In the following discussion I will outline some of the key considerations for conventional (anatomic) shoulder replacement and speak about replacements in general. I will then follow with more specific discussions on 2 other types of replacements: reverse total shoulder replacement and partial shoulder replacement (hemiarthroplasty).
Shoulder replacement is a time tested, reliable, solution that can decrease your shoulder pain and improve your motion.
Shoulder replacement can be an excellent option to reduce your pain, improve your motion and end the nagging, aching discomfort caused by shoulder arthritis.
But the decision to pursue replacement should be made prudently: you should understand the risks, rehabilitation commitment and potential complications. A good result after shoulder replacement requires not only a skilled surgeon, but willingness on your part to do extensive rehabilitation and follow some restrictions in the early post operative period.
Anatomic shoulder replacement has the longest track record of any type of shoulder replacement. The techniques employed today are well tested and predictable making it a good solution for the right person. Who is that person?
Shoulder replacement may be a good option for you if your glenohumeral (GH) joint has been destroyed by inflammation, arthritis, previous surgery or bone death and you have failed to get relief with other more conservative treatments. It is an “end of the line” type procedure. You’ve reached your limit, cannot live with the pain and grinding anymore and want a more permanent solution.
The goal of the procedure is to improve your comfort level and motion in your shoulder joint. It is usually best suited for “older” adults as replacement components do wear over time and may require revision. But sometimes there is no other good option in a young adult and a replacement can be considered.
It’s also important to note that this procedure only works well if you have an intact and functioning rotator cuff. If you don’t, and you have arthritis as well, you may be a candidate for a different type of implant.
Will a shoulder replacement be as good as my original shoulder?
After a shoulder replacement you should notice significant improvements in your ability to sleep, perform normal activities and do non-contact sports like golf. But the new shoulder will not be exactly like your original shoulder because a certain amount of scarring in your muscles may persist. Thus, if your range of motion is poor prior to surgery it will typically improve, but it may not return completely to normal.
When you say replacement, what actually are you replacing?
When you hear “shoulder replacement,” it may sound like your surgeon is literally removing your entire shoulder and putting in a new one. The truth is a little less drastic. Much of the bone, muscle and tendon in your shoulder remain intact after the operation.
The “replaced” portion consists primarily of the worn bearing surfaces themselves: the area where healthy cartilage once lived. This usually amounts to a few millimeters of bone on both the socket side and the ball part of the joint. Your surgeon should also remove all of the bone spurs that have built up over time and release scar tissue that may be restricting your motion.
The socket portion of the joint is replaced with a plastic component. After milling the socket surface a few small drill holes are placed into the bone and the new plastic surface is cemented into place. This then gives you a new smooth surface upon which to move. By replacing this surface, pressure is taken off of the old worn socket.
The ball portion if the joint (humerus) is replaced with a metal component (cobalt chrome alloy) that is shaped like a new, healthy joint surface. The metal ball is attached to a “stem” (titanium) that gets inserted into the normal canal of your humerus; arm bones are tubular in nature and the stem fits inside the bone itself. Sometimes the stem is cemented into place, other times a “press fit” stem is used. The press fit stem has a roughened surface that helps the bone inside your humerus grow directly into the implant so that it will remain stable over time.
“Prosthesis” or “arthroplasty” are other words that you may hear used to describe the shoulder replacement. They all mean joint replacement.
One of the common questions I hear is: “will the replacement shoulder set off a metal detector?” Usually the metal components do not set off metal detectors. If this is a concern, carrying a card with you to the airport documenting your procedure may help (although with airport screening as it is today, you may get frisked regardless).
Shoulder replacement is an elective procedure
Elective simply means that it is scheduled when the time is right. It is not an emergency. This doesn’t mean that it will be scheduled the day after you first come to the office. Some pre operative testing is always warranted prior to shoulder replacement: EKG, Chest X-ray, possibly a cardiology evaluation. It should be considered a major surgery and your underlying health is the most important consideration for deciding on whether to move forward with it.
Regional and general anesthesia is employed and most people do tolerate the procedure well from a medical standpoint.
How long will you be In the hospital?
Most patients stay in the hospital 1-2 days after surgery.
Many patients go straight home after surgery. Some may need a rehabilitation stay depending on overall health and support at home.
How painful will it be?
In the first 6-12 hours after surgery you will usually have little pain, assuming that your regional anesthesia was effective. I always warn my patients to start taking their oral pain medication prior to the block wearing off though because eventually you WILL feel some pain.
Depending on how bad your pain was prior to surgery you may actually be surprised by how comfortable you are after surgery. Some people have such excruciating pain prior to surgery that they are actually quite relieved, even in the early post operative period.
What patients often tell me is that the aching, deep, gnawing, “toothache in my shoulder” pain goes away immediately after surgery and they are left with a muscle soreness pain that is typical for surgery.
We do use a multimodal pain regimen that is meant to make you comfortable enough to participate in early therapy after the procedure and this should help keep pain in check. Every person’s perception of pain is different though, so it’s impossible to tell you exactly what your experience will be like. On average patients tend to be considerably more comfortable as they get past the first couple of weeks and approach the one-month time point after surgery.
You will then encounter a stretching type pain as you progress in your therapy. This is normal and occurs usually when you are working on regaining your motion.
Do you have to wear a sling?
Yes. I have my patients wear a sling for about 6 weeks after surgery. It not only protects the repaired muscles in the shoulder but it acts as a signal to other people around you that you recently had surgery and to be thoughtful. Although I’ve had more than one patient tell me that their friends seem to develop a proclivity for slapping them on the shoulder blade after surgery, hopefully yours won’t.
How long will the recovery take?
Your recovery will break down into a few distinct phases. The initial phase will be the most restrictive and involves wearing a sling and doing passive motion exercises. The goal of this phase is to maintain motion while protecting an important muscle repair that was performed in surgery. In the beginning you will not be lifting more than a coffee cup worth of weight in your operative arm.
Driving is often a priority with patients. Safe driving requires two hands. Usually it’s not advisable to drive until at least 6 weeks after surgery due to the passive motion restrictions
After about 6 weeks you will progress slowly to regaining your active motion and strength. As a good rule of thumb you should concern yourself with obtaining perfect biomechanics in active motion before worrying too much about strength.
You will usually work closely with a therapist in the first few months after surgery but can slowly taper this down to more of self-guided program over time.
On average you will achieve about 80% pain relief and functional improvement by about 6 months after surgery. But you should continue to improve for up to a year or more.
So be patient. It takes time.
What makes shoulder replacement different than other joint replacements?
The number of knee and hip replacements performed yearly in the U.S. outnumbers the number of shoulder replacements by about 15:1. Hence awareness about this operation tends to lag that of knee and hip replacement. Besides the decreased awareness of this procedure, there are both technical and practical aspects that make shoulder replacement unique.
One of the more technical aspects to the shoulder replacement is the soft tissue repair. It is necessary to detach and repair an important rotator cuff muscle known as the subscapularis in order to perform a shoulder replacement well. The success of this operation depends on you having a surgeon who can perform this repair well and know what to do if it fails.
Soft tissue balancing and scar release is another very technically challenging aspect of shoulder replacement surgery. Getting a “feel” for good balance takes experience and unique technical skill.
Practically speaking many fewer orthopedic surgeons perform shoulder replacements than knee and hip replacements. So not only is it technically challenging but it is less frequently encountered.
Only about 3% of all orthopedic surgeons perform more than 10 shoulder replacements per year. Like anything else it takes time and repetition to master shoulder replacement surgery and this should be a consideration for anyone thinking about undergoing this operation.
Dr. DiPaola is one of a small percentage of orthopedic surgeons in the country that performs shoulder replacement regularly. He performs dozens each year and is skilled at performing shoulder replacement for a variety of conditions including complex and revision cases. If you are considering shoulder replacement and would like more information please contact us for a personal consultation.