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Shoulder Replacement

Shoulder replacement surgery is an increasingly common procedure. It is very effective in relieving shoulder pain and is becoming as successful as hip and knee replacement surgery at reducing pain and enabling patients to resume everyday activities. Since its first use for severe shoulder fracture in the 1950s in the U.S, shoulder joint replacement has come to be used for many other painful conditions of the shoulder, such as different forms of arthritis and rotator cuff tear.


If nonsurgical treatments like medications, steroid injections, and activity changes are no longer helpful for relieving your shoulder pain and limited motion, you may want to consider shoulder joint replacement surgery. 

Anatomy

The shoulder is made up of three bones:

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  • The humerus (upper arm bone)

  • The scapula (shoulder blade)

  • The clavicle (collarbone)


The shoulder is a ball-and-socket joint: The ball, or head, of the upper arm bone fits into a shallow socket in the shoulder blade. This socket is called the glenoid.

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The surfaces of the bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. A thin, smooth tissue called synovial membrane covers all remaining surfaces inside the shoulder joint. In a healthy shoulder, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost any friction in your shoulder.
The muscles and tendons that surround the shoulder provide stability and support.

All of these structures allow the shoulder to rotate through a greater range of motion than any other joint in the body.

In shoulder replacement surgery, the damaged parts of the shoulder are removed and replaced with artificial components (parts), called a prosthesis.
The treatment options are either:

  • Replacement of just the head of the humerus bone (ball): Hemiarthroplasty

  • Replacement of both the ball and the socket (glenoid): Total shoulder replacement

Conditions That Can Benefit from Shoulder Replacement

Osteoarthritis (Degenerative Joint Disease)

Osteoarthritis is an age-related wear-and-tear type of arthritis. It usually occurs in people 50 years of age and older, but it may occur in younger people, too. The cartilage that cushions the bones of the shoulder wears away. The bones then rub against one another. Over time, the shoulder joint slowly becomes stiff and painful.
Unfortunately, there is no way to prevent the development of osteoarthritis. It is a common reason people have shoulder replacement surgery

Rheumatoid Arthritis
This is a disease in which the synovial membrane that surrounds the joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most common form of a group of disorders termed inflammatory arthritis.

Posttraumatic Arthritis

​This can follow a serious shoulder injury. Fractures of the bones that make up the shoulder or tears of the shoulder tendons or ligaments may damage the articular cartilage over time. This can occur after a broken bone, a dislocation, or both. Like the other forms of arthritis, posttraumatic arthritis causes shoulder pain and limits shoulder function.

Cuff Tear Arthropathy​

​A patient with a very large, long-standing rotator cuff tear may develop a condition called cuff tear arthropathy. In this condition, the changes in the shoulder joint due to the rotator cuff tear may lead to arthritis and destruction of the joint cartilage.

Avascular Necrosis ​(Osteonecrosis)

Avascular necrosis (AVN), or osteonecrosis, is a painful condition that occurs when the blood supply to the bone is disrupted. Because bone cells die without a blood supply, osteonecrosis can ultimately cause destruction of the shoulder joint and lead to arthritis.
Risk factors for avascular necrosis include:

  • Chronic steroid use

  • Complications from deep sea diving

  • Heavy alcohol use

  • Severe fracture of the shoulder

  • Sickle cell disease

Severe Fractures

​A severe fracture of the shoulder is another common reason people have shoulder replacements. When the head of the upper arm bone is shattered, it may be very difficult for a doctor to put the pieces of bone back in place. In addition, the blood supply to the bone pieces can be interrupted. In this case, a surgeon may recommend a shoulder replacement.
Older patients with osteoporosis are most at risk for severe shoulder fractures. In fact, even a fall from standing height can cause a severe shoulder fracture in an older person whose bones are weakened due to osteoporosis.

​Failed Previous Shoulder Replacement Surgery
Although uncommon, some shoulder replacements fail, most often because of:

  • Implant loosening

  • Wearing down of the implant parts

  • Infection

  • Dislocation

When this occurs, a second joint replacement surgery — called a revision surgery — may be necessary.

Is Shoulder Joint Replacement for You?

The decision to have shoulder replacement surgery should be a cooperative one between patient, patient’s family and family physician, and the surgeon.


Dr. Kim thinks that shoulder replacement surgery can be beneficial if a patient has:

  • Severe shoulder pain that interferes with everyday activities, such as reaching into a cabinet, dressing, toileting, and washing

  • Moderate to severe pain while resting and sleeping causing sleep disturbance.

  • Loss of motion and/or weakness in the shoulder.

  • Failure to substantially improve with other treatments such as anti-inflammatory medications, steroid injections, and/or physical therapy.

Shoulder Replacement Options

Shoulder replacement surgery is highly technical. It should be performed by a surgical team with a lot of experience in this procedure.


There are several types of shoulder replacements. The surgeon will evaluate the situation carefully before making any decisions. They will discuss with patient which type of replacement will best meet the patient’s health needs. Do not hesitate to ask which type of implant you will receive, and why that choice is right for you.

Anatomic Total Shoulder Replacement
This is the traditionally known total shoulder replacement and involves replacing the arthritic joint surfaces with a highly polished metal ball and a plastic (polyethylene) socket.

These components come in various sizes. They may be either cemented or press fit into the bone.
- If the bone is of good quality, your surgeon may choose to use a non-cemented (press-fit) humeral component.
- If the bone is soft, the humeral component may be implanted with bone cement (like glue).
- In most cases, a plastic (polyethylene) glenoid (socket) component is implanted with bone cement.
Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.

Hemiarthroplasty
In hemiarthroplasty, the surgeon replaces only the head of the humerus (the ball part of the joint) with a metal ball, similar to the component used in anatomic total shoulder replacement, but leaves the socket side alone without replacing it.
Hemiarthroplasty can be recommended when the humeral head is severely fractured, but the socket is normal. Hemiarthroplasty may also be the best option for patients with:

 

  • Arthritis that involves only the head of the humerus, with a glenoid that has a healthy and intact cartilage surface

  • Severely weakened or deficient (not enough) bone in the glenoid

  • Severely torn rotator cuff tendons and arthritis

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Studies show that patients with osteoarthritis get better pain relief from anatomic total shoulder arthroplasty than from hemiarthroplasty. However, anatomic total shoulder arthroplasty carries a risk of loosening of the socket-side (glenoid) component especially when done in young active patients, in which cases hemiarthroplasty could be a strategically better option.

Reverse Total Shoulder Replacement
Another type of shoulder replacement is called reverse total shoulder replacement. Reverse total shoulder replacement is used for people who have:
- Completely torn rotator cuffs with severe arm weakness
- The effects of severe arthritis and rotator cuff tearing (cuff tear arthropathy)
- A previous shoulder replacement that failed
- Severe humeral head fractures, with or without underlying arthritis
- Very severe osteoarthritis with glenoid and humeral bone loss
For these patients, a conventional anatomic total shoulder replacement is insufficient in improving pain or shoulder function, and also can potentially result in unstable implantation.

In reverse total shoulder replacement, the socket and metal ball are switched:

  • A metal ball is attached to the shoulder bone.

  • A plastic socket is attached to the upper arm bone.

What Does Shoulder Replacement Surgery Entail?

A typical shoulder replacement surgery takes approximately two hours and is performed under general anesthesia. To manage post-operative pain, a regional nerve block (interscalene brachial plexus block) is routinely administered roughly 30 minutes before the procedure. However, a nerve block may not be performed for patients with a history of nerve injury, an active infection, or certain respiratory conditions. Intravenous antibiotics are standard and typically administered immediately prior to the start of surgery. The procedure utilizes an incision approximately 4 inches long on the front of the shoulder, and the patient is positioned in a semi-reclined or 'beach chair' position throughout the surgery.

Healthy patients without significant medical comorbidities are typically discharged on the same day as their surgery. Patients of advanced age or with significant medical conditions may require an overnight hospital stay to ensure a safe recovery from anesthesia. Following surgery, patients are required to wear an arm sling with a cushion at all times for four weeks, removing it only for personal hygiene, showering, and dressing. Comprehensive post-operative care instructions will be provided by nursing staff prior to discharge. Post-operative follow-up appointments will occur at 2 weeks, 6 weeks, 4 months, and 1 year, with shoulder radiographs obtained at each visit.

Supervised physical therapy with a therapist will begin two weeks following shoulder surgery and continue for approximately four months, after which most patients are able to resume their normal activities. Following shoulder replacement, it is recommended that patients avoid strenuous activities involving the operated shoulder, such as heavy lifting, bench presses, and push-ups, to reduce the risk of implant wear and loosening. The maximum weight a patient can safely lift depends on their individual baseline muscle strength and can vary significantly. Conversely, patients can still participate in low-impact or non-contact aerobic activities like playing golf, tennis, pickleball, or swimming.

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