Total Shoulder Replacement

Shoulder Joint Replacement

Although shoulder joint replacement is less common than knee or hip replacement, it is just as successful in relieving joint pain.

Shoulder replacement surgery was first performed in the United States in the 1950s to treat severe shoulder fractures. Over the years, shoulder joint replacement has come to be used for many other painful conditions of the shoulder, such as different forms of arthritis.

If nonsurgical treatments like medications and activity changes are no longer helpful for relieving pain, you may want to consider shoulder joint replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain and help you resume everyday activities.

Whether you have just begun exploring treatment options or have already decided to have shoulder joint replacement surgery, this article will help you understand more about this valuable procedure.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (Humerus), your shoulder blade (Scapula), and your collarbone (Clavicle).

The shoulder is a ball-and-socket joint: The ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade. This socket is called the glenoid.

The surfaces of the bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. A thin, smooth tissue called synovial membrane covers all remaining surfaces inside the shoulder joint. In a healthy shoulder, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost any friction in your shoulder.

The muscles and tendons that surround the shoulder provide stability and support.

All of these structures allow the shoulder to rotate through a greater range of motion than any other joint in the body.

The bones of a healthy shoulder join

Description

In shoulder replacement surgery, the damaged parts of the shoulder are removed and replaced with artificial components, called a prosthesis. The treatment options are either replacement of just the head of the Humerus bone (ball), or replacement of both the ball and the socket (Glenoid).

Shoulder joint replacement

Cause

Several conditions can cause shoulder pain and disability, and lead patients to consider shoulder joint replacement surgery.

Osteoarthritis (Degenerative Joint Disease)
This is an age-related “wear and tear” type of arthritis. It usually occurs in people 50 years of age and older, but may occur in younger people, too. The cartilage that cushions the bones of the shoulder softens and wears away. The bones then rub against one another. Over time, the shoulder joint slowly becomes stiff and painful.

Unfortunately, there is no way to prevent the development of osteoarthritis. It is a common reason people have shoulder replacement surgery.

Osteoarthritis of the shoulder

Rheumatoid Arthritis
This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed “inflammatory arthritis.”

Post-traumatic Arthritis
This can follow a serious shoulder injury. Fractures of the bones that make up the shoulder or tears of the shoulder tendons or ligaments may damage the articular cartilage over time. This causes shoulder pain and limits shoulder function.

Avascular Necrosis (Osteonecrosis)
Avascular necrosis is a painful condition that occurs when the blood supply to the bone is disrupted. Because bone cells die without a blood supply, osteonecrosis can ultimately cause destruction of the shoulder joint and lead to arthritis. Chronic steroid use, deep sea diving, severe fracture of the shoulder, sickle cell disease, and heavy alcohol use are risk factors for avascular necrosis.

Failed Previous Shoulder Replacement Surgery
Although uncommon, some shoulder replacements fail, most often because of implant loosening, wear, infection, and dislocation. When this occurs, a second joint replacement surgery — called a revision surgery — may be necessary.

Is Shoulder Joint Replacement for You?

The decision to have shoulder replacement surgery should be a cooperative one between you, your family, your local doctor and your orthopaedic surgeon.

There are several reasons why your doctor may recommend shoulder replacement surgery. People who benefit from surgery often have:

• Severe shoulder pain that interferes with everyday activities, such as reaching into a cabinet, dressing, toileting, and washing.
• Moderate to severe pain while resting. This pain may be severe enough to prevent a good night’s sleep.
• Loss of motion and/or weakness in the shoulder.
• Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, or physiotherapy.

Orthopaedic Evaluation

Your family physician may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you can benefit from this surgery.

An evaluation with an orthopaedic surgeon consists of several components:

• A medical history. Your orthopaedic surgeon will gather information about your general health and ask you about the extent of your shoulder pain and your ability to function.
• A physical examination. This will assess shoulder motion, stability, and strength.
• X-rays. These images help to determine the extent of damage in your shoulder. They can show loss of the normal joint space between bones, flattening or irregularity in the shape of the bone, bone spurs, and loose pieces of cartilage or bone that may be floating inside the joint.
• Other tests. Occasionally blood tests, a magnetic resonance imaging (MRI) scan, or a bone scan may be needed to determine the condition of the bone and soft tissues of your shoulder.

(Left) An x-ray of a healthy shoulder joint
(Right) Osteoarthritis of the shoulder
Note the decreased joint space in the x-ray (arrow)

Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether shoulder joint replacement is the best method to relieve your pain and improve your function. Other treatment options — including medications, injections, physiotherapy, or other types of surgery — will also be discussed and considered.

Shoulder Replacement Options

There are different types of shoulder replacements. Your surgeon will evaluate your situation carefully before making any decisions. He or she will discuss with you which type of replacement would best meet your health needs. Do not hesitate to ask what type of implant will be used in your situation, and why that choice is right for you.

These components come in various sizes. They may be either cemented or “press fit” into the bone. If the bone is of good quality, your surgeon may choose to use a non-cemented (press-fit) humeral component. If the bone is soft, the humeral component may be implanted with bone cement. The same applies to the Glenoid side. Either a socket without cement is inserted (press fit) or an all-plastic component is implanted with bone cement.

Implantation of a glenoid component is not advised if:

• The glenoid has good cartilage
• The glenoid bone is severely deficient
• The rotator cuff tendons are irreparably torn

Hemiarthroplasty

Sometimes, surgeons make the decision between a total shoulder replacement and a hemiarthroplasty in the operating room at the time of the surgery.

Studies show that patients with osteoarthritis get better pain relief from total shoulder arthroplasty than from hemiarthroplasty.

Reverse Total Shoulder Replacement

For these individuals, a conventional total shoulder replacement can still leave them with pain. They may also be unable to lift their arm up past a 90-degree angle. Not being able to lift one’s arm away from the side can be severely debilitating.

In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder bone and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm.

(Left) Rotator cuff arthropathy
(Right) The reverse total shoulder replacement allows other muscles — such as the deltoid — to do the work of the damaged rotator cuff tendons

Complications

Your orthopaedic surgeon will explain the potential risks and complications of shoulder joint replacement, including those related to the surgery itself and those that can occur over time after your surgery.

When complications occur, most are successfully treatable. Possible complications include the following.

Infection
Infection is a complication of any surgery. In shoulder joint replacement, infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis.

Any infection in your body can spread to your joint replacement.

Prosthesis Problems
Although prosthesis designs and materials, as well as surgical techniques, continue to advance, the prosthesis may wear down and the components may loosen. The components of a shoulder replacement may also dislocate. Excessive wear, loosening, or dislocation may require additional surgery (revision procedure).

Nerve Injury
Nerves in the vicinity of the joint replacement may be damaged during surgery, although this type of injury is infrequent. Over time, these nerve injuries often improve and may completely recover.

Preparing for Surgery

Medical Evaluation
If you decide to have shoulder replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before surgery. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, must also be evaluated by a specialist, such a cardiologist, before the surgery.

Medications
Tell your orthopaedic surgeon and his team about the medications you are taking. He or your local doctor will advise you which medications you should stop taking and which you can continue to take before surgery.

Home Planning
Making simple changes in your home before surgery can make your recovery period easier.

For the first several weeks after your surgery, it will be hard to reach high shelves and cupboards. Before your surgery, be sure to go through your home and place any items you may need afterwards on low shelves.

When you come home from the hospital, you will need help for a few weeks with some daily tasks like dressing, bathing, cooking, and laundry. If you will not have any support at home immediately after surgery, you may need a short stay in a rehabilitation facility until you become more independent.

Your Surgery

Before Your Operation
Wear loose-fitting clothes and a button-front shirt when you go to the hospital for your surgery. After surgery, you will be wearing a sling and will have limited use of your arm.

You will most likely be admitted to the hospital on the day of your surgery. After admission, you will be taken to the preoperative preparation area and will meet your anaesthetist.

You, your anaesthetist and your surgeon will discuss the type of anaesthesia to be used. You may be provided a general anaesthetic (you are asleep for the entire operation), a regional anaesthetic (you may be awake but have no feeling around the surgical area), or a combination of both types.

Surgical Procedure
The procedure to replace your shoulder joint with an artificial device usually takes about 2 hours.

After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anaesthesia is monitored. After you wake up, you will be taken to your hospital room.

Recovery

Your medical team will give you several doses of antibiotics to prevent infection. Most patients are able to eat solid food and get out of bed the day after surgery. You will most likely be able to go home within a few days of surgery.

Pain Management
After surgery, you will feel some pain, but your anaesthetist and nurses will provide medication to make you feel as comfortable as possible. Pain management is an important part of your recovery. Physiotherapy will begin soon after surgery, and when you feel less pain, you can start moving sooner and get your strength back more quickly. Talk with your Orthopaedic and anaesthetic teams if postoperative pain becomes a problem.

Your Recovery At Home
When you leave the hospital, your arm will be in a sling. You will need the sling to support and protect your shoulder for the first 2 to 4 weeks after surgery.

Wearing a sling will protect your shoulder after surgery

Wound Care
You will have staples running along your wound or a suture beneath your skin. The staples will be removed several weeks after surgery. A suture beneath your skin will not require removal.

Avoid soaking the wound in water until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing.

Activity
Exercise is a critical component of your recovery. Specific exercises several times a day to restore movement and strengthen your shoulder are extremely important. You can’t perform the exercises without help and you will therefore require the help of a physiotherapist at a physiotherapy centre especially during the first few weeks after surgery

Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery. Some pain with activity and at night is common for several weeks after surgery.
Driving a car is not allowed for 2 to 4 weeks after surgery.

Do’s and Don’ts
The success of your surgery will depend largely on how well you follow your orthopaedic surgeon’s instructions at home during the first few weeks after surgery. Here are some common do’s and don’ts for when you return home:

• Don’t use the arm to push yourself up in bed or from a chair because this requires forceful contraction of muscles.
• Do follow the program of home exercises prescribed for you. You may need to do the exercises 2 to 3 times a day for a month or more.
• Don’t overdo it! If your shoulder pain was severe before the surgery, the experience of pain-free motion may make you do more than is prescribed. Early overuse of the shoulder may result in severe limitations in motion.
• Don’t lift anything heavier than a glass of water for the first 2 to 4 weeks after surgery.
• Do ask for assistance. Your doctors may be able to recommend an agency or facility if you do not have home support.
• Don’t participate in contact sports or do any repetitive heavy lifting after your shoulder replacement.
• Do avoid placing your arm in any extreme position, such as straight out to the side or behind your body for the first 6 weeks after surgery.

Many thousands of patients have experienced an improved quality of life after shoulder joint replacement surgery. They experience less pain, improved motion and strength, and better function.