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Tuesday, November 22, 2011

Shoulder Surgery - A KNOL about common shoulder problems and treatment

Overview
The shoulder joint is a ball-and-socket joint. The head of the upper arm bone, or humerus, is considered the ball and fits into a very shallow circular hollow in the shoulder blade, or scapula, which is considered the socket. The socket is also known as the glenoid. Both the ball and the socket are coated with a smooth, durable covering, called articular cartilage. To provide fluid movement, the joint has a thin, inner lining, known as the capsule, or ligament, that contains the joint fluid. The capsule provides stability to the shoulder. The capsule attaches to the glenoid as a thick rubbery structure, known as the labrum. The labrum acts as a bumper for the shoulder and provides stability during movement. The surrounding muscles and tendons, also known as the rotator cuff tendons, connect the scapula and the humerus. These muscles are important to provide motion to the shoulder joint.


The shoulder joint is one of the most flexible joints in the human body. It gives us great range of motion; however, it is the most common joint to dislocate. Falls or repeated trauma can also lead to injuries to any parts of the shoulder. Rotator cuff tears and labral tears are common injuries following trauma. Other conditions, such as arthritis and fractures, can damage the shoulders' smooth surfaces. This can all lead to painful and limited range of motion of the shoulder. In this KNOL we will outline a few commonly experienced shoulder injuries and describe some of the surgical procedures to treat them.

Shoulder Bursitis/Impingement
The bursa of the shoulder is the area above the rotator cuff tendons but below the acromion, the top bone of the shoulder joint. The bursa is a thin area that allows smooth movement between the tendon and the bone. The bursa can be inflamed and painful during range of motion. Shoulder bursitis is one of the most common complaints of shoulder pain.


Symptoms

•Pain with overhead movement
•Night pain
•May not have any weakness
Cause

•Rotator cuff weakness. Physical therapy to strengthen rotator cuff can decrease symptoms.
•Acromion spurs. The acromion is the bone on top of the shoulder joint. A bone spur, or outgrowth of the bone, can be present at the tip of the acromion. This spur can cause inflammation when we perform overhead activities.

•Secondary impingement syndrome can be caused by arthritis or inflammation of the acromioclavicular joint. An injection of corticosteriod to the acromioclavicular joint to decrease inflammation can decrease symptoms
•Post-traumatic scar formation. Scar can be formed in the bursa following injuries or trauma. This can lead to a painful shoulder with overhead activities.
•Shoulder instability or dislocation
•Os acromiale. This is a condition where a part of the acromion bone is not properly fused during puberty.


Non-operative Treatment

•Physical Therapy. The aim of therapy is to strengthen the rotator cuff muscles, restore normal glenohumeral and scapula rhythm, and stabilize the scapula. This can lead to better mechanics and less inflammation of the bursa.
•Steroid injection. Injection can be used to decrease inflammation in the bursa; however, when used alone, the inflammation may reoccur and can lead to failure of treatment. Recurrent injections have also raised concern of cartilage and rotator cuff degeneration.
•Anti-inflammatory medication. These medications, such as ibuprofen, naproxyn and motrin, can decrease inflammation in the bursa.



Surgical Treatment

•Arthroscopic Subacromial Decompression . With the improvement of arthroscopic technique and tools, arthroscopic shoulder surgeries have become the accepted standard for the treatment of impingement syndrome. Arthroscopic shoulder surgeries are usually performed using an arthroscope, a specialized camera, which is passed through a small incision. An intra-articular diagnostic evaluation is performed first, followed by inspection of the bursa. A bursectomy is performed to remove the inflamed tissue and to facilitate visualization. The undersurface of the coracoacromial ligament is usually frayed or torn, also known as the impingement lesion. A cautery device is then used to release the coracoacromial ligament from the edge of the acromion. An arthroscopic burr is then introduced to remove the spur in the front of the acromion. The goal of treatment is to remove the acromial spur and the inflamed bursa. With the arthroscope, the surgeon can also evaluate any other problems with the shoulder, such as rotator cuff tears or labral tears.


Rotator Cuff Tears
Rotator cuff injuries can be divided into traumatic or degenerative tears. For traumatic tears, early intervention is usually recommended to restore pre-injury anatomy and function. For degenerative tears, physical therapy is usually recommended to determine its response to non-operative measures. Most full thickness rotator cuff tear, or tears that are complete, will require surgical repair. A magnetic resonance imaging study (MRI) is helpful to determine the size of rotator cuff tear, the thickness of tear (partial or full), the degree of retraction, and quality of muscle. Surgical treatment is recommended if it is an acute tear, or tears that have good healing potential. The clinical presentation and MR findings can alter the treatment option.


Symptoms

•Weakness with lifting
•Difficulty in controlling shoulder motion
•Pain with overhead movement
•Night pain
Cause

•Falls or trauma. Dislocations or falls can tear the rotator cuff tendon.
•Acromial spurs. The bone spur can cause chronic inflammation and lead to rotator cuff tear.
•Degenerative tears can be caused by chronic inflammation or repeated trauma that has occurred over years. The rotator cuff tendon tear can lead to slow progression of symptoms.



Non-operative Treatment

•Physical Therapy. The aim of the therapy is to strengthen the remaining rotator cuff muscles, restore normal glenohumeral and scapula rhythm, and scapula stabilization. If the rotator cuff tear is small, there can be good success rate of non-operative treatment. However, if the tear involves multiple tendons or in patients with active life styles, this treatment may not be as effective.
•Steroid injection. Injection can be used to decrease inflammation in the bursa, which is the main source of pain. Injection itself does not lead to healing of the rotator cuff tendon. Recurrent injections have also raised concern with cartilage and rotator cuff degeneration.
•Anti-inflammatory medication. These medications can decrease inflammation in the bursa.
•If the rotator cuff tendon is treated non-operatively, there is a possibility of the tear progressing with time. We recommend close follow-up of patients with full thickness tears that are treated non-operatively.

Surgical Treatment

Arthroscopic rotator cuff repairs have become popular with the improvement of surgical techniques and repair tools. The majority of rotator cuff repairs performed in the United States consists of mini-open rotator cuff repairs and arthroscopic repairs. Open repairs are usually used for difficult and retracted tears with the need for tissue augmentation and tendon transfers. In all rotator cuff repairs, the goal is to mobilize the torn tendon, free up scar tissue, decompress the bursa by removing the acromial spur, and fixation of the torn rotator cuff tendon without excessive tension to its insertion.




•Open rotator cuff repair. For open rotator cuff repairs, the approach involves an incision about 5-6cm over the edge of the shoulder. The anterior deltoid is then detached from the clavicle and acromion. An open acromioplasty is then performed with and without a distal clavicle resection. A full thickness rotator cuff tear is easily identified through this approach and the torn tendon is mobilized. Scar tissues that are above the tendon along the clavicle and acromion are removed followed by releasing scar tissue below the tendon along the glenoid rim. The attachment site of the rotator cuff tendons are then prepared to facilitate the repair. The torn tendon is then repaired to its insertion with sutures through bone tunnels or suture anchors placed at the insertion site. The repair should be performed without excessive tension of the torn tendons. The anterior deltoid is then repaired back to its origin at the acromion with sutures through bone tunnels. This technique is usually used for massive rotator cuff tears or tears that need other treatment such as tendon transfers or augmentation. In the open procedure patients typically experience greater levels of post-operative pain because of the larger surgical exposure.


•Mini-open rotator cuff repair. The mini-open technique combines both arthroscopic and open approach to the shoulder. For mini-open rotator cuff repairs, shoulder arthroscopy is first performed through a small incision. An arthroscopic subacromial decompression is then performed using the methods described earlier. The rotator cuff tendon tear is then identified and prepared. After that, a small incision is made on the side of the shoulder. The deltoid muscle is then split and the torn tendons are visualized. The torn tendons are mobilized and then fixed to their attachments either using sutures through bone tunnels or suture anchors. The success rate of mini-open rotator cuff repairs is comparable to that of open repairs, with less complications and pain associated with deltoid detachment.

Arthroscopic rotator cuff repair. Arthroscopic rotator cuff repairs are performed using solely arthroscopic methods. New suture-passing devices and suture shuttle systems have allowed faster and more efficient approaches to arthroscopic rotator cuff repairs. Rotator cuff repairs can be performed using 2-3 additional small incisions and do not require any split or detachment of the deltoid muscle. The rotator cuff tendons are repaired to their insertions using suture anchors and the suture are tied via arthroscopic knot-tying techniques. Mid-term results of arthroscopic rotator cuff repairs have comparable patient satisfaction with mini-open rotator cuff repairs. Arthroscopic rotator cuff repairs tend to have less post-operative pain and faster restoration of motion. However, recent MR evaluations have found that arthroscopic rotator cuff repairs have higher radiographic failures than mini-open repairs despite similar patient satisfaction for massive rotator cuff tears. New techniques are being developed to improve the success rate of arthroscopic rotator cuff repairs.

•Partial rotator cuff repairs. Partial rotator cuff tears are tears that are not complete or retracted. Partial rotator cuff tears are very common; however, not all of these lesions are symptomatic. Partial rotator cuff tears are less tolerated in young, active, and athletic individuals. Most of these injuries can be treated without surgery. The goals of treatment of partial-thickness rotator cuff tears are very similar to those full-thickness rotator cuff tears. They can be divided into bursal-sided and articular-sided tears. Up to 50% of the partial rotator cuff tears may worsen in repeat imaging studies in a year and can progress to become a full thickness tear. Most retrospective studies have concluded that tears that are less than 50% of the width of the rotator cuff insertion can be treated with observation or debridement, whereas tears that are more than 50% of the width require a repair. ◦Articular-sided partial rotator cuff tears are more commonly seen. Smaller lesions (<50% of tendon width) can be treated with arthroscopic debridement, where the torn tissue is removed. For larger tears (more than 50% width of the tendon), the normal tendon can be incised to convert a partial tear into a full thickness rotator cuff tear. The tear is then repaired in a similar fashion as a full thickness rotator cuff repair. For more demanding athletes, an in situ repair can be performed by placing suture anchors through the intact bursal sided tissue and arthroscopic repair can be performed on the articular side of the rotator cuff tendon. The in situ repair is more technically demanding and is currently reserved for the more demanding athletes who perform motions with arms overhead. The in situ repair is an attractive repair as it minimizes damage to the intact bursal sided rotator cuff fibers.
◦Bursal-sided tears are usually related to traumatic events. They tend to be more painful and the subacromial space is more inflamed. The smaller tears can be debrided at the subacromial bursa. The larger tears can be repaired via arthroscopic or mini-open approach using suture anchors.


Instability
The shoulder joint is the most unstable joint in the human body. Shoulder instability can be classified by its direction (anterior, posterior, or multi-directional), etiology (traumatic, microtrauma, or atraumatic), or severity (dislocation or subluxation). Most dislocation or instability occurs in the anterior direction. More than 95% of all traumatic dislocations are anterior shoulder dislocation. The remaining are posterior dislocations, which are seen more commonly with seizures, fall from height, or electric shock. For traumatic anterior dislocation, there is a 90% chance of recurrence for patients under the age of 21. The older the individual at the time of their first dislocation, the less risk of recurrence. Most recurrent shoulder instability injuries require operative interventions, as they can lead to increase shoulder problems and premature arthritis. Multi-directional instability, or more than one direction of instability, is usually not related to trauma, involves both shoulders, and can be treated with physical therapy and rehabilitation. For traumatic shoulder dislocation, most young patients will have detachment of the anterior-inferior labrum (Bankart Lesion) , whereas older individuals (age >50 years old) tend to have rotator cuff tears. Pre-operative MRI evaluations are helpful to determine the extent of soft tissue labral and rotator cuff injuries, three-dimensional MR images also allow us to determine the significance of bony injuries with anterior glenoid bone loss or posterior superior Hill Sachs lesion of the humerus.

Symptoms

•Instability of the shoulder
•Difficulty in controlling shoulder motion, especially at the end range of motion
•Locking and sliding sensation of the shoulder
•Pain is usually less problematic than other shoulder conditions but may be present with arthritis or if the shoulder is dislocated or subluxed
Cause

•Falls or trauma. This is the most common cause of shoulder instability or dislocation
•Inherit ligament laxity. Patients with loose ligaments, sometimes referred to as being “double jointed,” can have shoulder instability. Most of these patients are treated without surgery as surgical treatment can have a higher failure rate.

Non-operative Treatment

•Immobilization. Patients that have dislocations should be immobilized to allow the capsule and labrum to heal. The arm is immobilized using a sling for up to 4-6 weeks, followed by physical therapy.
•Physical Therapy. The aim of the treatment is to strengthen the rotator cuff muscles and scapula muscles. The goal is to restore normal glenohumeral and scapula rhythm and scapula stabilization. The treatment is also designed to teach the patient how to avoid instability at the dislocation positions.
•Activity Modification. Some patients may be advised to avoid participation in higher risk activities, such as rock climbing, surfing, and skiing because of the high risk of recurrent dislocations.



Surgical Treatment

•Open stabilization. With open stabilization, an incision is made in the front of the shoulder. A split is made between the deltoid and pectoralis major muscle to access the shoulder joint. One of the rotator cuff tendons, the subscapularis, can be detached or split to gain access to the torn or stretched-out capsule. There are a number of surgical procedures described for anterior stabilization. We will generalize them into soft tissue or bone block procedures.
◦Soft tissue procedures. For soft tissue stabilization, a T-capsulorraphy can be performed. The anterior capsule is incised in a T-shape fashion. The anterior inferior leaf of the capsule is advanced superiorly to reduce the size of the axillary pouch. The anterior superior leaf of the capsule is then pulled inferiorly to augment the anterior structures. This tightens up the capsule of the shoulder. For Bankart lesions (anterior bands of the inferior glenohumeral ligament) where the labrum is pulled off the glenoid, the capsule can be incised and the insertion of the anterior inferior capsule can be reattached to the glenoid rim using suture anchors. The subscapularis tendon is then repaired back to its insertion using bone anchors or a tendon-tendon repair is performed.


For posterior dislocation, a posterior T-capsulorraphy can be performed through an incision at the back of the shoulder. The deltoid is retracted superiorly and the infraspinatus muscle can be split to expose the posterior capsule. The posterior capsular structures are thinner and more friable than the anterior structures. Care must be taken to avoid iatrogenic cause of recurrent instability. The infraspinatus tendon is usually split or cut along the tendon itself to avoid detachment of its insertion site which can lead to weakness and recurrent posterior instability.



◦Bony Procedures. For patients with multiple dislocations and significant glenoid wear, bone block procedures are needed to restore bony stability of the glenohumeral joint. The distal tip of the coracoid bone can be cut and fixed to the anterior inferior glenoid using a screw (Bristow procedure). The coracoid can be transferred over with the conjoint tendon which acts as a dynamic stabilizer around the split subscapularis tendon (Latarjet procedure). Lastly, bone graft from the hip can be obtained to augment the anterior inferior glenoid. For the posterior dislocating shoulder, a posterior bone block can be used to stabilize the joint. Bony procedures are usually reserved for patients with severe instability, or grade III instability.

•Arthroscopic stabilization. Shoulder stabilization using an arthroscopic approach has gained a significant amount of popularity and is more commonly performed than other stabilization techniques. For anterior instability, the displaced Bankart lesion is usually detached from its healed medial and inferior position. The Bankart lesion (anterior band of the inferior glenohumeral ligament) is then advanced superiorly and fixed using suture anchor techniques. The arthroscopic approach does not require any splitting or detachment of the subscapularis muscle, thus minimizing any significant complication associated with stabilization surgeries. The mid-term to long-term outcome of arthroscopic stabilizations are comparable to open capsular and Bankart repairs. Although arthroscopic stabilization can be safe and effective, there have been high failure rates when the patients have an ”engaging Hill Sachs lesion.” The Hill Sachs lesion is the indentation on the top part of the shoulder which happened when the shoulder is dislocated. When the patient has large bony defects, this needs to be addressed to avoid recurrent instability. Most clinicians will address unstable shoulder with no significant bony defect with arthroscopic stabilization whereas shoulders with significant glenoid wear or Hill Sachs lesion are generally approached with open technique and possible bone grafting.


SLAP lesions
SLAP lesions are injuries to the superior labrum where the attachment of the biceps is on the glenoid. SLAP lesions are disease of athletes who perform persistent overhead motions.



Symptoms

•Pain in the shoulder with movement
•Occasional clicking and locking of the joint
•Loss of velocity with pitchers
•Pain at late cocking and follow-through stages of throwing
•Pain during pull-through stage of swimming

Cause

•Over-use injuries with pitching, throwing, and repetitive overhead motion
•Falls onto the shoulder while the arm is stretched out; the biceps tendon anchor can be pulled off during the fall.



Non-operative Treatment

The treatment of SLAP lesion varies depending on the severities of injury. SLAP lesions can generally be divided into 4 types: Type I SLAP consist of fraying and tearing of the superior labrum. Type II SLAP consists of pathologic detachment of the superior labrum from the glenoid. The tear may extend anterior or posterior around the glenoid face. Type III SLAP consists of a bucket-handle type tear of the superior labrum that can displace into the glenohumeral joint. Type IV SLAP consists of a Type III tear that extends into the biceps tendon itself. The superior attachment of the biceps tendon can be intact (Figure 8, show SLAP classification). SLAP lesions are symptomatic and should be treated for overhead athletes. SLAP lesions are also common degenerative conditions in older patients and may not be symptomatic and do not require surgical treatment.



•Physical Therapy. The aim of the treatment is to strengthen the rotator cuff muscles and scapula muscles. The goal is to restore normal glenohumeral and scapula rhythm and scapula stabilization. The treatment geared toward relieving stress on the injured biceps anchor even during strenuous activities.
•Correction of overhead mechanics. Some of these injures are caused by poor technique in throwing or swimming. Modification or improvement in technique can help decrease symptoms.


Surgical Treatment

•Arthroscopic SLAP repair. SLAP lesions are injuries that are treated arthroscopically. The treatment of SLAP lesions depends on the age and activity level of the patient. ◦Type I SLAP. Most elderly patient show Type I SLAP lesion on MRI, however, these can easily be normal degenerative changes. Type I SLAP lesions in the young active individual can be pathologic and can be treated effectively by arthroscopic debridement using a mechanical shaver. ◦Type II SLAP lesions require surgical reattachment of the biceps anchor onto the glenoid. The treatment is similar to other labral repairs using bioabsorbable or metal anchors. The SLAP lesion is reattached and requires 10-12 weeks for healing.
◦Type III SLAP lesions are bucket-handle type tears where the displaced bucket-handle piece is usually removed using a mechanical shaver during surgery. Reattachment of these lesions by surgery has not led to any significant improvement of function, and by contrast, these tears may not heal and can lead to persistent pain.
◦Type IV SLAP. Treatment depends on the quality of the torn labrum and the involvement of the biceps tendon. If the patient is a young active individual and the torn segment is substantial (>30% of the biceps anchor), an arthroscopic repair is warranted. If the torn segment is less substantial in a low demand patient, the torn piece can be removed or a biceps tenodesis may have to be performed.


Shoulder Osteoarthritis
Shoulder osteoarthritis is present when the articular cartilage of the shoulder is worn out. Shoulder osteoarthritis can be a debilitating condition. The most definitive treatment of shoulder osteoarthritis is shoulder replacement. Shoulder replacements are less common than hip and knee replacements, but the long-term success is comparable to those procedures.



Symptoms

•Pain with any movement of the shoulder joint
•Night pain
•Clicking and locking sensation of the shoulder
•Stiffness and lack of motion
Cause

•Activity. Laborers and active individuals can wear out the joint surfaces, which leads to osteoarthritis
•Inflammatory arthritis, such as rheumatoid arthritis and gout
•Previous shoulder fractures or injuries
•Instability. Multiple dislocations can lead to arthritis
•Rotator cuff tears can lead to rotator cuff tear arthropathy; this can be difficult to manage because of the loss of muscle function
•Avascular necrosis. Blood supply to the shoulder can be compromised following trauma or steroid use; the shoulder joint can collapse after the blood supply is cut off.


Non-operative Treatment

•Steroid injection. Injection can be used to decrease inflammation in the shoulder joint; however, this is a temporary measure as the joint will not be resurfaced on its own. Recurrent injections have also raised concern with rotator cuff degeneration. Most recommendations suggest injections less than 3 times per year. The beneficial effects of steroid injection can decrease with increased exposure.
•Anti-inflammatory medication. These medications can decrease inflammation in the joint.
•Physical Therapy. The aim of the treatment is to strengthen the rotator cuff muscles so that there is less instability. However, the effect is limited as the joint surface is already worn out.


Surgical Treatment

•Shoulder replacement surgery replaces the shoulder's damaged bone and cartilage with a metal and plastic implant. During shoulder replacement surgery, the ball is removed from the top of the humerus and replaced with a metal implant. This is shaped like a half-moon and attached to a stem inserted to the center of the arm bone. The socket portion of the joint is then replaced with a plastic socket that is cemented into the scapula. A total shoulder replacement is performed when both the shoulder blade and humerus is replaced while a hemiarthroplasty replacement is performed when only the humerus is replaced. The decision to perform a total shoulder replacement or hemiarthroplasty is dependent on the condition of the patient. Patients with rotator cuff tears or severe glenoid wears are not eligible for total shoulder replacements. Patients often spend 1-2 days in the hospital after surgery.

Preparation for Shoulder Surgery
It is important to plan for the post-operative return home prior to the surgery to ensure maximum comfort . For most shoulder surgeries, the procedures can be performed as an outpatient procedure or 1-2 days hospital stay. The shoulder will be immobilized with a sling and it is important to prepare the home ahead of time to ensure an easier recovery. These are some of the tips that can be helpful for preparation

•It is recommended that a family member or friend be with you for the first few days until you are more independent.
•Make sure you have rides planned from the hospital and to your first follow-up visit.
•Most surgeons would not want your wound to be soaked or cleaned prior to follow-up. You will not be able to shower for the first week until the incision heals. Your friend or family member can help you with sponge baths and other hygienic care.
•As your arm will be in a sling for the first 4-6 weeks following surgery, you should place everything in your house that you use on a regular basis at elbow level. This way you will not have to raise your arm.
•You will not be able to drive while recovering from shoulder surgery. Make sure all your important appointments or meetings are scheduled before or after the recovery period. If you have to travel to clinic visits or physical therapy appointments, make sure that you have rides or public transportation that allows you to get to your destination safely.



Surgery Day
•You should not eat or drink after midnight the day before surgery; no breakfast or coffee on the day of surgery
•Bring a list of your medications with you
•Bring a loose fitting shirt or jacket that you can put over your shoulder; remember that you will be in a sling after surgery and you will have difficulty putting on a T-shirt or sweater
•The anesthesiologist will discuss with you the type of anesthesia that you will be having; most patients will have general anesthesia and also regional anesthesia, known as a nerve block; the regional anesthesia can decrease pain during surgery so that less anesthetic agent is needed for general anesthesia and the regional anesthesia can help control pain post-operatively.


Post-operative Recovery
•After surgery, you will be moved into the recovery room where you will stay for approximately 1-2 hours. During this time, you will be monitored until you awaken from anesthesia, at which time you will be discharged to home for outpatient procedures or taken to your hospital room.
•Your operated arm may be numb from the regional anesthesia and this is beneficial as it can provide good pain relief for the next day. Don’t be surprised that you are unable to move the fingers or wrist on the operated arm as this is part of the anesthesia. It can take up to 12-18 hours to wear off, during which time your hand and arm will be numb. When you are able to move your hand, begin by making a fist and holding it for 5 seconds. This small exercise helps to keep your blood circulating and should be done frequently.
•To avoid lung congestion after surgery, you should breathe deeply and cough frequently to clear your lungs
•An icepack or cooling machine is helpful for you to control pain and swelling of your shoulder
•Your arm will be in a sling for a few weeks depending on the type of surgery that you have; check with your physician to see what other restrictions in motion you should observe following your shoulder surgery
· Medications --You will be given prescriptions for pain medication and anti-inflammatory medicine. Use the pain medication only if you are experiencing pain. Take the anti-inflammatory medicine as prescribed. If the prescription was given to you at the pre-operative appointment, please fill the prescription and bring the medicine with you on the day of surgery. You will then be able to take the medicine on your way home. If you have a nerve block, you should take the pain medication even when the block is active. This can ease any pain when the nerve block wears off. You should avoid taking pain medications on an empty stomach as it will make you nauseous.

· Caring for Your Incision -- You may have stitches for the small incisions for arthroscopic surgeries and other non-absorbable stitches for your open incisions. These are usually removed at your follow-up appointments. Keep the incision clean and dry. Call your surgeon immediately if your incision swells, drains, becomes red or painful, or you develop a temperature over 101F.
•Physical Activity -- Being physically active is an essential part of recovery. For the 3-6 weeks after surgery, you need to protect the shoulder so that the tendons and repairs can heal. Most surgeries should have physical therapy started at the first or second week following surgery. During the first few weeks of recovery, the physical therapist may teach you or help you to perform specific exercises to strengthen your arm and shoulder. It is important to perform all the exercises as instructed, as prolonged immobilization can lead to frozen shoulder.
•You may experience swelling and bruising of the hand and arm. This is normal and results from the swelling and bruising from your shoulder, which travels down the arm. Unfortunately, there is no treatment for this, but it is recommended that you bend and straighten your elbow frequently and make a fist to help keep your circulation flowing. Warm compresses can be used to allow the bruises to dissolve quicker.
•Your arm should be in a sling and it is recommended that you wear it all the time including while sleeping. If you are reading, watching television, or working at a desk, you may loosen it. When you are getting dressed, it is easiest to put your operated arm through the shirt-sleeve first, and then put your sling on. You should check with your physician regarding your limitations after surgery. •You may be more comfortable sleeping in a semi-seated position the first few nights following surgery. Keep a pillow propped under the elbow and forearm for comfort. If you have a recliner type of chair it might be beneficial. If not that is fine too, but it would be helpful to sleep propped up with pillows behind your operated shoulder as well as under your elbow and forearm. This will reduce pulling on the suture lines.
· In most states it is against the law to drive while your arm is in a sling. You should have a family member or friend drive you while your shoulder is immobilized. After checking with your physician, you may be able to remove the sling while driving.



Although most shoulder surgeries take only 1-3 hours to complete, the post-operative recovery can last from 4-6 months. It is important to follow the restrictions and physical therapy regimen your physician prescribes, to permit healing and obtain the optimum result from your operation.

References
1.American Academy of Orthopaedic Surgery
2.UCSF Sports Medicine Service
3.Shoulder Replacement

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