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doi: 10.1097/01.ORN.0000396883.88895.5c
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Caring for a patient after shoulder arthroplasty

Bonner, Suzanne M. BSN, RN, CMSRN

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Suzanne M. Bonner is a staff nurse at Good Samaritan Hospital in Baltimore, Md. Adapted and updated from Bonner SM. Care of the post-op shoulder arthroplasty patient. Nursing made Incredibly Easy! 2010;3(3):38–48.The author has disclosed that she has no financial relationships pertaining to this article.

The number of procedures has doubled in the past two decades. Here's how to implement a multidisciplinary care plan.

As a nurse, you may be less familiar with providing postoperative care for shoulder arthroplasty patients than you are with postoperative hip and knee arthroplasty patients. But with the increasing number of shoulder arthroplasties being performed each year, you'll need to understand the basics of caring for patients who've undergone shoulder replacement surgery.1

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This article covers the indications for shoulder arthroplasty, the types of shoulder replacement surgeries, preoperative considerations, and postoperative nursing care and interventions, including pain management, possible complications, and patient teaching. First, let's briefly review shoulder anatomy.

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Fascinating, but unstable

The shoulder joint is a free-moving ball-and-socket joint with the greatest amount of movement out of all the joints in the human body. However, it's also the most unstable joint.

The shoulder consists of three muscle groups (see Picturing the shoulder muscles):

* The scapulohumeral group consists of the supraspinatus, infraspinatus and teres minor, and subscapularis muscles; rotates the shoulder laterally (the rotator cuff), and depresses and rotates the head of the humerus.

* The axioscapular group consists of the trapezius, rhomboids, serratus anterior, and levator scapulae muscles; attaches the trunk to the scapula, and rotates the scapula.

* The axiohumeral group consists of the pectoralis major and minor and the latissimus dorsi muscles; attaches the trunk to the humerus, and produces internal rotation of the shoulder.

The head of the humerus fits into the glenoid cavity of the scapula, secured by the tendon of the long head of the biceps brachii muscle of the arm (see Important bones of the shoulder). The distal end of the clavicle articulates with the scapula. Ligaments reinforce the shoulder and support the weight of the upper limb. Stability comes from the rotator cuff and the muscle tendons that cross over the shoulder joint.

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Indications for surgery

Shoulder arthroplasty is performed when the glenohumeral articulating surface is damaged (resulting in pain and decreased function and mobility) and conservative management, such as physical therapy, joint injections, and pain medications, is ineffective.

Structural damage to the shoulder joint can result from:

* osteoarthritis

* rheumatoid arthritis

* traumatic arthritis

* fractures

* neoplasm

* necrosis

* damage to the rotator cuff.2

The goals of surgery are to decrease pain, increase joint function and mobility, stabilize the joint, and correct any joint deformity.

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Surgical options

Several shoulder arthroplasty procedures are available, depending on the patient's age, health history, and shoulder joint pathology.

Hemiarthroplasty replaces the head of the humerus with a prosthesis, leaving the glenoid surface intact. Hemiarthroplasty can be performed to repair a fracture of the humeral neck when the glenoid cavity isn't affected and is still functional. This procedure is also used to repair:

* dislocated humeral fractures

* fractures that can't be reduced when the arterial blood supply to the humeral head is compromised and necrosis of the articular fragment is likely

* pathologic fractures from neoplasm

* damage to the joint from avascular necrosis

* focal cartilage damage

* irreparable rotator cuff tears

* rotator cuff tear arthropathy.3

Shoulder resurfacing replaces the head of the humerus with a metal covering, or cap. Resurfacing retains the humeral neck and more than 50% of the humeral head. The glenoid surface may also be replaced using a polyethylene glenoid prosthesis. Shoulder resurfacing is an option for younger patients and those with:

* irreparable rotator cuff tears

* rotator cuff tear arthropathy

* previous humerus surgery with placed hardware such as intramedullary nails or screws

* curvature and/or angulation deformities of the proximal humerus.4,5

* A major advantage of resurfacing is that it allows for future shoulder procedures and surgeries. However, resurfacing is contraindicated if the patient has severe bone loss or if the bone quality is insufficient to support the prosthesis.4,5

Reverse total shoulder arthroplasty was introduced in Europe 20 years ago and is now being performed in the United States. The procedure converts the humerus to a socket and the glenoid cavity to a ball, allowing for a stable center of rotation with the deltoid muscle compensating for the decreased rotator cuff function, and restoring elevation and abduction. Eligible patients must have a functional deltoid muscle and low functional shoulder use and demand. Although it's a relatively new procedure, reverse total shoulder arthroplasty has been successful as a treatment option for patients with:

* rotator cuff tear arthropathy

Figure. Picturing th...
Figure. Picturing th...
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* irreparable rotator cuff tears

* complex proximal humerus fractures

* shoulder arthroplasty revision.6

Total shoulder arthroplasty replaces both the humeral head and glenoid cavity with prostheses. This procedure is used when severe destruction of the humeral head and glenoid surface is present in cases of osteoarthritis, rheumatoid arthritis, osteonecrosis, or trauma.2

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Preparing for surgery

The surgeon will require an anterioposterior, axillary, and lateral X-ray to measure for the prosthesis and ensure that the implants and components chosen are anatomically correct. These views also let the surgeon evaluate the disease process of the humeral head and shaft and the glenoid capsule. Internal and external rotational views of the proximal humerus may be needed to evaluate for lesions. The surgeon may also order magnetic resonance imaging and a computed tomography scan of the shoulder to better visualize and evaluate the disease process of the shoulder joint and surrounding soft tissue.3,4

The patient's complete history and physical exam will need to be completed and the surgeon will need to obtain consent for the procedure. Additional tests, such as blood work (complete blood cell count, basic metabolic panel, and coagulation), ECG, chest X-rays, and cardiac stress tests, may need to be completed depending on the patient's age, medical-surgical history, and hospital policy. Although the surgeon may request that the patient donate blood before the surgery, blood isn't usually required or transfused after shoulder arthroplasty. About 25% of patients who undergo shoulder replacement surgery receive a blood transfusion.3,7

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Postoperative pointers

Nursing care for patients after shoulder arthroplasty is similar to that for other postoperative patients. The goals are pain management, increasing mobility and function, and reducing postoperative complications.

Several different techniques can be used to manage pain. Nerve blocks are often implemented in the OR, and can be used alone or in conjunction with general anesthesia. Interscalene blocks can provide pain relief for 10 to 24 hours, depending on the type of pain medications administered. Some surgeons prefer continuous peripheral nerve blocks, consisting of catheters placed in the soft tissue that infuse anesthesia toward the targeted nerve.8

For increased pain control, nerve blocks may be used in conjunction with patient-controlled analgesia (PCA). Optimal pain relief lets the patient take deep breaths, ambulate, and participate in therapy sessions, and decreases postoperative complications.9 Oral pain medications are usually introduced on the first postoperative day, and PCA is then discontinued.

Cold therapy, or cryotherapy, also can be used to reduce swelling and promote comfort. Various types and makes of cooling devices are designed to fit the shoulder. Cold therapy should be applied and removed as ordered by the surgeon, and its effectiveness assessed after the application and per hospital protocol. Also assess the patient's skin during each shift, when the cold therapy is applied and removed, and per hospital protocol.3

After shoulder arthroplasty, the patient must wear a sling at all times except when bathing and participating in therapy, unless otherwise ordered by the surgeon.3 Although there are several different brands of slings, all of them have the same purpose: to provide support, decrease dependent edema, and increase patient comfort. The surgeon determines the position in which the patient should wear the sling; however, the position that patients find most comfortable is when the sling is across the hips and slightly forward. This position prevents pressure being applied to the surgical site by preventing external or backward extension of the arm. You'll need to know how to remove and apply the sling in order to assess the surgical site and the patient's skin.3

Figure. Important bo...
Figure. Important bo...
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The type of sling most often used for shoulder arthroplasty is called a shoulder immobilizer, which is a combination of a sling that has an abduction pillow and a strap that goes around the waist. The sling portion of the immobilizer supports the arm; the strap around the patient's waist immobilizes the shoulder. The sling should provide support to the arm, and the elbow should fit as far back in the sling as possible. Make sure the sling is the correct size. It should support the wrist and cover the arm and hand up to the knuckles, exposing the fingers and letting the patient use his fingers and hand. The abduction pillow should be aligned with the patient's waist, and the curved section of the abduction pillow should be under the breast.3,10,11

Assess circulation, motion, and sensation of the affected arm when the patient is admitted to the nursing unit, and reassess every 2 to 4 hours or per hospital protocol or prescription. Keep in mind that your initial assessment of motion and sensation may be compromised if an interscalene block or a continuous peripheral nerve catheter is used for pain management. Also assess capillary refill time, ulna pulse, and radial pulse to ensure adequate circulation.3,10

To assess movement, ask the patient to open and close his hand, spread and close his fingers, flex and extend his wrist against resistance, and touch each finger with the tip of his thumb. To assess sensation, check the lateral aspect of the deltoid, as well as the patient's forearm and fingers, for numbness. Because of its location and proximity to the surgical site, the nerve most likely to be damaged or affected during shoulder surgery is the axillary nerve, which innervates the deltoid and teres minor muscles, skin, and shoulder joint capsule.3

Elevate the head of the bed to 30 degrees and support the elbow of the affected arm with pillows. These interventions will reduce stress on the surgical site, prevent external extension, keep the shoulder correctly aligned, and promote comfort.10

A drain is usually placed during surgery. Assess the drain site and shoulder dressing per hospital protocol. The drain contents should be emptied and recorded every 8 hours or per order. Usually, the drain is discontinued on the first postoperative day unless there's increased drainage.

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Preventing complications

As with all surgical procedures, shoulder arthroplasty puts the patient at postoperative risk for venous thromboembolism (VTE), atelectasis, and infection. Specific complications of shoulder arthroplasty include dislocation, fracture, detachment of the deltoid muscle, joint stiffness, and nerve injury.

While patients are hospitalized, they'll wear graduated compression stockings and sequential compression devices to prevent VTE. If the patient has a history of VTE or a high-risk medical history, the surgeon may also order anticoagulation medications. Compression stockings are worn at all times except during skin assessment and foot care. To further prevent VTE, patients should be out of bed on the first postoperative day, or as prescribed by the surgeon. Because the patient's arm is immobilized and can't swing, balance may be affected, so the patient should initially ambulate with assistance.

Encourage the patient to deep-breathe and cough or use an incentive spirometer to decrease the risk of postoperative atelectasis and pulmonary consolidation. Early mobilization and ambulation also increases deep breathing and lung ventilation.

Infection after joint surgery is a major problem. However, infections occurring after shoulder arthroplasty are uncommon and occur in only about 1% of patients. Antibiotics are administered during the surgery and two to three additional doses are given for the first 24 hours.12 The first 2 years after joint replacement is the most critical period for joint infection, which can be caused by infection or surgical procedures in other areas of the body. Patients who've had joint replacement should take prophylactic antibiotics before invasive dental work and certain urologic procedures.11

Dislocation of the artificial joint is another potential complication, especially after surgery and during the healing process. Activity restriction and shoulder immobilization can help reduce this risk. Additional surgery to stabilize the joint may be needed if repeated dislocation occurs.11

Fractures may occur during the surgery when the bone is prepared for the prosthesis. An additional surgical procedure may not be needed depending on the extent and location of the fracture; however, additional activity restrictions may be needed to promote healing. Muscle detachment, another possible risk, is uncommon: Detachment of the deltoid muscle occurs in less than 1% of shoulder arthroplasties. Careful repair of the deltoid muscle, use of a shoulder immobilizer, and restricting postoperative activity such as lifting and weight-bearing can prevent deltoid detachment.11

Joint stiffness occurs in less than 1% of patients after shoulder replacement surgery, and can be prevented by implementing flexion and range-of-motion (ROM) exercises on the first postoperative day. Nerve injuries occur in 1% to 2% of patients who've had shoulder surgeries, and permanent nerve damage is rare. Careful surgical technique and careful dissection, manipulation, and traction of the arm during surgery reduce the chances of nerve damage.11

The main reason artificial joints fail is loosening of the prosthesis, usually where the metal or cement meets the bone. Shoulder arthroplasties have a life expectancy of 10 to 20 years. As pain increases and joint function and mobility decrease, shoulder revision surgery may be necessary.

Figure. Shoulder ROM...
Figure. Shoulder ROM...
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What your patient needs to know

Before your patient is discharged, show him or her how to properly put on the shoulder immobilizer, as well as how to remove it. Explain that the shoulder immobilizer must be worn at all times except during dressing, showering, and ROM exercises for at least the first 3 weeks after surgery, unless indicated otherwise by the surgeon. Teaching the patient to dress and undress the surgical arm first. Patients may require adaptive dressing equipment, such as a long-handle shoehorn or a reacher/grabber, to assist with dressing and undressing. Ensure that the patient knows how to correctly use these tools.

The patient will usually wear compression stockings for up to 2 weeks after surgery. Make sure the patient knows how to apply the stockings correctly, and warn him or her not to roll down the stockings—this creates a tourniquet effect that may cause a reverse gradient of blood flow or skin breakdown.13 The stockings can be washed following the manufacturer's instructions, and shouldn't be placed in the dryer. Consider giving the patient an extra pair of stockings at the time of discharge to increase compliance with wearing them.

Explain the activity restrictions to the patient: no active internal rotation (pulling objects toward the body), no external rotation (rolling the shoulder backward), and no shoulder extension beyond neutral (taking the elbow behind the body). The patient must avoid putting weight on the affected arm and using the arm to push up from a sitting position. Tell the patient not to use the surgical arm actively or and not to use it to lift objects until instructed by the surgeon.14

Teach the patient or a caregiver to change the dressing once a day, and to assess the incision for healing. Tell the patient to notify the surgeon if he or she notices signs and symptoms of infection.

Some surgeons will let the patient resume showering 72 hours after surgery, as long as the surgical incision and dressing are covered with plastic wrap. Otherwise, the patient can resume showering (and the incision can get wet) after the staples or sutures are removed, usually 10 to 14 days after surgery. Most surgeons don't want the wound to be soaked or submerged for at least 1 month. Consequently, bathing in a tub or soaking in a pool or hot tub are contraindicated. Remind the patient that the nonsurgical arm is to be used for lathering, washing, and drying. If the patient can remove the sling for showering, remind him or her to keep the surgical arm at his side.13

The patient will begin ROM exercises on the first postoperative day and will be instructed to continue them at home, several times a day, 2 to 3 hours apart. Tell the patient that exercises will help maintain flexibility and obtain a good surgical outcome. Depending on the type of surgery, its complexity, and the surgeon's order, the patient will be required to perform several different exercises, such as pendulum exercises, elbow extension and flexion, hand exercises, shoulder flexion, and shoulder external rotation with the elbow at the side (see Shoulder ROM). Remind the patient to take pain medication 30 to 60 minutes before performing the exercises at home to allow for increased motion and flexibility.15

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Positive outcomes

Nursing care for the postoperative shoulder arthroplasty patient is similar to that for the hip and knee arthroplasty patient. As the number of shoulder arthroplasty procedures increases, being able to implement a multidisciplinary care plan can help you ensure positive outcomes for your patients.

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REFERENCES

1. Ilfeld BM, Wright TW, Enneking FK, Morey TE. Joint range of motion after total shoulder arthroplasty with and without a continuous interscalene nerve block: a retrospective case control study. Reg Anesth Pain Med. 2005;30(5):429–433.

2. Lafosse L, Schnaser E, Haag M, Gobezie R. Primary total shoulder arthroplasty performed entirely through the rotator interval: technique and minimum two-year outcomes. J Shoulder Elbow Surg. 2009;18(6):864–873.

3. Brown FM Jr. Nursing care after a shoulder arthroplasty. Orthop Nurs. 2008;27(1):3–9.

4. Burgess DL, McGrath MS, Bonutti PM, Marker DR, Delanois RE, Mont MA. Shoulder resurfacing. J Bone Joint Surg Am. 2009;91(5):1228–1238.

5. Scalise JJ, Miniaci A, Iannotti JP. Resurfacing arthroplasty of the humerus: indications, surgical technique, and clinical results. Curr Orthop Practice. 2008;19(4):443–450.

6. Hazel A, Lee TQ, Gupta R. Reverse shoulder arthroplasty: indications and future directions. Curr Orthopaed Pract. 2009;20(4):355–364.

7. Millett PJ, Porramatikul M, Chen N, Zurakowski D, Warner JJ. Analysis of transfusion predictors in shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(6):1223–1230.

8. Capdevila X, Ponrouch M, Choquet O. Continuous peripheral nerve blocks in clinical practice. Curr Opin Anaesthesiol. 2008;21(5):619–623.

9. D'Arcy Y. Keep your patient safe during PCA. Nursing. 2008;38(1):50–55.

10. Pullen RL Jr. Using slings without errors. Nursing. 2007; 37(7):24.

11. American Academy of Orthopaedic Surgeons. Rotator cuff tears. http://orthoinfo.aaos.org/topic.cfm?topic=A00064.

12. Marculescu CE, Osmon DR. Antibiotic prophylaxis in orthopedic prosthetic surgery. Infect Dis Clin North Am. 2005;19(4):931–946.

13. Walker L, Lamont S. Use and application of graduated elastic compression stockings. Nurs Stand. 2007;21(42):41–45.

14. Humphrey CS, Kelly JD, Norris TR, Sein AA. Shoulder surgery discharge instruction. http://www.shouldersurgeon.com/rehab/shoulder_exercises/full_shoulder_protocol.pdf.

15. Humphrey CS, Kelly JD, Norris TR, Sein AA. Shoulder postoperative rehabilitation: full home program. http://www.shouldersurgeon.com/rehab/shoulder_exercises/full_shoulder_protocol.pdf.

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RESOURCES
Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:588–595.
Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:2442.

© 2011 Lippincott Williams & Wilkins, Inc.

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