Lymphedema and Total Shoulder Replacement

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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)

Do wear the sling every night for at least the first month.
Don’t use your arm to push yourself up in bed or from a chair because this requires forceful contraction of muscles.
Do follow the program of home exercises prescribed for you. You may need to do the exercises 4 to 5 times a day for a month or more.
Don’t overdo it! If your shoulder pain was severe before the surgery, the experience of pain-free motion may lull you into thinking that you can do more than is prescribed. Early overuse of the shoulder may result in severe limitations in motion.
Don’t lift anything heavier than a cup of coffee for the first 6 weeks after surgery.
Do ask for assistance. Your physician may be able to recommend an agency or facility if you do not have home support.
Don’t participate in contact sports or do any heavy lifting for at least 6 months.

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.

Pat O'Connor

June 9, 2008

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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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Reverse Shoulder Arthroplasty

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.

Shoulder Surgeon

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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:

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Revision surgery following total shoulder arthroplasty: analysis of 2588 shoulders over three decades (1976 to 2008). Nov 2011

Journal of Bone and Joint Surgery

[[http://web.jbjs.org.uk/cgi/content/abstract/93-B/11/1513

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Prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) use for the treatment of infection aftershoulder arthroplasty. Nov 2011

Journal of Bone and Joint Surgery

http://www.jbjs.org/article.aspx?volume=93&page=2001

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Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis. Oct 2011

Journal of Bone and Joint Surgery

http://www.jbjs.org/article.aspx?volume=93&page=1915

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Ninety day mortality and its predictors after primary shoulder arthroplasty: an analysis of 4,019 patients from 1976-2008. Oct 2011

BioMed

Keywords: mortality, shoulder arthroplasty, humeral head replacement, shoulder hemiarthroplasty
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206490/?tool=pubmed

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Prevalence of neurologic lesions after total shoulder arthroplasty. Jul 2011

Journal of Bone and Joint Surgery

http://www.jbjs.org/article.aspx?volume=93&page=1288

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Complications in reverse total shoulder arthroplasty. Jul 2011

Journal of Bone and Joint Surgery

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

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Figure 1 - Shoulder bones and muscles, showing the humeral head, the glenoid, and part of the rotator cuff Figure 5 - Axillary incision leaves a small scar

About shoulder replacement surgery

Orthopaedic and Sports Medicine - University of Washington

http://www.orthop.washington.edu/faculty/Matsen/shoulrep/01

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axillary lymph nodes Lymph nodes of the shoulder

http://mywebpages.comcast.net/wnor/lesson3axillarylymphnodes.htm

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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

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External Links

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Shoulder surgery for shoulder arthritis: Explore your options

MayoClinic

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Total Shoulder Replacement or Arthroplasty(2)

American Academy of Orthopaedic Surgeons

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Arthroplasty

Amerisham Health

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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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Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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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.

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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 affect the intestinal tract, lungs and other critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

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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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