Total shoulder replacement: what it involves, risks and recovery in the UK

The shoulder is a ball-and-socket joint. An NHS orthopaedic hospital patient guide explains that the ball is the humeral head and the socket is the glenoid, and that a total shoulder replacement replaces them with an artificial joint, called a prosthesis. It says there are several different types, and the consultant selects the best for you depending on the quality and quantity of bone and the strength of the muscles around the joint. In certain cases a bespoke prosthesis may be designed from a CT scan.

A Leeds NHS patient guide describes two broad designs. A conventional or anatomic replacement mimics the natural joint, while a reverse shoulder replacement is chosen for some types of arthritis and is described as having a slightly higher rate of complications. Hemiarthroplasty replaces the ball only.

The same guide says that you should view the aim of the operation as the restoration of some of the function lost by relieving pain, and that it is not likely to dramatically improve the range of movement in your shoulder, but that any improvement is a bonus.

The orthopaedic hospital guide says the commonest reason is arthritis where the joint has worn out and become painful, swollen and restricted in movement, and that it may also be used following a fracture. The Leeds guide lists osteoarthritis, rheumatoid arthritis and problems after complex shoulder fractures, but says replacements are also carried out for other reasons.

It is generally considered once other treatments no longer control the pain. People with inflammatory arthritis such as rheumatoid arthritis who take disease-modifying drugs or biologic medicines have an increased risk of infection after orthopaedic surgery, so the guide says their medicines need to be managed before surgery with the rheumatologist and surgeon.

The Leeds guide says the operation is usually carried out under general anaesthetic, possibly with a nerve block that leaves the arm numb and floppy for some hours, and lasts about one to two hours. The orthopaedic hospital guide describes an interscalene nerve block, a local anaesthetic injection around the nerves supplying the arm, which gives the best pain relief for the first 24 hours.

After surgery the arm is supported in a sling and X-rays are taken. Exercises usually start the next day. Some people are suitable for day surgery, according to Leeds, while one London orthopaedic hospital aims to discharge within one to two days. You are discharged when you are comfortable, the wounds are healthy and you can manage.

Before admission you attend pre-assessment, where medical screening takes place and an occupational therapist may assess how you will cope with daily life in a sling. The hospital guide also asks you to remove nail polish, artificial nails and jewellery on the operated side, and to stop hormone-containing medicines if your surgeon advises.

The Leeds guide gives approximate frequencies and notes that risks vary by patient and by type of replacement. It says the risk of any adverse event within the first three months needing a further procedure is up to 5 per cent, and is highest in those over 80 years and in male patients.

The orthopaedic hospital guide describes a typical staged programme that varies from person to person. For a minimum of 6 weeks you wear the sling at all times and move the arm only as your therapists guide, with no active use of the arm, no hand behind the back and no weight bearing. Between about 6 and 16 weeks you wean off the sling, keep up physiotherapy and begin light movements at waist level. From 16 weeks you return to normal activities within comfortable limits, being mindful of overhead and heavy tasks.

The same guide says you will probably be off work for about 6 weeks, depending on the job, should avoid heavy household duties for about 12 weeks, and should avoid driving for about 10 weeks, confirming this with your consultant and telling the DVLA and your insurer if your ability to drive is affected. Non-contact activities such as gentle jogging, light gym work, light gardening and gentle swimming may be resumed from 3 months.

The Leeds guide says that a good deal of the movement you originally had should return in about six weeks, that up to six weeks you should work on movement but avoid lifting and pushing, and that after six weeks you build up work gradually so it does not hurt. It says three times a day is not too often for home exercises.

The Leeds guide says published studies suggest that 85 per cent of people have good or excellent pain relief one year after surgery, though most still have some discomfort with activity and in cold weather at that stage. It says the range of movement afterwards is somewhat unpredictable, but it would be rare to have less movement than before surgery.

You are normally seen about six weeks after surgery, then less often over time. Like all artificial joints, shoulder replacements loosen with time, and revision surgery may allow a new replacement to be inserted, though bone loss can sometimes prevent this. NHS surgery is free at the point of use; some people choose private surgery, but the operation, the rehabilitation and the risks described here are the same.