Lymphedema and Total Shoulder Replacement
===================
Total Shoulder Replacement
Related Terms: Arthroplasty, shoulder arthroplasty, shoulder prosthesis, lymphedema, infection
Discussion
From time to time there have been numerous questions posted on the lymphedema boards regarding complications involved with total joint replacement for those with lymphedema. There is only a limited amount of information available and only one published report of followup with lymphedema patients undergoing a major joint replacement and it is on knee replacement.
In that report the overall total complication rate was 31% in a group of 63 lymphedema patients. There were ten superficial wound infections, six deep infections and three deep venous thrombosis. The report does also conclude that despite the complications there was a significant improvement in joint function and patient mobility. View the entire article at the link provided below.(1)
This is apparently further verified by the random discussions of list members who have undergone the surgery. The other most commonly mentioned complications or set backs include an increased time of post surgical rehabilitation and a temporary increase in the lymphedema as a result of not being able to undergo decongestive massage therapy.
Complications
Complications include possible infections, especially around an implanted joint, possible instability of the implant, loosening of the implant, damage to nerves or blood vessels and of special concern to those with lymphedema, the lymph nodes of the region.
General Patient Post-Operative Considerations
Here are some do’s and don’ts for when you return home:(2)
Contact your Physician if
Pain, swelling, soreness or redness in any part any part of your arm or shoulder
Increase in shoulder pain
Fever
Discharge, pus or smelly drainage
Sudden or unexplained re-swelling of joint (after initial post operative swelling has decreased)
Loss of mobility or decreased ability to use joint
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Lymphedema Preoperative Considerations:
1. For the prevention of infection and/or to lower the risk of infection it may be necessary for you to be on a preventative therapy of antibiotics BEFORE surgery. Remember, we are already at high risk for cellulitis and infections thus far has been the most numerous complication.
2. For the prevention of blood clots (venous thrombosis) and based on any additional underlying medical conditions, you should also discuss the possibility of being on blood thinners before the surgery.
3. Make arrangements and plans for the scheduling and/or resumption of decongestive massage therapy for the lymphedema after the surgery.
4. Be sure to have your PCP, surgeon and lymphedema therapist working together to design a treatment/therapy modality that is best for you.
5. Familiarize yourself with the shoulder replacement surgery so that you will know what to expect. There are also support groups of patients undergoing this that you may want to participate in.
6. Before the final decision to have a shoulder replacement discuss alternatives. It is possible for non-steroidal anti-inflammatory drugs (NSAIDs) to help or COX-2 inhibitors. With consideration of surgical complications, it is important to try all methods of treatment before a surgery is planned. However, be careful with these drugs. NSAID's stop the minute contractions of the lymphatic system and can cause further swelling.
7. Shoulder replacement have an average usage expectancy from between eight to twenty years. What are the considerations of the need for a future second surgery affect your lymphedema.
8. If you are obese or morbidly obese discuss how the added strain of the surgery will affect your lymphedema.
9. Be sure to understand the specifics of what you can or can't do, how long you will be off work, financial arrangement and the need for personal assistance you may have.
10. Be sure to discuss which type of surgery is actually needed, the standard procedure or the smaller axillary incision surgery.
June 9, 2008
------------------------------------
From the British Lymphoedema Support Network
(LSN)
Newsletter.
Questions and Answers
The LSN's Chief Medical Adviser, Professor Peter Mortimer, MD, FRCP
Professor of Dermatological Medicine attended a meeting in March 2001
at the
Royal Marsden Hospital Chelsea and answered members' questions.
Question: Do you recommend hip or knee or shoulder replacements?
Answer: My attitude has changed somewhat. Previously I was hesitant to
recommend joint replacements for patients with lymphoedema because of
the
problems of poor healing, seepage or infection. But now that the
replacement
operations are more generally performed, I have begun to see lymphoedema
patients who have successfully had it done. And, after all, if your
mobility
deteriorates, your lymphoedema will get worse, so it's a Catch 22
situation.
The big enemy is the danger of infection in the prosthesis. Many
orthopaedic
surgeons write and ask me what I would recommend at the time of the
operation to prevent problems. I say that the antibiotics are crucial
and
obviously trying to reduce the swelling both before and after the
operation
minimises problems.
We have been trying to audit lymphoedema patients who
have had a hip or knee replacement and we would like to know through
the LSN
of patients who have had this done successfully.
~~~~~~~~~~~
Question: I have had lymphoedema for 35 years and it does not get any
better..... and have now developed arthritis of the knee.
Answer: As far as joint replacements are concerned, which is
of course an
option, I used to say "If you cannot walk very well, it does not help
the
lymphoedema and you are probably in pain". More and more lymphoedema
patients are having joint replacements and in general if we have
managed to
avoid infection and look after the lymphoedema, the likelihood of
problems
seems to be small. More mobility afterwards means that exercise will
help to
keep the lymph moving, but make sure the orthopaedic surgeon is fully
aware
of lymphoedema and what should be done.
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A newer type of shoulder replacement is called reverse total shoulder arthroplasty. This surgery was developed in Europe in the 1980s, and it was approved by the Food and Drug Administration (FDA) for use in the United States in 2004. Reverse total shoulder replacement is often used for people who have shoulder arthritis coupled with an irrepairable rotator cuff tear (a condition called cuff tear arthropathy, or CTA). It is also performed for patients with very complex shoulder problems, including those with failed previous surgical treatments.
Normally, the rotator cuff and deltoid muscles work together to allow a person to raise their arm overhead. With a large rotator cuff tear, the normal mechanics of the shoulder are disrupted, and it may be difficult or impossible for a patient to lift his or her arm. The reverse shoulder prosthesis provides a fixed fulcrum for the shoulder joint, allowing the arm to be raised overhead even when the rotator cuff muscles are absent
The results of reverse shoulder arthroplasty appear to be similar to that of total shoulder arthroplasty in some cases. In a recent paper, Boileau and associates [4] reported that at about 40 months after the procedure 78% of patients were satisfied or very satisfied with the result, and 67% had no or slight pain. Patients who had the procedure performed as a primary procedure for cuff tear arthropathy (CTA) faired better than others who had it performed for more complex shoulder problems. The surgical complication rate for patients with CTA was 5%, while it was much higher in the other group. The authors concluded that results are less predictable and complication and revision rates are higher in patients undergoing revision surgery as compared with those in patients with CTA.
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New Option for Shoulder Replacement
Every year, thousands of shoulder replacements are performed in the United States to help alleviate pain and restore arm and muscle function. Some patients may have shoulder replacement surgery because they are suffering from severe arthritis in combination with a tear in their rotator cuff, the group of four tendons that attach the four shoulder muscles to the upper arm.
For patients who have arthritis with an intact rotator cuff or a small reparable rotator cuff tear, the standard shoulder replacement surgery works well. "But for patients with severe shoulder arthritis, who have rotator cuffs torn beyond repair, the standard surgery isn’t always beneficial," says Joseph P. Iannotti, M.D., Ph.D., Chairman of the Department of Orthopaedic Surgery. "A major portion of the rotator cuff is needed to function properly with a standard replacement. With a massive rotator cuff tear, this is not possible - there is nearly complete loss of the function of the rotator cuff."
However, these patients now have a new option for shoulder replacement surgery. This procedure, called "reverse total shoulder replacement" makes better use of the large triangular deltoid muscle covering the shoulder joint. The deltoid is responsible for shoulder motions to the front, side and back. The procedure uses the DeltaÒ total shoulder prosthesis, which was specifically designed for use in patients with non-functional rotator cuffs and arthritis, but who still have a good, functioning deltoid muscle.
Shoulder
anatomy 101
In
each of us, the shoulder is made up of
a ball-and-socket joint, where the head of the upper arm bone is the
ball, and a
circular depression in the shoulder blade is the socket. In standard
total
shoulder replacement, a plastic socket is attached to the shoulder
blade and a
metal ball replaces the head of the upper arm bone. The new components
are held
in place with either acrylic bone cement or a bone prosthesis.
"Reverse total shoulder replacement is a unique procedure. It completely changes the structure of the joint," says Dr. Iannotti. In reverse total shoulder replacement, the socket and metal ball are switched. The implant places the metal ball onto the shoulder blade and the socket onto the top of the upper arm bone. By shifting the center of rotation, the strength needed to move the arm is shifted away from the damaged rotator cuff muscles and transferred to the healthier deltoid muscle.
"In this way, the reverse shoulder can substitute for the lost function of the rotator cuff," says Dr. Iannotti. In this procedure the general shape of the shoulder remains the same despite the fact that the ball and socket are reversed.
After
the surgery
Following
surgery, patients immediately
start physical therapy by doing simple stretches to get used to their
new
shoulder. This also allows the tissue in the shoulder to heal and the
pain to
decrease. Patients begin restoring passive motion during the first six
weeks
after surgery. After that, they begin strengthening the muscles.
Also after the surgery, says Dr. Iannotti, "Most patients feel much better with the replacement prosthesis; their pain is significantly less and in some cases it is completely gone."
The Cleveland Clinic
http://my.clevelandclinic.org/default.aspx
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Abstracts and Studies:
----
http://www.jbjs.org/article.aspx?volume=93&page=2001
----
----
----
----
http://www.jaaos.org/content/19/7/439.long
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|
|
http://www.clevelandclinic.org/health/health-info/docs/2000/2032.asp?index=8290&src=news
Total Shoulder Joint Replacement
The Cleveland Clinic
--------------------------------------
About shoulder replacement surgery
Orthopaedic and Sports Medicine - University of Washington
http://www.orthop.washington.edu/faculty/Matsen/shoulrep/01
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Lymph nodes of the
shoulder
http://mywebpages.comcast.net/wnor/lesson3axillarylymphnodes.htm
====================
CPT Codes
Physician
23472 Arthroplasty, glenohumeral joint; total shoulder - glenoid and proximal humeral replacement (eg, total shoulder
ICD-9-CM
Inpatient Hospital
80.01 Arthrotomy for removal; of prosthesis of shoulder
81.80 Total shoulder replacement
81.81 Partial shoulder replacement
81.97 Revision of joint replacement of upper extremity
Reference: Zimmer.com Shoulder coding
==================================
External Links
..............
Shoulder surgery for shoulder arthritis: Explore your options
-----------------------------------------------Total Shoulder Replacement or Arthroplasty(2)
American Academy of Orthopaedic Surgeons
----------------------------------------------
Arthroplasty
=======================================================
See also:
Edema
http://www.lymphedemapeople.com/wiki/doku.php?id=edema
Edema and Chronic Venous Insufficiency
http://www.lymphedemapeople.com/thesite/edema_chronic_venous_insufficiency.htm
Edema and Deep Venous Thrombosis
http://www.lymphedemapeople.com/thesite/lymphedema_deep_venous_thrombosis.htm
Edema and Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome
http://www.lymphedemapeople.com/thesite/edema_and_reflex_sympathetic_dystrophy.htm
Edema and Venous Pooling
http://www.lymphedemapeople.com/thesite/edema_and_venous_pooling.htm
Angioedema
http://www.lymphedemapeople.com/wiki/doku.php?id=angioedema
Edema of the Neck
http://www.lymphedemapeople.com/thesite/lymphedema_of_the_neck.htm
Edema and Nephrotic Syndrome
http://www.lymphedemapeople.com/thesite/edema_nephrotic_syndrome.htm
Edema of the Face
http://www.lymphedemapeople.com/thesite/edema_of_the_face.htm
Thrombophlebitis
http://www.lymphedemapeople.com/wiki/doku.php?id=thrombophlebitis
Edema and Diabetes
http://www.lymphedemapeople.com/thesite/lymphedema_and_diabetes.htm
===========================
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Lymphedema People / Advocates for Lymphedema
===========================
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===========================
Lymphedema People - Support Groups
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Children
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for families, parents,
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parents,
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......................
Lipedema
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No matter how you spell it, this is another very little understood and
totally
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......................
MEN WITH LYMPHEDEMA
If you are a man with
lymphedema; a man with a loved one with lymphedema who you are trying
to help
and understand come join us and discover what it is to be the master
instead of
the sufferer of lymphedema.
http://health.groups.yahoo.com/group/menwithlymphedema/
Subscribe: menwithlymphedema-subscribe@yahoogroups.com
......................
All
About Lymphangiectasia
Support group for parents, patients, children who suffer from all forms
of
lymphangiectasia. This condition is caused by dilation of the
lymphatics. It can
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Lymphatic
Disorders Support Group @ Yahoo Groups
While we have a number of support groups for lymphedema... there is
nothing out
there for other lymphatic disorders. Because we have one of the most
comprehensive information sites on all lymphatic disorders, I thought
perhaps,
it is time that one be offered.
DISCRIPTION
Information and support for rare and unusual disorders affecting the
lymph
system. Includes lymphangiomas, lymphatic malformations,
telangiectasia,
hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of
information
available through sister site Lymphedema People.
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===========================
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section. We
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Come
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Lymphedema
Glossary
http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing
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Exercises
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Lymphedema
People Online
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Manual
Lymphatic Drainage (MLD) and Complex Decongestive Therapy (CDT)
Infections
Associated with
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How
to Treat a Lymphedema
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http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound
Fungal
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Lymphedema
in Children
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Lymphoscintigraphy
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Magnetic
Resonance Imaging
http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging
Extraperitoneal
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Axillary
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Sentinel
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Lymphedema
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Lymphedema Gene VEGFC
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_vegfc
Lymphedema Gene SOX18
http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_sox18
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http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pregnancy
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