Total Shoulder Replacement Surgery: Everything You Need to Know

Total shoulder replacement, also known as total shoulder arthroplasty, is a procedure where portions of the bones in the shoulder joint are removed and replaced with artificial implants. It helps restore the function and mobility of the shoulder joint, while also reducing pain. This surgery may be recommended for a variety of conditions, such as degenerative joint disease (osteoarthritis) or severe fractures of the upper arm bone (humerus).

Some people may need a reverse total shoulder replacement, where the anatomy of the ball and socket joint is reversed with the artificial implants. Surgeons select the reverse approach for patients with badly-injured rotator cuffs, arm weakness, severe arthritis paired with a rotator cuff tear, or a failed total replacement surgery.

What Is Total Shoulder Replacement Surgery?

The shoulder joint is made up of three main bones: the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). These three bones are connected with ligaments and cartilage, which protects the ends of the bones where they meet. The head of the humerus meets the scapula at the socket (glenoid), forming the joint that allows range of motion of the upper arm and shoulder. 

In a total shoulder replacement, the damaged head of the humerus and the surface of the glenoid are removed. Then, artificial implants are placed to make the joint area smooth and functional, mimicking the size of the patient’s bone that was removed. By removing the damaged portions of the bone and cartilage, patients experience less pain and increased range of motion.

In most cases, this surgery is an inpatient and elective procedure. Generally, patients stay in the hospital for two to three days following the procedure.

Contraindications

Total shoulder replacement is typically performed on older adults. Prior to seeking out surgical options, patients may undergo conservative treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs), steroid injections, or physical therapy. There are some situations that would make a patient a poor candidate for this type of surgery:

• Patient is experiencing an infection anywhere in their body, especially at the surgical site
• Shoulder symptoms are not severe enough to cause disability or impact daily life activities
• There is loss or paralysis of both the cartilage inside the joint (rotator cuff) and the muscle of the upper arm (deltoid muscle)

Potential Risks

As with any surgery, there are risks for potential complications associated with having this type of procedure, which include:

• Infection (superficial to the wound or deep into the joint)
• Dislodged or loosened implants (which can cause dislocation of the shoulder joint)
• Nerve injury that may or may not improve over time
• Stiffness or decreased range of motion from incomplete physical therapy rehabilitation following surgery
• Bones breaking around the implanted prosthesis pieces (periprosthetic humeral or glenoid fractures)

Purpose of Total Shoulder Replacement Surgery

Patients with frequent shoulder pain or limited mobility of the shoulder can have a variety of conditions or issues that would lead a surgeon to recommend a total shoulder replacement. The surgery helps restore the function of the shoulder by providing stability and increased range of motion. People with shoulder pain may reach a point where conservative therapy no longer helps with their pain or range of motion.

The following conditions are examples of causes for shoulder pain that could require surgery:

• Osteoarthritis: In this condition, the joint gets worn out from use, and cartilage can be worn away, leaving the ends of the bones exposed without cushioning. This causes pain as the shoulder moves.
• Rheumatoid arthritis: Chronically inflamed tissues (specifically, the synovial membrane) of the joint could lead to damage of the cartilage, creating pain and instability.
• Severe fractures: People who experience shoulder trauma and have weakened bones (like in osteoporosis) are more likely to have a serious fracture of the bones in the shoulder (humeral fracture) that could potentially impact blood supply or stability of the joint.
• Avascular necrosis: Decreased blood supply to the bone causes the cells of the bone to die and could potentially lead to arthritis. This can occur due to sickle cell disease, chronic steroid use, excess alcohol consumption, and deep sea diving.

How To Prepare

Some patients will undergo a nerve block (interscalene block) prior to the surgery that will numb the shoulder and arm for the procedure. Even with a block, patients will generally still be asleep for the surgery because they will also receive general anesthesia. 

Location

Typically, patients have total shoulder replacement surgery in a hospital setting. When entering the operating room, the surgical team will ask the patient to move over to the surgical bed, which sits up like a beach chair, for the procedure. Sometimes surgical team members wear hood coverings to prevent possible contamination during the procedure. Patients may be surprised to see people in full protective gear as they enter the operating room.

What To Wear

It’s important to arrive on the day of the surgery wearing a button-down shirt or something loose enough to fit over a sling with the arm close to the chest or abdomen. A button-down shirt makes it easier to put a shirt on after the surgery, especially if the arm is still numb from the anesthesia block. Comfortable pants and shoes are a good choice, and potentially a sweater or jacket because the hospital can be cold.

Food and Drink

The surgeon will direct patients not to eat or drink anything after midnight the night before their surgery. Certain medications can be taken with small sips of water, but nothing else should be consumed unless otherwise directed by the surgeon.

Medications

Patients should provide a thorough list of current medications and alert the surgeon to any changes in or skipped medications on the day of the surgery. The surgeon will determine if medications that cause increased bleeding should be continued or stopped depending on the condition of each patient.

What To Bring

It’s important to bring a photo identification and insurance cards on the day of the surgery. An overnight bag with any belongings (such as glasses or a phone charger) should be available for patients staying a few days in the hospital.

What To Expect On The Day Of Surgery

Before the Surgery

In the preoperative area on the day of the surgery, a nurse will assess your vital signs, weight, pregnancy status, and blood sugar level. You will remove your clothes and jewelry, and change into a surgical patient gown that allows the surgeon to easily access the shoulder. The nerve block will be performed prior to arriving in the operating room.

During the Surgery

The patient will be rolled on a stretcher into the operating room and asked to move over to the surgical bed. The anesthesia providers will attach monitors to your back and chest on the nonoperative side to record vitals signs. The patient will be put to sleep with general anesthesia and a breathing tube will be inserted. Once the airway is safely established, the surgical team will begin positioning the patient into a sitting position. The surgical nurse will use an antiseptic solution to prepare the shoulder for surgery.

The surgical team typically consists of an orthopedic surgeon, assistant to help hold retractors, surgical nurse, surgical technologist, and anesthesia providers. There are different types of assistants depending on the facility, such as an orthopedic resident, physician’s assistant, nurse practitioner, or first assistant nurse or tech.  

The steps of the surgery are as follows:

1. The surgeon separates the deltoid and pectoral muscles to access the shoulder in a largely nerve-free area (to minimize nerve damage).
2. The shoulder is opened by cutting one of the front muscles of the rotator cuff, which covers the shoulder. This “opens the door” to allow the surgeon to view and manipulate the arthritic or damaged parts of the shoulder ball and socket.
3. The arthritic or damaged sections of the joint are removed.
4. The implant socket, ball, and stem components are inserted. The metal ball component is attached to the stem, which extends down inside the patient’s humerus.
5. The incision of the rotator cuff muscle is closed and stitched.
6. The external (skin-level) incision is cleaned and stitched, and a bandage applied as a temporary covering.

The surgery typically lasts two hours. Once the dressings and shoulder sling are in place, the patient will have the breathing tube removed. 

After the Surgery

The patient will be brought out of surgery to the post-anesthesia recovery unit, where they will recover for a few hours. As with any surgery, there is some pain associated with the procedure. Patients who had a nerve block may not experience pain until later when the block wears off.

Once the patient is more awake, they will be given liquids to see what they can tolerate before moving to solid foods. A postoperative X-ray may be taken the day of the surgery or the following day to get final views of the implants.

Most patients will stay in the hospital for two to three days, depending on how well they are feeling following the procedure and how much help they have when they return home.

Recovery

Following the surgery, patients will be immobilized in a sling during the beginning stages of recovery. They should not drive a car for two to four weeks. At-home exercises will be ordered by the surgeon and should be performed daily. However, do not lift anything heavy, extend the arm in an extreme position, or play sports. It will be important to have help for activities that require lifting anything heavier than a glass of water until further along in the recovery process.

Healing

The surgical wound will be covered with a dressing. If the dressing is waterproof, it may be possible to shower. Surgical wounds should not be submerged under water until fully healed and closed to prevent infection. The surgeon will provide postoperative instructions, depending on the dressing applied, about whether or not to shower or change the dressings. Some surgeons prefer for patients to wait until they are seen in the office for their first post-surgery visit before removing the dressings. 

Long-Term Care

Physical therapy is an essential and standard step in the process to rehabilitate the shoulder and regain function, strength, and mobility. For patients with desk jobs, the potential to return to work is about two to three weeks. Patients with heavy or physical labor will be out of work for around four months.

Around six weeks after the surgery, patients will be able to do light activity with the shoulder. Range of motion and strength will steadily increase with proper physical therapy over the following months, with significant improvement markers at 3, 6, and 12 months.

Each surgeon has a different preference for when their patients should start physical therapy after the procedure. It’s a good idea to have a discussion prior to the surgery about when to start physical therapy with your surgeon. 

A Word From Verywell

For those struggling with shoulder pain or stiffness, it’s important to see an orthopedic surgeon to evaluate the next steps toward improving range of motion and reducing pain. If surgery is recommended, it’s important to be prepared for needing extra support during recovery. A support person may have to help with activities of daily living while the shoulder is immobile in the sling postoperatively. Keeping the incision clean is essential to preventing an infection. Physical therapy following surgery (once ordered by your healthcare provider) is the only way to regain motion and to strengthen the muscles. 

Total shoulder replacement surgery can be life-changing for people who have experienced years of debilitating shoulder pain or have limited range of motion. While the initial surgery can take some time to recover from, there are many benefits to using the shoulder without pain.