Shoulder Replacement cost in India

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What is Shoulder Replacement?

Total shoulder replacement is a highly successful procedure to reduce pain and restore mobility in patients with end-stage shoulder arthritis and, in some cases, after a severe shoulder fracture. Shoulder replacement surgery relieves pain and helps restore motion, strength and function of the shoulder.  Most patients are able to return to playing golf or tennis, swimming, doing yoga or pilates, and other physical activity they previously avoided because of shoulder pain.

Why is it needed?

Shoulder arthritis is a condition in which the smooth cartilage that covers of the bones of the shoulder degenerate or disintegrate. In a healthy shoulder, these cartilage surfaces permit the bones to comfortably glide against one another. When these cartilage surfaces disappear, the bones come into direct contact, increasing friction and causing them to roughen and damage each other. Bone-on bone movement can be quite painful and difficult. Surgically implanted artificial replacement surfaces restore pain-free movement, strength and function.

Causes

There are two basic types of arthritis that affect the shoulder.

1. Osteoarthritis (OA): This is physical wear and tear on the cartilage inside the joint that develops from years of use. Although many older adults experience OA at some point, they are more likely to get it in their knees, hips or fingers than the shoulder. Osteoarthritis in the shoulder is more common in exceptionally active people (even at younger ages), such as tennis players, weightlifters and other athletes who put continual pressure on their shoulders. In some cases, a severe, acute injury triggers or contributes to this long-term damage, for example:

• torn rotator cuff
  
• shoulder fracture
  

1. Inflammatory arthritis (IA): This is an umbrella term for several chronic, autoimmune diseases which have no completely understood cause. The main two that affect the shoulder are:

• rheumatoid arthritis
  
• ankylosing spondylitis
  

Many people with these conditions who have replacement surgeries experience reduced pain and improved function in the shoulder. (Some ankylosing spondylitis patients may also benefit from elbow replacement). 

Diagnosing Condition

X-rays  or CT scan may also be necessary to evaluate a patient's bone integrity, and magnetic resonance imaging (MRI) may be ordered to determine the condition of important surrounding soft tissues, such as the rotator cuff tendon. If the doctor suspects there may be nerve damage, based discussions with the patient, an EMG test or nerve conduction study may be ordered to evaluate the nerves that feed the important muscles of the shoulder.

Who should not get a shoulder replacement?

These include those who:

• If you have symptoms that are not significantly disabling
• experience loss or paralysis of both rotator cuff and deltoid muscles
• If you have active infections
• If you have a progressive disease of the nervous system that has affected the joint (assessed on a case-by-case basis)

In addition, some patients who are experiencing early stage osteoarthritis may wish to first try nonsurgical, conservative management of their condition to determine whether a shoulder replacement is necessary or may be delayed. Such measures include:

• Physical therapy
• NSAIDs (nonsteroidal anti-inflammatory drugs)
• corticosteroid injections
  

Surgery

During a total shoulder replacement, the patient may have either regional anesthesia with interscalene block or general anesthesia – or both. During the operation, the patient will be positioned sitting upright and partially or completely sedated.

Surgical steps of a traditional shoulder replacement

A traditional (anatomic) shoulder replacement surgery is composed of the following six basic steps:

1. The surgeon separates the deltoid and pectoral muscles to access the shoulder in a largely nerve-free area (to minimize nerve damage).
2. The shoulder is opened by cutting one of the front muscles of the rotator cuff, which covers the shoulder. This “opens the door” to allow the surgeon to view and manipulate the arthritic parts of the shoulder ball and socket.
3. The arthritic sections of the joint are removed.
4. The implant socket, ball and stem components are inserted. The metal ball component is attached to the stem, which extends down inside the patient’s humerus.
5. The incision of the rotator cuff muscle is closed and stitched.
6. The external (skin-level) incision is cleaned and stitched, and a bandage applied as a temporary covering.

Types of shoulder replacement implants

Shoulder replacement surgery is highly technical. It should be performed by a surgical team with experience in this procedure. There are different types of shoulder replacements. Your surgeon will evaluate your situation carefully before making any decisions. He or she will discuss with you which type of replacement would best meet your health needs. Do not hesitate to ask what type of implant will be used in your situation, and why that choice is right for you.

Total Shoulder Replacement

The typical total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket. These components come in various sizes. They may be either cemented or "press fit" into the bone. If the bone is of good quality, your surgeon may choose to use a non-cemented (press-fit) humeral component. If the bone is soft, the humeral component may be implanted with bone cement. In most cases, an all-plastic glenoid (socket) component is implanted with bone cement.

Implantation of a glenoid component is not advised if:

• The glenoid has good cartilage
• The glenoid bone is severely deficient
• The rotator cuff tendons are irreparably torn

Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.

Stemmed Hemiarthroplasty

Depending on the condition of your shoulder, your surgeon may replace only the ball. This procedure is called a hemiarthroplasty. In a traditional hemiarthroplasty, the head of the humerus is replaced with a metal ball and stem, similar to the component used in a total shoulder replacement. This is called a stemmed hemiarthroplasty. Some surgeons recommend hemiarthroplasty when the humeral head is severely fractured but the socket is normal. Other indications for a hemiarthroplasty include:

• Arthritis that only involves the head of the humerus with a glenoid that has a healthy and intact cartilage surface
• Shoulders with severely weakened bone in the glenoid
• Some shoulders with severely torn rotator cuff tendons and arthritis

Sometimes, surgeons make the decision between a total shoulder replacement and a hemiarthroplasty in the operating room at the time of the surgery.

Resurfacing Hemiarthroplasty

Resurfacing hemiarthroplasty involves replacing just the joint surface of the humeral head with a cap-like prosthesis without a stem. With its bone preserving advantage, it offers those with arthritis of the shoulder an alternative to the standard stemmed shoulder replacement.

Resurfacing hemiarthroplasty may be an option for you if:

• The glenoid still has an intact cartilage surface
• There has been no fresh fracture of the humeral neck or head
• There is a desire to preserve humeral bone

For patients who are young or very active, resurfacing hemiarthroplasty avoids the risks of component wear and loosening that may occur with conventional total shoulder replacements in this patient population. Due to its more conservative nature, resurfacing hemiarthroplasty may be easier to convert to total shoulder replacement, if necessary at a later time.

Reverse Total Shoulder Replacement

Another type of shoulder replacement is called reverse total shoulder replacement. Reverse total shoulder replacement is used for people who have:

• Completely torn rotator cuffs with severe arm weakness
• The effects of severe arthritis and rotator cuff tearing (cuff tear arthropathy)
• Had a previous shoulder replacement that failed
• For these individuals, a conventional total shoulder replacement can still leave them with pain. They may also be unable to lift their arm up past a 90-degree angle. Not being able to lift one's arm away from the side can be severely debilitating.

In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder bone and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm.

Risks and complications of a shoulder replacement

Complications are rare in total shoulder replacement, but can include:

• instability (the ball slipping out of the socket)
• infection
• nerve damage
• glenoid loosening
• stiffness

Recovery

It generally takes eight weeks or more for patients to recover. It may be several months before a patient may do heavy labor or strenuous strength exercises.

On the day of surgery

Patients usually experience some temporary pain due to the surgery, but it is not the same type of pain they experienced due to their arthritis. Arthritic pain is largely absent from that point forward.

The day after surgery

X-rays will be taken to determine whether the implant is properly positioned. After the range of motion and stability of the implant are confirmed, physical therapy will begin that same day. Patients usually notice immediately that the shoulder is easier to move and the feeling grinding is gone. The shoulder will be immobilized by a sling during the early rehabilitation phase to permit the tendons which have been repaired to heal. This sling is removable for showering and for rehabilitation exercises. Mobility improves throughout the period of physical therapy.

Timeline for complete recovery

• Six weeks – The patient may use the whole arm, including shoulder, for light activity.
• Eight weeks – Most probably the patient may begin unrestricted, active use of the arm and shoulder.
• Three months – Most patients are reasonably comfortable, and experience some weakness.
• Six months – Most patients are pain-free (although they may experience pain during certain weather conditions), and have motion and strength about two-thirds that of a normal level.
• One year – Approximately 95% of shoulder replacement patients will be pain-free. The remaining 5% will usually have no more than a weather-related ache or an occasional pain due to excessive activity.

Frequently asked questions

What is the success rate of shoulder replacement surgery?

Total shoulder replacement is a very successful operation and the 10 year survival rate is up to 90 percent. Many patients end up with extremely functional shoulders and are able to return to the activities of daily living and low impact sports without pain.

What can you not do after shoulder surgery?

• You should not do any reaching, lifting, pushing, or pulling with your shoulder during the first six weeks after surgery. 
• You should not reach behind your back with the operative arm. 
• You may remove your arm from the sling to bend and straighten your elbow and to move your fingers several times a day.

Why do you have to sleep in a recliner after shoulder surgery?

The recliner allows you to lie down and rest without giving you the freedom to turn over. To maximize your comfort and protect your shoulder while it is immobilized, look over at your surgical arm when you are lying down.

How should I dress after shoulder surgery?

You will require loose clothing that preferably buttons down the front or tank tops with large sleeves. Avoid clothing with small buttons, hooks and zips.

How long is physical therapy after shoulder replacement?

Uncomplicated total shoulder replacement can expect to spend about six to eight weeks in physical therapy. Most often, people are back to normal about 12 to 16 weeks after surgery.

What is the fastest way to recover from shoulder surgery?

1. Wear your shoulder immobilizer or sling.
2. Participate in physical therapy.
3. Eliminate pain medication as quickly as possible.
4. Avoid certain shoulder positions and arm movements.
5. Don't rush your recovery.

What is the most painful shoulder surgery?

Rotator cuff repair is the most painful surgery in the first postoperative days. The main risk factor for pain is a work related accident or occupational disease, associated with higher VAS values from D1 to 1 year and greater morphine intake.

How painful is reverse shoulder replacement?

Another reason to have a reverse prosthesis is if the rotator cuff tendons are all torn and one cannot lift the arm high enough to function. Typically in this case the shoulder is not painful but the inability to lift the arm is very disrupting to the ability to function in life.