Shoulder Surgery

Total Shoulder Replacement

Total Shoulder Replacement

Total shoulder replacement is ideal for patients with shoulder joint arthritis with an intact rotator cuff and without significant glenoid wear. Many patients with shoulder arthritis can be managed without surgery; however, when nonoperative treatment has been exhausted surgery is a reliable option to restore function and relieve pain. The latest advances with 3D planning and printing, computer navigation, and patient specific instrumentation allow for accurate placement of components leading to improved outcomes for patients.

A total shoulder replacement involves replacing the arthritic shoulder joint surfaces with a highly polished metal ball attached to a short stem and plastic socket which is implanted on the glenoid. 

Essentially the abnormal surfaces (where the cartilage has worn away resulting in arthritis) are removed and replaced with a prosthesis (artificial joint). The anatomical arrangement and biomechanics of the shoulder are not changed – hence this is also called an anatomical shoulder replacement. The only caveat is that an anatomical shoulder replacement requires an intact and good quality rotator cuff to continue to function. 

Dr Pant almost always uses the “stemless” anatomical shoulder replacement to minimise bone loss from the humerus, reduce blood loss, improve efficiency, and make any future revision surgery easier. He also uses computer navigation and 3D planning for all total shoulder replacements.

Medical diagram showing the exploded view of the shoulder anatomy and total shoulder replacement components

Medical diagram showing a total shoulder replacement

The decision to have shoulder replacement surgery is unique to each patient. It is a shared decision between you (patient), your family, your local doctor, and your orthopaedic shoulder surgeon. 

There are several reasons why you may be a good candidate and be recommended a shoulder replacement: 

  • Severe shoulder pain that interferes with activities of daily living, such as self care, shopping, dressign, toileting, reaching up to shelf, and driving
  • Moderate to severe pain at rest; night pain waking you from sleep on a regular basis
  • Loss of motion and/or shoulder weakness leading to loss of independence 
  • Failure of nonoperative treatment to manage your pain

Computer navigation and 3D planning has revolutionised shoulder replacement surgery. It provides improved accuracy and precision during surgery. 

Dr Pant will upload your recent CT scan to a special planning software program. 3D measurements are taken of your shoulder, the exact wear pattern is analysed, the correction is planned and the “virtual” prosthesis can be implanted on the computer. 

Essentially the shoulder replacement is done on the computer first. Once Dr Pant is happy with the position of the implants, then custom patient-specific instruments are ordered (from the prosthesis company) for the day of surgery. Because the operation has already been done virtually, most of the workflow during the case is more efficient and predictable. Surgery time and blood loss are reduced, and the implant position is more accurate and reproducible, leading to better functional results.

Image showing the computer technology used to plan and perform a total shoulder replacement.

  • The procedure is performed under a General Anaesthetic where you will be positioned on your back
  • Using the pre-operative x-rays and CT scan is carefully reviewed 
  • Using 3D planning software the operation is performed virtually on the computer and Patient Specific Instruments (PSI) is organised. 
  • On the day of surgery – most of the components that will be required have already been selected to streamline your operation. 
  • A 7-10cm incision is made over the front of the shoulder and the shoulder joint arthritis identified
  • The biceps tendon is released from the shoulder joint and later re-anchored to the pectoralis tendon
  • The Subscapularis tendon is then elevated to allow access the shoulder joint
  • The Humerus (ball) is delivered and resected; The pre-operative planning will guide the appropriately sized implants for you will need. 
  • The Glenoid (socked) is exposed. The 3D planning and PSI instruments are used to replicate the planned operation “real-time” in your shoulder. This allows for any deformity/wear to be corrected at this time. The new socket (plastic) is then implanted as sized by the 3D planning. 
  • The subscapularis tendon is then repaired
  • The wound is finally closed in layers, a waterproof dressing is applied, and your arm is placed in a sling. 
  • Dr Pant will then organise close follow up at regular intervals and liaise with your Physiotherapist to maximise your recovery.
  • JPL rehabilitation program is commenced from 2 weeks post-surgery

There are three essential components to a good outcome from surgery:

  • Your surgeon
  • You as a patient
  • Your physiotherapist 

Post-operative physiotherapy

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.

The JPL pathway allows for self-directed, early passive shoulder range of movement: 

  • Passive = assisted with your other arm
  • Active = you move the affected arm independently

Therapy overview 

After the surgery you will be in a sling and protect your shoulder to allow the shoulder to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.

The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the shoulder begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 12 weeks post Total Shoulder Replacement surgery. 

Sling

A sling is required for the first 6 weeks after your surgery; the sling is worn for a further 6 weeks outside of the house (to remind others you have had shoulder surgery). The type of sling is selected specific to you and your shoulder surgery:

  • Total Shoulder Replacement – Normal sling

Cropped image of 2 women showing the normal sling and abduction sling used following a total shoulder replacement

 Driving after shoulder surgery

  • After shoulder surgery, you will be in a sling and you may be unable to drive for at least 6 weeks
  • This does vary depending on the complexity of your surgery and the patient. Some patients may be able to drive at 2-4 weeks, and some may not be able to drive for the full 12 weeks. This will be individualised to your situation. 

Showering and getting dressed

  • You may take the sling off to shower
  • Lean forward and allow your arm to “dangle” to wash under your arms
  • The dressings applied are waterproof and you may shower with them on
  • Usually, before you are discharged from Hospital, your dressings are changed after your morning shower.
  • These “new” dressings are then kept intact until your review at 10-14 days
  • If the dressings start to peel at the edges – you may reinforce them
  • If the dressings discolour with discharge (yellow or green) you may have a wound infection; do not be alarmed just yet – please notify SSU (02 9215 6100 or admin@drpant.com.au) and we will give you a plan.
  • When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery.
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 4-6 weeks after surgery. You should keep your sling on while asleep. 

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the sling. The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications. 

The risk of complications after a Total Shoulder Replacement is 1-2 % in the Sydney Shoulder Unit experience. General risks include: 

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating to a Total Shoulder Replacement include: 

  • Shoulder joint dislocation
  • Fracture around the prosthesis (either during surgery or postoperatively)
  • Early Rotator cuff failure (subscapularis tendon rupture/tear)
  • Late rotator cuff failure (supraspinatus tendon tear)
  • Neurovascular injury during surgery
  • Cutibacterium acnes (formerly Propionibacterium acnes) infection (often presents insidiously) 
  • Prosthesis failure (glenoid loosening, polyethylene wear) 

Patients who smoke, use tobacco products, have diabetes, or are elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone healing. Most healthy patients, however, cope well with shoulder replacement surgery and are unlikely to have complications. 

The latest advances in computer navigation, 3D planning and printing, and patient-specific instrumentation allow for accurate placement of components resulting in superior radiographic and functional outcomes for our patients. 

Sydney Shoulder Unit is a high volume shoulder practice that performs a large number of shoulder replacements each year with consistent outcomes for our patients.

When carried out carefully Shoulder Replacement is a safe and reliable procedure. The Sydney Shoulder Unit revision rates are some of the lowest in the world.

Australian Orthopaedic Association National Joint Replacement Registry Data (Individual Surgeon Reports) shows that Dr Pant’s revision rate for shoulder replacements is currently 0.00% (as of 2021); the national average is 1.06%. This includes Total Shoulder Replacements, Reverse Shoulder Replacements and Shoulder Replacements for fracture.

Patient results

Total Shoulder Replacement

This 70 year old lady presented with many years of shoulder pain. With the pain affecting her sleep and ability to undertake activities of daily living. Having trailed multiple cortisone injections over the years and an intense program of physiotherapy, she was at the end of her tether. 

Plain x-rays demonstrated end stage advanced osteoarthritis. MRI scan demonstrated an intact Rotator cuff – which is required for the “anatomical” total shoulder replacement to function well. 

CT scan with 3D planning was used to order “Patient Specific Instrumentation” for her stemless shoulder replacement. 

Dr Pant almost always uses the “stemless” anatomical shoulder replacement to minimise bone loss from the humerus, reduce bone loss, improve efficiency; and make any future revision surgery easier. 

The surgery was carried out as planned on the computer and the new shoulder was implanted using custom 3D printed targeting guides. She stayed overnight in hospital and was discharged home the following day. X-rays taken the following day after surgery shows a well positioned prosthesis. 

She underwent a standard post shoulder replacement rehabilitation pathway using the JPL method – commencing passive range of motion at 2 weeks post surgery. By 6 weeks she reported the old arthritis pain and the post surgery pain had all settled. At 3 months she had close to full passive range of motion and commenced a light strengthening program under the guidance of her physiotherapist. 

She is now pain free and delighted with her new shoulder joint.

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