Shoulder joint replacement though less common than knee or hip replacement is just as successful in relieving joint pain. Shoulder replacement surgery was first performed in the 1950s to treat complex shoulder fractures. Over the years, shoulder joint replacement has come to be used for many other painful arthritic conditions of the shoulder. If nonsurgical treatments like medications and activity changes are no longer helpful for relieving pain, you may want to consider shoulder joint replacement surgery. Shoulder joint replacement surgery is a safe and effective procedure to relieve pain and help you resume everyday activities. If you are 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 collar bone (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 components of a healthy shoulder joint.
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 the 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.
Basic description of shoulder replacement
Shoulder joint replacement.
In shoulder replacement surgery, the damaged parts of the shoulder are removed and replaced with artificial components. The treatment options are either replacement of just the head of the humerus bone (ball: hemi-replacement), or replacement of both the ball and the socket (glenoid: either anatomical total shoulder or reverse total shoulder replacement).
Indications for Shoulder replacement
Several conditions can cause shoulder pain and disability, and lead patients to consider shoulder joint replacement surgery.
Osteoarthritis (Degenerative Joint Disease)
Primary osteoarthritis 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. As the cartilage that covers the ends of the bones wears away, it can result in bone rubbing on bone and produce painful bone spurs.
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.
Rotator Cuff Tear Arthropathy
A patient with a very large, long-standing cuff tear may develop cuff tear arthropathy. In this condition, the changes in the shoulder joint due to the rotator cuff tear may lead to arthritis and destruction of the joint cartilage.
Avascular Necrosis (Osteonecrosis)
Avascular necrosis, or osteonecrosis, 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 all risk factors for avascular necrosis.
Complex Fractures
A complex shoulder injury is another common reason people have shoulder replacements. When the head of the upper arm bone is shattered, it may be very difficult for a doctor to put the pieces of bone back in place. In addition, the blood supply to the bone pieces can be interrupted. In this case, a surgeon may recommend a shoulder replacement. Older patients with osteoporosis are most at risk for severe shoulder fractures.
Is Shoulder Joint Replacement the right choice for You?
The decision to have shoulder replacement surgery should be taken in close consultation with your specialist orthopedic 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, and/or physical therapy.
Orthopaedic Evaluation
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. X-rays 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, your doctor may order blood tests, a computed tomography (CT) scan, a magnetic resonance imaging (MRI) scan, or a bone scan to determine the condition of the bone and soft tissues of your shoulder.
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, physical therapy, or other types of surgery — will also be discussed and considered.
(Left) An X-ray of a healthy shoulder joint. (Right) Osteoarthritis of the shoulder. Note the decreased joint space (arrow).
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. Your surgeon will evaluate your situation carefully before making any decisions. They will discuss with you which type of replacement will best meet your health needs. Do not hesitate to ask which type of implant will be used in your situation, and why that choice is right for you.
Anatomical total Shoulder Replacement
The standard total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket.
Anatomical total shoulder joint replacement.
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. In most cases, an all-plastic glenoid (socket) component is implanted with bone cement.
Implantation of an anatomical glenoid component is not advised if:
- The glenoid has good cartilage
- The glenoid bone is severely deficient
- The rotator cuff tendons are irreparably torn
The humeral component can be stemless, short stem or a conventional sized stem depending on the bone quality.
Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for anatomical total shoulder replacement.
X-rays after anatomical total shoulder replacement surgery for osteoarthritis.
Hemi shoulder replacement
Depending on the condition of your shoulder, your surgeon may replace only the ball. This procedure is called a hemi-replacement. In a traditional hemi-replacement, the surgeon replaces the head of the humerus with a metal ball and stem, similar to the component used in a total shoulder replacement. This is called a stemmed prosthesis. Hemi-replacement can also be performed using a stemless prosthesis
Some surgeons recommend hemi-replacement when the humeral head is severely fractured but the socket is normal. Other indications for a hemi-replacement include:
- Arthritis that involves only 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
Hemi shoulder replacement
Reverse Total 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
X-ray of a 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 your arm away from the side can be severely debilitating.
In reverse total shoulder replacement, the socket and metal ball are switched: 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 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 damage. 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 orthopedic surgeon 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 as a cardiologist, before the surgery.
Medications
Be sure to talk to your orthopaedic surgeon 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 1 week before surgery:
- Non-steroidal anti-inflammatory drugs (NSAIDs), 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.
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.
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 one day before 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 anesthesia to be used. You may be provided a general anesthetic (you are asleep for the entire operation), a regional anesthetic (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 anesthesia 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 on the first, second, or third day after surgery.
Pain Management
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 types of 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.
Pain management is an important part of your recovery. You will begin physical therapy soon after surgery, and when you feel less pain, you can start moving sooner and get your strength back more quickly.
Rehabilitation
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 2 to 6 weeks after surgery, depending on the complexity of your surgery and your surgeon's preference.
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 dissolving 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 home care, particularly during the first few weeks after surgery. Follow your surgeon's home exercise plan to help you regain strength. 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.
You are not allowed to drive a car for 6 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 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 to help 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.
Dr. Ashok S Gavaskar MS Orth, FRCS (Glasg), FACS
Clinical lead - Orthopedics
Head - Joint replacement and Trauma
Rela Hospital
