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Treatments & Procedures

Joint Replacement - Shoulder

Total shoulder joint replacement is an option given to patients who suffer from joint dysfunction. This is usually the result of osteoarthritis or rheumatoid arthritis, but more rarely for those who have sustained severe trauma from a shoulder fracture. Generally, all other modes of treatment are considered first, such as physical therapy and medication, but total shoulder replacement can provide pain relief and increased mobility for those who have not experienced relief.

This document presents a general overview of total shoulder replacement surgery at Cleveland Clinic. Because each patient's condition differs, please take note that certain aspects of your care may be altered according to your needs and the recommendations of your orthopaedic surgeon.

The shoulder anatomy

(Fig. 1) Similar to the hip joint, the shoulder is a large ball and socket joint. It is made up of bones, tendons, muscles and ligaments which hold the shoulder in place but also allow movement. Bones of the shoulder joint include: the clavicle (collar bone), scapula (shoulder blade), and humerus (arm bone). The clavicle attaches the shoulder to the rib cage and holds it out away from the body.

(Fig. 2) The clavicle connects with the large flat triangular bone, the scapula (shoulder blade) at the acromioclavicular joint (A.C. joint or the acromion). The rounded head of the humerus, or arm bone, rests against the socket in the shoulder blade.

In a total shoulder replacement, a metal ball is used to replace the humeral head while a polyethylene cup becomes the replacement of the glenoid socket.

The primary indication for a total shoulder replacement is pain which will not respond to non-operative treatment. Pain may be the result of abnormalities and changes in the joint surfaces as a result of arthritis or fractures.

The primary goal of total shoulder replacement surgery is to alleviate pain with secondary goals of improving motion, strength and function.

Consultation visit

Your consultation visit and initial appointment with the orthopaedic surgeon will include a series of x-rays, a physical examination and a thorough review of your medical history.

  • X-rays can usually reveal bone spurs, damaged joint surfaces and any narrowed joint spaces. The physical exam will help determine the source of pain with motion and also the decrease in range of motion.
  • Detailing a history of your shoulder problem includes describing for the surgeon the degree of pain with activity, limited use, loss of motion and pain at rest, if any.
  • You, your surgeon and your family are all active participants in selecting the most appropriate treatment.

Preparing for your surgery

Except for emergency reasons, your surgery will be scheduled in advance. Knowing the date of your operation, you will have enough time to prepare and plan for any special help you might need following discharge from the hospital. The average length of stay in the hospital for a total shoulder replacement is two to three days.

It is important to have a partner to assist you with your home exercises following discharge. Your partner should accompany you to physical therapy at least once or twice during your hospital stay.

You should discontinue use of any anti-inflammatory medication, including aspirin, one week before surgery. Check with your doctor before discontinuing use of any medication.

A series of pre-operative tests will be scheduled one to two weeks before surgery. They will usually include: blood tests, an electrocardiogram (EKG) or test that records electrical activity of the muscle, a physical examination, a visit with your orthopaedic surgeon and anesthesiologist (the physician that will administer pain medication during the procedure). You will receive your routing schedule by mail.

Most patients spend the night before surgery either at home or in a hotel nearby. They are then admitted to the hospital the next morning. This method of admission is called TCI - "to come in." This allows you to be with your family the night before your surgery. Your surgeon will inform you of your scheduled surgery appointment time and where to go to within the hospital on the day of the surgery.

Anesthesia

You may not eat or drink anything after midnight the day before your surgery. Your anesthesiologist will give you instructions about your daily medications. Some medications may be discontinued because they will complicate surgery and other medications you may need.

Your physician and the anesthesiologist will discuss with you the type of anesthetic that is most appropriate for you. The most frequent form is a regional or block anesthetic supplemented with general anaesthesia. You will also be given medications through your IV which will keep you relaxed, comfortable and sedated.

After surgery, most patients are able to eat a regular dinner and walk to the bathroom. Regional anesthesia offers prolonged pain relief after the operation.

Hospital admission - TCI Center

The morning of your surgery, you will be admitted to the TCI center. Two family members may remain with you until the time of your surgery. Any nail polish should be removed prior to admission. You will be asked to remove all jewelry, glasses, dentures, wigs and contact lenses. No rings may be worn on either hand, and any articles of value should be left home or given to your family members.

The nurses will prepare you for surgery by taking your blood pressure, pulse, temperature and administering pre-operative medications. These medications may cause drowsiness and a dry mouth. An IV or intravenous line for fluid, medication and antibiotics will then be inserted in your arm before transfer to the operating room.

You will be transported to surgery on a cart. Different hospital staff will be asking your name, verifying your identification bracelet and asking you which shoulder will be operated on, right or left. Prior to surgery, please use a marker to write "no" on the non-operative shoulder. This indicates the correct shoulder should any miscommunication occur.

Your family may wait in the designated area, where they can check in with the receptionist. As soon as your surgery is over, your surgeon will call the waiting area and ask to with speak with your family.

Surgery

In the operating room, you will meet nurses, physicians, technicians and anesthesiologists. You will then be moved to the operating table and made comfortable. Your head will be positioned, turned away from the shoulder to be operated on. Sterile surgical draping will be hung to shield and protect the surgical site. The anesthesiologist will remain by your head, monitoring your condition throughout the surgery.

The operating room will be bright and very cool. Blankets are available to keep you warm. Because of the number of people working, the room will seem very busy and somewhat noisy. The surgery will last approximately two hours.

Post anesthesia recovery unit

After surgery, you will be transported to the Post Anesthesia Recover Unit (PACU), where you will be cared for by skilled nurses and members of the anesthesiology team. They will monitor your vital signs (blood pressure, pulse and breathing) frequently while you are recovering from the effects of anesthesia. When you awake, you will have a large bulky dressing on your shoulder with a drain and possibly a cooling unit attached. The movement, sensation and temperature of your operative arm will also be checked frequently. An X-ray of your shoulder will be done during your stay in the recovery room.

The minimum stay in a PACU is at least one hour. The length of your stay depends on many factors including the effects of anesthesia. Your physicians and nurses will evaluate your condition and determine the best time for you to be released to a hospital room. Your family will not be permitted in the PACU, but may visit when you are assigned to a hospital room.

Post operative hospital stay

After being transported to your room and assisted into your bed, your nurse will evaluate your condition - checking your vital signs, shoulder dressing and the movement and sensation of your hand.

Because shoulder surgery is painful, pain control is very important. For the first twenty-four hours after surgery you will receive a pain medication regularly and you may have a PCA (Patient Controlled Analgesia) pump.

The drain from your shoulder will be removed by your physician the day after surgery. The bulky dressing will then be removed and replaced with a smaller dressing. Your IV will remain in place for needed fluids, antibiotics and possible pain medication for the first 24 hours after surgery.

During your hospitalization, you are encouraged to get out of bed and move around. You may even begin to use your arm within comfortable limits, performing simple activities such as eating and grooming. Bring loose-fitting clothing with you, as this will make dressing easier.

The physical therapist will help you learn specific exercises and how to continue them after your hospital stay at home. You will also be given written instructions upon your discharge. These exercises are fairly simple and require only a short amount of time.

A successful outcome to your total shoulder joint replacement depends heavily on the meticulous performance of your exercises. Through this structured exercise program, your muscles will be methodically and progressively stretched and strengthened over one year's time. The desired effect is the optimal function of your new total shoulder replacement.

In certain situations, prolonged formal physical therapy after hospital discharge may be required. This can be done in outpatient therapy at home. Most patients, however, do not require any formal outpatient therapy.

An occupational therapist will visit you at least once before you are discharged. Your therapist will provide instruction and assistive devices to help you maintain your independence and protect your new shoulder from the wear-and-tear of daily activities.

Physical therapy is the most important component of a successful surgery. The first day after surgery, you will be beginning physical therapy (P.T.) twice each day to perform passive stretching exercises. You and your nurse will need to plan for pain medication and a heating device or ice, one-half hour before therapy, as prescribed by your doctor. This will ease pain and enable you to perform better in therapy. In addition to physical therapy sessions, you will be expected to perform several exercises on your own. Your nurses will remind you about and be available to assist you with these exercises.

Home going instructions

At the time of your hospital discharge, sutures and staples will remain in the shoulder incision. Until the sutures and staples are removed:

  • Keep the incisional area dry (no showering or bathing of the area).
  • Check the incision daily for increased swelling or drainage.
  • Do not use spray deodorants (you may use the roll- on type).
  • Call your physician's office with any concerns
  • At discharge, you will be given a return appointment, 10-14 days later for suture removal as well as a prescription for pain medication.
  • Your physician will advise you of specific precautions and the limitation of activity.
General instructions include the following:
  • Drive as instructed by your physician. You will, however, need a driver available to take you home at the time of discharge.
  • Limit lifting heavy objects for two months.
  • Resume active movement of arm within limits of pain.
  • Continue exercises at home as instructed by your physical therapist and physician.
After discharge

Your rehabilitation will be ongoing and progressive. It may take six months to one year to achieve the optimal benefit. It is important to realize that progress is sometimes slow and not always steady. You must persevere your therapy program without getting discouraged. The physician will monitor your progress during visits at intervals of six weeks for the first four to five months, and then less frequently for one year.

Please note that any physician or dentist contemplating a future operative or invasive procedure, including dental work, must give you antibiotics preoperatively and postoperatively to prevent infection.

This includes all surgeries, minimally invasive (or "oscopy") procedures, tooth extractions and root canals. Any infection, such as a urinary tract infection, must be treated promptly with antibiotics, as bacteria can spread to the replaced joint. When receiving any medical treatment, notify the person in charge that you have had a total shoulder replacement.

During your first post-operative visit, you will be given a card, verifying that you have a joint replacement. You will need to carry this with you, especially when in public or when visiting the doctor. This may be necessary to use when passing through airport or any other security gate. The reverse side outlines the recommended antibiotic treatment for other physicians and your dentist to use.

If you are experiencing any problems or have questions and concerns, call your surgeon's office. Any symptoms, such as fever, increased drainage, redness, swelling or sudden and significant increase in pain should be reported promptly to your physician.

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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 7/21/2009…#8290