Shoulder Replacement Surgery

This leaflet aims to help you understand and gain the maximum benefit from your operation. It is intended for patients who are either thinking about or have decided to have surgery.

Shoulder joint

Your shoulder is a ball and socket joint, it is the most mobile joint in the body. Most shoulder movement occurs where the ball at the top of your arm bone (humerus) sits into the socket (glenoid).  The shoulder depends on a group of strong muscles called the rotator cuff and ligaments to move and stabilise it.

Why does the shoulder need replacing?

The most common reason for replacing the shoulder joint is osteoarthritis or rheumatoid arthritis. It may also be necessary after having a previous injury like a fracture or dislocation. In some cases, the rotator cuff tendons which help to move the shoulder, become damaged after an injury or can become worn as we get older (this is very common over the age of 70). The shoulder may become painful, stiff and difficult to move which may limit your function. It can also disturb your sleep.

What are the treatment options?

The treatment options for managing a painful shoulder are:

• Leaving it alone/pain killers – The arthritic changes in your shoulder will not change but if the symptoms are manageable, you can choose not to have surgery. Physiotherapy may help to improve your pain and movement with exercises that can help your function.
• Corticosteroid injections – injections maybe used in mild to moderate osteoarthritis or in those for medical reasons, surgery is not advised. Pain relief is usually temporary. There is also the option of a referral to the chronic pain team clinic for a suprascapular nerve block injection.Although it is not a cure for the pain, it is used for pain relief.
• Surgery maybe recommended if the above measures have not improved your symptoms. The main reason for an operation is to improve pain and function although depending upon the type of surgery you have; your movement may not fully improve. This will be discussed with you. 

Shoulder replacement surgery

The two main types of shoulder replacement are anatomical or reverse.

Anatomical total shoulder replacement

Replaces the ball of your shoulder with a metal ball and the glenoid (socket) with a plastic socket.  The rotator cuff tendons need to work normally to allow for this replacement.

Reverse total shoulder replacement

This is used if the rotator cuff tendons are torn or non-functional. In these cases, the anatomical shoulder replacement may not provide improved function or relieve pain. This replacement involves reversal of the ball and socket joint making the humeral head the socket and the glenoid the ball, different muscles are used to move the arm.

The main reason for having a reverse shoulder replacement is to reduce pain. As a secondary benefit you may also gain more comfortable movement in your shoulder; it will be unlikely you will regain full range of mobility, but the aim is to raise your arm to, or above shoulder height.  Inward and outward movement may remain restricted, but you can normally brush your hair and manage personal hygiene. Many patients are able to reach to their lower back or same side back pocket, but some are limited to the outer side of the hip.

Hemiarthroplasty

This is replacing only the ball of the shoulder joint, the socket (glenoid) is left alone. Many surgeons recommend hemiarthroplasty when the head of the arm bone is affected but the socket is normal.

Are there any complications with this operation?

The intended benefits of the operation are to improve pain and function, although all surgical procedures are associated with a degree of risk.

General complications:

• Pain – the preoperative pain may settle very quickly post-surgery although it is normal to have pain related to the shoulder surgery which can settle within 3 months. Pain levels can vary.
• Bleeding & bruising – requirement for a blood transfusion is rare. Bruising is common and will disappear over a few weeks.
• Infection – (less than 1%) although the infection rates are low, with any surgery there is always a risk of infection either deep in the joint or in the wound. You will be given antibiotics after surgery.
• Scar – this usually becomes invisible over time.

Specific complications:

• Stiffness and/or persistent pain – less than 5% will have some on-going stiffness or pain after this operation.
• Nerve or blood vessel injury (2-3%) is uncommon after surgery although there is a higher risk in repeat (revision) shoulder replacements and complex fracture surgery. Nerve injury can be temporary, or it may not recover. If it does not improve, you may need further investigations.
• Dislocation – (2-3% if reverse TSR). Sometimes the shoulder replacement can come out of joint. It is more likely to happen soon after surgery.
• Loosening/implant failure – rare complication. If your shoulder replacement becomes loose, this may require further surgery. The lifespan of a shoulder replacement with a new generation implant is expected to be over 10 years.
• Worsening of symptoms -whilst rare, it is possible that your pain, function and movement is worse after surgery than beforehand.
• Stress fracture – is a rare complication after reverse total shoulder replacement. If present, it will usually occur a few months after surgery with a sudden onset of pain and loss of function. Pain eventually settles although you may have residual limitation of function.
• Fracture this is uncommon (2% risk higher in soft bone). A fracture can occur around the shoulder during or after surgery and you may need further surgical treatment.
• Rotator cuff tear – if you develop a rotator cuff tear (which can happen as we get older) after having an anatomical total shoulder replacement, and your shoulder becomes painful, you may require revision shoulder replacement surgery.
• Revision surgery – may be required in case of any complication including infection, fracture, increased pain, rotator cuff failure and implant loosening.
• Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE). A DVT is a blood clot in the leg and the clot can spread to the lungs (PE) and make you unwell. These are rare after shoulder surgery.
• Anaesthetic complications – the anaesthetist will discuss this with you.

Alternatives to surgery

The decision to proceed with an operation is an individual choice between every patient and their consultant or surgical team. You will only be offered an operation if your consultant believes that this will help improve your symptoms. Some patients can learn to manage their symptoms with painkillers, physiotherapy and occasional steroid injections or suprascapular nerve blocks.

How long will I be in hospital?

The operation is usually carried out either as a day case or as an inpatient and you will require an overnight stay in hospital after the operation. The majority of patients are admitted to hospital on the day of surgery; however it may be necessary to admit you the day prior to the operation. The anaesthetist will make this decision and inform you.

What happens before the operation?

Pre-admission assessment

This is an assessment of your health to make sure you are prepared for your admission, treatment and discharge. Please bring a list of all your current medication including a list of allergies and the type of reactions. Before the date of your admission please, read very closely, the instructions given to you by the pre-admission assessment and your confirmation appointment letter.

Planning ahead

Once you have your date for surgery, you can do several things to aid preparation for your operation and to improve your recovery. It is important to plan and arrange for how you will manage when home. Stocking up your freezer with easy cook items is advised (particularly if you live alone), as you may find daily tasks such as cooking more difficult initially after your operation. If you have family or friends, who can stay with you or visit regularly, this may make your recovery easier both for helping with household tasks and moral support.

Smoking

Smoking is shown to delay wound healing and increase complications after surgery. Patients, who stop smoking benefit from long-term improvements to general health, decrease the risks associated with anaesthetic and may have a better outcome from the operation. If you are interested in stopping smoking, please speak to your pre assessment nurse or GP for advice and services available.

Weight

Even though you may feel fit and healthy at your current weight, patients with a higher body mass index are most likely to experience potential serious complications both during and after surgery. If you are keen to lose weight, please speak to your GP or pre assessment nurse for services available.

Cancellation

If you are unable to attend your appointment, please contact us immediately so that we can offer your appointment to another patient.

Your surgery

Anaesthetic

Total shoulder replacement surgery is performed under a general anaesthetic (which puts you to sleep) and a regional anaesthetic (nerve block), which will numb the affected arm and will assist with pain control after the operation.  It can take up to 24 hours before this completely wears off, during this time, you will not be able to move your arm and you may have some altered sensation of the arm or hand that persists for some weeks.

Surgical procedure

The surgery is performed through an incision on the front of the shoulder, this is usually 8-12cm long. This will allow the surgeon to have access to the shoulder and insert the new joint. The shoulder replacement will consist of metal and plastic components that are designed to be durable.

Wound

The wound may be closed with either clips, dissolvable stitches or glue. The wound will be checked usually 10-14 days after your operation when the clips will be removed. This is usually in an orthopaedic clinic or at your GP surgery. You will be informed about this.

If you get a temperature, become unwell, if your wound becomes red, sore and painful or you notice pus, always contact the ward or your consultant’s secretary immediately.

Day of surgery

You will be given specific instructions about when to stop eating and drinking, please follow these carefully as otherwise, this may pose an anaesthetic risk and we may have to cancel your surgery. You should bath or shower before coming into hospital.

The anaesthetist, surgeon or a member of the team will visit you prior to the operation and can answer any questions and discuss your anaesthetic with you. You are asked to sign a consent form.

Prior to and during the operation, a blood pressure cuff is placed on your arm, some leads placed on your chest and a clip attached to your finger. This will allow the anaesthetist to check your heart rate, blood pressure and oxygen levels during the operation. With a general anaesthetic, a needle will be put into the back of your hand to administer the drugs to send you to sleep.

Recovery after surgery

After surgery, you will see a physiotherapist on the ward or in the recovery room. They will give you advice around your surgery, wearing the sling and provide you with a post-surgical exercise leaflet. It is important you do these exercises regularly to prevent your shoulder from becoming stiff. 

Pain

Although the operation is to relieve pain it may be several weeks before you begin to feel the benefit. You may have had a local anaesthetic nerve block as part of the anaesthetic so you may wake up with a numb arm. This local anaesthetic will wear off over the first day. You will be given appropriate painkillers on discharge from hospital. If you feel you are unable to manage your pain, please discuss this with your GP, surgeon or physiotherapist.

Wearing a sling

On return from theatre, your shoulder will be in a sling, this will need to be worn for up to 6 weeks. The physiotherapist/surgical team will guide you on this. 

You must not remove your sling except for washing, dressing and appropriate exercise. Ensure that your wrist and hand is positioned correctly in the sling.

Sleeping

The sling must be worn in bed, for the duration that you are advised to wear the sling. You should not lie on your operated shoulder for the first 6 weeks after surgery. We would recommend that you lie on your back or on the non-operated side:

• If you are lying on your back, place a pillow under your upper arm / elbow to make it more comfortable.
• If lying on your non-operated side, you can fold or hug a pillow in front of you to support the arm. You can also tuck a pillow along your back, to help prevent rolling onto the operated shoulder.
• Once the sling can be removed, you may still find it comfortable to continue sleeping in these positions.

Washing and dressing

Getting washed and dressed needs to be done carefully. Sitting down is usually best as you can support your arm on a pillow while it is out of the sling.

You may find it easier wearing loose clothing with front fastenings. When getting dressed, dress your operated arm first and when getting undressed, this arm comes out last.

Daily activities

You will need to use your non-operated arm for activities like eating, dressing and cooking for the first 6 weeks. Even if you come out of your sling before 6 weeks, you still need to protect the operated arm:

• avoid lifting or pushing up from a chair
• we would advise you that you do not reach behind your back for the first 6 weeks.

After this you can use your operated arm for light tasks but avoid any activities involving weight (ie: lifting a kettle, pan or iron) for at least 3 months after surgery.

Your recovery

The recovery time after total shoulder replacement surgery is variable for each individual. The pain should gradually lessen within the first few weeks after the operation and within 8-12 weeks you should be able to move your arm comfortably below shoulder height. Your movement and function should gradually return although it can take 6-12 months for both pain and function to improve overall. Remember both strength and movement can continue to improve for 18 months after surgery.

Below is the estimated progress you should be making following your surgery, although individuals vary:

• 0-6 weeks:    You will be in a sling. Exercises will be given to you that involve gentle movement that is assisted with the other hand. Lifting your arm out in front of you will be difficult at this stage.

 Avoid:

• placing your hand behind your back
• pushing up from a chair
• avoid trying to brush the back of your head
• avoid taking your arm out to the side in a ‘high five’ position

• 6-12 weeks: Your exercises will be progressed to allow you to start moving your arm on its own and strengthening your muscles. Your pain will start to reduce. You will be able to do more day-day activities with your arm, but we advise that you do not lift anything heavy.

• 12 weeks +: Your movement and function will be improving, and your strengthening exercises will be progressed. Most movement should improve within the first 6 months but remember both strength and movement can continue to improve over time.

Physiotherapy

You will be referred to out-patient physiotherapy and an appointment will be sent out in the post. When you are advised to move your arm out of the sling, do not be frightened, it is normal to feel discomfort, aching and pulling sensation. Over time, the movements will become less painful. The physiotherapist will progress your exercises and assist in your recovery. Continuing the exercises at home will enable you to gain maximum benefit from your operation.

If you have not received a physiotherapy appointment within 2 weeks of your operation, please contact physiotherapy on the number(s) below.

Physiotherapy locations

Please note, depending on the location of your GP, the physiotherapy provider may be different:

• If you have a Gateshead / Newcastle GP, your physiotherapy provider will be Tyneside Integrated Musculoskeletal Service (TIMS). If you have a query about your first appointment with TIMS, please contact the booking team on 0191 445 2643
• If you have a Durham GP, your physiotherapy care will come under Durham. Please contact the Queen Elizabeth hospital, physiotherapy department should you not receive your first appointment on 0191 445 2320
• If you have a GP that is outside of the Gateshead / Newcastle or Durham area and you have had elective surgery, your physiotherapy will be at the Queen Elizabeth hospital. If your surgery is due to trauma, your physiotherapy provider will be with the hospital affiliated to your GP practice. Should you not receive your first appointment, please contact physiotherapy reception on 0191 445 2320

Driving

You will be able to return to driving when you no longer require the sling and have good shoulder movement. It is your responsibility to decide when you can safely control the car, this is likely 8-12 weeks following your operation. Return to driving will be more difficult if your left arm has had surgery, because this is usually the side you use the gear stick or handbrake. Check with a member of the upper limb team/physiotherapist prior to returning to driving and you advised to contact your insurance company.

Flying

Discuss with your consultant and with the airline’s medical department if you wish to fly within 6 weeks of your operation due to the risk of clot formation.

Return to work

This will depend on the type of shoulder replacement you have had. It will usually require a minimum of 8 weeks off work if you have a light job. If your job involves heavy work including lifting and overhead activities, you will need to be off for longer. Please discuss this with the consultant or member of the team.

If you have any caring responsibilities for others, you may need to make specific arrangements to organise extra help. Discuss your needs with your GP or hospital staff prior to your surgery.

Functional activities (these are minimum times and could be longer) examples are:

Telephone numbers