Mr Apurv Sinha 

Consultant Trauma and orthopaedics 

 

 

SHOULDER REPLACEMENT 

What is a shoulder replacement?

There are two types of shoulder replacement which may be offered to you:

  1. Total shoulder replacement

  2. Hemiarthroplasty

 

A total shoulder replacement is an operation to replace the “ball and socket” components of the shoulder joint.

  • The ball component is known as the humeral head, which sits at the top of the arm bone (humerus).

  • The socket is known as the glenoid fossa, which is part of the shoulder blade (scapula).

The humeral head is removed and replaced with a metal implant, and the glenoid fossa is also shaved and resurfaced with a polyethylene (plastic) cup to provide the bearing surface.

 

A hemiarthroplasty replaces just the ball of the shoulder joint.

 

What are the benefits of having a shoulder replacement?

A shoulder replacement is often advised when there are severe degenerative changes in the shoulder joint, such as arthritis, causing pain and reduced movement.

  • Osteoarthritis is “wear and tear” arthritis, which can damage the joint surfaces.

  • Rheumatoid arthritis is another type of arthritis, which can effect many joints in the body including the shoulder, resulting in pain and reduced movement.

It is normal to experience some pain after the operation but a shoulder replacement can relieve a lot of the pain previously experienced. In addition, there may be some improvement in the range of movement of your shoulder, but this largely depends upon the condition and strength of your muscles before surgery. It is unlikely you will get as much movement as in a normal shoulder but due to the decreased pain you may be able to carry out functional activities more easily.

 

Are there any complications in having a shoulder replacement?

As with most types of surgery there are risks involved and complications can occur which are unrelated to the shoulder replacement.

These include:

  • anaesthetic risks (such as sickness, nausea or rarely cardiac, respiratory or neurological (less than 1%)

  • chest infections,

  • blood clots in the legs (deep vein thrombosis) or in the lungs (pulmonary embolus).

 

Some of the complications which can occur rarely with a shoulder replacement are:

  1. infection

  2. the new joint becoming loose

  3. damage to the nerves and blood vessels (less than 1%)

  4. dislocation

  5. fracture

  6. unwanted pain and stiffness in the shoulder (up to 20%).

 

These risks are very small but if any occur, further treatment or an operation may be necessary.

1. Infection can be a very serious complication - it is thought that the risk of developing an infection is about 1%. Some infections show up immediately whilst you are still on the ward, others are not apparent for months. Due to this risk your surgeon may recommend you take antibiotics, if you have dental work or other surgery, to prevent any infection spreading to your new joint.

 

2. Loosening is a main reason why joint replacements can eventually fail. It is a process that occurs where the metal or cement meets the bone. Most will eventually loosen and require revision, as loosened joints are painful. On average you can expect your shoulder replacement to last about 10 - 15 years.

 

3. Nerve damage can occur during the surgery as many of the large nerves and blood vessels that enter the arm pass very close to the site of the operation Damage can be temporary if retractors holding them out the way stretch them; it is rare that permanent damage can occur, but is possible.

 

4. Dislocation of the new shoulder joint is a possibility after surgery, before the tissues holding the joint in place have healed fully. Your therapist will show you which positions to avoid in order to minimise the risk.

 

5. Fracture during surgery is very rare, but if this happens, you may require additional surgery or a slightly different prosthesis. There is a small risk of a periprosthetic (below the metal work) fracture after surgery, which are most likely following a fall.

 

What happens if I agree to a shoulder replacement?

If you and your surgeon agree that a shoulder replacement is necessary, you will be given an appointment for pre-operative assessment clinic to ensure you are fit for the operation and to record some baseline information. You will see your consultant, or a member of the team, to discuss your surgery and to sign a consent form. You will have the opportunity at this appointment to discuss any concerns you may have and ask any questions. We must seek your consent for any procedure or treatment beforehand. Staff will explain the risks, benefits and alternatives where relevant before they ask for your consent.

If you are unsure about any aspect of the procedure or treatment proposed, please do not hesitate to ask for more information. During your clinic appointment the nurse will discuss your stay in hospital and organise any other necessary tests. These may include a blood test, urine test and a ECG (heart tracing).

If you have any concerns about how you will manage at home after your operation, please mention this to the consultant at your preoperative assessment clinic appointment who may be able to arrange for extra support or assistance following your operation.

 

How long will I be in hospital for?

The actual operation will last about 1½ hours, and you will generally be expected to remain in hospital for a further two days. This is to ensure you are well enough to manage at home and to start your postoperative rehabilitation.

 

Will it be painful?

Although the operation is to relieve pain it may be several weeks until you feel the benefit. You will be given painkillers whilst in hospital and a prescription for pain medication for your discharge home. Please visit your GP if you require further medication.

You will have some bruising around the shoulder/upper arm and it may be swollen. This will settle after a few weeks.

 

Will I have to wear a sling?

Your arm will be supported in a sling immediately after the operation. This needs to be worn continuously for four weeks, apart from when you remove it to do the exercises taught to you by your physiotherapist. The occupational therapist will also show you how to remove the sling carefully to wash and dress.

 

How will I sleep?

Sleep may be uncomfortable if you try and sleep on your affected side, as you will need to continue to wear the sling whilst in bed. We recommend that you lie on your back or on the opposite side, as you prefer. Pillows can be used to give you comfort and support (feather pillows are easier to mould than foam ones).

 

What clothes should I wear with the sling?

Most people find it difficult to manage ordinary clothes immediately after surgery due to the limitation of shoulder movements; therefore we advise you to wear a loose fitting button through shirt or blouse, and comfortable trousers/skirt. A bra may be uncomfortable in the early days so it would be advisable to bring an under slip or loose fitting underwear.

 

When can I drive again?

You should not drive for at least six weeks after your operation. After this point you should return to driving only after discussion with your therapist or surgeon. You should also inform your insurance company and the DVLA as your operation may effect your insurance.

 

What exercises will I need to do after the operation?

The day after your shoulder replacement, the ward physiotherapist and occupational therapist will begin your rehabilitation. This is very important if you are to get the most out of your new shoulder replacement. You will be able to move your elbow, wrist and hand ad start gentle supported pendular exercises for the first two weeks following your operation.

From weeks two to four your physiotherapist will give you a range of “active assisted” exercises to do. These are exercises where you use your healthy arm to lift up and move your operated arm as much as you can within comfort. You will need to do these exercises at least three times a day, but please be guided by your level of discomfort - you can do to much! Example of an “active assisted” exercise for shoulder flexion. You will need to exercise the shoulder daily at home for several months after your operation. This will enable you to gain maximum benefit.

 

What happens when I leave hospital?

When you leave hospital, we will make you an appointment to attend the outpatient physiotherapy department within the following 2 weeks to check on and continue your exercises. You will need to have physiotherapy regularly to ensure your new shoulder doesn’t become stiff and also to get the muscles working. You may also need to attend occupational therapy. You will be seen in clinic two weeks after your operation. At this appointment they will check that your rehabilitation is going to plan. Your surgeon may then see you about 3 months after surgery.

 

When will my stitches be removed?

Generally the stitches we use are dissolvable, so you do not need a separate appointment to remove them. Any protruding ends of stitches will be checked at your clinic appointment at 2 weeks and trimmed if necessary. Keep the wound dry until it is healed. This is normally 10-14 days. Avoid using deodorant, talcum powder or perfumes near or on the scar.

 

When can I resume normal activities?

This depends on your symptoms. Most people find they are comfortable within three months after their surgery, but that they continue to improve for up to a year afterwards. It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, if you experience intense and lasting pain (more than 30 minutes) do the exercise or activity less forcefully, or less often and discuss any problems with your physiotherapist.

Light activities such as sewing, knitting and computer work are best avoided until six weeks after your operation. Avoid taking your arm out to the side and twisting it backwards. Avoid leaning with all your body weight on your arm with your hand behind you. Tasks such as ironing should be avoided for the 6 weeks, and following this only for short periods of time, such as 15 minutes in any one session. Y

ou can swim after six weeks. Heavier work above shoulder level and tasks such as mowing the lawn should be avoided until at least 12 weeks after the operation. Bowls after three to six months.

Guide to daily activities - first four to six weeks Some difficulties are common. The occupational therapist will help you be as independent as possible during your rehabilitation.

1. Getting on and off seats Raising the height can help, e.g. extra cushion, raised toilet seat, chair or bed blocks.

2. Getting in and out of bath Using bath boards may help (initially you jay prefer to strip wash).

3. Hair care and washing yourself Long handled combs, brushes and sponges can help.

4. Dressing Wear loose clothing. Dress operated arm first and undress your operated arm last.

5. Eating Use your operated hand as soon as possible for cutting food and using a cup.

Non-slip mats are simple aids can help.