Should I Have a Knee Replacement

Should I have a shoulder replacement?

Introduction

Shoulder replacement surgery is an operation to remove the arthritic parts of the shoulder and replace them with an artificial joint made of metal and plastic.

It can either replace the whole joint, with a procedure called a total shoulder replacement (including reverse), or just one part of it through a procedure called a hemiarthroplasty (or resurfacing hemiarthroplasty).

The purpose of the operation is to reduce pain and improve function.

What are the benefits of this operation?

Shoulder replacement surgery is recommended for people who have got sufficient pain or loss of function to make the risks of a major operation worth taking.

Before undertaking surgery, all attempts must have been made to control the symptoms by other safer methods such as painkillers, anti-inflammatory drugs (if tolerated), the use of physiotherapy, exercise programmes and adaptations to the home and lifestyle. All of these measures have been shown to help in a small degree and together may make a significant difference.

When pain and functional loss becomes so severe that activities of daily life are restricted, independent existence is difficult and sleep is disturbed, then most people will choose to go ahead with the operation.

We do not recommend joint replacement in the following situations:

1.When there is active infection in or near the shoulder.

2.When we feel the risks of the anaesthetic and operation are too high.

3.When the arthritis is early and pain is mild.

4.When we feel people are expecting too much from it (e.g vigorous sport or heavy manual work).

Timing of surgery

There is no specific time when surgery has to be done.

The risk of an anaesthetic complication is higher in older patients than in younger ones.

Most joint replacements last at least ten years so the procedure might have to be repeated in the future. (See below under ‘Revision Surgery’.) Each time we re-operate the risks go up, while the possible benefits go down.

Pain is the deciding factor and even young patients in their teens have had their shoulders replaced if the symptoms justify it and they fully understand the risks of revision (having to re-operate) and restriction of activity.

Over 85 years of age the risk of a life threatening problem rises to a significant level and surgery is often discouraged in this age group.

Alternatives to shoulder replacement

Unfortunately there is no other operation for arthritis that is as good as joint replacement.

Arthroscopic surgery (keyhole surgery), which doesn’t replace any parts of the shoulder, may occasionally be used in younger patients or in less advanced cases. It is not usually suitable in advanced arthritis.

Injections of cortisone or other agents may help control arthritis pain. These are usually only temporary solutions, however, and they can be associated with complications such as increased risk of infection in subsequent joint replacements.

Risks of not operating

There are no real risks of not having a joint replacement apart from the fact that the pain might get worse with time. In some instances advanced arthritis can progress to a stage where more complex surgery has to be considered. If the operation is put off for too long it may become difficult to manage at an age when the risks of surgery rise steeply (for patients over 85 years old).

Success rates of surgery

Shoulder replacement surgery has been around for many years so we understand most of the likely outcomes.

80% of people who undergo the surgery get a satisfactory pain-free result which lasts ten years or more. 20% of patients may feel that their shoulder is less painful, but do admit to being disappointed that their function level is not as high as they would like it, or they suffer a complication which reduces the benefit or truly makes them worse than they were before (see below under ‘Risks and Complications’).

Operative technique

Shoulder replacement is usually performed under a general anaesthetic (where the patient is fully put to sleep). It cannot be done with keyhole surgery so will always include a cut across the shoulder, and will leave a permanent scar. The joint is exposed and the arthritic ends of the bone are trimmed away with special tools and resurfaced or replaced on one (hemiarthroplasty) or both (total) sides. The replacement may be just metal (cobalt chrome) or metal and plastic (high density polyethylene). Sometimes the joint replacement is cemented into place with bone cement at other times it can rely solely on a press fit.

Complications

Shoulder replacement surgery is a big operation with a number of uncommon but well recognised complications. The most serious and frequent are outlined below:

Infection: A serious deep infection occurs in approximately 1% of cases although superficial minor infections around the scar are a little more common. These infections usually do not lead to long-term trouble and can normally be managed with antibiotics alone.

With deep infection, the joint replacement almost always has to be taken out and replaced by another one some time later. This is called a two-stage revision. At the first stage the whole joint replacement is removed and the germ tested so that we know which antibiotics are required. The antibiotics are then given either in tablet form or by intravenous drip. Teatment might need to continue for at least six weeks and possibly a lot longer, depending on the germ and the patient’s response to treatment. Treatment is monitored by blood tests which indicate whether the infection has been cleared.

When there is no evidence of any infection, the second stage of the operation is completed where a new joint replacement is put in place. Even after antibiotic treatment, the risks of further infection are significant and the whole process might need to be repeated.

Deep vein thrombosis and pulmonary embolus: Deep vein thrombosis is a relatively uncommon complication after major upper limb surgery.

Post-operative arm pain, tenderness and swelling are regarded as a serious risk and require immediate investigation and treatment. Normally this can be done with simple ultrasound scanning and medication. If it occurs at home postoperatively, it needs emergency hospital treatment and is not a situation to leave to the next clinic appointment.

The risks of deep vein thrombosis are:

(1) Long term pain and swelling in the arm (known as post-phlebitic syndrome) which may last indefinitely.

(2) The clot can break off and circulate into the lung – this is known as a pulmonary embolus. This often gives rise to chest pain and shortness of breath, but can in extreme cases be a cause of sudden death. Stiffness: Stiffness is a well-recognised complication of surgery. Our goal is to achieve enough movement in the shoulder to allow most normal activities. However, sometimes we fail to achieve this range of movement despite appropriate surgery and physiotherapy.

Some temporary stiffness is to be expected after surgery and time in a sling. However, prolonged stiffness may be caused by excessive scarring, deep infection or most commonly due to poor quality or absent rotator cuff muscles. It is not always possible to improve the movement of a stiff shoulder replacement and this can be a cause of an unsatisfactory result.

Persistent pain: Persistent unexplained pain is a recognised complication occurring in a small number of patients and can lead to a disappointing long term result. Nerve injury: All the nerves in the arm originate in the neck and pass into the arm close to the shoulder joint. Although great care will be taken during the operation there can be rare instances of permanent nerve injury. The extent of nerve injuries vary from minor patches of abnormal sensation of the skin to devastating paralysis of the whole arm. Minor temporary nerve abnormalities are quite common but thankfully severe permanent nerve injury is very rare.

Dislocation: The shoulder replacement can dislocate but this usually only occurs as a problem within the first few months. You will be taught how to minimise the risk of dislocation by your physiotherapist and surgeon.

Rare and extreme risks

Other rarer complications resulting from shoulder surgery include fracture at the time of surgery, circulation damage, disassembly of the joint (where the components come apart), and complications from the anaesthetic. The overall mortality (risk of dying) is 1 in 300, and is usually caused by a pulmonary embolus or heart attack soon after the operation.

On a final note

Shoulder replacement may sound like a new invention but actually it has been performed successfully for decades, though it is less common than hip or knee replacements and therefore less talked about. Much like a knee replacement you are likely to be very pleased with the outcome even though the shoulder will never feel exactly like it used to before you had problems. It is a very successful long-term pain relief operation.

Although everyone worries about the genuine risks involved in joint replacement in the vast majority of cases everything goes smoothly and the replacement works successfully for many years.

Where to get further information

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