GLENOHUMERAL DJD AND SHOULDER REPLACEMENT

Glenohumeral degenerative joint disease (GDJD), also known as osteoarthritis of the shoulder, is a condition characterized by degeneration or wearing away of the protective cartilage that covers the ends of your bones (articular cartilage). As a result of degeneration of the articular cartilage, the ends of the two bones rub together and form bony growths (osteophytes).

The shoulder is a ball-and-socket joint. The shoulder joint is also called as glenohumeral joint, the joint formed by glenoid and humerus bones. The shoulder joint is formed when a ball at the top of the upper arm bone, humerus, fits neatly into a socket, the glenoid, which is part of the shoulder blade.

What are the causes of GDJD?

Glenohumeral DJD is most often seen in people over 50 years. It can also develop after an injury or trauma to the shoulder. The condition may also be hereditary.

What are the symptoms of GDJD?

A person with glenohumeral DJD is likely to have tenderness and shoulder pain that aggravates during activity. Swelling of the joint may also be seen. You may hear a clicking or creaking sound as you move your shoulder.

How is GDJD diagnosed?

To diagnose glenohumeral DJD, your doctor will review your medical history and perform a physical examination of your shoulder. X-rays of an arthritic shoulder may be useful to see osteophytes and loss of joint space.

What are the treatment options?

Treatment for glenohumeral DJD includes both non-surgical treatment and surgical treatment. Non-surgical treatment includes use of anti-inflammatory medications, applying ice, moist heat to the joint, performing range-of-motion exercises and physical therapy, corticosteroid injections, and dietary supplements of glucosamine and chondroitin.
Surgery may be indicated if non-surgical treatments are not effective. Glenohumeral DJD can be surgically treated with two forms of replacement, hemiarthroplasty and total shoulder arthroplasty. In total shoulder arthroplasty, the entire shoulder joint is replaced with an artificial joint, where as in hemiarthroplasty, only the head of the upper arm bone is replaced.

Shoulder replacement

Shoulder joint replacement is a surgical procedure performed to replace the damaged shoulder joint with artificial joint parts. Shoulder joint replacement is usually performed when the joint is severely damaged by osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, rotator cuff tear arthropathy, avascular necrosis, and failed former shoulder replacement surgery.
During the surgery, an incision is made over the affected shoulder to expose the shoulder joint. The humerus is separated from the glenoid socket of the scapula. The arthritic part of the humeral head and the socket is removed and prepared so as to take the artificial components. The glenoid component is then pressed into the socket, and the humeral component is cemented into the upper arm bone. The humeral head component made of metal is then placed on the humeral stem. The artificial components are fixed in place. The joint capsule is stitched together. The muscle and tendons are then repaired and the skin is closed.

Risks and Complications

Possible risks and complications specific to shoulder joint replacement surgery include:
• Infection around an implanted joint
• Dislocation or instability of an implanted joint
• Fracture of the humerus or scapula
• Damage to nerves or blood vessels
• Blood clots (deep vein thrombosis)
• Wound irritation
• Arm length discrepancies
• Wearing of the joints
• Scar formation

Shoulder Joint Replacement

Shoulder Anatomy

The shoulder is a highly movable body joint that allows various movements of the arm. It is a ball and socket joint, where the head of the humerus (upper arm bone) articulates with the socket of the scapula (shoulder blade), which is called the glenoid. The two articulating surfaces of the bones are covered with cartilage, which prevents friction between the moving bones. The cartilage is lubricated by synovial fluid. Tendons and ligaments around the shoulder joint provide strength and stability to the joint. 

What is Arthritis?

When the cartilage is damaged, the two bones rub against each other causing pain, swelling and stiffness of the joint. This condition is called arthritis. There are many types of arthritis. Osteoarthritis (wear-and-tear brought about by old age) and rheumatoid arthritis (autoimmune disease) are two forms of arthritis. 

What is Shoulder Joint Replacement?

Total shoulder replacement surgery is performed to relieve these symptoms. In this surgery, the damaged articulating parts of the shoulder joint are removed and replaced with artificial prostheses. Replacement of both the humeral head and the socket is called a total shoulder replacement. 

What are the Indications for Shoulder Joint Replacement?

Total shoulder joint replacement is a surgery indicated for conditions such as osteoarthritis or rheumatoid arthritis when medication, injections, physical therapy, and activity changes do not help relieve pain. Your doctor recommends surgery when you have the following symptoms:

  • Severe shoulder pain that restricts daily activities
  • Moderate to severe pain during rest
  • Weakness and/or loss of motion

Preparation for Shoulder Joint Replacement

To decide whether total shoulder replacement is a good option for you, your surgeon will evaluate your condition thoroughly. 
Your surgeon reviews your medical history and performs a physical examination of your shoulder to assess the extent of mobility and pain. Imaging tests such as X-ray or MRI (magnetic resonance imaging) are ordered. 

Shoulder Joint Replacement Procedure 

The surgery is performed under regional or general anesthesia. An incision is made over the affected shoulder and the underlying muscles are separated to expose the shoulder joint. The surgery may be performed as an open surgery, where a large incision is made, or minimally invasive, where small incisions are made to insert an arthroscope (a thin tube with a camera and light source) and surgical tools. 

The upper arm bone (humerus) is separated from the glenoid socket of the shoulder bone. The arthritic or damaged humeral head is cut and the humerus bone is hollowed out and filled with cement. A metal ball with a stem is gently press-fit into the humerus. 

Next, the arthritic part of the socket is prepared. The plastic glenoid component is fixed in the shoulder bone. 
After the artificial components are implanted, the joint capsule is stitched, and the wound is closed.

Postoperative Care for Shoulder Joint Replacement

After the surgery, medications and antibiotics are prescribed to control pain and prevent infection. Your arm may be secured in a sling or cast. The rehabilitation program includes physical therapy, which is started soon after the surgery and is very important to strengthen and provide mobility to the shoulder. You may be able to perform gentle daily activities two to six weeks after surgery. 

Risks and Complications of Shoulder Joint Replacement

As with any major surgery, there may be potential risks involved:

  • Anaesthetic complications such as nausea, dizziness, and vomiting
  • Infection of the wound
  • Dislocation, requiring repeat surgery
  • Damage to blood vessels, nerves or muscles
  • Failure to relieve pain 
  • Pulmonary embolism
  • Wear and tear of the prosthesis

Revision Knee Replacement

What is Arthritis?

The knee joints are lined by soft articular cartilage that cushion the joints and aid in smooth movement of the joint bones. Degeneration of the cartilage due to wear and tear leads to arthritis, which is characterized by severe pain.

What is Revision Knee Replacement?

Revision knee replacement surgery involves replacing a part or all your previous knee prosthesis with a new prosthesis. Although total knee replacement surgery is successful, sometimes the procedure can fail due to various reasons and may require a second revision surgery. 

What is Total Knee Replacement?

During total knee replacement, the damaged cartilage and bone is removed from the knee joint and replaced with artificial components. Artificial knee joints are usually made of metal, ceramic or plastic, and consist of the femoral and the tibial components. 

Indications for Revision Knee Replacement

Revision knee replacement surgery may be advised if you have one or more of the following conditions:

  • Trauma to the knee joint
  • Chronic progressive joint disease
  • Increased pain in the affected knee
  • Worn out prosthesis
  • Knee instability or a feeling of giving way while walking
  • Loosening of the prosthesis
  • Infection in the prosthetic joint
  • Weakening of bone around the knee replacement - a process known as osteolysis (bone loss)
  • Stiffness in the knee
  • Leg length discrepancy 
  • Fracture

Revision Knee Replacement Procedure

Revision knee replacement surgery may involve the replacement of one or all the components.

The surgery is performed under general anesthesia. Your surgeon makes an incision over your knee to expose the knee joint. The kneecap along with its ligament may be moved aside so that there is enough room to perform the operation. Then, the old femoral component of the knee prosthesis is removed. The femur is prepared to receive the new component. In some cases, the damaged bone is removed and bone graft or a metal wedge may be used to make up for the lost bone. 

Next, the tibial component along with the old plastic liner is removed. The damaged bone is cut and the tibia is prepared to receive the new component. Like the femur, the lost bone is replaced either by a metal wedge or bone graft. Then, a new tibial component is secured to the end of the bone using bone cement. A new plastic liner will be placed on top of the tibial component. If the patella (kneecap) has been damaged, your surgeon will resurface and attach a plastic component. The tibial and femoral components of the prosthesis are then brought together to form the new knee joint, and the knee muscles and tendons are reattached. Surgical drains are placed for the excess blood to drain out and the incision is closed.

Risks and Complications of Revision Knee Replacement

Like all major surgical procedures, there may be certain risks and complications involved with revision knee replacement surgery. The possible complications after revision knee replacement include:

  • Stiffness in the knee
  • Infection
  • Bleeding
  • Formation of blood clots in the leg veins
  • Injury to nerves or blood vessels
  • Prosthesis failure
  • Patella (kneecap) dislocation
  • Ligament injuries

Postoperative Care for Revision Knee Replacement

Following revision knee replacement surgery, a continuous passive motion (CPM) machine may be used to allow your knee joint to slowly move. The machine, attached to the treated leg, slowly moves the joint through a controlled range of motion, while you are at rest. 

You can walk with crutches or a walker. You will be sent for rehabilitation within a couple of days of surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore range of motion to the knee. Your physical therapist will also provide you with a home exercise program to strengthen the thigh and calf muscles.

Knee immobilizers are used when performing physical therapy, walking and while sleeping to keep the knee stabilized. 

 

 

Minimally Invasive Shoulder Joint Replacement

Shoulder Anatomy

The shoulder is a ball and socket joint that allows various arm movements. The head of the upper arm bone (humerus) articulates with the glenoid cavity of the shoulder bone (scapula). The two articulating surfaces of the bones are covered with cartilage which prevents friction between the moving bones. A rotator cuff is a group of four tendons that join the head of the humerus to the deeper muscles and provides stability and mobility to the shoulder joint. 

What is Minimally Invasive Shoulder Joint Replacement?

Shoulder joint replacement is a surgical procedure that replaces damaged bone surfaces with artificial humeral and glenoid components to relieve pain and improve functional ability in the shoulder joint. 

It can be performed by a traditional open approach or through a minimally invasive approach. The incision of a minimally invasive shoulder joint replacement is about 5 cm compared to 17 cm with the traditional approach. 

Indications for Minimally Invasive Shoulder Joint Replacement

When conservative measures such as medications, injections, physical therapy, and activity changes do not help relieve pain from conditions such as arthritis, avascular necrosis, and humeral head fractures, then shoulder joint replacement is considered as a treatment option.

The decision to perform shoulder replacement via the traditional approach or the minimally invasive approach depends on the pathology. Exposure of the glenoid is often difficult even when the incision is long as in the traditional approach. Therefore, if the pathology is such that more exposure to the joint is required for the surgical treatment then a traditional approach is preferred.

The minimally invasive approach is generally preferred when the problem can be rectified by replacement of only the humeral head such as with the following conditions:

  • Shoulder arthritis with not much damage to the glenoid and with only small bone spurs
  • Four-part humerus fractures with intact rotator cuff
  • Avascular necrosis of the humerus, resulting in tiny multiple fractures 

Diagnosis

To determine the pathology, your surgeon orders an X-ray of the shoulder in the anteroposterior and axillary view. The axillary X-ray is especially important to check the condition of the glenoid. In case the condition is not very clear, your surgeon orders a CT scan of the shoulder to provide more detailed cross-sectional images of the bone and soft tissue of the shoulder including the glenoid.

Minimally Invasive Shoulder Joint Replacement Procedure

  • The surgery is performed under sterile conditions in the operating room under regional or general anesthesia. 
  • You will lie in a beach chair position with the operated arm held by an arm positioner.
  • A 5-cm incision is made over the shoulder joint.
  • The muscle overlying the shoulder bones are cut just enough to expose the head of the humerus. 
  • The humeral head is dislocated and released from the capsule. 
  • The arthritic or damaged humeral head is cut at the neck and removed. 
  • The humeral component is matched in diameter and thickness to the natural humeral head.
  • A bone tunnel is made in the humerus to take the humeral stem.
  • The humeral stem is then inserted into the humerus. This may be press-fit, relying on the bone to grow into it or cemented, depending on several factors such as bone quality and your surgeon’s preference.
  • If the glenoid also needs to be replaced, your surgeon then proceeds to the preparation of the glenoid component.
  • The glenoid is sized for the appropriate implant.
  • Next, the glenoid is prepared to take the artificial component by drilling holes in the glenoid to fix the plastic glenoid component.
  • Bone cement is placed in the holes and the glenoid implant is inserted.
  • Once the glenoid is replaced with the plastic component, your surgeon works on the humeral component.
  • The correct sized metallic humeral component is then fixed to the humeral stem.
  • The soft tissue covering the joint is sutured back together and the incision closed with absorbable sutures.
  • An X-ray is taken to verify the correct fit (size and position) of the implant.

Postoperative Care for Minimally Invasive Shoulder Joint Replacement

After the surgery, your arm will be placed in a sling, which you will wear for 2-4 weeks while your shoulder heals. Pain medications and antibiotics are administered to keep you comfortable and prevent infection. 
The rehabilitation program includes physical therapy, which is started soon after the surgery and is very important to strengthen and provide mobility to the shoulder. Follow your therapist’s instructions for home exercises to achieve the best outcome.

It is critical to follow the postoperative instructions given to you by your surgical team. The postoperative instructions include the following:

  • Rest your shoulder. No lifting, pushing or pulling for the first few weeks.
  • Perform home exercises as advised by your therapist. 
  • Do not overuse your shoulder while healing as it may result in severe limitations in motion later.
  • Do not drive a car for the first few weeks after the surgery.
  • Avoid getting the incision wet until fully healed.

Advantages of Minimally Invasive Shoulder Joint Replacement

The benefits of minimally invasive surgery include less damage to the soft tissues and underlying muscles, enabling a faster recovery with less pain and a smaller scar. Blood loss during the surgery is also less and complications after the surgery are fewer when compared to the open technique.

Risks and Complications of Minimally Invasive Shoulder Joint Replacement

Some of the possible risks and complications of minimally invasive shoulder joint replacement include infection, nerve injury and prosthesis problems. Most of these can be treated successfully; however, prosthesis problems such as excessive wear, loosening of components or dislocation may require additional revision surgery.