A Patient's guide to Total Shoulder Replacement

The shoulder joint is a ball (Humeral Head) and socket (Glenoid) joint.  A TSR replaces the ball and socket with an artificial joint.  This is called a prosthesis and there are several different types. Your consultant will select the best type for you depending on the quality and quantity of bone as well as the strength of the muscles around your shoulder joint. In certain cases a bespoke prosthesis may need to be designed and made for you. 

This type of prosthesis is designed from a CT scan of your shoulder joint.  This is called a CADCAM.  

Pre-assessment

Shortly before your operation you will be asked to attend a pre-assessment for anaesthetic and medical screening and you may require a further pre-assessment appointment for the anaesthetist to see you. This is a medical examination to make sure you are well enough for surgery.

You may also be assessed by an Occupational Therapist (OT) at the pre-assessment clinic. The OT will review the information you provide, to highlight any concerns that may arise, or how you will cope with daily life following surgery. The Occupational Therapist will provide you with information about the sling that you will be expected to wear. If you have any particular concerns as to how you will manage after your surgery, please contact the OT team on the number provided on this webpage.

Contraceptive Pill or hormone replacement therapy (HRT)

You may be required to stop any medicines containing hormones (for example, the oral contraceptive pill, HRT or Tamoxifen) six weeks before surgery. This will be confirmed by your GP or surgeon.

Rheumatoid Arthritis

People with inflammatory forms of arthritis, such as rheumatoid arthritis, who take traditional disease-modifying antirheumatic drugs (DMARD), or a type of biologic drug known as a TNF inhibitor, have an increased risk of infection following orthopaedic surgery. It is important to manage their medications optimally before undergoing such surgery.

Please consult your rheumatologist to advise you on whether your medication needs to be stopped or adjusted prior to surgery, your surgeon will also discuss this with you pre-operatively

Wearing nail polish, nail decorations or false nails (hands and feet)

Anaesthetic monitoring uses sensors which are clipped onto fingers or toes. Nail varnish, gel, acrylic or false nails will affect readings, therefore these need to be removed prior to your surgery. Failure to do so could lead to your operation being cancelled or delayed. These nail additions can also be a risk of potential infection. 

If you wear rings or any form of jewellery on the side you are to be operated on, you will be required to remove these before surgery.

Transport

Patients are responsible for their own transport to and from the hospital. You will be informed of your admission and discharge date in advance so that you can arrange for a relative, friend or taxi to transport you. In most cases it will not be appropriate to use public transport on discharge. Please note that patients who wish to claim their travel costs must prove that they are eligible to do so by providing relevant benefit documentation and travel receipts.

If you are eligible for patient transport the assessment team will be able to assess your needs through a brief telephone conversation. The interview remains completely confidential. The Transport control room can be contacted on 0800 953 4138.

On the morning of your surgery you will be greeted by the admission staff on your arrival. You will be assessed by the Surgeon and the Anaesthetist to perform a final check that you are fit for surgery and to answer any questions you may have. You will be asked to sign a form, giving your consent to the operation.

Your surgery will be carried out by your Consultant and assistants, possibly including other members of the surgical shoulder and elbow team including our Clinical Nurse Specialist who is an accredited Surgical First Assistant.

(Please note that most operating lists run all day and your operation may not take place until the late afternoon depending on the order and progress of the list.)

On the admissions ward you will be greeted by the nursing staff looking after you and ask you to change into a hospital gown to get you prepared for theatre. You will then go to theatre, accompanied by a nurse where your personal details and the operation will be confirmed before you are given an interscalene nerve block and a general anaesthetic.

An interscalene block is an injection of local anaesthetic around the nerves that supply your arm. The purpose of the injection is to provide pain relief for the operation. When you wake up from the general anaesthetic the shoulder and upper arm will be numb.

Interscalene block is offered for shoulder surgery because it is the best form of pain relief for this procedure in the first 24 hours after the operation. It is important that you are aware that it is not the only method for providing pain relief for this type of operation and also that it does not affect what the surgeon will do. Your anaesthetist will discuss the pros and cons of this procedure as well as the possible complications and alternatives with you on the day.

Although rare, any operation involves potential risks or complications and it is important that you are aware of them.

General Risks

• Infection – All possible precautions are taken to avoid infection during your operation. Your skin is thoroughly cleaned with a disinfectant solution and all clinical staff wear masks, sterile gowns and gloves throughout the procedure. If a superficial skin infection develops post-operatively it is usually treated with oral antibiotics. 
• Nerve/blood vessel damage around the shoulder – The risk of  this is less than 1%. If it happens we will investigate it carefully and take appropriate action to restore function. 
• Dislocation – Initially a TSR is not as stable as a normal shoulder  joint so there is a small chance of dislocation. This means that the ball comes out of the socket and will require a doctor to correct  it or further surgery to relocate it back to its correct position. To prevent this from occurring there will be post-operative movement restrictions. You will also be given a sling to wear, and instructions on how to use it, put it on and take off. Please be careful to follow these instructions.
• Stiffness – This happens to nearly all TSRs early on and is treated through the physiotherapy exercise programme.
• Fracture (a break) of surrounding bone – If this happens we may fix the fracture straight away, manage it non-operatively in a brace or alternatively with another operation at a later date.
• Loosening of Prosthesis – Over a period of time the TSR may become loose and further surgery may be required to correct this. It may be due to infection, but more often it is simply due to using our shoulders in the course of normal daily life.
• Deep Vein Thrombosis (DVT) - A DVT is a blood clot in the deep veins of the calf or thigh. To reduce the risk of developing a DVT and  to help with your circulation you will be given stockings and will be  fitted with inflatable pads to wear around your legs whilst in bed. These inflate automatically and provide pressure at regular intervals, thereby increasing blood circulation in your legs. You may require blood-thinning medication, which will be decided by your surgeon, depending on your individual risk factors. The physiotherapist and nursing staff will show you how to exercise your legs and ensure that  you start to move about quickly after your operation. If a clot develops and part of it breaks away, it can travel to the lungs, where it is called a Pulmonary Embolus (PE). A PE is potentially life threatening and so everything is done to prevent a DVT from developing. We ask you to help avoid this complication by wearing your stockings at all times while you are in hospital, except when you are bathing.
• Sickness/nausea, heart problems, breathing problems and nervous system problems - caused by the anaesthetic

You will be transferred to the recovery room, where you will be closely monitored as the effects of the general anaesthetic wear off. Your arm will be supported in a sling to support the repair. Initially you may feel some pain or discomfort, which will be relieved by medication. If you have had a nerve block, your arm and hand can feel numb and heavy; this will usually resolve within 24 hours. The shoulder may initially be bruised, tender and swollen. You will have water resistant dressings over your wounds, but please check with your nurses before showering.You may also have the following:

•  Small drainage tubes coming from your wound
•  Patient Controlled Analgesia (PCA) Device
•  Oxygen mask
•  A drip to replace lost fluids
•  A urine catheter

These will be removed as soon as possible following the surgery.

Once the anaesthetic has fully worn off you will be encouraged to get up and mobilise, with help if needed, as soon as you are able. This will help prevent the risk of any post-operative complications.

You will be seen by a physiotherapist after your surgery to discuss your post -operative restrictions and show you your exercises. Your physiotherapist will also refer you for outpatient physiotherapy; you can usually choose where this takes place. You will be provided with specific exercises, in addition to those detailed below. DO NOT commence these exercises until guided by a therapist.

Neck, shoulder, forearm, wrist and hand

These parts of the body will not be directly affected by the surgery and therefore you can move them normally. Complete the following movements as comfort allows:

• Neck movements in all directions
• Shoulder shrugs
• Forearm rotations (palm up, palm down), keeping your arm in the sling
• Freely move wrist and fingers 

Following a TSR the surrounding muscles and tissues need time to heal, and it is important that you avoid certain movements to reduce the risk of complications. These are guidelines only and may vary person to 
person. 

0-6 weeks

Your consultant will clearly state in the operation record, your restrictions and, for a minimum of 6 weeks, these are likely to include:

• Wear sling at all times; only move arm as guided by your therapists
• No active use of operated arm
• No hand behind back
• No weight bearing e.g. pushing up from a chair, carrying anything, or  holding a stick.
• No hand across chest
• Do not allow arm to fall backwards past the midline of your body.  Please support upper arm with pillow when lying down
  
  Note - Your consultant may perform a Biceps Tenodesis as part of your procedure. This involves detaching and re-attaching a tendon of the biceps. To allow this to heal you will not be allowed to actively bend and straighten your elbow. The therapist will advise you further

6-16 weeks

• Wean off using the sling and wear only as necessary i.e. when tired, or in crowds
• Maintain your physiotherapy exercises as instructed by your physiotherapist
• Commence light, un-resisted movements/activities at waist level. 
• Avoid hand behind back
• Avoid weight bearing e.g. pushing up from chair
• Gradual return to functional activities
• Avoid activities/exercises that cause or increase pain

16+ weeks

• Return to normal activities within comfortable limits
• Be mindful of activities above shoulder height
• Be mindful of heavy tasks

Shoulder and Elbow

You may need assistance with the following exercises. If you have any concerns about how to complete the exercises please discuss this with your therapist.

Starting position for the following exercises

Lie on your back with a towel/pillow under your operated arm. (Please note that these can also be done in sitting).

	Bend and straighten the elbow of your operated arm, assisting the movement with your other hand.  A Biceps Tenodesis is where the biceps muscle has been cut and reattached. To protect the repair:  DO NOT  fully straighten the  arm  DO NOT actively bend your  elbow Assist your operated arm to rotate outwards to neutral, in line with your body.  Do not go beyond this unless directed to do so by your therapist.
	Assist your operated arm into the position shown as comfort allows. Do not go beyond           degrees.  This is a static exercise and the shoulder should not move. You will be providing gentle resistance from your non-operated arm. Gently push your operated arm outwards against your other hand.
	This is a static exercise and the shoulder should not move. You will be providing gentle resistance from your non-operated arm. Gently push your operated arm forwards against your other hand.

You will be assessed by an Occupational Therapist after your surgery to discuss how you will manage your daily activities whilst wearing the sling. You will be one-handed for a while and the following advice gives some tips on how to manage. Any equipment suggested can be purchased through the companies detailed in 'Useful contacts' on this webpage.

Washing and Dressing

Your Occupational Therapist will discuss your personal care activities with you. Depending on your restrictions, you may be provided with a collar and cuff for showering. Showering is advised as opposed to taking a bath, to protect the wound and to avoid weight bearing on your operated arm. Your wound dressing is water resistant, however you should avoid direct exposure to water when showering. Please be aware that your balance may be affected while wearing a sling and therefore consider safety aspects when stepping in/out of the bath/shower or on uneven ground.

You will require loose clothes that preferably fasten down the front. Avoid clothing with small buttons, hooks and zips. Ladies may find a bra uncomfortable and may prefer to wear a strapless or front-fastening bra. Consider slip-on, easy fitting shoes.

You will usually be allowed to wear your sling over clothes but will need to check this with the team.  Always dress your operated arm first and undress it last.  

Dressing Procedure whilst using a Sling

	Sit on the bed and place a pillow(s) under your arm so it is rested in the sling position. Undo the Velcro fastenings at the elbow and wrist. This will release the shoulder strap. You do not need to undo the Velcro on the shoulder strap. Gently slide out the sling from underneath your forearm by pushing down into the pillows. Keep the operated shoulder as still as possible
	Thread the sleeve onto your operated arm and take the garment as far up to the shoulder as possible. Keep the operated shoulder as still as possible. You will then be able to put your non operated arm into the sleeve, bringing the garment up and around your shoulders to do the clothing up.
	Replace the sling by gently sliding it under your forearm. Replace the Velcro fastenings. You may need to lean forward to do up the fastenings. For undressing complete this procedure in reverse. If you have been provided with a Collar ‘n’ Cuff for showering use the above procedure for guidance on how to put on and take off.

Sleeping

Immediately after the operation, you should avoid lying on your operated arm.  Lying on your back may be the most comfortable position.  A pillow placed behind the operated arm may be recommended  to prevent the arm from falling backwards. Your therapist will advise you.

Domestic Tasks

Use ready prepared meals or food items that need little preparation e.g. pre-chopped vegetables.  There is equipment available which can help with food preparation, for example, easy-grip jar openers, pizza cutters. Some of this is available in large supermarkets or from the suppliers which are listed in 'Useful Contacts' on this webpage.  Your Occupational Therapist will advise you if required.

You should avoid heavy household duties that may put undue stress on your shoulder for approximately 12 weeks post-op or when advised by 
your Physiotherapist.

Returning to work

You will probably be off work for approximately 6 weeks depending on the type of job you have. Please discuss any queries with the team.

Driving

You should not attempt to drive until you are out of your sling and your pain has subsided, and you feel confident in your own ability to control the vehicle in the event of an emergency situation.

You should avoid driving for about 10 weeks, however please confirm this with your consultant. If your ability to drive has been affected, you are required by law to contact the DVLA and you may need to inform your insurance company of your operation, as your insurance may be otherwise invalid.

Returning to leisure activities

Prior to restarting any leisure activities you should discuss them at your post-operative clinic review or with your outpatient Physiotherapist. The ability to return to leisure activities will depend on pain, range of movement, strength and the procedure undertaken.  Non-contact activities such as gentle jogging, light gym work, light gardening tasks and gentle swimming may be resumed from 3 months.  

We aim to discharge you from hospital within 1-2 days of the surgery however this may vary depending on your needs. The ward nurses may change your dressings if they become wet and give you water resistant dressings to take home with you. Prior to discharge we need to ensure:

• You can mobilise safely 
• You have adequate social support, 
• You understand your exercises and precautions
• Your pain is managed with effective pain relief
• Your wound is clean and dry
• Your post-operative x-ray is satisfactory

On discharge a district/practice nurse letter will be provided for them to check your wound. Excessive redness or inflammation of the wound must be reported to your GP or to our patient support line, 0208 385 3024. Please arrange for your practice nurse to remove your dressings and cut the exposed end suture knots (If any) at 10-14 days following your surgery. The sutures under the skin are fully disolvable.

Usually a follow-up clinic appointment will be arranged for you to attend some 6 weeks following surgery. If you do not receive a follow up appointment letter within 3 weeks of discharge please contact your consultant’s secretary, using the numbers on this webpage.

Please note that this is an advisory leaflet only. Your experiences may differ from those described.

In the event that you are unable to contact a member of the upper limb team and feel that you have an urgent problem, you should visit your GP or local emergency department for advice.

Physiotherapy/Occupational Therapy Service
Tel: 020 8909 5820
Email: rnoh.ulpnitherapies@nhs.net
Website

Shoulder and Elbow Unit Secretaries
Contact via the switchboard: 020 8947 0100

Mr Butt – 020 8909 5671 
Mr Falworth – 020 8385 3025
Miss Higgs – 020 8909 5457
Mr Majed – 020 8909 5565
Mr Rudge – 020 8909 5671
Clinical Nurse Specialist – 020 8909 5727
Email: rnoh.shoulderelbowunit@nhs.net

Alternative direct number to secretaries:
020 3947 0052

Clinical Nurse Specialists, Shoulder and Elbow Unit - Amanda Denton and Ying Liu
Patient Support Line (answer phone response service, non-emergency) 
Tel: 020 8385 3024
Monday to Friday 08:00 to 17:00
Email: rnoh.shoulderelbowcns@nhs.net

Please leave your full name, hospital number/date of birth, a telephone number and the reason for your call. The CNS aims to return all calls within 2 working days.

Should you require urgent medical attention we advise that you contact your GP or attend your local accident and emergency department first.

Equipment

Disabled Living Foundation
Website

Patterson Medical
Website