TOTAL SHOULDER REPLACEMENT

 

 


The shoulder

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 Rheumatoid Disease.
  • 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 move.
  • 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 operative procedure.


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 the front.

 


Two main design categories are:

  1. Stemmed component (link to picture – Global Advantage)
  2. Surface replacement component (link to picture – Copeland)


1. Stemmed



2. Same picture as above - but with Copeland or Global CAP surface replacement

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 your shoulder.

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 strength.

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.



What are the risks?

All operations involve an element of risk. Whilst severe complications are rare, patients must nonetheless be made aware of them. They include:

  • 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.


Anaesthesia:

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 surgery.

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 your operation.

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

  1. 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.

  2. 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 if necessary.


How am I likely to progress?

This can be divided into four phases:

Phase 1.
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 side.

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”. (Link)

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.

Phase 2.
After you have been discharged and for up to 6 weeks after the operation

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 later).

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 doctor.


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.

General examples:

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 help.

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 tasks.