Total shoulder joint replacement for shoulder arthritis: Surgery with a dependable, time-tested conservative prosthesis and accelerated rehabilitation can lessen pain and improve function in shoulders with arthritis.
Edited By: Frederick A. Matsen III, M.D., Winston J. Warme, MD
Last updated Wednesday, October 28, 2009
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Figure 1 - This is a humeral head in situ that has been damaged by arthritis.
Figure 2 - Humeral implant
Figure 3 - Glenoid bone spurs: The figure on the left shows bone spurs at the bottom of the joint. The figure on the right shows that the ball is not centered and has worn down the back part of the socket.
Figure 6 - Humeral Implant
Figure 7 - Glenoid bone being reshaped with a spherical reamer.
Figure 8 - Humeral Cut: the amount of the damaged ball that is removed
Figure 9 - Axillary incision
Figure 12 - Continuous passive motion machine
Summary
Overview
Diagnosis and treatment of shoulder arthritis with Total shoulder replacement arthroplasty
Total shoulder replacement surgery (arthroplasty) helps restore comfort and
function to shoulders damaged by degenerative joint disease, osteoarthritis, or
rheumatoid arthritis.
In shoulder arthritis the joint surface is destroyed by wear and
tear, inflammation, injury, or previous surgery. Figure 1 shows the
surface of a ball of the shoulder joint (humeral head) which has been
destroyed by arthritis. This joint destruction makes the shoulder
stiff, painful and unable to carry out its normal functions.Treatment of shoulder arthritis may include exercises , a ream and run procedure, or a total shoulder.
After performing a clinical exam and x-rays, a shoulder surgeon experienced in
joint replacement can find out if arthritis is the cause of the problem
and if surgery would be helpful. Patients are most likely to benefit
from this surgery if they are well motivated and in good health.
The goal of shoulder replacement arthroplasty is to restore the best
possible function to the joint by removing scar tissue, balancing
muscles, and replacing the destroyed joint surfaces with artificial
ones.
Total shoulder joint replacement arthroplasty is a highly technical
procedure and is best performed by a surgical team who performs this
surgery often. Such a team can maximize the benefit and minimize the
risks. The two-hour procedure is performed under general (or nerve
block) anesthesia.
Streaming video
Dr. Matsen and Sarah Jackins, physical therapist with the UW Bone
and Joint Surgery Center, discuss shoulder surgery with an emphasis on
patient involvement in the UWTV video, "Total Shoulder Replacement: Partnership with the Patient".
Types
Rheumatoid arthritis, arthritis after injury (traumatic arthritis), arthritis after previous surgery (for example, capsulorrhaphy arthropathy), and arthritis associated with rotator cuff disease (known as cuff tear arthropathy). Arthritis may also follow infection; this is known as septic arthritis. If the ball of the shoulder joint (humeral head) dies from lack of circulation, a condition known as avascular necrosis of the shoulder may result.Similar conditions
Shoulder arthritis must be distinguished from rotator cuff disease,
frozen shoulder, and neck arthritis, each of which may produce similar
symptoms. Rotator cuff tears usually cause pain and weakness, but
stiffness is less common. Frozen shoulder is characterized by shoulder
stiffness, but the X-rays are usually normal. Neck arthritis may cause
shoulder pain and weakness that is worse when the head is held in
certain positions.
Incidence and risk factors
While not as common as rotator cuff disease, shoulder arthritis is
among the most prevalent causes of shoulder pain and loss of function.
Arthritis of the shoulder joint is less common than arthritis of the
hip or knee. Individuals with arthritis in one joint are more likely to
get it in another joint.Diagnosis
A physician diagnoses shoulder arthritis by reviewing the patient's
history, performing a thorough physical examination of the joint and
taking the proper X-rays. The examination of an arthritic shoulder
reveals stiffness and roughness of
the joint.
X-rays of the shoulder reveal the contour of the joint surfaces and
the status of the cartilage space between them. X-rays of an arthritic
shoulder usually show a narrowing of the space between the ball and
socket--often to the point that bone is touching bone. The left side of
figure 3 shows bone spurs at the bottom of the joint. The right side of
figure 3 shows that the ball is not centered and has worn down the back
part of the socket. These findings indicate that the normal cartilage
has been destroyed. X-rays do not show the soft tissues, such as scar
tissue, that may also be limiting joint motion.
It is essential that the shoulder surgeon establish the diagnosis of arthritis before shoulder joint replacement is considered.
Medications
Medications may be helpful in managing arthritis. In the case of
rheumatoid arthritis, specific drugs may treat the inflammation that
destroys the cartilage. Some of these medications are administered by
injection and others by mouth. Some individuals take anti-arthritic
medications for their entire lives. These medications can be quite
helpful, but there may be side effects. These medications should be
taken under the close supervision of a rheumatologist or other
physician experienced in their use. In other types of arthritis,
anti-inflammatory drugs may lessen the pain, but do not change the
course of the condition. It is important that the patient be aware of
the possible side effects of these medications, including stomach
irritation, kidney problems and bleeding. Injections of steroids
(cortisone) or lubricants (such as hyaluronic acid) into the shoulder
have not been demonstrated to have lasting benefit and carry some risk
of infection.
For each medication, patients should learn:
- the risks,
- possible interactions with other drugs,
- the recommended dosage, and
- the cost.
Exercises
If exercises are not too painful, they may be helpful in maintaining
the flexibility and strength of joints with arthritis. In most cases
these exercises can be done in the patient's home with minimal
equipment. Shoulder exercises are best performed gently several times a
day on an ongoing basis. Often the exercises will help during the
earlier phases of the condition. The exercises are not dangerous if
they are performed gently. The diagrams show two examples of these
exercises.
Figure 4 shows a patient using the left arm to help lift the stiff
right shoulder in a forward direction. Figure 5 shows a patient using
the left arm to gently stretch the stiff right arm in external rotation
using a yardstick.
Sometimes other types of therapy are used by physical therapists.
Patients should learn the possible risks of these approaches as well as
their costs and anticipated effectiveness.
Possible benefits of shoulder replacement surgery
When combined with a good rehabilitation effort, shoulder joint
replacement arthroplasty allows arthritic shoulders to regain some of
their lost comfort and function. In experienced hands, this procedure
can address the restricting scar tissue that frequently accompanies
arthritis. It can also restore smooth, stabilizing joint surfaces when
these surfaces have been damaged by arthritis.
Joint replacement surgery can improve the mechanics of the shoulder,
but cannot make the joint as good as it was before the onset of
arthritis. In many cases, the tendons and muscles around the shoulder
have been weakened from prolonged disuse before the shoulder
replacement. The scar around them needs to be removed. After the
surgery, it may take months of gentle exercises before the shoulder
achieves maximum improvement.
The effectiveness of the procedure depends on the health and
motivation of the patient, the condition of the shoulder, and the
expertise of the surgeon. When performed by an experienced surgeon, the
published literature shows that shoulder replacement arthroplasty
usually provides improved shoulder comfort and function. The greatest
improvements are in the ability of the patient to sleep, to perform
activities of daily living, and to perform non-contact recreational
activities.
Total shoulder joint replacement for shoulder arthritis
Types of surgery recommended
Joint replacement surgery is the most effective method for restoring
comfort and function to shoulders damaged by severe arthritis.
When the normally smooth surfaces of the shoulder joint are severely
damaged by arthritis, injury or surgery, shoulder joint replacement
arthroplasty may be the most effective method for restoring comfort and
function to the joint. Other surgical options, such as arthroscopy or
"clean up" operations have not been shown to give lasting benefit.
Shoulder fusion can stabilize the joint, but does not allow motion at
the shoulder joint. Removing the joint allows some motion at the joint,
but does not provide stability.
Who should consider shoulder replacement surgery?
Joint replacement surgery is considered when:
- the arthritis is a major problem for the patient,
- the patient is sufficiently healthy to undergo the procedure,
- the patient understands and accepts the risks and alternatives,
- there is sufficient bone and tendon to permit the surgery, and
- the surgeon is experienced in shoulder replacement surgery.
Total shoulder replacement is most effective when the patient
follows a simple exercise program after surgery. Thus, the patient's
motivation and dedication are important elements of the partnership.
What happens without surgery?
In general, this surgery is elective, and can be performed whenever
conditions are optimal. Sometimes the pain and stiffness from shoulder
arthritis will stabilize at a level that is acceptable to the patient.
In such cases the patient can delay surgery without compromising the
potential for future surgery. However, in cases of rheumatoid
arthritis, excessive delay may result in loss of the tendon and bone,
making the surgery more difficult for the patient and for the surgeon.
Surgical options
Several types of shoulder arthroplasty are used to manage arthritis. In
total shoulder arthroplasty, the surfaces of both the humeral head
(ball) and the glenoid (socket) are resurfaced with metal and plastic
implants. Figure 6 shows the metal humeral ball and humeral stem as
well as the plastic glenoid prosthesis. In shoulder hemiarthroplasty,
only the humeral head surface is replaced. In shoulder hemiarthroplasty
with non-prosthetic glenoid arthroplasty, the humeral surface is
replaced and the glenoid socket is reshaped, but Figure 7 shows the
glenoid bone being reshaped with a spherical reamer. Figure 8 shows the
amount of the damaged ball that is removed (humeral cut).Effectiveness
In the hands of an experienced surgeon, shoulder arthroplasty can be
very effective in restoring comfort and function to the shoulder of a
well-motivated patient. The greatest benefits are often the ability to
sleep on the affected shoulder and the ability to perform usual
activities of daily living. As long as the shoulder is cared for
properly and subsequent injuries are avoided, the benefit can last for
decades.Urgency
Shoulder arthroplasty for arthritis is an elective procedure that can
be scheduled when circumstances are optimal. It is not an urgent
procedure. The patient has plenty of time to become informed and to
select and experienced surgeon.Risks
The risks of total shoulder surgery include but are not limited to the
following: infection, injury to nerves and blood vessels, fracture,
stiffness or instability of the joint, loosening or wear of the
artificial parts, failure of the rotator cuff, pain, and the need for
additional surgeries. There are also risks to anesthesia and blood
transfusion (although transfusions are not always necessary). An
experienced shoulder joint replacement team will use special techniques
to minimize these risks, but cannot totally eliminate them.Managing risk
Many of the risks of shoulder arthroplasty surgery can be
effectively managed if they are promptly identified and treated.
Infections may require a "wash out" in the operating room--occasionally
removal of the artificial components is necessary. Blood vessel or
nerve injury may require repair. Fracture may require surgical
fixation. Stiffness or instability may require exercises or additional
surgery. Loosening or wear of the components may require surgical
revision. If the patient has questions or concerns about the course
after surgery, the surgeon should be informed as soon as possible.
Total shoulder joint replacement for shoulder arthritis
Preparation
Total shoulder joint replacement surgery is considered for healthy
and motivated individuals in whom arthritis interferes with shoulder
function.
Successful shoulder replacement depends on a partnership between the
patient and the experienced shoulder surgeon. Patients should optimize
their health so that they will be in the best possible condition for
this procedure. Smoking should be stopped a month before surgery and
not resumed for at least three months afterwards. Any heart, lung,
kidney, bladder, tooth, or gum problems should be managed before
surgery. Any infection may be a reason to delay the operation. The
shoulder surgeon needs to be aware of all health issues, including
allergies and the non-prescription and prescription medications being
taken. Some of these may need to be modified or stopped. For instance,
aspirin and anti-inflammatory medication may affect the way the blood
clots. Since blood transfusion may be necessary, patients may choose to
have a blood bank draw and store their own blood for a possible
autotransfusion.
Figure 9 shows the incision used for a total shoulder replacement.
This area of skin must be clean and free from sores and scratches.
Before surgery, patients should consider the limitations,
alternatives and risks of surgery. Patients should also recognize that
the result of surgery depends in large part on their efforts in
rehabilitation after surgery.
The patient needs to plan on being less functional than usual for
six to twelve weeks after the procedure. Driving, shopping and
performing usual work or chores may be difficult during this time.
Plans for necessary assistance need to be made before surgery. For
individuals who live alone or those without readily available help,
arrangements for home help should be made well in advance.
Timing
Shoulder replacement arthroplasty can be delayed until the time that is
best for the patient's overall well-being. However, in cases of
rheumatoid or other types of inflammatory arthritis, excessive delays
can result in the loss of bone and tendon tissue. These losses can
compromise the quality of the surgery and its result.Costs
The surgeon's office should provide a reasonable estimate of:
- the surgeon's fee, and
- the hospital fee.
Surgical team
Shoulder replacement arthroplasty is a technically demanding procedure
that should be performed by an experienced surgeon in a medical center
accustomed to performing shoulder joint replacements at least several
times a month. Patients should inquire as to the number of shoulder
arthroplasty procedures that the surgeon performs each year and the
number of these procedures performed in the medical center each year.Finding an experienced surgeon
Because less than twenty thousand of these procedures are peformed
in the United States each year, it is unlikely that every community has
an experienced shoulder arthroplasty surgeon who performs many of these
procedures each year. Surgeons specializing in shoulder joint
replacement may be located through university schools of medicine,
county medical societies, or state orthopedic societies. Other
resources include local rheumatologists or professional societies such
as the American Shoulder and Elbow Surgeons Society.
Facilities
Shoulder replacement arthroplasty is usually performed in a major
medical center that performs these procedures on a regular basis. These
centers have surgical teams and facilities specially designed for this
type of surgery. They also have nurses and therapists who are
accustomed to assisting patients in their recover from shoulder
replacement surgery.
Total shoulder joint replacement for shoulder arthritis
Technical details
Shoulder replacement surgery is a highly technical procedure; each step plays a critical role in the outcome.
After the anesthetic has been administered and the shoulder is
prepared, an incision is made across the front of the shoulder from the
middle of the collarbone to the middle of the arm bone as shown in
figure 9. This incision allows access to the joint without damaging the
important deltoid or pectoralis muscles that are responsible for a
significant portion of the shoulder's power.
The muscles and other tissues near the shoulder are mobilized by
removing any scar tissue that may restrict their motion. Figure 10
shows how the tendon of the subscapularis muscle is cut to gain access
to the joint and released circumferentially (a 360-degree release) to
restore its length and mobility. Figure 11 shows where the arthritic
humeral head (ball of the joint) is removed. The bone spurs are removed
to prepare the bone for the humeral prosthesis.
If the glenoid socket is unaffected or in other selected conditions,
a hemiarthroplasty may be performed (replacing the ball only). For
example in cuff tear arthropathy, a hemiarthroplasty (replacing the
humeral joint surface only) is usually selected because the anatomy
does not favor the use of a glenoid prosthesis. The humeral component
is made of metal and is usually press fit, but sometimes cemented, into
the shaft of the bone of the humerus.
If the glenoid is affected, but conditions do not favor the
insertion of a glenoid component, a non-prosthetic glenoid arthroplasty
may be performed along with a humeral hemiarthroplasty. In this
procedure, the glenoid shape and orientation are corrected, but a
glenoid prosthesis is not inserted. The reshaping of the socket using a
spherical reamer is shown in the figure. The prosthetic ball of the
humeral component articulates with the reshaped bony socket of the
glenoid. This procedure may be selected when the patient is interested
in performing heavy activities that might endanger the fixation of a
polyethylene glenoid component.
In a total shoulder joint replacement, the glenoid bone is shaped
and oriented as in the non-prosthetic glenoid arthroplasty and then
covered with a polyethylene glenoid component, as seen in the figure. A
small amount of bone cement is used to hold the artificial glenoid
socket in place.
At the conclusion of any of these procedures, the subscapularis
tendon is securely repaired to the bone. This repair requires
protection from active use for at least 6 weeks while it is healing.
Anesthetic
Shoulder joint replacement surgery may be performed under a general
anesthetic or under a brachial plexus nerve block. A brachial plexus
block can provide anesthesia for several hours after the surgery. The
patient may wish to discuss their preferences with the anesthesiologist
before surgery.Length of shoulder replacement surgery
The procedure usually takes approximately two hours, however the
preoperative preparation and the postoperative recovery may add several
hours to this time. Patients often spend two hours in the recovery room
and two to four days in the hospital after surgery.
Pain and pain management
Recovery of comfort and function after shoulder arthroplasty
continues for the first year after surgery. The rehabilitation is
carried out largely by the patient under the supervision of the surgeon.
Shoulder replacement arthroplasty is a major surgical procedure that
involves cutting of skin, tendons and bone. The pain from this surgery
is managed by the anesthetic and by pain medications. Immediately after
surgery, strong medications (such as morphine or Demerol) are often
given by injection. Within a day or so, oral pain medications (such as
as hydrocodone or Tylenol with codeine) are usually sufficient.
Use of medications
Initially pain medication is usually administered intravenously or
intramuscularly. Sometimes patient controlled analgesia (PCA) is used
to allow the patient to administer the medication as it is needed.
Hydrocodone or Tylenol with codeine are taken by mouth. Intravenous
pain medications are usually needed only for the first day or two after
the procedure. Oral pain medications are usually needed only for the
first two weeks after the procedure.
Effectiveness of medications
Pain medications can be very powerful and effective. Their proper
use lies in the balancing of their pain relieving effect and their
other, less desirable effects. Good pain control is an important part
of the postoperative management.
Important side effects
Pain medications can cause drowsiness, slowness of breathing,
difficulties in emptying the bladder and bowel, nausea, vomiting and
allergic reactions. Patients who have taken substantial narcotic
medications in the recent past may find that usual doses of pain
medication are less effective. For some patients, balancing the benefit
and the side effects of pain medication is challenging. Patients should
notify their surgeon if they have had previous difficulties with pain
medication or pain control.Hospital stay
After surgery the patient spends an hour or so in the recovery room.
A drainage tube is usually used to remove excess fluid from the
surgical area. The drain is usually removed on the second day after
surgery. Bandages cover the incision. They are usually changed the
second day after surgery.
Patients are discharged as soon as the incision is dry, the shoulder
is comfortable with oral pain medications, the patient can perform the
range of motion exercises, and the home support systems for the patient
are in place. Discharge is usually on the third or fourth day after
surgery.
Recovery and rehabilitation in the hospital
Early motion after total shoulder replacement is helps achieve the
best possible shoulder function. Arthritic shoulders are stiff. One of
the major goals of total shoulder replacement surgery is to relieve
much of this stiffness. However, after surgery scar tissue will tend to
recur and limit movement unless motion is started immediately. This
early motion is facilitated by the complete surgical release of the
tight tissues so that after surgery the patient has only to maintain
the range of motion achieved at the operation.
A continuous passive motion (CPM) machine is often used to gently
move the shoulder in the recovery room immediately after surgery. The
CPM machine, shown in figure 12, is used for the first few days after
surgery whenever the patient is in bed.
During the hospitalization, the patient learns a simple
rehabilitation program that will be used for maintaining the range of
motion at home after discharge. Figures 13 and 14 show two of the
exercises used to maintain elevation and rotation of the arm. On the
day of surgery or on the day after, the physical therapist teaches the
patient gentle range of motion exercises. The patient is usually shown
how to stretch the shoulder forward and out to the side, preventing
stiffness and adhesions.
Walking and use of the arm for gentle activities are encouraged soon after surgery.
Hospital discharge
At the time of discharge, the patient should be relatively
comfortable on oral medications, should have a dry incision, should
understand their exercises and should feel comfortable with the plans
for managing the shoulder. For the first month or so after this
procedure, the operated arm may be less useful than it was immediately
beforehand.
The specific limitations can be specified only by the surgeon who
performed the procedure. It is important that the repaired tendons not
be challenged until they have had a chance to heal. Usually the patient
is asked to lift nothing heavier than a cup of coffee for six weeks
after the surgery.
Management of these limitations requires advance planning to
accomplish the activities of daily living during the period of recovery.
Convalescent assistance
Patients usually require some assistance with self-care, activities
of daily living, shopping and driving for approximately six weeks after
surgery. Patients usually go home after this surgery, especially if
there are people at home who can provide the necessary assistance, or
if such assistance can be arranged through an agency. In the absence of
home support, a convalescent facility may provide a safe environment
for recovery.
Recovery of comfort and function after shoulder arthroplasty
continues for many months after the surgery. Improvement in some
activities may be evident as early as six weeks. With persistent
effort, patients make progress for as long as a year after surgery.
Total shoulder joint replacement for shoulder arthritis
Physical therapy
Early motion after total shoulder replacement is critical for achieving optimal shoulder function.
Arthritic shoulders are stiff. One of the major goals of total
shoulder replacement surgery is to relieve much of this stiffness.
However, after surgery scar tissue will tend to recur and limit
movement unless motion is started immediately. This early motion is
facilitated by the complete surgical release of the tight tissues so
that after surgery the patient has only to maintain the range of motion
achieved at the operation. Later on, once the shoulder is comfortable
and flexible, strengthening exercises and additional activities are
started.
Rehabilitation options
It is often most effective for the patient to carry out their own
exercises so that they are done frequently, effectively and
comfortably. Usually, a physical therapist or the surgeon instructs the
patient in the exercise program and advances it at a rate that is
comfortable for the patient. For the first six weeks after surgery,
emphasis is placed on optimizing the flexibility and range of motion of
the shoulder through gentle stretching exercises. After six weeks,
these stretching exercises are continued and strengthening exercises
are added.Can rehabilitation be done at home?
In general the exercises are best performed by the patient at home.
Occasional visits to the surgeon or therapist may be useful to check
the progress and to review the program.Usual response
Patients are almost always satisfied with the increases in range of
motion, comfort and function that they achieve with the exercise
program. If the exercises are uncomfortable, difficult, or painful, the
patient should contact the therapist or surgeon promptly.Risks
This is a safe rehabilitation program with little risk.Duration of rehabilitation
Once the range of motion and strength goals are achieved, the exercise
program can be cut back to a minimal level. However, gentle stretching
is recommended on an ongoing basis.Returning to ordinary daily activities
In general, patients are able to perform gentle activities of daily
living using the operated arm from two to six weeks after surgery.
Walking is strongly encouraged. Driving should wait until the patient
can perform the necessary functions comfortably and confidently.
Recovery of driving ability may take six weeks if the surgery has been
performed on the right shoulder, because of the increased demands on
the right shoulder for shifting gears.
With the consent of their surgeon, patients can often return to
activities such as swimming, golf and tennis at six months after their
surgery.
Long-term patient limitations
Patients should avoid activities that involve major impact (chopping
wood, contact sports, sports with major risk of falls) or heavy loads
(lifting of heavy weights, heavy resistance exercises). These
activities may increase the chance of rotator cuff tear, loosening,
wear or fracture.Costs
The surgeon and therapist should provide the information on the usual
cost of the rehabilitation program. The program is quite
cost-effective, because it is based heavily on home exercises.
Summary of shoulder replacement surgery for shoulder arthritis
Total shoulder replacement arthroplasty helps restore comfort and
function to shoulders damaged by degenerative joint disease,
osteoarthritis, or rheumatoid arthritis.
In the hands of an experienced surgeon, shoulder joint replacement
arthroplasty can be a most effective method for restoring comfort and
function to shoulders with damaged joint surfaces in a healthy and
motivated patient. Pre-planning and persistent rehabilitation efforts
will help assure the best possible result for the patient.
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Surgery for shoulder arthritis at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington
If you are interested in making an appointment to discuss this procedure in Seattle, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-BONE (2663) to make an appointment. Our clinical center is located in Seattle Washington, USA