Shoulder Replacement Surgery

 

The shoulder joint is a ball-and-socket joint, much like the hip joint.  This means that the ball-shaped surface of one bone fits into a rounded depression of another bone, which allows for movement in many directions. The ball is the top of the arm bone (the humerus), and the socket (glenoid) is within the shoulder blade (scapula). This joint allows people enormous range of motion at the shoulder. Through surgery, the shoulder joint may be entirely replaced, part of the joint might be resurfaced, or excess bone may be removed to reduce pain and increase function.

Types of surgery

Anatomic Total Shoulder Joint Replacement

An anatomic total shoulder joint replacement, with a ball and socket implant.An incision is made on the front of the shoulder and the top (ball) of the humerus is removed and replaced with a metal implant, designed to attach to a stem in the centre of the bone. The socket portion (glenoid) of the joint is cleaned of any damaged areas or debris and removed sections are replaced with a plastic implant cemented into the shoulder socket. This alleviates pain by replacing damaged bone and cartilage with a combination metal and plastic implant.

Partial Shoulder Joint Replacement (Hemiarthroplasty)

A partial shoulder joint replacement, with a ball implant.Instead of removing and replacing both the ball (humeral head) and socket (glenoid) of the shoulder blade (scapula), only the humeral head is removed and replaced. This is usually done when the damage to the shoulder is focused on the humeral head and the socket is still working well.

Humeral Head Resurfacing Arthroplasty 

Humeral head resurfacing, with an implant over the existing joint.While total shoulder joint replacement involves removing the entire humeral head (ball of the joint) and replacing it with an implant, humeral head resurfacing requires removing part of the humerus and adding a metal cap to restore the natural anatomy of the ball of the joint. This type of operation allows for shorter surgery time, easier revision to the shoulder joint, and reduced need to remove extra bone.

Reverse Total Shoulder Joint Replacement

A reverse total shoulder joint replacement, with implants reversing the ball and socket location.When a shoulder has a long-standing rotator cuff tear and develops osteoarthritis, traditional total shoulder joint replacement is not successful. The rotator cuff is a stabilizing group of muscles and tendons that ensures successful motion of the joint, but when it gets damaged, it causes joint stress that can affect long-term functioning of an implant. In reverse total shoulder joint replacement, the metal ball portion of the implant is instead attached to the socket of the shoulder bone (scapula), while the plastic socket is placed at the top of the humerus in the arm (normally the ball portion), reversing the anatomy of the joint. This can improve functioning and reduce pain for patients where traditional shoulder replacement is not able to be performed.

Arthroscopic (Minimally-Invasive) Debridement

Zoomed in view of the shoulder joint, with a camera and needle making repairs.By making several small incisions in the shoulder area, a surgeon can use an arthroscope (scope), a small cable-like probe with a camera, to look inside and perform surgical work using small tools. Using this technique, the surgeon can remove damaged or excess cartilage and other debris around the shoulder joint – this procedure is called “debridement”. It can provide a period of improved function but won’t necessarily stop arthritis issues in the shoulder.

When is shoulder surgery performed?

Shoulder surgery is usually considered when shoulder pain and loss of function become severe and when other treatments no longer relieve pain. The type of surgery suggested will be based on the condition of your shoulder. For instance, partial shoulder replacement (hemiarthroplasty) will only be performed if the socket (glenoid) is in good condition. The condition of your rotator cuff may also determine whether an anatomic or reverse shoulder replacement might be indicated.

How well it works

Most people will be able to do many of their day-to-day activities more easily after shoulder surgery and experience less pain. The shoulder may not move as far as it did before it developed arthritis but should function much better. Like any implant, the life expectancy of the new joint will depend on your activity level, stress on the joint, and care for the joint.

Risks

All surgery includes risks related to the surgery itself and the recovery period. Risks specific to shoulder replacement surgery include:

  • Blood clots
  • Infection
  • Shoulder dislocation
  • Instability of the new joint
  • Loosening of the implant in the bones
  • Nerve or blood vessel damage
  • Problems associated with the use of anesthesia
  • Problems with wound healing
  • Stiffness or lack of good range of motion

Pre-operative visit

Most hospitals will ask you to come in several weeks before your shoulder surgery to review your medical status and talk about what will happen before, during and after your surgery. It’s a good idea to bring a family member or friend to this visit to take notes and ask questions. You will be given lots of information, and this can be overwhelming and difficult to remember if you don’t have someone to support you.

During the pre-operative visit, the team will talk about what kind of anaesthesia is best for you. This depends on many things, including your age, general health and preference. The team may suggest a regional anaesthesia (pain block) so you don't feel the area of the surgery. With this option you'll also have medicine that helps you relax or lightly sleep but you will breathe on your own. Alternatively, your surgical team may suggest a general anaesthesia that puts you completely asleep during the surgery, with a breathing tube inserted down your throat and attached to a breathing machine (ventilator).

Preparation

Physical Activity

To aid recovery, you should be in the best physical condition you can be before surgery. You can strengthen your shoulders before surgery with exercises that allow you to maintain or improve the range of motion in your shoulders, such as shoulder rotations and shoulder blade squeezes.

Your surgeon or physiotherapist may recommend that you do some regular pre-operative exercises. Some are aimed at strengthening your arms and opposite shoulder, to help you manage while your affected arm is in a sling. Other exercises help maintain the strength of your leg muscles. The exercises take about 20 minutes to complete, and if possible, you should do them twice a day.

Your Home

Your house or apartment may need certain changes to meet your needs after your operation. Consider the following to decide what you need to do:

  • Move any items you might need from high shelves or cupboards to shelves at arm level to avoid reaching up
  • You may need to use your non-dominant hand/arm during recovery, so practice completing daily living activities that require the use of this arm ahead of time
  • Rearrange furniture so you will have space to maneuver while wearing a sling
  • Remove small mats and area rugs; tape down the edges of larger rugs so you don’t trip over them.
  • Prepare and freeze meals ahead of time to reheat during initial recovery from your surgery

What to expect after surgery

Right After Surgery

After surgery, you will take medications to ease discomfort. Rehabilitation will start right way, including having you up and moving as soon as possible. You may feel discomfort in your shoulder joint. This is normal. Let your nurse or doctor know if you are in pain so they can adjust your medication if needed.

A nurse of physiotherapist may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is reduced.

Moving Around

After surgery you will be using a removable sling, which is provided to limit the motion of your shoulder. Wear your sling as directed by your surgeon. You should remove the sling to gently and occasionally move your hand, wrist and elbow to reduce swelling. While you can remove the sling for this exercise a few times a day, it should remain on until it is no longer needed, as directed by your surgeon.

You can use your arm to help with getting dressed and eating, unless your doctor specifically tells you not to. You can also use the hand of your other arm to help move the affected arm during recovery.

Leaving the Hospital

When you are discharged from the hospital, your arm will remain in the sling. You’ll need to wear the sling from 2 to 4 weeks. If you have arthroscopic surgery, avoid lifting anything heavier than a glass of water for a few weeks. If you have any kind of joint replacement surgery, avoid lifting anything at all for a few weeks to allow the incision to heal and the joint to recover.

You may have some difficulty sleeping in the first week after surgery. It may be helpful to sleep in a reclined position. This can help reduce pain from lying flat on your back. You will still need to wear your sling when you sleep.

Continuing your rehabilitation exercise program is essential to get your shoulder strength and movement back. For replacement surgery, you’ll learn how to use a pulley device to help lift your arm and keep it flexible during recovery. This device will ensure you don’t use your shoulder muscles as they heal.

Continued recovery

Recovering from arthroscopy will be faster than recovery from shoulder joint replacement surgery. With either procedure, it will still take a few weeks for your shoulder joint to completely recover.

Lying flat on your back may pull on your shoulder, even though it does not affect your shoulder healing. For the first few days after surgery, you may be more comfortable sleeping in a reclining chair or propped up in bed.

You will likely have less arm function for about a month after surgery. You should avoid any activities that require pushing and pulling. As well, you should not drive for about six weeks after the surgery.

You will have an exercise program to follow when you go home, even if you are still attending physiotherapy appointments. You should use the pulley device you receive to move your arm 4 to 5 times each day. If you notice any soreness, try a cold pack on your shoulder and perhaps reduce your activity a bit, but don't stop completely. Staying on your exercise program will help speed up your recovery.

Over time, you will gain strength in your shoulder by performing all home exercises provided to you by your care team. It will take four to six months before you can return to more vigorous activities like golfing or swimming.

Living with a shoulder replacement

Your doctor may want to see you from time to time for several months or more following surgery to monitor your shoulder replacement. Over time, you will be able to do most of the things you could do before surgery.

Stay active to help maintain your strength, flexibility, and endurance. Your activities might include light yard work, swimming (after your wound has completely healed), dancing, or golf. You should avoid heavy lifting, repetitive activities or high-contact sports.

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Contributors

This information was reviewed in October 2019 with expert advice from:

Dr. Christian Veillette, MD, MSc, FRCSC
Division Head, Orthopaedic Surgery, University Health Network
Assistant Professor, University of Toronto
Clinician Investigator, Krembil Research Institute

Sources

https://orthoinfo.aaos.org/en/treatment/shoulder-arthroscopy/ https://orthoinfo.aaos.org/en/treatment/shoulder-joint-replacement/
https://www.healthline.com/health/shoulder-replacement#recovery
https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=zt1157&#tp23177
https://med.nyu.edu/orthosurgery/sites/default/files/orthosurgery/shoulder_0.pdf