged from the hospital, they return home with instructions from their surgeon and the hospital staff. The first postoperative appointment occurs around the two-week mark. Physical therapy continues throughout recovery to improve balance, coordination, strength, and flexibility. A full recovery typically takes 6-12-months.
Not all patients are candidates for a minimally invasive knee replacement. The following are evaluated to determine if a patient is a candidate:
- Surgical history
Generally, patients who are overweight, unhealthy, and have had previous knee surgeries are not candidates.
Patients who are interested in having a minimally invasive total knee replacement are encouraged to make an appointment with an orthopedic surgeon who specializes in the procedure. They have the experience, knowledge, and skills needed to diagnose knee conditions and determine is minimally invasive total knee replacement is a viable treatment option.
In rare cases, a total knee replacement may cause patients to experience pain, swelling, stiffness, and instability. A revision total knee replacement is a procedure used to remove and replace total knee implants that do not work properly. The procedure generally takes longer than a total knee replacement because it is more complicated.
A revision total knee replacement is usually performed by a revision specialist. Careful planning and preparation measures are taken to ensure the revision surgery is a success. During the procedure, the surgeon removes failed components and replaces them with special revision ones. Bone loss may be treating using metal or bone graft augmentation. In some cases, not all components need to be replaced and bone loss is not present.
A revision total knee replacement may be indicated for the following reasons:
- The implants become loose. Several factors may contribute to the loosening of implants. Being overweight or overactive can lead to excessive force and pressure being placed on the implant and it loosening as a result. Other factors include the implant not being placed or fixated properly.
- The implants become worn. Implants can outlast a patient. When the spacer between components is worn out, it can easily slide out of place and alter joint anatomy. Careful precaution is taken to ensure this does not happen and total knees are never performed on patients before the time is right.
- Infection. Infection is a risk with any surgery. Although rare, a replaced knee may become infected at anytime—even years after surgery. An infected knee needs to irrigated and debrided and the implants need to be replaced.
- Knee instability develops. Some knee ligaments are kept intact to stabilize and move the knee. When these ligaments are damaged or torn due to injury or aging, knee instability can result. Revision surgery may be needed if nonsurgical treatment does not improve instability.
- Scar tissue builds up. Excessive scar tissue formed after surgery can cause the knee to become stiff. If the knee does not loosen up on its own, an orthopedic surgeon can perform a manipulation under anesthesia. If this does not work, a revision may be necessary.
Revisions may also be needed when a fracture occurs near the knee. Causes of this type of fracture include motor vehicle accidents and high impact trauma.
There are risks associated with any type of surgery. The fact that some total knee replacements may need to be revised should not scare patients. To alleviate concern and get answers to any questions they may have, patients are encouraged to have a discussion with their orthopedic surgeon.