Shoulder Replacement

You are completely fed-up with the pain and loss of function in your bad shoulder; you can’t sleep and you can’t do the things you want to do; the painkillers aren’t doing the job and you have had enough.

So now maybe the time to consider a new shoulder.

This sounds like quite a big job though?

You are right – it is. But after we have been through all the pros and cons, it usually becomes a fairly straight-forward decision to take the hit now so that in 6 months or so you will be back doing all those things you can’t now.

How long am I in hospital?

It depends a bit on your personal circumstances and general health. If you have good support at home and have no other medical or physical problems then you probably only need to be in for one night. That allows us to make sure your pain is under control and that there are no immediate complications.

If you are by yourself or a little bit less active then we will keep you in for 3 or 4 nights so we are happy you can manage.

I am by myself and I don’t think I can cope with being in a sling for a month but I do need this operation.

Now is the time to mobilize family, friends and social support from your GP because you are right, it will be very difficult all by yourself. But if you can organize someone to come in twice a day to help with dressing and washing and generally help around the home, then you should be fine. You will need help to some extent for about 6 weeks.

How long does the operation take and do I need a general anaesthetic?

The procedure takes about an hour and we do it under a combination of a general aneasthetic – which allows us to control your blood pressure and stops you moving about when I am doing the tricky bits  – and an Interscalene Block – which gives you a pain-free arm for 20 hours or so. So you should be pain-free when you wake up.

Is there a big scar and what about stitches?

The scar is about 12 cms long down the front of the shoulder and it will fade to a faint line that will be visible but not obvious.

I usually close the wound with metal clips that are removed after 10 days.

So what do you do? Not sure I really want to know the details but I suppose I should!

It is a good idea to know the details of what is being done to your body but I appreciate not everyone wants to know the gory details! So feel free to skip this bit. (see shoulder replacement video)

I need to get down to the worn-out shoulder joint and I approach it through the front of the shoulder. I have to divide one major tendon (subscapularis) in order to get that access so that is the first step. Once that has been released and moved out of the way I am looking at your grotty shoulder joint. Then I release the scar tissue that has built up and tightened the shoulder so that I can dislocate the ball from the socket and pop it out.

The next stage is to measure what size your humeral head is using a special guide and then I saw off the worn out humeral head using a jig to get the angle right.

If there are any obvious osteophytes (sticky-out bony bits of arthritis) on the socket then I trim those back.

Now I prepare the cut surface of the humeral neck to accept the base onto which the new humeral head will be attached.

And when that has been hammered solidly into place I am ready to put on the humeral head. Note that I don’t use bone cement to glue things into place because that is a potential weak spot that can crack and fail and allow the implant to loosen. Instead the new shoulder has a coating on it that encourages the natural bone to grow onto and bond with the metal.

The new ball is pressed onto the base and I check that it is a good fit and an accurate match to your shoulder. The new ball is then popped back onto the socket to recreate the ball and socket joint and I check that it all moves smoothly.

And then I finish off by reattaching the tendon I cut at the beginning and close everything up, put on the dressings and a sling.

You go to the recovery bay until you are wide awake and then back up to your room.

That is the carpentry bit over and soon the hard work will start!

You mentioned a sling. How long am I in that and how much can I move my arm?

You are in the sling day and night for 4 weeks but coming out daily to do some gentle exercises. Then you spend the next 2 weeks weaning yourself out of the sling i.e. wearing it less and less and moving your arm more and more.

Do I have to wear it at night?

Yes you do.

Will it be painful?

One of the first things you will notice is that your original, horrible, constant nagging arthritic pain will have gone. That is what this operation is all about and it is a wonderful feeling (I am told) to realise that that pain has gone.

But yes, there will be the pain I have given you from the operation and we will give you painkillers and anti-inflammatories to keep that under control.

That will settle over the next couple of weeks but you are likely to need continued but less regular medication for a couple of months as you start getting the shoulder moving again.

Will I need physiotherapy?

That is absolutely vital. We have to get your shoulder moving again and stretch out all those tissues around the joint that have tightened up over the years while your shoulder has stiffened up. Those bits haven’t been stretched out or lengthened during the surgery so that is where the hard work comes in – to stretch everything back out to normal or near normal.

So, straight away we will get you bending and straightening the elbow and using your hand as normal.  The physiotherapists will see you to do ‘passive’ exercises bringing the arm up to 90 degrees in front of you and moving it out about 30 degrees. Passive means someone else moves the arm for you, or you use your good arm to move it, rather than firing up the muscles and trying to lift the arm under its own steam

Physiotherapy sessions will continue at least weekly after you have gone home.

At the 4-week mark (when you start to come out of the sling more) you start ‘active’ exercises i.e. moving the arm using its own muscles. And this can be pretty hard and quite sore.

The amount you can move the shoulder passively recovers quite quickly but you can feel a bit despondent that the active movement seems to lag a long way behind. That’s just what it does. But slowly and gradually the two will match up and you will feel that have a functioning shoulder again.

This sounds like it is going to take a long time!

It will. Always remember the main reason why you had the surgery – to get rid of the pain. That should have gone fairly quickly so the first goal has been achieved. But you want a pain-free and functioning shoulder and that second goal takes longer to achieve.

Yes, but how long?

I expect you to be pretty good by 3 months. What do I mean by that? You should have active movement above 90 degrees so be able to get your hand comfortably to your head and maybe a bit above and be functioning rather well in front of you. So day-to-day activities should be fine.

By 6 months you should be very good with the range of movement nearly the same as your good side and the strength coming back. At this point you should be returning to your usual activities and sports.

Overall I tell you that it will take up to a year to get as good as you are going to get.

It is very variable though and age does play a role. People have very different starting points in terms of their activity levels, job and sports. Some of you will be gagging to get back to tennis while others just want to be pain free.

So you have to play it by ear a bit and you can do things with it as you feel you can. I know that’s sounds like a bit of a cop out but as everyone is different it is not easy to be too detailed.

Ok, I understand that but what about driving? I need my independence back.

You can’t drive while in a sling – even if you have an automatic – because your insurance company won’t cover you. So that’s a minimum of 6 weeks. Usually it is about 8 weeks before you can drive but be sensible about it and when you start just go round the block gently and see how you get on. You have to be sure that you can control the vehicle.

There is no question that this is a big operation and it s a bigger deal than having a new hip or knee simply because those joints don’t move anything like as much as the shoulder does.

But the end result should be loss of that awful pain and the recovery of a much, much more normal and useful shoulder.

Hard work but worth it.