Shoulder Replacement

Total or partial joint replacement with a prosthetic joint has become a more common treatment to relieve pain and restore independence. Most joint replacements are done for hips and knees, but shoulder replacement is becoming more and more popular as a remedy for arthritis and fractures of the shoulder. Shoulder replacement is recommended to repair painful arthritic shoulders and increase limited motion. The treatment can replace the head of the humerus or the entire shoulder joint.

The Shoulder Joint

The glenohumeral joint (shoulder joint) is a ball-and-socket joint, similar to the hip joint and is the most mobile joint in the body which also makes it unstable. The shoulder joint is made up of three bones:

• the scapula, or the shoulder blade
• the humerus, or the upper arm bone
• the clavicle or the collarbone

The glenoid is the shallow, flat portion of the scapula that forms a small socket, called the glenoid fossa. Strong ligaments and muscles surround the glenoid. The head of the humerus is shaped like a ball, which fits into the glenoid socket and held in place by the rotator cuff muscles. The ball of the humerus is covered with a smooth, durable surface (articular cartilage) and a thin inner lining (synovium) which allows smooth motion of the glenohumeral joint. The joint capsule is a thin sheet of fibers that surrounds the shoulder joint and helps keep the joint stable. A group of muscles (rotator cuff) cover the joint capsule and attach your upper arm to your shoulder blade and your trunk.

See Shoulder Structure, Function for more information about shoulder anatomy.

Causes for Shoulder Joint Replacement

Shoulder replacement is used when there is severe destruction of the humeral head and glenoid surface from osteoarthritis, rheumatoid arthritis, osteonecrosis, or trauma.

The most common cause for shoulder joint replacement is osteoarthritis or degeneration of the joint. Though osteoarthritis is more common in the hip and knee joints, because these are weight-bearing joints, it can also affect the shoulder joint with wear and tear over time, even if without an injury to the joint. Very often the injuries, like joint dislocations, that happened many years earlier can lead to wear-and-tear osteoarthritis in later life due to normal movement of the joint causing damage to the articular cartilage and other joint tissues and ligaments.

Many doctors may suggest shoulder replacement for patients suffering from rheumatoid arthritis where the shoulder becomes painful and makes it hard to use for activities of daily living like dressing and caring for oneself.

Shoulder replacement is also recommended in cases of osteonecrosis (bone death), a condition where the blood vessels do not heal after an injury and the blood supply to that area stops. Eventually the loss of blood supply to part of the bone causes the bone to die. Necrosis usually happens with a fracture of the shoulder. Even if the fracture heals, the blood vessels may not. Therefore, there is no blood supply to the humeral head. A fracture might also lead to arthritis. In some cases, the fracture is so severe the doctor may feel that the chance of necrosis is too high, he will recommend a shoulder joint replacement immediately.

Severe cases of rotator cuff tears may also need shoulder replacement.

Surgical Options for Shoulder Replacement

If your surgeon finds that surgery is needed, there are several types of shoulder replacement procedures. Replacing or reshaping the damaged or diseased joint with a prosthetic one is called arthroplasty. Depending on your age, overall health, and your specific shoulder joint problem, your surgeon may recommend:

• partial shoulder replacement
• partial shoulder resurfacing
• reverse total shoulder replacement
• total shoulder replacement

Hemiarthroplasty replaces the head of the humerus with a prosthesis. The glenoid surface is left intact. Hemiarthroplasty can be done to repair a fracture of the humeral neck when the glenoid cavity isn’t affected and is still functional. Hemiarthroplasty can also used to repair:

• certain types of cartilage damage
• damage to the joint from avascular necrosis (bone death)
• dislocated humeral fractures
• fractures that can’t be repaired because the blood supply to the humeral head has been altered and necrosis (bone death) is likely
• fractures that result from tumors
• rotator cuff tears that can’t be repaired including tears where arthritis is also present

Shoulder resurfacing replaces the head of the humerus with a metal covering, or cap. Resurfacing retains the humeral neck and more than 50% of the humeral head. The glenoid surface may also be replaced using a plastic prosthesis. Shoulder resurfacing is an option for younger patients and those with:

• deformities of the humerus
• rotator cuff tears that can’t be repaired including tears where arthritis is present
• prior surgery on the humerus using nails or screws

A major advantage of resurfacing is that it allows for future shoulder procedures and surgeries. However, resurfacing is not recommended when severe bone loss is present or if the bone is not healthy enough to support the prosthesis.

Reverse total shoulder replacement converts the humerus from its normal ball structure to a socket and the normal glenoid socket into a ball. This change allows a stable center of rotation and uses the deltoid muscle to compensate for the loss of function of the rotator cuff. To be a good candidate for this surgery, you must have a functional deltoid muscle and a lifestyle that puts a low demand on using your shoulder. Although reverse shoulder replacement is relatively new, it has been a successful treatment for patients with rotator cuff tears that can’t be repaired and arthritis is also present.

Total shoulder arthroplasty replaces both the humeral head (ball) and glenoid socket with prostheses. Total shoulder replacement is used when there is severe destruction of both the humeral head and glenoid surface from osteoarthritis, rheumatoid arthritis, osteonecrosis, or trauma. Approximately 7000 total shoulder replacements were performed each year in the U.S. from 1996 through 2002.

Getting Ready for Shoulder Surgery

The decision of going ahead with shoulder replacement surgery should be made together with your surgeon after you have undergone a thorough orthopedic evaluation. The surgeon will tell you the alternatives of having surgery, the benefits of having shoulder replacement surgery, and the risks involved so that you can make an informed decision. If you have any questions or concerns, you should get them cleared up before signing the informed consent form. By signing the consent form, you are saying you know why you are having the surgery and that you understand the risks, benefits and alternatives of surgery and agree to the procedure.

Risks of Shoulder Replacement

The risks of having complications vary from person to person. That’s because each persons health status is different as well as the type of shoulder replacement they will need. The most common problems after shoulder replacement include:
• Infection (most susceptible within the first two years)
• Stiffness in the shoulder – following your physical therapy routine can help prevent stiffness
• Instability in the glenohumeral joint
• Component failure or loosening requiring more surgery
• You may not get complete pain relief
• Rotator cuff tears
• Fractures in the joint
• Deep vein thrombosis
• Pneumonia
• Dislocation – most likely to occur during the healing process, which is why it’s important to wear the shoulder immobilizer
• Nerve injury
• Detachment of the deltoid muscle

Pre-op Tests and Preparation

Once you are comfortable with going ahead with surgery—you feel the benefits will outweigh the risks—and want to have it done, your surgeon will schedule surgery. Depending on your age and overall health, your surgeon may have you get a thorough physical examination done by your general physician or if you have heart disease to get checked by your cardiologist. Your surgeon may also order pre-surgery tests such as:
• urinalysis
• chest x-ray
• EKG
• ECG
• Blood tests (depending on your medical history)

These tests are to make sure that you are healthy enough to have surgery and to prevent possible complications during and after surgery.

You will need to stop taking certain medicines, like aspirin, ibuprofen, or other anti-inflammatory or arthritis medicines that you have been taking. These medications can thin the blood and cause excessive bleeding during surgery. Also, be sure to tell your surgeon about any other medicines that you take so that he can advise whether to stop taking them. Also, if you get a cold, flu, cough, or infection prior to your surgery date, let you surgeon know because your surgery may have to be postponed.

If you are a smoker, you should quit smoking at least for a few days prior to surgery, as smoking can cause complications during the surgery and slow down healing. Do not use nicotine patches or gum to stop smoking as they contain nicotine.

You may be asked to donate a unit of blood to be kept on hand in case you need blood during surgery. If you are unable to donate blood, a family member with a blood type compatible with yours can donate for you. The blood bank will help you arrange your blood donation. All donated blood is screened and typed and the blood supply today is safer than ever. About 25% of patients have a blood transfusion during shoulder replacement.

Your surgeon may also have you visit the physical therapist that will be taking care of your rehabilitation after surgery. The therapist will be able to prepare you for the surgery and get to know your physical condition before the surgery. This will make it easier for the therapist to offer the best treatment and therapy exercises for you.

Getting Your Home Ready for Your Return

Arrange your home for your return before you go for surgery. You will need some help after the surgery as you won’t be able to move your shoulder or arm. Arrange for a family member or friend to be with you all the time for at least the first week after surgery. You also need to arrange to get to and from the hospital for surgery as well as for follow-up visits after surgery, since you will not be able to drive for six weeks or longer.

You may not be allowed to take shower for a week after surgery, so you’ll need help with a sponge bath. You also want to prevent falls of any kind, especially in the shower. Putting up temporary handrails in the shower will help you step in and out.

Your arm will be in an immobilizer sling so you won’t be able to raise you arm after surgery. Go through your home and make sure that items you will need two arms to reach are placed at waist height so you can get to them.

Going for Shoulder Surgery

Usually, on the day of the surgery, you will be admitted to the hospital or surgical unit early in the morning. The night before surgery, you must not eat or drink anything after midnight. Bring anything to the hospital your surgeon has asked for including medications that you are already taking, since you will have to stay in the hospital for a few days. Take a shower and wash you hair before admission—it will be hard to wash your hair after surgery because you can’t raise your arm. Try to get to bed early and get a good night’s sleep.

Shoulder Surgery

On the day of surgery, you will be asked to arrive a couple of hours prior to surgery. If you have not already met with the anesthesiologist, the anesthesiologist will evaluate you. Usually, in total shoulder replacement surgery, regional anesthesia is used. The anesthesia is a brachial plexus nerve block, where the complete shoulder region gets numb and lasts for several hours after surgery. For some surgeries, you may have general anesthesia.

The procedure starts with a 4-6 inch incision on the front of the shoulder from the middle of your collarbone to the middle of your arm. This allows access to the shoulder joint without harming the deltoid or pectoralis muscles that are used for the shoulder’s power. The procedure involves the removal of the damaged shoulder joint and replacing it with metal and plastic implants. If the socket is unaffected or can be repaired a hemiarthroplasty may be performed—replacing only the ball of the humerus. In a total arthroplasty, socket of the scapula is also replaced. The ball is replaced by a half-moon shaped metal implant that may or may not be cemented into place; the socket is replaced with a plastic socket that is fixed into the scapula with bone cement.

When the procedure is complete tendons and ligaments are secured or repaired. Then incision is closed with either stitches or staples, covered with a bandage, and your arm immobilized with a sling. The repair requires protection from active use for at least 6 weeks. Procedures usually take about 2 hours, however, due to preoperative preparation and postoperative recovery time you can expect about 6 hours for the entire process. Patients usually spend 2 to 4 days in the hospital depending on their progress and type of surgery.

In the Recovery Room

After surgery, you will be taken to the recovery room where you are monitored until you wake up and/or the effects of the anesthesia wear off which is usually about 1-2 hours. Nerve blocks (regional anesthesia) are often used during surgery and can provide pain relief for 10-24 hours afterward.

To help prevent blood clots in the legs, you will likely be wearing compression stockings and a sequential compression device. You may have also been given anticoagulation medicine. To further prevent blood clots, you need to get up and walk around soon after surgery. Your arm will be in a sling and may affect your balance, so be careful when you first try to walk.

From recovery you will be taken to your hospital room where you will stay for at least three to four days depending on how quickly you recover. Pain medicine will be given in the form of injections into your IV or pain pump. You’ll be asked to breathe deeply and cough frequently in order to relieve any lung congestion from surgery.

Pain control is very important after surgery and a combination of regional and patient-controlled analgesia (PCA) (pain pump) may be used. Controlling pain allows you to take deep breaths, get up, move around, and participate in physical therapy—all of which decreases complications from surgery. Pain pills are usually started on the first day after surgery and the pain pump is discontinued.

A special icing machine made to fit the shoulder may be used to relieve pain and swelling of the shoulder area. This is usually started in the recovery room. Your surgeon may send you home with the ice machine or have you use ice packs to control pain and swelling.

It may take several hours to regain feeling in the affected shoulder and arm. Once your regional anesthesia wears off move your fingers and make a fist off and on to help to maintain the blood flow to the area and speed healing.

If a drain was placed in your shoulder during surgery, it is usually removed the day after surgery unless there is still a lot of drainage.

If you had same-day surgery, you will be allowed to go home when the effects of anesthesia have worn off, you’re past the stage where complications are likely to occur and you’re reasonably free of pain. A nurse usually reviews going-home instructions with you, gets your prescriptions, tells you when to make a follow-up appointment with your surgeon and what to do if you have problems when you get home.

The stitches inside your shoulder will dissolve, stitches or clips in the skin will be removed 10-14 days after surgery. Keep the wound dry until it is well healed.

Recovery and Home Care After Shoulder Surgery

Wearing a Sling

You will be wearing a special sling that immobilizes the shoulder when you come out of surgery. The sling has a strap that goes around your waist. Your elbow should fit far back into the sling; the sling should support and cover your wrist and hand up to your knuckles. Your fingers should be exposed so you can use them. The sling provides support, decreases swelling, and increases comfort while your shoulder heals. Your surgeon will tell you how and how long to wear the sling—usually 4-6 weeks. You will be shown how to take the sling on and off so that you don’t injure your shoulder. Do not remove your sling except to dress, shower, and do your physical therapy exercises. For the first 6 weeks, all activities of daily living should be done using your “good” arm.

You must wear the sling even in bed. It’s best if you lie on the opposite side or your back. Use pillows to help you get comfortable and keep you from rolling onto your affected shoulder during the night. Do not lie on your affected side for the first 6 weeks, or until your surgeon says it’s OK. Some people find it easier to sleep in a recliner and supporting their arm with pillows.

Weight Bearing Activities While Healing From Shoulder Surgery

You will have limits on the weight-bearing activities you can do:
• do not pull objects toward your body
• do no roll your shoulder backward
• do not take your elbow behind the body
• avoid putting weight on the affected arm
• do not use the affected arm to push up from a sitting position
• do not use the affected arm to lift objects
• do not use the affected arm until your surgeon says it’s OK

You may be allowed to shower 72 hours after surgery if you cover the surgical incision and dressing with plastic wrap. If you’re not to take a shower, take a sponge bath until after the staples or sutures are removed (usually 10 to 14 days after surgery) and the incision can get wet. Don’t bathe in tub or soak in a pool or hot tub where the incision is under water for at least 1 month. Use your unaffected arm for lathering, washing, and drying. If you’re allowed to remove the sling to take a shower keep your affected arm close to your body. Avoid putting your hand or arm behind your back when dressing by undressing your affected arm last; dress your affected arm first.

Physical Therapy in the Hospital

A physical therapist will work with you in the hospital and teach you the proper way to do exercises that you will continue once you get home. Make sure you carefully follow the home exercises the physical therapist gives you. Do not overdo the exercises even if you feel like you can. Overuse of the joint while it is healing can lead to permanent problems. Do your exercises exactly as prescribed. Keep these tips in mind:

• Avoid putting force or pressure on the affected shoulder by pushing yourself up from a chair or bed with the help of the affected arm. This pressure will cause the shoulder muscles to contract and can lead to problems with your new shoulder.
• Avoid placing your arm in extreme positions, like behind your body, or lifting anything heavier than the weight recommended by your surgeon for at least six weeks after surgery.
• Avoid driving for at least six weeks after surgery. Ask someone to drive for you. If you don’t have help from a family member or friend, ask the hospital to recommend an agency.

When to Call Your Surgeon

Shoulder replacement is usually a very successful operation, but like any other surgery, it can have complications. Call your surgeon immediately if you have any of the following complications once you get home:

• Infections in the surgical site or in the shoulder can occur in patients who are already suffering from other health issues like diabetes, rheumatoid arthritis, chronic liver disease, or taking corticosteroids. If you are otherwise healthy, you should not have problems.
• Wound healing can be a problem for people who are suffering from rheumatoid arthritis or diabetes, which weaken the immune system and people who take corticosteroids.
• Problems with anesthesia usually happen in people who have recently had a heart attack or those who have chronic illnesses of the lungs, liver, kidney, or heart.
• There may be instability of the joint, either due to loosening of the pieces that have been replaced or stretching of the soft tissues right after surgery.
• The range-of-motion of the shoulder usually gets better as the days go by. However, some patients are unable to move their shoulder very much, keeping them from performing activities of daily living. Sometimes this can last for a long time after surgery. If the muscles seem tight, your surgeon can prescribe medicines to relax the adjoining muscles and loosen the tissues for easier movement of the arm and shoulder.
• If the soft tissues are stretched too much soon after surgery, it can cause the humerus to dislocate. You can keep this from happening by not putting your arm too far behind you.
• Thrombophlebitis (blood clots in any leg vein) can form after surgery. Clots are more common in patients who are elderly, overweight, or those who have had blood clots before. Clots can occur in patients with cancer. A blood clot can be dangerous if it blocks the blood flow back to the heart or if it gets into the lungs.
• In very rare cases, there can be nerve injury associated with surgery. The symptoms of nerve injury are tingling, numbness, and/or difficulty in moving a muscle. These symptoms usually get better with time.
• Dislocation of the humerus can happen during or after surgery, though it is quite unusual.

Keep 24-hour phone numbers handy. Call your surgeon’s office if you feel you are not healing as you should. Check your incision every day when you change the bandage for signs of infection and to make sure it is healing as it should. If you think you have a fever take your temperature. If you have signs of infection or other complications, call your surgeon right away.

Physical Therapy Program After Shoulder Replacement

Restoring movement to the shoulder and arm is a very critical factor in recovering from shoulder replacement surgery. Soon after the surgery, the surgeon or physical therapist will teach you exercises that will prevent your wrist, elbow or shoulder from becoming stiff, which will speed up your recovery. At first pain may make difficult for you to do the exercises, but slowly it will get easier each day. You will have physical therapy sessions with a physical therapist while in the hospital. The physical therapist, occupational therapist, and discharge planner will give you guidelines to help you speed up the healing process.

See Shoulder Rehab to learn more about rehab exercises for the shoulder.

Long-term Care for Your New Shoulder

The most important thing is that you keep your follow-up visits with your surgeon. It will take time for you to get back to your normal activities that you did prior to surgery or shoulder injury. Depending on the type work you do, you may be able to return to work in 8 weeks. If you have a physical job, it may be much longer. Do not drive until your surgeon says it’s OK.

The best way to a total recovery is to stay active by walking, dancing, doing yard work, and, if OK with your surgeon, playing golf or swimming. These exercises will increase your strength, flexibility, and build endurance.

The surgeon may restrict how much weight you lift and/or prohibit repetitive activities. For the first few years after surgery, your surgeon may have you take antibiotics before any invasive procedure or dental procedure, in order to prevent infection in your shoulder. How long you have to take antibiotics will depend on your general health and recovery status.

Total shoulder replacements have a life expectancy of 10-20 years depending on how active you are with your new joint. Being very active puts added demands on your new joint.

Recovery Timetable:

• 3 months after surgery: most patients are reasonably comfortable; have motion of about half of normal, but notice they have some weakness.
• 6 months after surgery: most patients are pain-free (although weather has some effect); they have motion and strength of about two-thirds of normal.
• One year after surgery: about 95% of patients will be pain-free, and the remaining 5% will usually have no more than a weather ache or an occasional ache with over activity. There probably won’t be significant strength limitations depending on the condition of the rotator cuff and deltoid muscle.