What is Shoulder replacement?
Shoulder is a ball and socket joint with the upper arm bone forming the ball and the glenoid (shoulder blade) forming the socket. Shoulder replacement is a rewarding procedure for the patients suffering with arthritis associated with stiffness and severe pain of the shoulder joint. It is not as common as knee or hip replacement. It is the procedure of replacement of damaged areas of the shoulder with artificial parts that is usually made of cobalt-chromiom alloy and polyethylene. The main aim of the operation is relief of the pain with the restoration of range of motion, function, and strength. It is mainly recommended for irreversible degenerative damage occurring in the shoulder joint. It is of following types –
- Total shoulder replacement- it is also known as shoulder arthroplasty. The whole arthritic joint surface and head of the humerus (upper arm bone) is replaced with a plastic socket and a highly polished metal ball respectively. This is commonly performed in patients with arthritis and intact tendons (rotator cuff) in the shoulder
- Reverse shoulder replacement- it is a procedure in which the places of ball and socket is interchanged. The artificial ball is fitted to shoulder blade and the artificial socket is attached to the humerus (upper arm). This is commonly performed in patients with arthritis + massive rotator cuff tear and elderly patients with severe fractures. In reverse TSR the deltoid acts like rotator cuff in helping patients to perform overhead activities.
- Partial shoulder replacement- in this procedure, the head of the humerus is usually replaced with a metal ball. This procedure is also termed as hemiarthroplasty, as only half of the joint is replaced.
What are the Indications for the procedure?
- Severe arthritis not responding to conservative treatment
- joint erosion and subluxation
- Severe fracture
- Inflammatory arthritis
- Rheumatoid arthritis
- Avascular necrosis
What are its benefits?
The surgery has high success rates which are beneficial in
- Relief of extreme pain that hinders one’s normal daily activities like dressing, bathing, and using the affected arm.
- Relief of night pain that disturbs one’s normal sleep
- Relief of pain when treatment fails to respond to painkillers, anti-inflammatory medicines, steroid injections or physical therapy.
- Relief of longstanding weakness, loss of function and range of motion of the shoulder.
What are its risks?
Shoulder replacements possess very low-risk rates, less than 5 %. The risks that may occur are following-
- Injury to nerves Axillary and Brachial plexus
- Damage to the blood vessel
- Loosening or dislocation of the artificial replacements
- Rotator cuff tear
- Stiffness/frozen shoulder
- Allergic reaction – your body may react against artificial components and produce allergic reactions.
- Implant problems– wearing of the implant may happen and the components may get loosened. This calls for their replacement and you may require additional surgery if the implant break or wears down excessively.
- Implants usually last for 10-20 years, however gives a good quality of life during that period. Patients will need a revision replacement after that time, the risks associated with revision surgery are more.
- Thrombosis and blood clots
How should I prepare for the procedure?
If you have selected to under shoulder replacement surgery, you should be prepared for the following-
- Before surgery, your surgeon will investigate your general condition through certain tests such as blood tests, electrocardiogram or chest X-ray to rule out any health risks. This helps to rule out any possible risks of surgery such as bleeding, heart diseases etc.
- It is advisable to inform your surgeon about any medications or supplements (esp. Blood thinners) you are taking. He may ask you to stop them before the surgery as they may complicate the operation.
- If you are a smoker, you should stop smoking at least 48 hours before the operation. Smoking increases the risk of chest and wound infection. It also affects your recovery process after the surgery by slowing it down.
- Some patients require help for household activities as many activities that require upper movement of the shoulder and other household activities such as bathing, dressing, laundry and cooking for around six weeks.
- Any infection in the body including common cold or a cough should be cleared up before the operation.
- You should also stop eating or drinking 8 hours before the operation.
- Positive attitude towards the operation and your condition are necessary for the success of the surgery. This will help you for better health benefits and faster recovery.
How is it performed?
- The patient is admitted to the hospital on the day of operation and he may have to stay in the hospital for 2-3 days after the operation.
- In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation but he cannot feel whatever is happening in the surgical area. Your surgeon can select the combination of both local and general anaesthetic.
Positioning- after anaesthesia, your surgeon will give you antibiotics as a precautionary step to avoid infection during and after the surgery. Your surgeon will place you in the following position- Beach chair position– in this position, the patient is semi-seated just like sitting in an inclined chair.
- Procedure– The operation is an open surgery in which a 5-10cm incision on the skin in front of the shoulder joint. The surgeon separates the deltoid and pectoral muscles to access the shoulder ensuring minimal damage to the soft tissues of this area. The damaged head of the humerus (upper arm bone) is replaced by an artificial metal ball and a plastic socket is implanted in to the damaged socket (glenoid-shoulder blade). After the replacement, the soft tissues are closed in layers. Then, the skin is closed and stitched with an absorbable suture and covered by a bandage temporarily.
- The operation may take 2-3 hours.
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery; the patient is encouraged to start taking painkillers before the pain starts. This will help to relieve your pain and discomfort caused by the operation.
- You may be discharged from the hospital in 2 to 3 days as shoulder replacement surgery is a major surgery.
- A shoulder sling is applied on your operated shoulder to provide support and avoid new injury to this area. You may have to wear the sling for 4 weeks.
- The function of arm and shoulder should be restricted for nearly a month after the surgery. It is recommended not to perform strenuous activities nor lift any heavy object more than 1 pound. Pushing or pulling activities should also be avoided.
- You can use your arm to do light activities (writing, using keyboard etc) that don’t cause excessive pain or discomfort.
- The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
You could start gentle range of movement (ROM) exercises at 3 weeks and progress to more strenuous activities around six weeks. This will be guided by your surgeon and is based on radiographic (X-ray) and healing of other pathologies in this area. It is advisable to avoid any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of dislocation or fracture or shoulder pathology, quality of bone and method of fixation.
What are the results of the operation?
Most patients report great relief of pain and restoration of good function of the shoulder after surgery. The outcome of the operation is more predictable in the author’s experience.
When can I return to driving and work?
You can return to work in 1- 2 weeks and resume driving in 4-6 weeks after arthoplasty. Immobilization/restrictions in movements usually ends in 6 weeks after the surgery, after this, you can get back to your normal activities. However, it may take another 6-12months to achieve full recovery. Your surgeon can give you the correct estimation.
- Arhtritis in a yound patient with good bone stock – Total Shoulder Replacement with an stemless implant
- Arhtritis in an older patient with poor bone stock – Total Shoulder Replacement with an stemmed implant
- Arhtritis in an older patient with long standing rotator cuff tear – Reverse Polarity Total Shoulder Replacement.