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Total Shoulder Replacement

Introduction

A total shoulder replacement (or 'TSR') is a surgical procedure which replaces the entire shoulder joint (the 'glenohumeral joint') with a prosthetic joint. It is sometimes referred to as a 'total shoulder arthroplasty'.

It is a different procedure to the 'reverse shoulder replacement', which is where the ball and socket of the shoulder joint are literally reversed (the ball is attached where the socket was and vice-versa).

To distinguish the total shoulder replacement procedure from the reverse shoulder replacement, it is also sometimes referred to as an 'anatomic shoulder replacement', as the anatomy remains the same.

Prof Jegan Krishnan and Dr Sunil Reddy are experienced shoulder arthroplasty surgeons who will work with you to achieve the best possible results. Please make an appointment to discuss your shoulder problem – arthritis, rotator cuff tears or complex fractures.

X-rays showing advanced arthritis of shoulder and post-operative picture after a Reverse shoulder replacement.

3D CT reconstruction of a severely comminuted proximal humerus fracture and X-ray after Reverse shoulder replacement and tuberosity reconstruction.

What causes problems with the shoulder which this procedure can treat?

There are a number of conditions that can affect the shoulder which a total shoulder replacement may be able to treat. The most common conditions which may require the procedure are...

Arthritis in the shoulder

Arthritis describes a condition caused by the cartilage in the shoulder joint wearing away. This results in the loss of cushioning between the bones and causes ongoing pain.

Arthritis can have a range of causes - osteoarthritis is where the cartilage deterioration happens over time as we age (hence it is also called 'degenerative joint disease'). It generally develops from the age of fifty.

Another cause of arthritis is any inflammation of the lining of the shoulder joint - this is called 'rheumatoid arthritis'. The final form of arthritis is where cartilage damage is caused by some type of injury ('trauma') to the shoulder. In this case it is referred to as 'post-traumatic arthritis'.

Fracture of the proximal humerus (the bone in the upper section of the arm)

Referred to as a 'fracture of the proximal humerus', this is very common in older - especially female - patients, often caused by a fall. Where the resultant fracture is severe there may be many shards of bone which can be challenging to re-assemble and decreased blood supply to the bone.

Reverse total shoulder replacement may be the best treatment option with a severe proximal humerus fracture in the elderly..

Osteonecrosis

Also referred to as 'avascular necrosis', this is the death of bone tissue caused by lack of blood supply, which, if affecting the shoulder joint, can destroy it. Osteonecrosis is a risk where there has been a previous severe fracture, or where there is a history of alcohol abuse or steroid abuse. It can also be a risk in deep sea divers if they decompress too quickly (causing 'the bends').

Cuff tear arthropathy

Massive tears of the rotator cuff tendons in elderly can lead to pseudoparalysis or in more severe cases a condition called cuff tear arthropathy. This condition is managed with a Reverse total shoulder replacement.

Problems related to previous shoulder replacement surgery

In some cases, the prosthetic joint may loosen, shift out of position or become infected, in which case a revision procedure will be necessary.

Procedure

A total shoulder replacement procedure is carried out under general anaesthesia (in addition a regional anaesthetic and/or nerve block may also be used) and generally takes around an hour and a half. It is normally conducted using conventional open surgical techniques.

During the procedure, the surgeon replaces the natural ball joint (which is located on the head of the humerus bone) and the natural socket (the 'glenoid') with artificial components. After the components are put in place, the wound is closed with absorbable sutures.

A technique called 'patient specific technology' allows an accurate 3D model of the natural joint and patient-specific 'jigs' (used to help correct positioning of the artificial joint) to be made using a CT or MRI scan. This then allows the surgeon to make very precise cuts to the bone and accurate location of the socket ('glenoid'). Accurate positioning of the artificial joints (to mimic as closely as possible the form of the natural joint components) may contribute to a better outcome for the patient.

Postoperative Instructions

Most total shoulder replacement procedures require a hospital stay of 2-3 days. The day after surgery your surgeon and your physiotherapist will run through the sorts of exercises you will need to complete once you are home in order to speed your recovery. They will also explain what you should do and what you should avoid doing during recuperation.

Pain Management

You will be advised on the most suitable pain medication. For the first 14 days after surgery you should also apply an ice pack for 10 minutes 5 times every day. You should continue to wear your sling for at least a month after surgery, removing it only for your daily exercise regime (3 15-20min exercise sessions every day) or when taking a shower. The wound dressings are waterproof and when you are showering it is advisable to keep the affected arm at your side.

Please see our section on Total Shoulder Replacement Rehabilitation Protocol for more detailed information on recovery and rehabilitation.

Risks

As with all surgical procedures there are some risks associated with total hip replacement. These are...

  • Infection.
  • Bleeding.
  • Nerve injury causing numbness/weakness in the shoulder area.
  • Blood clot (DVT or embolism).

Risks specific to this procedure include...

  • Loosening of the artificial joint.
  • Dislocation of the artificial joint.
  • 'Frozen shoulder' - a condition where the shoulder becomes stiff and painful.