SHOULDER Health Library ( 1 )
SHOULDER Health Library ( 1 )
In 2011, more than 50 million people in the United States reported that they had been diagnosed with some form of arthritis, according to the National Health Interview Survey. Simply defined, arthritis is inflammation of one or more of your joints. In a diseased shoulder, inflammation causes pain and stiffness.
Although there is no cure for arthritis of the shoulder, there are many treatment options available. Using these, most people with arthritis are able to manage pain and stay active.
Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).
The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm bone centered in your shoulder socket. These tissues are called the rotator cuff.
There are two joints in the shoulder, and both may be affected by arthritis. One joint is located where the clavicle meets the tip of the shoulder blade (acromion). This is called the acromioclavicular (AC) joint.
Where the head of the humerus fits into the scapula is called the glenohumeral joint.
To provide you with effective treatment, your physician will need to determine which joint is affected and what type of arthritis you have.
Five major types of arthritis typically affect the shoulder.
Also known as «wear-and-tear» arthritis, osteoarthritis is a condition that destroys the smooth outer covering (articular cartilage) of bone. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. During movement, the bones of the joint rub against each other, causing pain.
Osteoarthritis usually affects people over 50 years of age and is more common in the acromioclavicular joint than in the glenohumeral shoulder joint.
Rheumatoid arthritis (RA) is a chronic disease that attacks multiple joints throughout the body. It is symmetrical, meaning that it usually affects the same joint on both sides of the body.
The joints of your body are covered with a lining — called synovium — that lubricates the joint and makes it easier to move. Rheumatoid arthritis causes the lining to swell, which causes pain and stiffness in the joint.
Rheumatoid arthritis is an autoimmune disease. This means that the immune system attacks its own tissues. In RA, the defenses that protect the body from infection instead damage normal tissue (such as cartilage and ligaments) and soften bone.
Rheumatoid arthritis is equally common in both joints of the shoulder.
Posttraumatic arthritis is a form of osteoarthritis that develops after an injury, such as a fracture or dislocation of the shoulder.
Rotator Cuff Tear Arthropathy
Arthritis can also develop after a large, long-standing rotator cuff tendon tear. The torn rotator cuff can no longer hold the head of the humerus in the glenoid socket, and the humerus can move upward and rub against the acromion. This can damage the surfaces of the bones, causing arthritis to develop.
The combination of a large rotator cuff tear and advanced arthritis can lead to severe pain and weakness, and the patient may not be able to lift the arm away from the side.
Avascular necrosis (AVN) of the shoulder is a painful condition that occurs when the blood supply to the head of the humerus is disrupted. Because bone cells die without a blood supply, AVN can ultimately lead to destruction of the shoulder joint and arthritis.
Avascular necrosis develops in stages. As it progresses, the dead bone gradually collapses, which damages the articular cartilage covering the bone and leads to arthritis. At first, AVN affects only the head of the humerus, but as AVN progresses, the collapsed head of the humerus can damage the glenoid socket.
Causes of AVN include high dose steroid use, heavy alcohol consumption, sickle cell disease, and traumatic injury, such as fractures of the shoulder. In some cases, no cause can be identified; this is referred to as idiopathic AVN.
Pain. The most common symptom of arthritis of the shoulder is pain, which is aggravated by activity and progressively worsens.
If the glenohumeral shoulder joint is affected, the pain is centered in the back of the shoulder and may intensify with changes in the weather. Patients complain of an ache deep in the joint.
The pain of arthritis in the acromioclavicular (AC) joint is focused on the top of the shoulder. This pain can sometimes radiate or travel to the side of the neck.
Someone with rheumatoid arthritis may have pain throughout the shoulder if both the glenohumeral and AC joints are affected.
Limited range of motion. Limited motion is another common symptom. It may become more difficult to lift your arm to comb your hair or reach up to a shelf. You may hear a grinding, clicking, or snapping sound (crepitus) as you move your shoulder.
As the disease progresses, any movement of the shoulder causes pain. Night pain is common and sleeping may be difficult.
Medical History and Physical Examination
After discussing your symptoms and medical history, your doctor will examine your shoulder.
During the physical examination, your doctor will look for:
X-rays are imaging tests that create detailed pictures of dense structures, like bone. They can help distinguish among various forms of arthritis.
X-rays of an arthritic shoulder will show a narrowing of the joint space, changes in the bone, and the formation of bone spurs (osteophytes).
As with other arthritic conditions, initial treatment of arthritis of the shoulder is nonsurgical. Your doctor may recommend the following treatment options:
Rest or change in activities to avoid provoking pain. You may need to change the way you move your arm to do things.
Physical therapy exercises may improve the range of motion in your shoulder.
Nonsteroidal anti-inflammatory medications (NSAIDs), such as aspirin or ibuprofen, may reduce inflammation and pain. These medications can irritate the stomach lining and cause internal bleeding. They should be taken with food. Consult with your doctor before taking over-the-counter NSAIDs if you have a history of ulcers or are taking blood thinning medication.
Corticosteroid injections in the shoulder can dramatically reduce the inflammation and pain. However, the effect is often temporary.
Ice your shoulder for 20 to 30 minutes two or three times a day to reduce inflammation and ease pain.
If you have rheumatoid arthritis, your doctor may prescribe a disease-modifying drug, such as methotrexate.
Dietary supplements, such as glucosamine and chondroitin sulfate may help relieve pain. (Note: There is little scientific evidence to support the use of glucosamine and chondroitin sulfate to treat arthritis. In addition, the U.S. Food and Drug Administration does not test dietary supplements. These compounds may cause negative interactions with other medications. Always consult your doctor before taking dietary supplements.)
Your doctor may consider surgery if your pain causes disability and is not relieved with nonsurgical options.
Arthroscopy. Cases of mild glenohumeral arthritis may be treated with arthroscopy, During arthroscopy, the surgeon inserts a small camera, called an arthroscope, into the shoulder joint. The camera displays pictures on a television screen, and the surgeon uses these images to guide miniature surgical instruments.
Because the arthroscope and surgical instruments are thin, the surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.
During the procedure, your surgeon can debride (clean out) the inside of the joint. Although the procedure provides pain relief, it will not eliminate the arthritis from the joint. If the arthritis progresses, further surgery may be needed in the future.
Shoulder joint replacement (arthroplasty). Advanced arthritis of the glenohumeral joint can be treated with shoulder replacement surgery, in which the damaged parts of the shoulder are removed and replaced with artificial components, called a prosthesis.
Replacement surgery options include:
Hemiarthroplasty. Just the head of the humerus is replaced by an artificial component.
Total shoulder arthroplasty. Both the head of the humerus and the glenoid are replaced. A plastic «cup» is fitted into the glenoid, and a metal «ball» is attached to the top of the humerus.
Reverse total shoulder arthroplasty. In a reverse total shoulder replacement, the socket and metal ball are opposite a conventional total shoulder arthroplasty. The metal ball is fixed to the glenoid and the plastic cup is fixed to the upper end of the humerus. A reverse total shoulder replacement works better for people with cuff tear arthropathy because it relies on different muscles — not the rotator cuff — to move the arm.
Resection arthroplasty. The most common surgical procedure used to treat arthritis of the acromioclavicular joint is a resection arthroplasty. Your surgeon may choose to do this arthroscopically.
In this procedure, a small amount of bone from the end of the collarbone is removed, leaving a space that gradually fills in with scar tissue.
Recovery. Surgical treatment of arthritis of the shoulder is generally very effective in reducing pain and restoring motion. Recovery time and rehabilitation plans depend upon the type of surgery performed.
Pain management. After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.
Complications. As with all surgeries, there are some risks and possible complications. Potential problems after shoulder surgery include infection, excessive bleeding, blood clots, and damage to blood vessels or nerves.
Your surgeon will discuss the possible complications with you before your operation.
Clavicle Fracture (Broken Collarbone)
A clavicle fracture is a break in the collarbone, one of the main bones in the shoulder. This type of fracture is fairly common—accounting for about 5 percent of all adult fractures. Most clavicle fractures occur when a fall onto the shoulder or an outstretched arm puts enough pressure on the bone that it snaps or breaks. A broken collarbone can be very painful and can make it hard to move your arm.
Most clavicle fractures can be treated by wearing a sling to keep the arm and shoulder from moving while the bone heals. With some clavicle fractures, however, the pieces of bone move far out of place when the injury occurs. For these more complicated fractures, surgery may be needed to realign the collarbone.
The clavicle is located between the ribcage (sternum) and the shoulder blade (scapula). It is the bone that connects the arm to the body.
The clavicle lies above several important nerves and blood vessels. However, these vital structures are rarely injured when a fracture occurs.
Clavicle fractures are fairly common and occur in people of all ages. Most fractures occur in the middle portion, or shaft, of the bone. Occasionally, the bone will break where it attaches at the ribcage or shoulder blade.
Clavicle fractures vary. The bone can crack just slightly or break into many pieces (comminuted fracture). The broken pieces of bone may line up straight or may be far out of place (displaced fracture).
Clavicle fractures are most often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In a baby, a clavicle fracture can occur during the passage through the birth canal.
A clavicle fracture can be very painful and may make it hard to move your arm. Other signs and symptoms of a fracture may include:
Sagging of the shoulder downward and forward
Inability to lift the arm because of pain
A grinding sensation when you try to raise the arm
A deformity or «bump» over the break
Bruising, swelling, and/or tenderness over the collarbone
Your doctor will want to know how the injury occurred and will ask about your symptoms. He or she will then carefully examine your shoulder.
In a clavicle fracture, there is usually an obvious deformity, or «bump,» at the fracture site. Gentle pressure over the break will bring about pain. Although it is rare for a bone fragment to break through the skin, it may push the skin into a «tent» formation.
Your doctor will also perform tests to ensure that no nerves or blood vessels were damaged when the fracture occurred.
X-rays. X-rays provide images of dense structures, such as bone. Your doctor will order an x-ray to help pinpoint the location of the fracture and to learn more about the severity of the break.
He or she may also order x-rays of your entire shoulder to check for additional injuries. If other bones are broken, your doctor may order a computerized tomography (CT) scan to see the fractures in better detail.
If the broken ends of the bones have not significantly shifted out of place, you may not need surgery. Most broken collarbones can heal without surgery.
Nonsurgical treatment may include:
Arm support. A simple arm sling is usually used for comfort immediately after the break and to keep your arm and shoulder in position while the injury heals.
Medication. Pain medication, including acetaminophen, can help relieve pain as the fracture heals.
Physical therapy. Although there will be some pain, it is important to maintain arm motion to prevent stiffness. Often, patients will begin doing exercises for elbow motion immediately after the injury.
After a clavicle fracture, it is common to lose some shoulder and arm strength. Once the bone begins to heal, your pain will decrease and your doctor may start gentle shoulder exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises will be started gradually once the fracture is completely healed.
Follow-up care. You will need to see your doctor regularly until your fracture heals. During these visits, he or will take x-rays to make sure the bone is healing in a good position. After the bone has healed, you will be able to gradually return to your normal activities.
Complications. In some cases, a clavicle fracture can move out of place before it heals. It is important to follow up with your doctor as scheduled to make sure the bone stays in position.
If the fracture fragments do move out of place and the bones heal in that position, it is called a «malunion.» Treatment for this is determined by how far out of place the bones are and how much this affects your arm movement.
A large bump over the fracture site may develop as the fracture heals. This usually gets smaller over time, but a small bump may remain permanently.
If the broken ends of the bones have significantly shifted out of place, your doctor may recommend surgery.
Surgery typically involves putting the broken pieces of bone back into position and preventing them from moving out of place until they are healed. This can improve shoulder strength when you have recovered.
Open reduction and internal fixation. This is the procedure most often used to treat clavicle fractures. During the procedure, the bone fragments are first repositioned (reduced) into their normal alignment. The pieces of bone are then held in place with special metal hardware.
Common methods of internal fixation include:
Plates and screws. After being repositioned into their normal alignment, the bone fragments are held in place with special screws and metal plates attached to the outer surface of the bone.
After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because the clavicle lies directly under the skin, you may be able to feel the plate through your skin.
Plates and screws are not routinely removed after the bone has healed, unless they are causing discomfort. Problems with the hardware are not common, but some patients find that seatbelts and backpacks can irritate the collarbone area. If this happens, the hardware can be removed after the fracture has healed.
Pins or screws. Pins or screws can also be used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin or screw placement are usually smaller than those used for plates.
Pins or screws often irritate the skin where they have been inserted and are usually removed once the fracture has healed.
Pain management. After surgery, you will feel some pain.This is a natural part of the healing process. Many patients find that using ice and simple, non-prescription medications for pain relief are all that is needed to relieve pain.
If your pain is severe, your doctor may suggest a prescription-strength medication, such as an opioid, for a few days.
Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue. For this reason, opioids are typically prescribed for a short period of time. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids.
Rehabilitation. Specific exercises will help restore movement and strengthen your shoulder. Your doctor may provide you with a home therapy plan or suggest that you work with a physical therapist.
Therapy programs typically start with gentle motion exercises. Your doctor will gradually add strengthening exercises to your program as your fracture heals.
Although it is a slow process, following your physical therapy plan is an important factor in returning to all the activities you enjoy.
Complications. There are risks associated with any type of surgery. These include:
Risks that are specific to surgery for clavicle fractures include:
Before your surgery, your doctor will discuss each of the risks with you and will take specific measures to avoid complications.
Whether your treatment involves surgery or not, it can take several months for your collarbone to heal. Healing may take longer in diabetics or in people who smoke or use tobacco products.
Most people return to their regular activities within 3 months of their injury. Your doctor will tell you when your injury is stable enough to do so. Returning to regular activities or lifting with your arm before your doctor advises may cause the fracture fragments to move or the hardware to break. This may require you to start your treatment from the beginning.
Once your fracture has completely healed, you can safely return to sports activities.
Questions to Ask Your Doctor
If you experience a clavicle fracture, here are some questions you may wish to ask your doctor:
When can I start using my arm?
When can I return to work?
Do I have any specific risks for not doing well?
If I have to have surgery, what are the risks and benefits and how long will I be in the hospital?
What are the risks and benefits of nonsurgical treatment?
Chronic Shoulder Instability
Chronic Shoulder Instability
The shoulder is the most moveable joint in your body. It helps you to lift your arm, to rotate it, and to reach up over your head. It is able to turn in many directions. This greater range of motion, however, can cause instability.
Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse.
Once a shoulder has dislocated, it is vulnerable to repeat episodes. When the shoulder is loose and slips out of place repeatedly, it is called chronic shoulder instability.
Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).
The head, or ball, of your upper arm bone fits into a shallow socket in your shoulder blade. This socket is called the glenoid. Strong connective tissue, called the shoulder capsule, is the ligament system of the shoulder and keeps the head of the upper arm bone centered in the glenoid socket. This tissue covers the shoulder joint and attaches the upper end of the arm bone to the shoulder blade.
Your shoulder also relies on strong tendons and muscles to keep your shoulder stable.
Shoulder dislocations can be partial, with the ball of the upper arm coming just partially out of the socket. This is called a subluxation. A complete dislocation means the ball comes all the way out of the socket.
Once the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can occur repeatedly. Chronic shoulder instability is the persistent inability of these tissues to keep the arm centered in the shoulder socket.
There are three common ways that a shoulder can become unstable:
Severe injury, or trauma, is often the cause of an initial shoulder dislocation. When the head of the humerus dislocates, the socket bone (glenoid) and the ligaments in the front of the shoulder are often injured. The labrum — the cartilage rim around the edge of the glenoid — may also tear. This is commonly called a Bankart lesion. A severe first dislocation can lead to continued dislocations, giving out, or a feeling of instability.
Some people with shoulder instability have never had a dislocation. Most of these patients have looser ligaments in their shoulders. This increased looseness is sometimes just their normal anatomy. Sometimes, it is the result of repetitive overhead motion.
Swimming, tennis, and volleyball are among the sports requiring repetitive overhead motion that can stretch out the shoulder ligaments. Many jobs also require repetitive overhead work.
Looser ligaments can make it hard to maintain shoulder stability. Repetitive or stressful activities can challenge a weakened shoulder. This can result in a painful, unstable shoulder.
In a small minority of patients, the shoulder can become unstable without a history of injury or repetitive strain. In such patients, the shoulder may feel loose or dislocate in multiple directions, meaning the ball may dislocate out the front, out the back, or out the bottom of the shoulder. This is called multidirectional instability. These patients have naturally loose ligaments throughout the body and may be «double-jointed.»
Common symptoms of chronic shoulder instability include:
Physical Examination and Patient History
After discussing your symptoms and medical history, your doctor will examine your shoulder. Specific tests help your doctor assess instability in your shoulder. Your doctor may also test for general looseness in your ligaments. For example, you may be asked to try to touch your thumb to the underside of your forearm.
Your doctor may order imaging tests to help confirm your diagnosis and identify any other problems.
X-rays. These pictures will show any injuries to the bones that make up your shoulder joint.
Magnetic resonance imaging (MRI). This provides detailed images of soft tissues. It may help your doctor identify injuries to the ligaments and tendons surrounding your shoulder joint.
Chronic shoulder instability is often first treated with nonsurgical options. If these options do not relieve the pain and instability, surgery may be needed.
Your doctor will develop a treatment plan to relieve your symptoms. It often takes several months of nonsurgical treatment before you can tell how well it is working. Nonsurgical treatment typically includes:
Activity modification. You must make some changes in your lifestyle and avoid activities that aggravate your symptoms.
Non-steroidal anti-inflammatory medication. Drugs like aspirin and ibuprofen reduce pain and swelling.
Physical therapy. Strengthening shoulder muscles and working on shoulder control can increase stability. Your therapist will design a home exercise program for your shoulder.
Surgery is often necessary to repair torn or stretched ligaments so that they are better able to hold the shoulder joint in place.
Arthroscopy. Soft tissues in the shoulder can be repaired using tiny instruments and small incisions. This is a same-day or outpatient procedure. Arthroscopy is a minimally invasive surgery. Your surgeon will look inside the shoulder with a tiny camera and perform the surgery with special pencil-thin instruments.
Open Surgery. Some patients may need an open surgical procedure. This involves making a larger incision over the shoulder and performing the repair under direct visualization.
Rehabilitation. After surgery, your shoulder may be immobilized temporarily with a sling.
When the sling is removed, exercises to rehabilitate the ligaments will be started. These will improve the range of motion in your shoulder and prevent scarring as the ligaments heal. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.
Be sure to follow your doctor’s treatment plan. Although it is a slow process, your commitment to physical therapy is the most important factor in returning to all the activities you enjoy.
Common Shoulder Injuries
Common Shoulder Injuries
In 2006, approximately 7.5 million people went to the doctor’s office for a shoulder problem, including shoulder and upper arm sprains and strains. More than 4.1 million of these visits were for rotator cuff problems.
Shoulder injuries are frequently caused by athletic activities that involve excessive, repetitive, overhead motion, such as swimming, tennis, pitching, and weightlifting. Injuries can also occur during everyday activities such washing walls, hanging curtains, and gardening.
Warning Signs of a Shoulder Injury
If you are experiencing pain in your shoulder, ask yourself these questions:
If you answered «yes» to any one of these questions, you should consult an orthopaedic surgeon for help in determining the severity of the problem.
Most problems in the shoulder involve the muscles, ligaments, and tendons, rather than the bones. Athletes are especially susceptible to shoulder problems. In athletes, shoulder problems can develop slowly through repetitive, intensive training routines.
Some people will have a tendency to ignore the pain and «play through» a shoulder injury, which only aggravates the condition, and may possibly cause more problems. People also may underestimate the extent of their injury because steady pain, weakness in the arm, or limitation of joint motion will become almost second nature to them.
Orthopaedic surgeons group shoulder problems into the following categories.
Sometimes, one of the shoulder joints moves or is forced out of its normal position. This condition is called instability, and can result in a dislocation of one of the joints in the shoulder. Individuals suffering from an instability problem will experience pain when raising their arm. They also may feel as if their shoulder is slipping out of place.
Impingement is caused by excessive rubbing of the shoulder muscles against the top part of the shoulder blade, called the acromion.
Impingement problems can occur during activities that require excessive overhead arm motion. Medical care should be sought immediately for inflammation in the shoulder because it could eventually lead to a more serious injury.
Rotator Cuff Injuries
The rotator cuff is one of the most important components of the shoulder. It is comprised of a group of muscles and tendons that hold the bones of the shoulder joint together. The rotator cuff muscles provide individuals with the ability to lift their arm and reach overhead. When the rotator cuff is injured, people sometimes do not recover the full shoulder function needed to properly participate in an athletic activity.
Treatment of Shoulder Injuries
Early detection is the key to preventing serious shoulder injuries.
Often, an orthopaedic surgeon will prescribe a series of exercises aimed at strengthening the shoulder muscles.
Here are some easy shoulder exercises that you can do to strengthen your shoulder muscles and prevent injuries.
Basic shoulder strengthening
Attach elastic tubing to a doorknob at home. Gently pull the elastic tubing toward your body. Hold for a count of five. Repeat five times with each arm. Perform twice a day.
Stand facing a wall with your hands on the wall and your feet shoulder-width apart. Slowly perform a push-up. Repeat five times. Hold for a count of five. Perform twice a day.
Sit upright in a chair with armrest, with your feet touching the floor. Use your arms to slowly rise off the chair. Hold for a count of five. Repeat five times. Perform twice a day.
Anti-inflammatory medication also may be prescribed to reduce pain and swelling.
The shoulder joint is the body’s most mobile joint. It can turn in many directions, but this advantage also makes the shoulder an easy joint to dislocate.
A partial dislocation (subluxation) means the head of the upper arm bone (humerus) is partially out of the socket (glenoid). A complete dislocation means it is all the way out of the socket. Both partial and complete dislocations cause pain and unsteadiness in the shoulder
Symptoms of a dislocated shoulder include:
Sometimes a dislocation may tear ligaments or tendons in the shoulder or damage nerves.
The shoulder joint can dislocate forward, backward, or downward. A common type of shoulder dislocation is when the shoulder slips forward (anterior instability). This means the upper arm bone moved forward and out of its socket. It may happen when the arm is put in a throwing position.
The muscles may have spasms from the dislocation, and this can make it hurt more. When the shoulder dislocates time and again, there is recurrent shoulder instability.
Your doctor will examine the shoulder and may order an x-ray. It is important that your doctor know how the dislocation happened and whether the shoulder had ever been dislocated before.
Your doctor will place the ball of the upper arm bone (humerus) back into the joint socket. This process is called a closed reduction. Severe pain stops almost immediately once the shoulder joint is back in place.
Your doctor may immobilize the shoulder in a sling or other device for several weeks following treatment. Plenty of early rest is needed. The sore area can be iced 3 to 4 times a day.
After the pain and swelling go down, your doctor will prescribe rehabilitation exercises for you. These help restore the shoulder’s range of motion and strengthen the muscles. Rehabilitation may also help prevent dislocation of the shoulder again in the future. Rehabilitation will begin with gentle muscle toning exercises. Later, weight training can be added.
If shoulder dislocation becomes a recurrent problem, a brace can sometimes help. However, if therapy and bracing fail, surgery may be needed to repair or tighten the torn or stretched ligaments that help hold the joint in place, particularly in young athletes.
At times, the recurrently dislocating shoulder can result in some bone damage to the humerus or shoulder socket. If your surgeon identifies some bone damage, he or she may recommend a bone transfer type of surgery.
Joint Replacement Infection
Joint Replacement Infection
Knee and hip replacements are two of the most commonly performed elective operations. For the majority of patients, joint replacement surgery relieves pain and helps them to live fuller, more active lives.
No surgical procedure is without risks, however. A small percentage of patients undergoing hip or knee replacement (roughly about 1 in 100) may develop an infection after the operation.
Joint replacement infections may occur in the wound or deep around the artificial implants. An infection may develop during your hospital stay or after you go home. Joint replacement infections can even occur years after your surgery.
This article discusses why joint replacements may become infected, the signs and symptoms of infection, treatment for infections, and preventing infections.
Any infection in your body can spread to your joint replacement.
Infections are caused by bacteria. Although bacteria are abundant in our gastrointestinal tract and on our skin, they are usually kept in check by our immune system. For example, if bacteria make it into our bloodstream, our immune system rapidly responds and kills the invading bacteria.
However, because joint replacements are made of metal and plastic, it is difficult for the immune system to attack bacteria that make it to these implants. If bacteria gain access to the implants, they may multiply and cause an infection.
Despite antibiotics and preventive treatments, patients with infected joint replacements often require surgery to cure the infection.
A total joint may become infected during the time of surgery, or anywhere from weeks to years after the surgery.
The most common ways bacteria enter the body include:
Some people are at a higher risk for developing infections after a joint replacement procedure. Factors that increase the risk for infection include:
Signs and symptoms of an infected joint replacement include:
When total joint infection is suspected, early diagnosis and proper treatment increase the chances that the implants can be retained. Your doctor will discuss your medical history and conduct a detailed physical examination.
Imaging tests. X-rays and bone scans can help your doctor determine whether there is an infection in the implants.
Laboratory tests. Specific blood tests can help identify an infection. For example, in addition to routine blood tests like a complete blood count (CBC), your surgeon will likely order two blood tests that measure inflammation in your body. These are the C-reactive Protein (CRP) and the Erythrocyte Sedimentation Rate (ESR). Although neither test will confirm the presence of infection, if either or both of them are elevated, it raises the suspicion that an infection may be present. If the results of these tests are normal, it is unlikely that your joint is infected.
Additionally, your doctor will analyze fluid from your joint to help identify an infection. To do this, he or she uses a needle to draw fluid from your hip or knee. The fluid is examined under a microscope for the presence of bacteria and is sent to a laboratory. There, it is monitored to see if bacteria or fungus grow from the fluid.
The fluid is also analyzed for the presence of white blood cells. In normal hip or knee fluid, there are a low number of white blood cells. The presence of a large number of white blood cells (particularly cells called neutrophils) indicates that the joint may be infected. The fluid may also be tested for specific proteins that are known to be present in the setting of an infection.
In some cases, just the skin and soft tissues around the joint are infected, and the infection has not spread deep into the artificial joint itself. This is called a «superficial infection.» If the infection is caught early, your doctor may prescribe intravenous (IV) or oral antibiotics.
This treatment has a good success rate for early superficial infections.
Infections that go beyond the superficial tissues and gain deep access to the artificial joint almost always require surgical treatment.
Debridement. Deep infections that are caught early (within several days of their onset), and those that occur within weeks of the original surgery, may sometimes be cured with a surgical washout of the joint. During this procedure, called debridement, the surgeon removes all contaminated soft tissues. The implant is thoroughly cleaned, and plastic liners or spacers are replaced. After the procedure, intravenous (IV) antibiotics will be prescribed for approximately 6 weeks.
Staged surgery. In general, the longer the infection has been present, the harder it is to cure without removing the implant.
Late infections (those that occur months to years after the joint replacement surgery) and those infections that have been present for longer periods of time almost always require a staged surgery.
The first stage of this treatment includes:
Spacers are made with bone cement that is loaded with antibiotics. The antibiotics flow into the joint and surrounding tissues and, over time, help to eliminate the infection.
Patients who undergo staged surgery typically need at least 6 weeks of IV antibiotics, or possibly more, before a new joint replacement can be implanted. Orthopaedic surgeons work closely with other doctors who specialize in infectious disease. These infectious disease doctors help determine which antibiotic(s) you will be on, whether they will be intravenous (IV) or oral, and the duration of therapy. They will also obtain periodic blood work to evaluate the effectiveness of the antibiotic treatment.
Once your orthopaedic surgeon and the infectious disease doctor determine that the infection has been cured (this usually takes at least 6 weeks), you will be a candidate for a new total hip or knee implant (called a revision surgery). This second procedure is stage 2 of treatment for joint replacement infection.
During revision surgery, your surgeon will remove the antibiotic spacer, repeat the washout of the joint, and implant new total knee or hip components.
Single-stage surgery. In this procedure, the implants are removed, the joint is washed out (debrided), and new implants are placed all in one stage. Single-stage surgery is not as popular as two-stage surgery, but is gaining wider acceptance as a method for treating infected total joints. Doctors continue to study the outcomes of single-stage surgery.