Shoulder and elbow joint replacement surgery

Surgery for arthritis of the shoulder and/or elbow joint is only advised if conventional forms of treatment such as medication, physiotherapy and cortisone injections have failed to work.

These types of surgery are less common than knee replacement surgery and hip replacement surgery: but shoulder replacement is the third most popular form of surgery for arthritis in the UK.

(Source: Arthritis Research UK/shoulder and elbow surgery)

Elbow replacement is a mature procedure which is not available at every hospital in the UK. Check with your GP to see if this operation is available in your area.

Shoulder or elbow replacement is usually carried out to treat osteoarthritis but can also be performed on fractures and cases of rheumatoid arthritis.

One of the reasons why these replacements are less common is that there are fewer cases of arthritis in the shoulder or elbow compared to the lower body, for example the knee.

Note: this section discusses shoulder and elbow surgery as two separate procedures.

Shoulder and elbow surgery is discussed in this order:

• Why shoulder and elbow joint replacement surgery?
• Criteria for shoulder and elbow joint replacement surgery
• Not suitable for shoulder and elbow joint replacement surgery?
• Benefits of shoulder and elbow joint replacement surgery
• Disadvantages of shoulder and elbow joint replacement surgery.
• Before and on the day of surgery
• Shoulder joint replacement procedures
• Elbow joint replacement procedure
• Complications of shoulder and elbow joint replacement surgery.
• Recovery from shoulder and elbow joint replacement surgery
• Alternatives to shoulder and elbow joint replacement surgery

Why shoulder and elbow joint replacement surgery?

These procedures are an effective form of treatment for conditions such as osteoarthritis or a severe fracture.

They are worth considering if treatments such as painkillers, injections, splints or physiotherapy have failed to ease the pain and other symptoms caused by arthritis.

Another factor is the effect arthritis is having on your quality of life. If it has impacted on this to the extent that you are unable to move as freely as you would like or cannot carry out even the most simple of tasks then consider having a replacement.

Your first step is to discuss this with your GP. He/she will assess your arthritis and ask you a series of questions before referring you to a surgeon.

If you are planning on having surgery on the NHS then this involves a consultation with the surgeon (orthopaedic surgeon) who will examine you, send you for tests and then place you on a waiting list for surgery.

There is the option to pay for treatment at a private hospital or clinic if you prefer not to wait. But this can be expensive so consider this option carefully.

Criteria for shoulder and elbow joint replacement surgery

The surgeon will have a set of criteria which are used to determine a person’s suitability for this type of operation.

Your general state of health will be taken into account as will the type and extent of your arthritis. He or she will be interested in the effect this is having on your quality of life and how surgery will improve this for you.

Your lifestyle will play a part in this decision. If, for example, you are overweight then you will be asked to lose this excess weight as this will reduce the strain on your joints. Plus this also reduces the risk of any complications during surgery.

Being overweight does not mean that you will automatically be excluded from surgery but you will be advised to lose weight and control this before and after surgery.

Joint replacement surgery is a very effective form of treatment which eases pain, improves mobility and prevents any further deterioration.

Not suitable for shoulder and elbow joint replacement surgery?

If you are advised against having surgery then as disappointing as this may be, there will be a very good reason for this. The surgeon will act with your best interests at heart and if he/she feels that surgery would jeopardise your health then this will be the reason behind his/her decision.

The thing to remember is that shoulder or elbow joint replacement is major surgery and major surgery has its risks. These are small but nevertheless, they do occur so this will be a factor in the decision.

The surgeon’s decision about whether to operate or not will depend, to a large extent, upon your health and medical history. If you have an existing medical condition such as heart disease or a lung disorder as well as arthritis then this will rule you out. This also applies to several other conditions.

Your surgeon will be able to recommend a few alternatives which can help you to manage the symptoms of your arthritis on a daily basis.

Benefits of shoulder and elbow joint replacement surgery

Any surgery for arthritis comes with a range of benefits which include:

• Reduction in pain or possibly a complete absence of pain and discomfort although this depends upon the extent of the arthritis and the success of the procedure.
• Improved flexibility and movement
• Prevents further deterioration and the risk of a disability
• Return to independence and your normal routine

What most people find is that surgery enables them to return to their normal way of life. They can get around and about, do jobs around the house, return to work, drive a car or use public transport and participate in sports and exercise.

In other words, they have their freedom and independence back.

Both shoulder surgery and elbow surgery are successful procedures and many people are happy with the results.

Disadvantages of shoulder and elbow joint replacement surgery

We have mentioned about the advantages of surgery but it is important that you are aware of the disadvantages as well. This balanced approach will enable you to make an informed decision about these surgeries.

The disadvantages include:

• An artificial joint is not quite as good as a natural joint. They are durable and made from materials which ensure that they last for a long period of time. But these joints often show signs of wear and tear after 15 to 20 years.
• An artificial joint does not give a full range of movement. A natural joint is very flexible with a wide range of movements but this is not the case with an artificial joint. For example, you will find it difficult or even impossible to raise your arm above shoulder height. Your surgeon will be able to advise you about the outcome of your operation and the degree of mobility in your new joint.
• Artificial joints wear out after a period of 10 to 15 years on average so you will require further surgery – known as ‘revision surgery’ after then. You can have more than one revision surgery but the results become less effective after each operation.

These are effective forms of surgery with very good results but they are not perfect. There are people who find that the surgery is not as successful as they hoped or has failed altogether. Failure only occurs in a very small percentage of cases.

Before and on the day of surgery

This section talks about preparing for your operation and what to expect on the day of surgery.

Pre-admission

Once you have reached the top of the waiting list you will given a day and time for your surgery. But you will be asked to attend a pre-admission appointment before this day to undergo a check up and a series of tests.

The idea behind this is to ensure that you are safe to have surgery. You need to be in good health before any form of surgery which reduces the risk of complications.

You will have the chance to discuss issues related to your operation with your surgeon and his/her team. They will explain what the operation will entail and what the results are likely to be. They will also provide you with instructions on preparing yourself for surgery and what will happen on the day of your operation.

Preparing for your operation

Start planning before you undergo surgery. This means arranging for time off work with your employer, someone to drive you to and from the hospital and help and support once you are back at home.

It is important that you do this well in advance as you will be unable to this once you have had surgery. There is a long and sometimes painful recovery period which means plenty of rest followed by a gradual return to your normal activities.

But if you are single or live on your home then your surgeon and his/her staff may be able to arrange for you to have help and support with this.

You will be encouraged to exercise (if possible) before your operation so that your muscles are toned and strong enough to support your new joint.

Plus the fitter you are before surgery the better your recovery.

Stop taking any medication such as non-steroidal anti-inflammatory drugs (NSAID’s) or other forms of arthritis drugs at least two weeks before your operation.

It is important that you follow this and any other instructions such as when to have your last meal and any fluids before surgery.

Pack a small bag or case with nightwear, change of clothing, toiletries, medication and books, CD’s etc.

The day of your operation

Once you are admitted to hospital you will be taken to your ward (or room). A nurse will perform a few routine tests, e.g. blood pressure and you will be asked to change into a hospital gown.

You will be given special compression stockings to wear which help prevent the risk of a blood clot. Alternately, you may be given an injection of a medicine called heparin which is an anti-blood clotting agent. This may be given instead of the stockings or as well as.

The surgeon and his/her anaesthetist will discuss the procedure with you and will answer any questions you may have. You will then be asked to sign a consent form.

You will then be taken down to theatre.

Shoulder joint replacement procedures

Arthritis in the shoulder cause the joints to become stiff, inflamed and unable to move freely. This is usually caused by bones within the joint rubbing against each other or problems with tendons or ligaments (e.g. rotator cuff injury) around these joints.

The most likely cause is osteoarthritis but other possible causes include an accident or injury.

The aim of surgery is to remove the damaged areas and replace these with a set of artificial components – also known as a prosthetic joint.

If you undergo this surgery then it will return normal movement to your shoulder or elbow.

Shoulder joint

The shoulder joint is what is known as a ‘ball and socket’joint which is comprised as follows:

• The top part of your upper arm bone (humerus) is the ‘ball’part.
• The end of your shoulder blade (scapula) is the ‘socket’

The ball slots into the socket and enables you to move your arm and shoulder in a variety of ways.

If you want to know more about this then visit your joints section within this guide.

Shoulder replacement surgery involves means replacing the natural joint with a metal ball and a plastic socket, although the socket may be left intact in some procedures.

Four types of shoulder surgery

There are four types of shoulder replacement procedures which are:

• Total arthroplasty
• Hemiarthroplasty
• Reverse anatomy arthoplasty
• Shoulder resurfacing

Total arthroplasty

This is where both the ball (top part of the humerus) and socket (part of the shoulder blade) are removed and replaced with an artificial joint.

This is performed for certain types of arthritis but depends upon the age and health of the patient. It also depends upon the extent of the damage to the natural joint.

Hemiarthroplasty

The ball part of the shoulder joint is replaced with a metal head and shaft which fits into the humerus. This is used to treat certain forms of arthritis, e.g. osteoarthritis and upper arm fractures.

Reverse anatomy arthroplasty

This is a reverse of the total arthroplasty procedure: in this procedure the ball is fitted onto the shoulder blade and the socket onto the top part of the upper arm bone.

This is a fairly new procedure which is performed in people with arthritis who have a very limited range of shoulder movements due to torn muscles or ligaments.

Shoulder resurfacing

This is a similar procedure to hip resurfacing: a metal component is fitted over the top part of the upper arm bone (humerus) rather than removing this top section.

A small section of bone is hollowed out from the top part of the humerus which allows the metal part to neatly slot into that hollow.

Less bone is removed as a result which means a quicker recovery.

These types of surgery are usually performed under a general anaesthetic and involve an incision being made in the front of the shoulder to allow access to the joint.

The arthritic area of the humerus is removed and the remaining bone treated for the fitting of the artificial joint. Acrylic cement is only used in fracture cases and on socket components.

Elbow joint replacement procedure

This surgery involves the replacement of both sides of the joint with artificial components. Acrylic cement may be used to fix these in place.

Elbow joint

The elbow joint is what is known as a ‘hinge joint’in that it enables the arm to extend, flex and rotate. It consists of three bones known as the humerus (upper arm bone), ulna (forearm bone) and radius (other forearm bone) which are surrounded by tendons, muscle and cartilage.

These enable the joint to move easily and in a variety of ways.

Hinge joints are discussed in greater detail in your joints section.

Elbow replacement surgery is performed under a local or general anaesthetic. An incision is made at the back of the elbow joint and the damaged areas of the joint removed.

The areas of the joint to be replaced are the bottom part of the humerus (upper arm bone) and the top part of the ulna (forearm bone).

The remaining areas of the ulna and humerus are prepared, ready to accept the artificial joint. This joint is then inserted in position and secured in place with acrylic cement.

The artificial joint consists of two metal components which are attached to a pivot that acts as a hinge. The other option is to insert the two components without this pivot which are held in place by muscle tension.

Both of these surgeries take around 2 to 3 hours on average and require you to remain in hospital for three nights.

Complications of shoulder and elbow joint replacement surgery

There is always a risk of complications with any form of surgery but they are rare. But most of these are minor issues which can be easily treated.

They include:

• Infection
• Joint dislocation
• Joint loosening
• Fracture of the humerus or ulna during surgery
• Poor wound healing
• Blood clots
• Bruising of the ulna nerve (only applies to elbow surgery)

Minor infections can be treated with drugs but a serious infection will mean removing the new joint, treating the infection and then implanting a new set of components.

Further surgery (or revision surgery) is required in cases where the joint has dislocated itself or become loose.

Recovery from shoulder and elbow joint replacement surgery

Once you have regained consciousness in the recovery room you will be returned to your ward (or room). Expect to feel groggy and out of sorts if you have had a general anaesthesia although this will wear off after 24 to 48 hours.

You may some pain and discomfort but you will be given painkillers to ease this. You will be on a drip and will have slim tubes or ‘surgical drains’inserted into your incision/s which will remove excess fluid and help with wound healing.

These drains will be taken out a couple of days later.

You will be encouraged to move around as soon as you are able. A physiotherapist will visit you as will an occupational therapist to show you how to move and adjust to your new joint. They will give you exercises to do and suggest ways of adapting areas of your home or tasks to make things easier for you.

You will be given a date for a follow up appointment and advice about looking after your new joint once you are back home.

Have someone drive you home from the hospital especially as your arm will be in a sling for next 4 to 6 weeks.

Recovering at home

Keep your arm in this sling and avoid any unnecessary movement. Try not to perform any movements which will put a strain on your new joint or risk a dislocation. Continue with the exercises you have been given.

If you play sport then check with your surgeon or GP about when you can resume this or if you need to take up a new activity.

Use over the counter painkillers such as paracetamol if you need to.

It will take several months before you notice the full benefits of this surgery but this does vary from one person to another. Expect to notice a difference after 6 weeks or so but it will be months before your new joint is fully functioning.

When can you return to work? This does depend on the type of job you do. If you have an office job then you can return to work sooner than someone who has a physical type of job. Discuss this with your employer.

You will attend a series of follow up appointments at the hospital which will become less frequent over time.

If you want to know more about coping with your new joint or arthritis in general then visit our living with arthritis section.

A word of warning

Your recovery should proceed with little or no problems but contact your GP or hospital immediately if you experience the following symptoms:

• Shortness of breath
• Difficulty in breathing
• Chest pains
• Build up of fluid around the joint
• Areas around the joint which have a red appearance, a hard texture and feel tender when touched.

It is important that you seek medical advice as soon as possible as these may signs of a blood clot in the lungs –known as a pulmonary embolism, or a blood clot in the legs.

Do this if these symptoms appear once you are back at home.

Alternatives to shoulder and elbow joint replacement surgery

There are several alternatives to a shoulder replacement which include:

• Cleaning out the joint (this is known as ‘debridement’)
• Fusing the joint together (rarely done)
• Removing part of the radial head near the elbow (bottom part of the radius)
• Removing the membrane (lining) inside the joint if inflamed (this is known as a synovectomy).