Download Restoring Function Knee Camp

Joint PREP Class
Shoulder Replacement
T. Andrew Israel MD
Mayo Clinic Health System Adult Reconstruction
Goals for you and your family
• Recognize shoulder replacement is a reliable operation
to improve quality of life
• Describe what to expect of the shoulder replacement
procedure.
• Discuss the risks of shoulder replacement surgery.
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Goals of Your Shoulder Replacement
• Improve your quality of life by:
• Relieve your pain
• Improved motion
• Improved strength
• Better function
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Shoulder Joint Replacement
Indications
• Bone on bone osteoarthritis
• Intact rotator cuff tendons
Shoulder Arthritis
• Loss of
cartilage leads
to narrowing
of the joint
space
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Shoulder Arthritis
• As the
cartilage
wears, bone
spurs form
and the
shoulder
becomes stiff
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Surgical Technique of Total Shoulder
Replacement
• Replaces the worn bony
surfaces with metal ball
and plastic socket
(glenoid)
• Restores shoulder motion
and stability
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Hemiarthroplasty
• A metal ball and stem
go down into the
humerus.
• No plastic socket is
placed.
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Reverse Total Shoulder
Indications
Replacement Components
• Completely torn rotator cuff with severe
arthritis
• Complex fractures
• Previous failed shoulder replacement
REVERSE TOTAL SHOULDER
• Socket and ball are
reversed
• Humeral head (ball)
becomes the socket
• Glenoid (socket)
becomes the ball
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Surgical Technique
Incision
• The incision is made in the front of the shoulder
• Your surgeon will make the incision long
enough to see the joint area
• Your surgeon will use techniques to spare
muscle
• Surgical techniques continue to improve as
technology advances
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Day of Surgery
• Your surgeon will meet you in the Surgical Prep and
Recovery area to initial your shoulder and answer final
questions.
• Family can wait with you in the Surgical Prep and
Recovery area.
• You will go to the Operating Room (OR). Surgery lasts
2 hours.
• You will then go to the recovery room for 1-2 hours.
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After Surgery in the Hospital
Occupational Therapy is critical for a good outcome
• Therapy will visit after surgery to educate you on practicing
activities of daily living
• Wear an arm sling immobilizer full time for 6-8
weeks
• No forceful contraction of muscles such as
pushing up out of chair or bed.
• Follow the exercise program as instructed
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Shoulder precautions
• Do not overdo it! Early overuse may result in severe
limitations of motion
• Do not lift anything heavier than a glass of water for the first 68 weeks
• Do not participate in contact sports or any repetitive heavy
lifting after your shoulder replacement.
• Avoid placing your arm in any extreme position for the first 68 weeks
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Other Doctors in the hospital
• Additional Doctors take care of non-orthopedic issues (such
as high blood pressure or diabetes).
• If you have an Internal Medicine doctor here, they will see you
after surgery.
• If your regular doctor does not see patients in the hospital, a
Hospitalist will see you after surgery.
• If you are not getting a medication you think you should,
please ask.
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Risks of Surgery
Anesthetic Complications
• Anesthesia providers meet with you the day of surgery.
• They discuss anesthetic options for postoperative pain relief.
• Nausea and vomiting are common but more serious side
effects or complications may occur.
• Please tell the anesthesia provider of any past experience with
anesthesia.
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Risks of Surgery
Blood Clots
• Lower risk for blood clots with total shoulder
replacement
• Clots can go to the lungs and be fatal
• Your risk is reduced to <1% if treated with
medication (aspirin)
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Blood Clot Prevention
• Enteric coated aspirin 325 mg twice a day while in hospital to
prevent blood clots. Continue at home for 3 weeks.
• SCDs (calf squeezers) are on in the hospital whenever you are
in bed.
• Exercising your legs and being up and walking promotes
blood flow.
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Risks of Surgery
Infection
• You will get antibiotics at the time of surgery and for 24
hours after surgery.
• Surgeons, assistants and scrub techs wear
“spacesuits.”
• Using all precautions, risk of infection is ~1%.
• Infection may occur months or years after surgery.
• Infection may mean removal of your implants.
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“ Spacesuits worn during surgery”
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Risks of Surgery
Blood loss
• Bony surfaces bleed during surgery.
• There may be some bleeding after surgery.
• Your blood count will be checked each morning after
surgery.
• If you have symptoms from a low blood count, you may
need a blood transfusion.
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Risks of Surgery
Medical Complications
• Surgery is a stress to your body.
• Heart and lung problems, stroke, stomach problems,
constipation - all may occur.
• A physical with your regular doctor and an EKG are
required before surgery.
• Despite precautions, unforeseen medical complications
may still occur.
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Risks of Surgery
Dislocation
• This is an artificial joint and may slip out of joint.
• If it does dislocate, this often requires a trip to the
hospital to have the shoulder put back in place.
• You may be required to wear a brace if it dislocates.
• Multiple dislocations may require revision surgery to fix
the problem.
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Risks of Surgery
Need for Revision
• We encourage patients to wait as long as possible
before replacement.
• Implants wear with time..
• Wear rate is about 1% a year
• Revision surgery may involve changing the plastic or
changing one or all metal parts.
• Revision surgery is more challenging with a more
difficult recovery.
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Recovery time
• 3-4 months: ‘normal’ activity
• 6 months: ‘normal’ endurance
• 12 months: maximal recovery
• Focus on exercises for movement and then
strength
• Getting back to work is individual - check with
your surgeon
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Summary
• Shoulder replacement is a reliable operation to improve
quality of life with less pain, improved motion, strength
and better function.
• As with any operation, there are associated risks.
• All of the precautions we take are to minimize risk and
to provide for a “routine” operation
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Patient Resource and Education Program
Joint PREP Class
Goals for you and your family
• Discuss steps to take to get ready for the surgical
procedure
• Discuss what to expect of the surgical experience
• Recognize why it is important for you to participate in
your plan of care
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Plan Ahead
• Appointments:
• Your regular doctor for pre-surgery;
• Blood work, EKG, Physical exam, discuss
• medications
• Your surgeon for final discussion and update
• Stop smoking – talk to your regular doctor to get
help
• Call your surgeon if you get a fever, cold, infection or
rash before your surgery date
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Plan Ahead
• Plan for your return home
• Identify who will take care of you after surgery. Plan for
about 2 weeks
• Identify who will assist you with shoulder exercises for
6-8 weeks
• Practice daily activities not using the arm affected by
surgery
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Plan Ahead
• Simplify meals. Plan for 2 weeks of easy or no preparation meals
• Pick up throw rugs and other hazards that may cause you to trip
• Place frequently used items in convenient locations…not too high or
not too low
• Any planned dental work should be finished about 1 month before
your surgery date
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What to bring to the hospital
• Loose comfortable clothing to wear home
• Non skid comfortable shoes
• Personal items: toiletries, books, etc.
• Medication list, inhalers, C-PAP mask and machine
• Cell phones may be used in room
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What not to bring to the hospital
• Valuables/Jewelry
• Credit cards, check book, or large sums of
money
• Your medications (except inhalers)
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The day before surgery
• A Surgical Prep and Recovery nurse will call you to:
• Review your medications
• Tell you what medications to take and not
take the day of surgery
• Review eating, drinking, and smoking
restrictions
• Give hygiene instructions
• *You will call a toll free number after 4 p.m. the day
prior to your procedure to establish your arrival time.
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Day of surgery
• Take medications at
home as instructed
• Check in at Mayo
Clinic Health System
registration desk
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Day of Surgery
• You will be taken to the Surgical Prep and
Recovery area
• You will be asked your name and date of birth
by everyone who has contact with you – this is
done for your safety
• Family and friends are welcome. Try to limit to
2 people on day of surgery
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Surgical Prep and Recovery
• Nursing admission in the Surgical Prep and Recovery
area - We will ask you many questions and get you
ready for your surgery
• Leg squeezers
• Anesthesia visit
• Surgeon visit
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Leg Squeezers – SCDs
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Going to the Operating Room
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Operating Room (OR)
• Monitors
• Anesthesia
• Surgical scrub
• Staff will
communicate to
your family if the
surgery is longer
than 2-3 hours
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Recovery Room/Post Anesthesia Care Unit
(PACU)
• Your nausea and pain
are managed as you
awaken
• When you are ready,
you will be transferred
to a hospital room
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Arrival in your Hospital Room
• You will have…
• Oxygen
• An IV
• Your affected arm will be in a shoulder immobilizer after
surgery
• A pulse oximeter – a device that fits on your finger to
measure blood oxygen level
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Pulse Oximeter
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Arrival in your Hospital Room
• We will check on you,
take your vital signs
• You will be able to start
drinking and eating
when ready
• Activity as you tolerate
• Help you with control of
pain and nausea.
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Pain Management
 It is vital for you to describe your pain and
where it is located.
 Rate your pain: The Pain Scale
0—1—2—3—4—5—6—7—8—9—10
NO
PAIN
MODERATE
PAIN
WORST
POSSIBLE PAIN
 We must work together to treat your pain-what
makes it better/worse?
 Using medication, deep breathing-relaxation,
distraction, position change are some ways to help
manage pain and discomfort
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Pain Management
Our goal is NOT to
scare you, but
PREPARE you
for the pain you may
have after surgery.
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After Shoulder Surgery
• The nurse will check your bandage on your shoulder
• Report any soreness, numbness or tingling in your arm or
fingers to the nurse
• Ice will be applied to your shoulder to reduce pain and
swelling
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Post operative day
You will have….
• Blood work
• Medication
• For pain control
• Aspirin 325 mg for blood thinning to
prevent blood clots
• Activity – Occupational Therapy to assist with activities of daily
living
• You are a partner in your care!
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Discharge Planning
You will be discharged home from the hospital when:
• Your medical condition is stable
• You are able to manage safely at home with assistance
• You are able to do your exercises safely
• Your pain is under acceptable control
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Discharge Day
• The person who will be taking care of you after you go home
needs to come to the hospital to learn about:
• Safety
• Exercises – Therapy
• When and how to use
shoulder immobilizer, sling
• Lifting restrictions
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Day of Discharge
• Prepare for discharge between 11a.m. and noon to home or
transitional care
• Receive discharge instructions for:
• Incision care/bathing instructions to keep incision
clean and dry
• Icing and how to keep swelling down
• How to take pain medications correctly
• Continuing aspirin 325 mg at home for blood
thinning for 3 weeks
• When to contact your surgeon
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To control swelling and pain at home
• Apply ice to your shoulder after exercises (do not apply heating
pad) for 6-8 weeks as directed
• Pain medication as directed especially before exercises
• Physical therapy/exercises as directed
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After Discharge
• A person to care for you will need to be available 24
hours a day to:
• assist you at home the first two weeks
• drive you to appointments
• encourage you in your home exercise
program
• Change your incision dressing every day
• Wear the immobilizer sling for 6-8 weeks, according to
your surgeon’s directions
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Bathing


1. You may shower when
your incision is dry (no
drainage) Support your
arm as directed by nursing
 3. Wash under arm,
2. Place a plastic barrier
over the incision, taped in
place, prior to showering
 4. Place a new
dry thoroughly and
place dry padding to
absorb moisture
dressing on the
incision after shower
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Driving
 No driving. Talk with your surgeon about when you will
be allowed to drive again
 After permission you must :
 Be off narcotic pain medicines to drive
 Able to sit in car comfortably
 Drive in a safe area
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A Follow-Up Appointment with your surgeon will
be made 10-14 days after surgery
At your appointment:
• X-ray will be done of your shoulder
• Your stitches will be removed
• We will give you care instructions about your:
incision, bathing, exercises, and a handout titled
‘Joint Replacement- Dental Procedures and
Antibiotics’
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Total Shoulder Replacement
Rehabilitation Services:
Focusing on Function
Purpose
• Identify precautions (Do’s and Don’t’s)
• Discuss what to expect from therapy
• Explain home exercise program
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After Surgery
• You will wear a sling except when performing
self-cares and exercises
• You can move your elbow, wrist and fingers with
your arm at your side
• You should not move your shoulder until you
have been shown the proper ways to do so
(nursing/therapy)
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After Surgery
• You will learn how to move your arm safely when:
• Taking care of yourself
• Taking sling on/off
• Walking/moving about
• Exercising
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Activity After Surgery
• No ACTIVE motion of your operative shoulder
• Control pain and swelling—ICE OFTEN!
• Try to keep the muscles around your shoulder
relaxed, “quiet”
• Keep moving elbow, wrist and fingers to control
swelling
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Therapy for home
• You will learn a home exercise program that includes:
• Passive range of motion for your
shoulder (no muscle flexing)
• Active range of motion for your elbow,
wrist and fingers (moving them on your
own)
• Techniques to control swelling and pain
• It is recommended that a person be available at home
to assist you
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Exercises
Codmans
“Pendulums”
Elbow Bend
“Fist-Five”
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At home you will:
• Continue with range of motion exercises
• Wear immobilizer/sling
• Practice your total shoulder precautions
• Call your doctors office with questions or
concerns
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You are a Partner in Your Care!
• Make your plans…
• Start getting ready for surgery!
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JOINT PREP
Social Sevices
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Roles of Social Services and Case Management
in Your Care
Work in teams of Social Workers and RN Case
Managers to assist with:
• Transition Planning
• Insurance and Funding Issues
• Advance Directives for Healthcare
• Counseling and Advocacy
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Insurance-Prior Notification/Authorization
• Prior to surgery, you will need to notify your
insurance company of your surgery plans.
• Also make sure the clinic/hospital has your
correct insurance information for preauthorization purposes.
• Prior authorization for surgery can take
anywhere from 15-30 days to process, so call
your insurer as soon as you know your
scheduled surgery date.
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Insurance-Denial
• If for any reason your insurer denies your prior
authorization request, the hospital will be
notified and we will contact you to let you know
your request was denied.
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Insurance-Notification
• Notification of elective surgery is NOT required for those
who have only Medicare as their insurer. Medicare
rules do not require pre-authorization of elective
surgery.
• Many Medicare Advantage plans and private insurance
companies do require notification of elective surgery by
both the surgeon’s office and the patient himself.
Although this is not the case for every Medicare
Advantage plan and private insurance plan, play it safe
by notifying your Medicare Advantage plan or private
insurance plan yourself about your surgery plan.
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Insurance-Contact Once You are Admitted
• Once you are an inpatient in the hospital, your
RN case manager will monitor your approved
stay days and be a contact person for your
insurance company for any questions or
concerns.
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Counseling and Advocacy
• Surgery and hospitalization are stressful
life events.
• Meeting your emotional needs is important
to all staff at Mayo Clinic Health System.
• If you have any concerns about your care
or wish to talk to someone, please let your
nurse know.
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Transition Planning-Length of Stay
• Length of stay in the hospital is decreasing
nation-wide.
• Your insurance company will authorize days of
stay based on your medical needs.
• The usual hospital stay for joint replacement
surgery ranges from less than a day to four
days depending on your needs.
©2011 MFMER | slide-73
Transition Planning
• Once you are in the hospital, a Social Worker or
RN Case Manager will meet with you to discuss
your transition plan.
• You, your support people, doctor, and
therapists will help determine what transition
plan will best suit your needs.
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Transitional Care Options
• Home with outpatient services
• Home with Home Care
• Skilled Nursing Facilities
• Transitional Care Units or Swing Beds
©2011 MFMER | slide-75
Transitional Care Options-Home with
Outpatient Services
• Home with outpatient services is an option for
the person who is generally in good health, has
someone available to stay with them the
majority of the time for a few weeks, has
progressed sufficiently in therapies during
hospitalization, and is self-motivated to perform
their exercises at home on a consistent basis.
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Transitional Care Options-Home Care
• Home with Home Care services is an option for
the person who has a skilled nursing need such
as complex dressing changes or IV antibiotics.
Physical Therapy is available through home
care agencies but, generally the maximum
amount of home therapy they can provide is 2
times a week. In addition to having a skilled
nursing or skilled therapy need, home care also
requires that you are “homebound,” meaning
leaving your home requires a great deal of
effort.
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Transitional Care-Skilled Nursing Facilities
• Skilled Nursing Facilities are area nursing homes that
offer short-term rehabilitation stays along with their longterm care. This is an option for the person who requires
more medical care than family or friends can safely
provide.
• After shoulder surgery, you may not have any skilled
physical therapy or occupational therapy for an
extended period after your surgery. As a result, you may
not qualify for Medicare or your private insurance to pay
for your nursing home stay.
• Supportive care like help with bathing, dressing, meal
preparation, etc. is not paid for by Medicare.
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Transitional Care-Swing Beds
• Transition Care Units or Swing Beds are located in a
rural hospital with care provided by hospital staff and
physician. This is an option for the person who has a
more skilled nursing care need. Examples would
include complex dressing changes or difficult to control
blood sugar levels or a pre-existing medical issue such
as cardiac disease. Swing Beds can also provide more
intensive rehabilitation therapies than the Skilled
Nursing Facilities.
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Insurance and Medicare Coverage for
Transitional Care Options
• Home with Home Care-Medicare
Supplements and private insurance
companies vary in what they cover and how
much they cover; it’s a good idea to call
these insurers to find out the details on what
and how much they will cover for each
transition care option.
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Funding Options-Home Care
• Medicare will pay for home care services if you
are homebound and have a skilled nursing or
skilled therapy need. Medicare will not pay for
home care services such as help with meals,
shopping, personal care, or housekeeping
services.
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Funding Options-Transitional Care Skilled
Nursing
• Skilled Nursing Facilities-Medicare requires a skilled
nursing and/or therapy need plus a three overnight
inpatient status stay in the hospital to cover a skilled
rehabilitation stay in a nursing facility.
• Some Medicare Advantage plans do not require the
three overnight stay.
• Private insurance coverage varies tremendously. It is
important to check your benefits and which facilities are
available to you under your plan.
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Funding Options-Swing Bed
• Swing Bed-Medicare requires a skilled nursing
and/or therapy need plus a three overnight
inpatient status stay in the hospital to cover a
skilled rehabilitation stay in a swing bed.
• Not all Medicare Advantage Plans will cover
swing bed stays. Check your insurance plan to
find out if swing bed is an option for you.
• Private insurance coverage for swing bed stays
varies greatly. Check with your insurance
company regarding this.
©2011 MFMER | slide-83
Advance Directives for Healthcare
• What are advance directives?
• What are the 2 types of advanced directives?
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Declaration to Physicians or Living Wills
• Describes the kind of life-sustaining care you would
want only if you had a terminal condition or were in a
persistent vegetative state
• Living wills direct your physician regarding lifesustaining treatment and use and withdrawal of
feeding tubes
• Living wills do not give authority to anyone to make
health care decisions on your behalf
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Power of Attorney for Health Care
• Your health care agent can tell your physician what
kind of care you would want in all types of health
decisions, not just concerning life-sustaining
treatment
• You appoint an agent to make all health care
decisions for you in collaboration with your physician
• Guardianship can usually be avoided if a health care
power of attorney has been completed.
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Who Can Help you Complete an Advance Directive?
• Mayo Clinic Health System Social Services
• Mayo Clinic Health System Spiritual Care
Chaplains
• Your personal attorney
©2011 MFMER | slide-87
Safekeeping of Advance Directives
• Store the original document in a safe place.
• Give a copy of the document to family
members, especially those named in the
document.
• Bring a copy of the document to the clinic or
hospital. It will be scanned into your medical
record.
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QUESTIONS?
• THANK YOU!!
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