Shoulder and Elbow Replacement

You may need a joint replacement if your pain can't be reduced enough by other treatments (such as drugs, injections or physiotherapy) and it's affecting your quality of life.

Increasingly, joint replacements are carried out to deal with fractures close to the joints. This is only the case if the fracture can't be fixed reliably and your lifestyle and other factors make you suitable for a shoulder or elbow replacement.

Joint replacement surgery should be considered carefully in consultation with your surgeon and any other healthcare professionals who are helping you (such as a GP, physiotherapist or nurse) and with your family and friends. Your surgeon will be able to advise you on what the surgery involves and on the pros and cons of having or delaying an operation.

The possible advantages and benefits of shoulder or elbow joint replacement include:

• reduced joint pain
• an improved range of joint movement in some cases
• improved quality of life.

Shoulder and elbow joint replacements are very successful and most people are delighted with the results and the improvement to their quality of life. However, you should expect it to take several months before you get the full benefit and some people will have better results than others.

A replacement joint can never be as good as a normally-functioning natural joint.

The range of movement will be less than with a healthy natural joint. Some movements, such as reaching above your head, may not be possible, although most people will be able to carry on with normal everyday activities. You should discuss with your surgeon before an operation how much they expect your movement to improve, as each case is slightly different.

Replacement joints will also wear out after a time, but it's likely that they'll last for 10 years.

Most people with arthritis of the shoulder or elbow joint will receive other treatments from either their doctor, physiotherapist or a rheumatologist before they see a surgeon for a joint replacement. These include:

• non-steroidal anti-inflammatory drugs (NSAIDs)
• disease-modifying anti-rheumatic drugs (DMARDs)
• steroid injections
• injections of local anaesthetic to numb the nerves
• physiotherapy.

If these treatments don't relieve the pain then you may need surgery. However, a joint replacement won't always be the most suitable option. Other possible surgical treatments include:

• cleaning out the joint (debridement) to ease pain
• removal of the lining of the joint (synovectomy) if it's very inflamed (this isn’t usually carried out on the shoulder joint)
• removal of part of the bone (the radial head) at the elbow.

What are the different types of shoulder and elbow joint replacement?

Shoulder replacement

The shoulder is a ball-and-socket joint. The end of the upper arm bone (the humeral head) forms the ball, while part of the shoulder blade (the glenoid) forms the socket.

Shoulder replacement surgery replaces the ball and sometimes the socket with man-made parts. There are several types of shoulder replacement surgery:

Hemiarthroplasty is where the ball part of the joint (the humeral head) is replaced with an artificial ball component with a stem that extends into the shaft part of the bone. This is usually used for fractures but is also used in many cases of arthritis.

Shoulder resurfacing is a different type of hemiarthroplasty where, instead of removing the humeral head and replacing it with an artificial ball on a stem, a metal cap is fitted over the ball part of the joint. This means less bone has to be removed during the operation.

Total arthroplasty is where both the ball (of the upper arm) and socket (of the shoulder blade) are replaced. This is increasingly used for very specific kinds of arthritis depending on your age, how badly worn the natural joint is and the state of the tendons around the joint. Occasionally a total arthroplasty will be carried out using a resurfacing component.

Reverse shoulder replacement is where the artificial components are fitted in reverse – that is, the socket to the upper arm bone and the ball to the shoulder blade. Currently this is only used in patients with severe arthritis of the shoulder joint and very poor tendon cover around the joint. It can sometimes be used if a patient has both a severe joint fracture  and poor tendon function.

Your surgeon will consider which type of joint replacement will be most suitable for your shoulder problem. They'll discuss this and the possible complications with you, and you'll then have time to think things through before you decide whether to go ahead.

The operation will be carried out using a general anaesthetic (in which case you’ll be asleep) and/or a local anaesthetic (which numbs the nerves to the arm and shoulder). The shoulder joint is normally opened from the front or top and the muscles moved out of the way (retracted). The damaged bone of the humeral head is then removed and the remaining bone is prepared for the artificial component to be fitted.

Elbow replacement

In elbow replacements both sides of the joint are replaced. The upper arm and forearm components (humeral and ulnar components) are made of both metal and plastic. The operation will be carried out using a general and/or a local anaesthetic. The elbow joint is usually opened from the back and the muscles moved back. The parts of the bone with damaged joint surfaces are then removed and the shafts of the prepared ulna and humerus have the components inserted, which are usually cemented in. Most designs have a hinge or pivot  between the two halves.

If the arthritis affects only the radial head then a metal radial head replacement is occasionally used. This leaves the rest of your elbow joint unchanged. This may also be used for some fractures.

Once you’ve decided to go ahead with surgery, your name will be put on a waiting list and the hospital will contact you, usually within 6–12 weeks.

It's a good idea to have a dental check-up and get any problems dealt with well before your operation. This is because bacteria from dental problems could cause an infection if they get into the bloodstream.

Pre-admission clinic

Most hospitals invite you to a pre-admission clinic, usually about 2–3 weeks before the surgery. A pre-admission clinic is a chance to discuss any questions or worries you have about the operation and find out more about preparing for, and recovering from, surgery. During the clinic you’ll be examined to make sure you’re generally well enough for the anaesthetic and the operation. This may involve the following tests:

• blood tests to check for anaemia and to make sure your kidneys are working properly
• x-rays of the affected body part
• a urine sample to rule out infection
• an electrocardiogram (ECG) scan to make sure your heart is healthy.

The hospital team will probably tell you at this stage whether the operation will go ahead as planned.

You should discuss with your surgeon, anaesthetist or nurse at the pre-admission clinic whether you should stop taking any of your medications before you have surgery.

You may also be invited to see an occupational therapist to discuss how you’ll manage at home in the weeks after your operation. They can advise you on aids and appliances that might help. If you're not invited to see an occupational therapist and you're worried about coping at home after the operation then you should ask about this at your pre-admission clinic.

In some hospitals you’ll see a physiotherapist in this clinic as well. You’ll be able to discuss your exercise regime before and after your operation.

Going into hospital

Before you go into hospital you should think about the following:

• Do you have someone to take you to the hospital and bring you home after the operation?
• Is everything set up at home ready for your return - is everything you need within easy reach?
• Do you have any special equipment ready for when you come home?
• Do you need someone to stay with you for a while after your operation?

You’ll probably be admitted to hospital early on the day of surgery, but it may be earlier if you haven’t attended a pre-admission clinic or if you have another medical condition that needs to be cleared up before surgery can go ahead. You’ll be asked to sign a form consenting to surgery.

Just before your operation you’ll be taken (usually in your bed, but you may be walked) from the admission ward to the operating theatre. If you're feeling worried, you may be given a sedative medication (a pre-med) while you’re in the ward, which will make you feel a little drowsy.

You’ll then be given an anaesthetic. This may be either a general anaesthetic or a local anaesthetic (regional block):

• A general anaesthetic will affect your whole body and make you lose consciousness or put you 'to sleep'.
• A local anaesthetic doesn't put you to sleep but stops you feeling anything in the affected area. It's usually given by an injection into the base of your neck or in the armpit. Some anaesthetists use an ultrasound scan to help guide the needle to the right spot. You can take a book or some music along to help you relax during the operation, but you may also be sedated if need be.

After the operation

The operations usually take around an hour and a half. Giving the anaesthetic takes about half an hour, and recovery before going back to the ward takes another half an hour to an hour.

You'll be taken to a recovery room or high-care unit until you're fully awake and the doctors feel that your general condition is stable. Then you'll be taken back to the ward.

Sometimes the local anaesthetic from the operation wears off in the middle of the night. This can cause disturbed sleep and tiredness. You'll probably be given painkillers before you go to sleep to make sure you'll be more comfortable. The drip and any drains are usually removed within 24 hours. After that you'll be able to start gently moving your arm again.

You'll usually be in hospital for 2–3 nights after your surgery. During this time medical, nursing, physiotherapy and occupational therapy staff will be involved in your care. You'll be given drugs after the operation to keep your arm as free from pain as possible. These may include:

• local anaesthetic
• 'patient-controlled analgesia' (PCA) – a system where you can control your own supply of painkiller going into a vein by pressing a button
• painkilling injections or tablets.

X-rays of your new joint will be taken during your stay in the hospital. Your arm will be in a sling or splint to protect it. If a tube was placed in the wound during the operation to allow blood to drain out, it's normally removed after 1–2 days (this isn't painful and is usually done on the ward).

It's important during the first few days after your surgery that you keep your hand and forearm raised (preferably above the level of your heart) and exercise your fingers on a regular basis. These exercises are simple to do and include making a full fist and stretching your fingers.

If you had a shoulder replacement you'll be in a sling to support your shoulder. You may need to keep this on for up to 4 weeks but different surgeons have different procedures.

After an elbow replacement, some surgeons use a plaster support (called a slab) behind the elbow to keep it in a fairly straight position for a few days. You won't be able to move your elbow in the slab, but once it's removed you can start moving your elbow again.

Physiotherapy and occupational therapy

Your physiotherapist will see you in hospital after the operation to help get you moving and advise you on exercises to strengthen your muscles. Either your physiotherapist or occupational therapist will tell you the dos and don'ts after your surgery. It's very important to follow this advice.

Because there are several different types of shoulder and elbow surgery, there's no single aftercare programme. Your post-op therapy will differ depending on the procedure you've had and also between different units and surgeons, so we can't recommend specific exercise plans. We suggest that you discuss with your surgeon what to expect after the operation.

Going home

Most people are ready to leave hospital within 2–3 days. How soon you can go home depends on how well the wound is healing and whether you'll be able to get about safely. After about 2 weeks you'll need to attend the outpatient department for a routine check-up to make sure your recovery is going well and your wound is healed. You may also be offered outpatient physiotherapy if your doctors feel that this will help your recovery.

If you stopped taking any of your regular medications or had to alter the dose before the operation, it's very important to talk to your rheumatologist or another healthcare professional for advice on when to start taking them again.

After elbow replacement surgery, you shouldn't lift objects heavier than a small bag of sugar for the rest of your life. The current artificial elbow joints aren't designed for any heavier work and the new joint probably won't last as long if you over-stress it.

If you had both sides of your shoulder joint replaced (total shoulder replacement), you should also avoid heavy loads to help your new joint last longer. This is especially important if you've had a reverse anatomy arthroplasty.

Getting back to normal

Some patients spend longer in rehab than others. Usually after 6 weeks the pain has subsided enough for you to lift your arm and perform daily activities such as dressing, feeding and washing yourself.

Can I work and drive afterwards?

It may take up to 3 months before you can return to work, depending on the type of work you do. Heavy manual activities aren't recommended at any time following shoulder or elbow replacements. This is because heavy activity can loosen the replaced parts in the bone and damage the artificial joint.

You'll be able to drive after your joint replacement as long as you can safely control the vehicle and do an emergency stop. It's important to check with your insurance company, and you need to be confident that you can control the vehicle at all times.

As with any operation, a very small number of people may have problems after a shoulder or elbow joint replacement. Most of these problems are quite minor and can be treated easily. The main problems include:

• infection
• stiffness
• pain
• loosening of the replacement parts
• fracture of the bone during or after surgery
• poor healing of the wound
• wound haematoma (bleeding)
• damage to nearby nerves causing temporary or, rarely, permanent loss of function.

Your orthopaedic surgeon will discuss the risks with you in detail before you decide to have the operation.

In most cases, infections can be cleared up with tablets or injections of antibiotics. For a more serious infection you may need another operation to treat the infection and replace the components.

There's a very good chance that your shoulder or elbow replacement will last for 10 years. After this time it may loosen or wear out. A second joint replacement (revision surgery) may then be possible, although it's usually not so effective in easing symptoms.

Revision surgery

In a revision operation the original components will be removed, along with any cement that may have been used. The shaft of the humerus will often have become thinner by the time revision surgery is needed, and because further bone is removed during the operation the humerus is more prone to fracture.

If the original surgery was a shoulder resurfacing operation, revision surgery is usually a little easier because less bone will have been removed in the first operation. In this case the component forming the new bone surface is usually replaced with a stemmed component.

The number of reverse shoulder arthroplasty surgeries has increased dramatically over recent years. It's not clear how long this type of joint replacement lasts, and this is currently being studied.