Shoulder Joint Replacement
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.
Modern advancements in shoulder replacement surgery have resulted in high rates of successful outcomes for patients with osteoarthritis. It is therefore not surprising that more patients are being treated with a shoulder replacement than ever before. In fact, over the last several years, the number of shoulder replacements performed in the United States has increased at a faster rate than even hip or knee replacements.
Modern Total Shoulder Replacement surgery has shown clinical success rates of 93-95% with improvements in pain relief and restoration of shoulder function. Thus, for a patient with severe osteoarthritis of the shoulder who has failed attempts at conservative treatment, a total shoulder replacement is a remarkable surgical alternative. Following a shoulder replacement, patients are typically able to return to previous activities with improved ability. In fact, over 70% of patients treated with a shoulder replacement noted improvements in their ability to play tennis, golf, and swim. Most patients are able to return to these activities within 3-4 months. A study performed ten years ago found that it took approximately 4.5 months to be able to play a full round of golf, however, the shoulder replacement helped to improve golf scores by an average of 5 strokes.
Many patients initially fear undergoing a shoulder replacement based on anecdotal experiences of others who were treated in the past. Several recent studies have investigated the risks involved in shoulder replacement surgery. As a recent study from Johns Hopkins University illustrated, total shoulder replacement is actually safer than hip or knee replacement surgery with a 50% lower complication rate and shorter hospital stays.1 Complication rates were also 50% lower in patients treated by surgeons who perform a high volume of shoulder replacement surgeries. Patients should therefore be encouraged to seek out a shoulder specialists who routinely perform a high volume of shoulder replacement to best determine if a shoulder replacement is indicated.
Whether to proceed with a total shoulder replacement should be a quality of life decision. If the patient’s quality of life is dramatically affected by shoulder pain and loss of function from arthritis, then a total shoulder arthroplasty should be strongly considered. Physicians should be encouraged to identify those surgeons who perform a high volume of shoulder arthroplasty, as these surgeons are likely best able to determine of a shoulder replacement is indicated and may perform the surgery with lower rates of complications.
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 muscles and tendons that surround the shoulder provide stability and support. These structures allow the shoulder to rotate through a greater range of motion than any other joint in the body.
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 replacing just the head of the humerus bone (ball) or replacing both the ball and the socket (glenoid).
Several conditions can cause shoulder pain and disability, and lead patients to consider shoulder joint replacement surgery.
- Osteoarthritis (Degenerative Joint Disease)
- Rheumatoid Arthritis
- Post-traumatic Arthritis
- Rotator Cuff Tear Arthropathy
- Avascular Necrosis (Osteonecrosis)
- Severe Fractures
- Failed Previous Shoulder Replacement Surgery
Is Shoulder Joint Replacement for You?
The decision to have shoulder replacement surgery should be cooperative between you, your family, Prof Imam, and the team.
There are several reasons why your doctor may recommend shoulder replacement surgery. People who benefit from surgery 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 physical therapy.
Clinical examination, plain radiographs, and special investigations in the form of CT or MRI scans are usually required before your shoulder replacement surgery.
Shoulder Replacement Options
Shoulder replacement surgery is highly technical. It should be performed by a surgical team with experience in this procedure. There are different types of shoulder replacements. Prof Imam or a team member will tell you the best replacement option based on your circumstances.
What are the types of shoulder replacement?
Anatomic Total Shoulder Replacement
The typical total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem and a plastic socket. Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.
Depending on the condition of your shoulder, Prof Imam may replace only the ball. This procedure is called a hemiarthroplasty. In a traditional hemiarthroplasty, the head of the humerus is replaced with a metal ball and stem, similar to the component used in a total shoulder replacement. This is called a stemmed hemiarthroplasty. Some surgeons recommend hemiarthroplasty when the humeral head is severely fractured but the socket is normal. Other indications for a hemiarthroplasty include:
• Arthritis that only involves the head of the humerus with a glenoid that has a healthy and intact cartilage surface
• Shoulders with severely weakened bone in the glenoid
• Some shoulders with severely torn rotator cuff tendons and arthritis
Sometimes, surgeons decide between a total shoulder replacement and a hemiarthroplasty in the operating room at the time of the surgery. It is worth mentioning that studies show that patients with osteoarthritis get better pain relief from total shoulder arthroplasty than from hemiarthroplasty.
Resurfacing hemiarthroplasty involves replacing just the joint surface of the humeral head with a cap-like prosthesis without a stem. With its bone preserving advantage, it offers those with arthritis of the shoulder an alternative to the standard stemmed shoulder replacement. Resurfacing hemiarthroplasty may be an option for you if:
• The glenoid still has an intact cartilage surface
• There has been no fresh fracture of the humeral neck or head
• There is a desire to preserve humeral bone
For young or very active patients, resurfacing hemiarthroplasty avoids the risks of component wear and loosening that may occur with conventional total shoulder replacements in this patient population. Due to its more conservative nature, resurfacing hemiarthroplasty may be easier to convert to total shoulder replacement, if necessary at a later time.
Reverse Shoulder Replacement
Another type of shoulder replacement is called reverse total shoulder replacement. Reverse total shoulder replacement is used for people who have:
• Completely torn rotator cuffs with severe arm weakness
• The effects of severe arthritis and rotator cuff tearing (cuff tear arthropathy)
• had a previous shoulder replacement that failed
Reverse shoulder replacement is a type of shoulder replacement in which the glenohumeral joint’s normal ball and socket relationship is reversed, creating a more stable joint with a fixed fulcrum. This form of shoulder replacement is utilized when conventional shoulder replacement surgery leads to poor outcomes and high failure rates.
The combination of improved design features and excellent clinical outcome data has led to reverse shoulder replacement instead of other types to primary manage various shoulder problems. We have published our results as part of a multicentre clinical study looking at 159 reverse shoulder replacement results with five years of follow-up. We reported that reverse total shoulder arthroplasty restores the function in the shoulder with significant improvements in function and moderate complications with significant improvement in clinical functions.
Prof Imam or a team member 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 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.
Although prosthesis designs and materials and 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).
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
Suppose you decide to have shoulder replacement surgery. In that case, Prof Imam or a team member may ask you to schedule a complete physical examination with your GP 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 cardiologist before the surgery.
Be sure to talk to Prof Imam about the medications you take.
Some medications may need to be stopped before surgery. For example, the following over-the-counter medicines may cause excessive bleeding and should be stopped for a week or two before surgery.
• Non-steroidal anti-inflammatory medications, such as aspirin, ibuprofen, and naproxen
• Most arthritis medications
If you take blood thinners, either your primary care doctor or cardiologist will advise you about stopping these medications before surgery.
Making simple changes in your home before surgery can make your recovery period easier. It will be hard to reach high shelves and cupboards for the first several weeks after your surgery. 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 do not have any support at home immediately after surgery, you may need a short stay in a rehabilitation facility until you become more independent.
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 a doctor from the anesthesia department.
You, your anesthesiologist, 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.
The procedure to replace your shoulder joint with an artificial implant 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.
Your medical team will give you several doses of antibiotics to prevent infection. Most patients can eat solid food and get out of bed the day after surgery. You will most likely be able to go home on the first, second or third day after surgery.
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 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 and minimize the need for opioids.
A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. You usually start gentle physical therapy soon after the operation. Your surgeon or physical therapist will provide you with a home exercise program to strengthen your shoulder and improve flexibility.
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 4 -6 weeks after surgery. Wearing a sling will protect your shoulder after surgery.
You will have either stitches or staples running along your wound or a suture beneath your skin. These 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.
Exercise is a critical component of home care, particularly during the first few weeks after surgery. Follow your surgeon’s home exercise plan to help you regain strength. Most patients can perform simple activities such as eating, dressing and grooming within 2 weeks after surgery. Some pain with movement 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 mainly 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 lull you into thinking that you can 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 physician 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.
Work is being done to design and develop newer and better shoulder replacements that can be done with less invasive surgical techniques. Researchers are collecting data to determine which patients are the best candidates for which type of shoulder replacement surgery. This information will allow your surgeon to offer you the best recommendation for treating your arthritic shoulder.