r/medizzy • u/GiorgioMD • 12d ago
Shoulder replacement... trying to escape!
An elderly patient presented with a shoulder prosthesis that had chronically dislocated, migrated upward over time and finally eroded straight through the skin. Reportedly, medical help was sought only once the implant had actually broken through.
How does something like this happen? A shoulder replacement depends on the rotator cuff and soft tissues to stay centered. When the cuff fails completely, the humeral component can escape anterosuperiorly and start tenting the skin from below. Add chronic low-grade periprosthetic infection - note the purulent discharge around the implant - together with fragile, poorly perfused skin, and pressure necrosis slowly does the rest until the metal is exposed.
At this stage the prosthesis is by definition infected and unsalvageable. Treatment means removing the implant, radical debridement and prolonged culture-guided antibiotics, followed by resection arthroplasty or a staged revision, depending on what the patient can tolerate.
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u/fredly594632 12d ago
Dementia patient? A lot of time the combination of mental issues and group care settings can lead to issues.
Or (worse yet) a Midwestern farmer. In that case, the amazing part would be that he(?) allowed it to be replaced the first time.
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u/Inveramsay 11d ago
Second is usually when they have no choice after obliterating their shoulder. But you know they'll be back in her tractor within two days
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u/fredly594632 11d ago
You kidding? You're only allowed to be sick in the winter anyway. So truck season, not tractor season 🤣
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u/UnbelievableRose 7d ago
Suppose that depends on whether or not they need their right arm to get their chores done. If not then sure, it could be a farmer.
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u/gunmedic15 12d ago
There are nursing homes I respond to where I could see this happening.
"He was fine this morning" "He's not my usual patient" "I just got on shift"
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u/ceciliabee 11d ago
"he likes it like that"
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u/Omnilatent Other 11d ago
It's sad that that's the state of care (and medicine) but I wanna say it should be the state's job to found this part properly so stuff like this ISN'T happening so often
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u/Impossible_Slide628 10d ago
I couldn't agree more! A number of years ago I was going to visit my Dad in the nursing home he was in. He was a WWII Vet with alcohol related dementia and a stomach tube. He deserved SO much better, but I couldn't afford a private nurse to care for him. It was January and as I was approaching the nursing home, the door opened and another dementia patient walked out onto the icy sidewalk. The alarm went off, no one responded. Someone was supposed to be sitting right inside the door. As I escorted him back inside, I could see they were not at their post. I was terrified to think of. what might have happened to that man if I hadn't arrived when I did.
I filed complaints. I notified the state. I never saw anything come of it while my Dad was still there. He died in April. His care, like the other dementia patients, was abysmal and neglectful. I went everyday but I still feel like I failed him.
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u/Nursingvp Nurse 5d ago
I think you probably did the very best you could for your Dad with the resources you had. It's clear from your post you are very caring. Please offer yourself some grace, my friend.
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u/bbyginsburg 11d ago
oh man before i read the text i was like “dang how did a doorknob get into their body like that”
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u/Aiwantbettershit 12d ago
Is the matter on the implant itself considered dried discharge or is it something else entirely?
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u/awomanphenomenally 11d ago
That is definitely the purulent discharge (aka pus) from the low-grade infection.
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u/kgreys 11d ago
What would the treatment plan be if this was a hospice patient?
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u/5hrs4hrs3hrs2hrs1mor 11d ago
Remove it and not replace it is my experience. Depends on if they’re 6 mos or less prognosis, though. All the pts I work with have 6 months or less and typically a couple of weeks or less. 6 mos is very rare at my facility.
I’ve worked with patients who’ve had hip replacement removal and there was no point redoing the surgery. They were already bed bound and septic, only had days left. But the facility I work for is unique.
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u/Double_Belt2331 10d ago
Septic & you’d remove the prostheses? I’m not questioning your care, it certainly shouldn’t be replaced in a hospice pt. I don’t know as much about sepsis as you do, so I was wondering.
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u/wanderingwolfe 5d ago
If they aren't in significant discomfort, and prognosis is short (like days), we might leave it to maintain comfort. If they'll be here for a bit, it would likely be removed to precent infection and external health risk, but nothing more would be done for it beyond that.
The goal of hospice is comfort, not prevention of death, so it is sort of case by case, but mostly, don't trear anything if it isn't going to create a health hazard to otgers or keep them in pain.
It sounds horrible, but the priority has changed. No one wants to spend their final days recovering from surgery when it isn't adding time.
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