Your Total Shoulder Replacement at HSS: What to Expect

Anna Maria Bombardieri, MD, PhD
Anesthesia Research Fellow, Hospital for Special Surgery


The following is a timeline to help you understand and prepare for your shoulder replacement at Hospital for Special Surgery (HSS). Although this outline of things to expect from your surgery is a typical one, please keep in mind that your experience may differ. Your experience may be modified and individualized according to your medical needs.

The Weeks and Days before Your Surgery

When scheduling your procedure with your surgeon, make sure you discuss the estimated length of stay in the hospital and the post-operative rehabilitation plan. Elective surgery allows advance consideration of work schedules, holidays, and upcoming family plans.

  • Clearance: You will be referred by your surgeon to an internal medicine specialist for medical evaluation and clearance for surgery. If your own internist is on the staff at Hospital for Special Surgery and is available to see you after surgery, then he or she can provide this clearance. This typically includes a history and physical examination, laboratory tests, radiographic studies such as a chest x-ray, and an electrocardiogram. If your particular medical condition warrants it, further diagnostic testing may be required before surgery.
  • Medications: You may be instructed by your surgeon and/or primary doctor to stop certain medications (such as blood thinners like Plavix or Coumadin) several days to a week before your surgery, depending on the medication. A new medication might be added for you to take until the time of surgery, depending on your medical history. In addition, you may be instructed to take some of your medications the morning of surgery with a sip of water, the only exception to the requirement of not eating or drinking anything that morning. It is important for you to bring a list (or a bag of pill bottles) including all your medications to your medical clearance, including vitamins, over-the-counter medications, and supplements (a number of medications and supplements may interact with medications you might receive after surgery).

The day before your scheduled procedure, a nurse from HSS will call you with additional instructions and reminders. You will be told when and where to arrive the next morning, and you will be reminded not to eat or drink anything after midnight. This does not apply to the medications that you have been instructed to take with a small sip of water the morning of surgery.

The Morning of Surgery

On the morning of your surgery, you will arrive several hours before your procedure is scheduled to begin.

  • The “Holding Area”: You will come to the preoperative holding area, where you will be prepared for surgery. There will be storage for your belongings, but please leave any valuables at home. This includes all jewelry, as you will be asked to remove everythng before entering the operating room. You will be asked to change into a hospital gown and assigned a bed in the holding area. There may be other patients in the room, all separated from each other by curtains for privacy. Your family can be with you during this time. A nurse will ask you questions pertaining to your surgery and confirm the site of surgery before starting an intravenous line (most commonly called an “IV”) to give you fluids. The IV will be placed in the hand or arm opposite of the site of surgery. If you are a woman of child-bearing age, you will be asked to provide a urine specimen for a pregnancy test.
  • Preoperative Exam: A Physician’s Assistant will take your history and perform a physical examination. The main purpose of this examination is to see if anything has changed since you last saw your medical or surgical physicians. You will be asked to confirm what type of surgery you are having and to sign a consent if you have not already done so. Your surgeon will come to speak to you and sign your surgical site. This is simply a safeguard to confirm where on your body the surgery will be performed. At this time, you will also meet your anesthesiologist and discuss what type of anesthesia you will receive.

Anesthesia

The anesthesiologist will review your medical history and chart, confirm with you the correct site of the operation, and explain the anesthetic plan. At HSS, the anesthetic plan for shoulder arthroplasty will most likely entail a nerve block of the brachial plexus and sedation. With this type of anesthesia, known as regional anesthesia, local anesthetics will be injected around the nerves going to your shoulder in order to make certain you experience no pain during the surgery. An ultrasound is used for the nerve block to ensure the local anesthetic is injected into the correct location. As a result of using regional anesthesia, you will require less sedative and pain medication, which would enable you to recover faster, feel more comfortable, and experience fewer side effects, such as sleepiness and nausea. You will be sedated prior to the nerve block and afterward be placed in a deeper sleep for the surgery. Depending on the extent of the surgery, a catheter may be placed to allow more local anesthetic to be injected around the nerves to help minimize the pain after surgery.

Some cases of shoulder arthroplasty are performed under general anesthesia, either alone or in combination with the regional anesthesia. General anesthesia involves being put to sleep with medications that are given through your intravenous line. Once you are completely asleep, a breathing device is placed into your mouth and your anesthesiologist will assist your breathing with a ventilator. You will remain completely asleep until the surgery is complete, at which time you will start breathing on your own and wake up comfortably in the operating room.

After having all of your questions answered, you will be presented with the anesthesia consent form.

The Operating and Recovery Rooms

  • Anesthesia/Surgery: After consultation with the anesthesiologist, your nurse will transport you to the operating room. The anesthesiologist will start by measuring your blood pressure and heart rate, while providing supplemental oxygen via a nasal cannula (a small tube). The anesthesiologist will then give you sedative medication, followed by one of the anesthesia techniques discussed above. An arterial line, which is an IV placed in the underside of your wrist, may be placed to allow closer monitoring of your blood pressure and facilitate blood draws for measuring your blood count. When the surgery is complete, your surgeon will speak with your family and you will be transported to the recovery room.
  • Recovery: In the recovery room, you will gradually wake up from the sedation. If you had the nerve block, your shoulder and arm may still be weak and numb. In addition, your voice may be a bit hoarse and your chest may feel heavy. These are some of the expected effects from the nerve block and should resolve once the nerve block dissipates. When you wake up further, you are given light snacks and drinks and can begin to receive visitors. Your doctor or someone from the surgical team will speak with you about the operation. Postoperative pain will be managed with a combination of pain pills and an infusion of medication through either your IV or a peripheral catheter that you control with a button. This is called PCA, or patient-controlled analgesia. The pain pump is calibrated so you cannot deliver too much medication, no matter how many times you push the button.

Recovering in the Hospital

  • Physical Therapy: The recovery process will be an active one. You will begin working with a physical therapist the day after your surgery. This is an important part of your recovery that will allow you to get back to your normal activities as soon as possible.
  • Pain Management: Upon your surgeon’s request, an anesthesiologist and nurse from the Acute Pain Service will evaluate and help you manage your pain. Depending on the progress of your recovery, you will gradually transition off the PCA and onto pain medications by mouth. If a catheter was placed, it will be removed once your are comfortable on the oral pain medications. After two to three days of recovery, you will be discharged with a prescription for pain medication, a prescription for physical therapy, and a follow-up appointment with your surgeon.

Updated 12/5/2011 by Shawna Dorman, MD


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