Shoulder replacement surgery

Surgery Overview

Joint replacement involves surgery to replace the ends of bones in a damaged joint. This surgery creates new joint surfaces.

In shoulder replacement surgery, doctors replace the ends of the damaged upper arm bone (humerus) and usually the shoulder bone (scapula) or cap them with artificial surfaces lined with plastic or metal and plastic. Shoulder joint components may be held in place with cement, or they may be made with material that allows new bone to grow into the joint component over time to hold it in place without cement.

The top end of your upper arm bone is shaped like a ball. Muscles and ligaments hold this ball against a cup-shaped part of the shoulder bone. Surgeons usually replace the top of the upper arm bone with a long metal piece, inserted into your upper arm bone, that has a rounded head. If the cup-shaped surface of your shoulder bone that cradles your upper arm bone is also damaged, doctors smooth it and then cap it with a plastic or metal and plastic piece.

Surgeons are now trying a newer procedure called a reverse total shoulder replacement for people who have painful arthritis in their shoulder and also have damage to the muscles around the shoulder. In this procedure, after the surgeon removes the damaged bone and smoothes the ends, he or she attaches the rounded joint piece to the shoulder bone and uses the cup-shaped piece to replace the top of the upper arm bone. Early results are encouraging.¹

Surgeons do most joint replacement surgeries using regional anesthesia. That means you can't feel the area of the surgery and you are sleepy, but you are awake. The choice depends on your doctor, on your overall health, and, to some degree, on what you prefer.

Your doctor may recommend that you take antibiotics before and after the surgery to reduce the risk of infection. If you need any major dental work, your doctor may recommend that you have it done before the surgery. Infections can spread from other parts of the body, such as the mouth, to the artificial joint and cause a serious problem.

What To Expect After Surgery

Right after surgery

You will have intravenous (IV) antibiotics for about a day after surgery. You will also receive medications to control pain, and perhaps medications to prevent blood clots (anticoagulants). It is not unusual to have an upset stomach or feel constipated after surgery. Talk with your doctor or nurse if you don't feel well.

When you wake up from surgery, you will have a bandage on your shoulder and probably a drain to collect fluid and keep it from building up around your joint. You may have a catheter, which is a small tube connected to your bladder, so you don't have to get out of bed to urinate. You may also have a compression sleeve on your arm, which squeezes your arm to keep the blood circulating and to help prevent blood clots.

A physiotherapist may begin gentle exercises of your shoulder on the day of surgery or the day after. These exercises are just passive motion; you relax and let the therapist move your arm for you.

Most people who have shoulder replacement surgery are able to sit up and get out of bed with some help later on the day of surgery.

Your health professional may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is decreased.

The first few days

You will probably still be taking some medication. You will gradually take less and less pain medication. You may continue anticoagulant medications for several weeks after surgery.

A physiotherapist will move your arm for you to keep your shoulder loose as it heals. The therapist will also show you how to use a pulley device so you can move your arm when you go home from the hospital. Your therapist may also begin some simple exercises to keep the muscles of your other arm and your legs strong.

Rehabilitation (rehab) after a shoulder replacement starts right away. It is not too demanding early on, but it is very important that you do it. Most doctors will not allow you to use the shoulder muscles for several weeks after surgery. The main goal of rehab is to allow you to move your shoulder as far as possible so it's easier for you to do daily activities, such as dressing, cooking, and driving. Most people eventually regain about two-thirds of normal shoulder motion after surgery. However, other factors that affect how much movement you get after surgery are how much movement you had before surgery and whether the soft tissues around your shoulder were also damaged. It is very important that you take part in physiotherapy both while you are in the hospital and after you are released from the hospital to get the most benefit from your surgery.

Most people go home 1 to 3 days after surgery. Some people who need more extensive rehab or those who don't have someone who can help at home go to a specialized rehab centre for more treatment.

Continued recovery

Once you go home, monitor the surgery site and your general health. If you notice any redness or drainage from the wound, notify your surgeon. You may also be advised to take your temperature twice each day, and to let your surgeon know if you have a fever over 38°C (100.4°F).

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

Rehabilitation generally continues after you leave the hospital until you are able to function more independently and you have recovered as much strength, endurance, and mobility in your shoulder as you can. Total rehabilitation after surgery will take several months.

An example of a typical rehabilitation schedule is:¹

• 6 weeks of very limited activity. No movement of the shoulder using the shoulder muscles is permitted. You will use the pulley to help lift your arm and keep your shoulder flexible. Your physiotherapist may also show a family member how to do some other exercises for you, such as rotating your arm to the outside and elevating your shoulder. You will have a sling to wear at night, and it's a good idea to also put a small stack of folded sheets or towels under your upper arm while you are in bed to keep your arm from dropping too far back. Your arm should stay next to your body or in front of it for several weeks, both while you are up and during sleep. Don't lift anything heavier than a cup of coffee during this time.
• Exercises and stretching, starting 6 weeks after surgery. This stage usually lasts until 3 months after surgery and includes active use of the shoulder muscles to do exercises. The therapist will also begin more vigorous stretching of the soft tissues around the shoulder.
• More intensive strength training starting 3 months after surgery.

Living with a shoulder replacement

Your health professional may want to see you periodically for several months or more to monitor your shoulder replacement. Gradually, you will return to many of your presurgery activities.

Stay active to help maintain strength, flexibility, and endurance. Your activities might include light yard work, walking, swimming (once your wound is completely healed and your health professional has approved), dancing, and golf. Your doctor may recommend that you avoid heavy lifting and repetitive activities.

Your doctor may want you to take antibiotics before dental work or any invasive medical procedure for the rest of your life. This will help prevent infection around your shoulder replacement.

Why It Is Done

Doctors recommend joint replacement surgery when shoulder pain and loss of function become severe, and medications and other treatments no longer relieve pain. Your doctor will use X-rays to look at the bones and cartilage in your shoulder to see whether they are damaged and to make sure that the pain isn't coming from somewhere else.

Shoulder replacement may not be recommended for people who:

• Have poor general health and may not tolerate anesthesia and surgery well.
• Have an active infection or are at risk for infection.
• Have osteoporosis (significant thinning of the bones).
• Have severe weakness of or damage to the muscles around the shoulder.

Some doctors will recommend other types of surgery if possible for younger people and especially for those who do strenuous work. A younger or more active person is more likely than an older or less active person to have an artificial shoulder joint wear out.

Doctors usually do not recommend shoulder replacement surgery for people who have very high expectations for how much they will be able to do with the artificial joint (for example, people who expect to be able to play competitive tennis, paint ceilings, or do other activities that stress the shoulder joint). The artificial shoulder allows a person to do ordinary daily activities with less pain. It does not restore the same level of function that the person had before the damage to the shoulder joint began.

How Well It Works

Most people have much less pain after shoulder replacement surgery and are able to do many of their daily activities more easily.

• The shoulder will not move as far as it did before you developed shoulder problems, but the surgery will allow you to do more of your normal activities without pain.
• After surgery, you may be allowed to resume activities such as golfing, riding a bike, swimming, walking for exercise, dancing, and cross-country skiing (if you did these activities before surgery).
• Your doctor may discourage you from doing things that put a lot of stress on the joint.

The younger you are when you have the surgery, and the more stress you put on the joint, the more likely it is that you will eventually need a second surgery to replace the first artificial joint. Over time, the components wear down or may loosen and need to be replaced.

Your artificial joint should last longer if you do not do hard physical work or play sports that stress the joint. If you are older than 60 when you have joint replacement surgery, the artificial joint will probably last the rest of your life.

Risks

The risks of shoulder replacement surgery include:

• Blood clots. People can develop a blood clot in a leg vein after shoulder joint replacement surgery, but usually only if they are inactive. Blood clots can be dangerous if they block blood flow from the leg back to the heart or move to the lungs. Blood clots occur more commonly in older people, people who are very overweight, people who have had blood clots before, and those who have cancer.
• Infection in the surgical wound or in the joint. Infection is rare in people who are otherwise healthy. People who have other health problems, such as diabetes, rheumatoid arthritis, or chronic liver disease, or those who are taking corticosteroids are at higher risk of infection after any surgery. Infections in the wound usually are treated with antibiotics. Infections deep in the joint may require more surgery, and, in some cases, the artificial joint must be removed.
• Nerve injury. In rare cases, a nerve may be injured around the site of the surgery. It is more common (but still unusual) if the surgeon is also correcting deformities in the joint. A nerve injury may cause tingling, numbness, or difficulty moving a muscle. These injuries usually get better over time and in some cases may go away completely.
• Problems with wound healing. Wound healing problems are more common in people who take corticosteroids or who have diseases that affect the immune system, such as rheumatoid arthritis and diabetes.
• Lack of good range of motion. How far you can move your shoulder after surgery depends a lot on how far you could move your shoulder before surgery. Some people are not able to move their shoulder far enough to allow them to do their regular daily activities, even after several weeks of recovery. If this happens, the doctor may give you a medication to relax your muscles and will gently force the shoulder to move further. This may loosen tissues around the joint that are preventing you from bending it.
• Dislocation of the upper arm bone (humerus). This usually only happens if the soft tissues around the shoulder are stretched too soon after surgery. To help prevent dislocation, do not allow your elbow to move past your body toward your back.
• Fracture of the upper arm bone. This is an unusual complication, but it may happen either during or after surgery.
• Instability in the joint. This can be the result of either the soft tissues being stretched too soon after surgery, or the new joint pieces loosening.
• The usual risks of general anesthesia. Risks of any surgery are higher in people who have had a recent heart attack and those who have long-term (chronic) lung, liver, kidney, or heart disease.

What To Think About

Continued exercise is important for your general well-being and muscle strength. Discuss with your doctor what type of exercise is best for you.

You may donate your own blood to use during surgery if needed. This is called autologous blood donation. If you choose to do this, start the donation several weeks before the surgery so that you have time to donate enough blood and rebuild your blood volume before surgery.

If you need more than one joint replacement surgery, such as a shoulder and a hip or a shoulder and an elbow, there are some general guidelines that may help you and your doctor decide in which order to do the surgeries.

Complete the surgery information form (PDF)(What is a PDF document?) to help you prepare for this surgery.

Author:	Douglas Dana Robin Parks, MS	Last Updated: July 24, 2007
Medical Review:	Anne C. Poinier, MD - Internal Medicine E. Gregory Thompson, MD - Internal Medicine Brian D. O'Brien, MD - Internal Medicine Stanford M. Shoor, MD - Rheumatology
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