TOTAL SHOULDER REPLACEMENT
The shoulder joint is a ball and socket joint. Most of the overall
shoulder movement occurs between the ball (‘Humeral Head’)
at the top of your arm bone (‘Humerus’) and the socket
(‘Glenoid’) which is part of the shoulder blade (‘Scapula’).
See diagram below.
Why the joint needs replacement
- The most common reason for replacing the shoulder joint
is arthritis, either osteo-arthritis (wear of the joint lining:
the articular cartilage) or inflammatory Arthritis such as with
- Osteo-arthritis may be made worse by past injury, instability
or severe and neglected rotator cuff deficiency.
- It may also be necessary immediately following a fracture
or bad accident.
- With arthritis the joint becomes painful and difficult to
- Sometimes the deep layer of muscles (the ‘rotator
cuff’ group), which control shoulder movements, can also be
worn or damaged and may need repairing as well, during the same
About the shoulder replacement (arthroplasty)
The operation replaces the damaged joint surfaces with a metal
replacement for the ball component and if indicated, a plastic one
for the socket. See picture below the right shoulder, viewed from
Two main design categories are:
- Stemmed component (link to picture – Global Advantage)
- Surface replacement component (link to picture – Copeland)
2. Same picture as above - but with Copeland or Global CAP surface
The advantage of the latter, is that it replaces only the damaged
surface of the joint, and preserves the remaining bone almost entirely.
It is not however always possible to do this and some patients require
a stemmed humeral replacement. Both types are very good at controlling
pain and if the muscles work well, should restore a very good range
of movement, strength, and overall function.
The main reason for doing the operation is to reduce the pain in
You should also have more movement in your shoulder. This depends
partly on how stiff the joint was before the operation but most
importantly, how well the muscles around the shoulder work. If they
are damaged, sometimes they can be repaired surgically, but may
need a lot of exercise post-operatively for them to regain sufficient
If the muscles are badly damaged, then only the ball part of the
joint is replaced and not the ‘socket’ (or glenoid).
When you have the operation the surgeon will be able to see if there
is significant damage to the muscles and give you a realistic idea
of what movements to expect.
In those cases where the deep layer of muscles (the rotator cuff
group) is severely damaged and beyond repair, this used to present
a very difficult problem to treat. There is now, however the option
of a special type of shoulder replacement, called a “Reversed
Polarity” replacement which can give good results and lead
to both loss of pain and improved function (link to picture) in
carefully selected patients who might be suitable for this.
All operations involve an element of risk. Whilst severe complications
are rare, patients must nonetheless be made aware of them. They
What are the risks?
- a) Complications relating to anaesthetic.
b) Infection - These are usually superficial wound problems. Occasionally
deep infection may occur after the operation; this could require
further surgery or long-term antibiotics.
c) Damage to the nerves and blood vessels around the shoulder.
d) Deep Vein Thrombosis (blood clot in the arm veins)
e) Excessive stiffness and/or pain in (and around) the shoulder.
f) Early loosening of the implant requiring revision (redo) surgery.
g) Fracture of the bones around the shoulder.
h) Dislocation (implant coming out of joint).
As with all joint replacements, the components can loosen. This
is not normally a problem until very many years after the operation.
These issues will be discussed with the surgeon, when considering
a shoulder replacement.
This type of surgery is usually conducted under General Anaesthesia
(so you are fully asleep).
A common additional procedure is the combination of a regional
anaesthetic (usually an Interscalene Block) plus a general anaesthetic.
This has the advantage of controlling the pain very well both after
the operation (when you wake up) as well as during the operation,
thus allowing a lighter general anaesthetic. This means you will
recover from the anaesthetic much better and faster.
Will it be painful?
Although the operation is to relieve pain, it may be several weeks
until you feel the full benefit. Usually the ‘arthritis’
pain settles very quickly, but it replaced by “wound healing”
and muscular pain, which is maximal during the first 2 weeks or
so. Whilst in hospital, you will be given pain-killers (either as
tablets or injections) to help reduce the pain. The anaesthetist
will discuss the method of pain relief before the operation. This
often includes a self-administered automatic system, controlled
by a button (which you control yourself) called a P.C.A. (Patient
Controlled Analgesia), to be used during the first day following
A prescription for continued pain medication will be given to you
when you are discharge home. You should contact your General Practitioner
(GP) if you require further medication after that.
Swelling and Bruising
You will probably have some bruising around the shoulder/upper
arm and the arm may be swollen. This will gradually disappear over
a period of a few weeks, helped by increased arm exercise. You may
find ice packs over the area helpful. Use a packet of frozen peas,
placing a towel between your skin and the ice pack. Until it is
healed, also use a plastic bag to protect the wound from getting
wet. Leave on for 10-15 minutes and you can repeat this several
times a day.
Wearing a sling:
The sling is for comfort and to protect the shoulder after the
operation and is usually worn most of time, day and night, for the
first 4 to 5 weeks after surgery but you will need to remove it
to perform specific exercises, and for washing and dressing. You
can take it off as instructed by the physiotherapist and you do
not need to have your arm strapped to your body.
The therapists and nurses will show you how to take the sling on
and off (link to diagrams).
You will gradually wear the sling less between weeks 5 to 8 after
surgery. You may find it helpful to wear the sling at night (with
or without the body strap), particularly if you tend to lie on your
side or are a restless sleeper.
If you are lying on your back to sleep you should place a pillow
or folded towel under your upper arm/elbow supporting the arm forwards.
(Link to “using a sling”)
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Exercise after surgery:
These are very important. You will be shown exercises by the physiotherapist.
You will start exercises to move the shoulder on the first day after
the operation. You will then need to continue with exercises when
you go home and you will also need outpatient physiotherapy appointments.
You will need to get into the habit of doing regular daily exercises
at home for several months, in order to gain maximum benefit from
The exercises aim initially to stop your shoulder getting stiff
and, most importantly and in the longer term, to strengthen the
muscles in a structured and balanced way. They will be changed as
you progress and made specific to your shoulder as well as your
lifestyle. (Link physio protocols).
What do I do about the wound?
Keep the wound clean and dry until it is healed. This is normally
for 10-14 days. You can shower or wash and use ice packs but protect
the wound with cling film or an oversized waterproof adhesive dressing,
which should then be removed immediately after. Avoid using deodorant,
creams, talcum powder or perfumes near or on the scar.
Normally your stitches or clips will be removed (or the wound checked
in the case of absorbable sutures) by the nurse at the hospital
or at your GP surgery after 14 days. You will need to make an appointment
at the surgery to have this done.
When do I return to the clinic?
This is usually arranged for approximately 4 weeks after surgery,
to check on your progress. Please discuss any queries or worries
you may have when you are at the clinic. Appointments are made after
this as necessary, on an individual basis.
Are there things that I should avoid?
For the first 6 weeks
- Avoid taking your arm out to the side and
twisting it backwards. For example; when putting
on a shirt or coat, put your operated arm in its
sleeve first, with the arm close to and in front of the
body. Try not to reach up and behind you (e.g. seat belt in
car - it is normally too painful/difficult to do!).
Do not force these movements for 3 months and
until your muscles have become stronger with your daily exercises,
except under instruction from your physiotherapist.
- Avoid leaning with your body weight on your operated arm especially
not with your hand behind you. For example, leaning on your arm
to get out of a chair, or roll over in bed. The new replacement
will not be capable of withstanding our full body weight often not
until 3 months after surgery.
The occupational therapist or physiotherapist will show you ways
of avoiding these movements and can give you aids and appliances
How am I likely to progress?
This can be divided into four phases:
Immediately after the operation until you are discharged
You will start to move the shoulder with the help of the physiotherapist,
but to begin with you will be one-handed. Your daily activities
will be affected and you will need some help, especially if your
dominant hand (right hand if you are right-handed) is the operated
Activities that are affected include dressing, bathing, hair care,
shopping and preparing meals. The occupational therapist will discuss
ways and show you how to be as independent as possible during this
time. Some common difficulties, which are encountered with examples
of practical solutions to help, are listed in the section entitled
“Guide to daily activities in the first 4-6 weeks”.
Before you are discharged from hospital, the staff will help you
plan for how you will manage when you leave. Please discuss any
worries with them. We may be able to organise or suggest ways of
getting help for when you are at home.
After you have been discharged and for up to 6 weeks after
The pain in your shoulder will gradually begin to reduce and you
will become more confident. Wean yourself out of the sling slowly
over this time, using it only when you feel necessary. Do not be
frightened to try and use your arm at waist level and in front of
you for light tasks. You will be seeing a physiotherapist and doing
regular exercises at home to get the joint moving and to start regaining
muscle control. If you are unsure about what you can and cannot
do, please discuss this with the physiotherapist. Lifting your arm
in front of you unaided may still be difficult at this stage.
Phase 3. Between 6 and 12 weeks
The pain should be lessening. The exercises are now designed to
improve the movement available and get the muscles to work, taking
your arm up in the air or away from your body when you are sitting
or standing. Overall, you will have an increasing ability to use
your arm for daily tasks (see driving, work and leisure sections
Phase 4. After 12 weeks
You can progress to more vigorous stretches if this is necessary
for the activities that you want to do. If the muscles are weak
because before the operation the shoulder pain stopped you being
able to use them, you should find that you will gain the strength
in them with regular exercise. Strength can continue to improve
for many months, even up to a year or more. However, unfortunately
sometimes the muscles are badly damaged and then you may find it
difficult to regain movement even though you are trying very hard.
Even if the muscles will not work properly, the pain in the shoulder
should still be much less than before your operation and often you
can find small ‘trick’ movements that enable you to
do what you want to do. Most improvement will be felt in the first
6 months, but strength and movement can continue to improve for
18 months to 2 years.
When can I return to work?
You will probably be off work approximately 6 - 8 weeks, depending
on the type of job you have. If you are involved in lifting, overhead
activities or manual work you are advised not to do these for 3
- 6 months. Please discuss any queries with the therapists or hospital
When can I drive?
It is normally about 8 weeks before you can do this safely. This
will be sooner if it is an Automatic car.
You may find it is more difficult if your left arm has been operated
on because of using the gear stick/handbrake.
Check you can manage all the controls and it is advisable to start
with short journeys. The seat belt may be uncomfortable initially
but your shoulder will not be harmed by it.
In addition, check your insurance policy. You may need to inform
your insurance company of your operation.
When can I participate in my leisure activities?
Your ability to start these activities will be dependent on pain,
range of movement and the strength that you have in your shoulder
following the operation. Please discuss activities in which you
may be interested with the therapists or hospital doctor. Start
with short sessions, involving little effort and gradually increase.
Swimming – breast stroke after 6 weeks. Specific exercise
with the arm underwater is also very useful.
Gardening (light tasks e.g. weeding) – after 8 weeks
(heavier tasks e.g. digging, mowing lawn) after 3-6 months
Bowls – after 3-6 months
Golf, tennis, badminton or squash – after 4-6 months
Guide to daily activities in the first 4-6 weeks
Some difficulties are quite common, particularly in the early stages.
The occupational therapist (OT) will help you to be as independent
as possible during your rehabilitation. Special equipment can be
borrowed from the OT department. Everyone is different so your individual
needs will be assessed. We appreciate that you may have been having
many of these problems before your operation. Please discuss your
difficulties with the occupational therapist.
1. Getting on and off seats. Raising the height can help e.g. extra
cushion, raised toilet seat, chair or bed block.
2. Getting in and out of the bath. Using bath boards may help.
(Initially you may prefer to strip wash).
3. Hair care and washing yourself. Long handled combs, brushes
and sponges can help to stop you twisting your arm out to the side.
4. Dressing. Wearing loose clothing, either with front fastening
or which you can slip over your head. For ease also remember to
dress your operated arm first and undress your operated arm last.
In addition, dressing sticks, long handled shoe horns, elastic shoe
laces, sock aids and a ‘helping hand’ can help.
5. Eating. Use your operated arm as soon as you are able for cutting
up food and holding a cup. Non-slip mats and other simple aids may
6. Household tasks/cooking. Do light tasks as soon as you feel
able e.g. lifting the kettle with small amount of water, light dusting,
ironing, rolling pastry. Various gadgets can help you with other