Surgical Treatment of Arthritis of the Shoulder

Surgical treatments for shoulder arthritis have improved greatly over the past ten years. Surgery has helped people of all ages affected by arthritis to improve their quality of life. Stiff and painful joints damaged by arthritis are now potentially successfully replaced, relieving pain and improving joint function.

Arthritis of the shoulder may be caused by:

  • Age-related osteoarthritis (wear-and-tear arthritis).
  • Injury-related (such as repeated dislocation of the shoulder) osteoarthritis that can appear many years after the injury.
  • A shoulder fracture involving the joint surface due to severe trauma.
  • Chronic inflammatory disease (rheumatoid arthritis).

Arthroscopy of the shoulder is a common surgical procedure to examine the inside of the joint. In some patients, surgical treatment during arthroscopy can improve the symptoms from a damaged joint. Some symptoms of early arthritis may be relieved by arthroscopic treatment. When joint damage causes severe pain and the shoulder joint becomes stiff, the most common surgical treatment is joint replacement.The shoulder is a complex joint made of three bones: the humerus, the scapula (shoulder blade) and the clavicle (collar-bone). As shown in the figures, the larger of two joints in the shoulder is the shoulder joint, a ball-and-socket joint where the rounded head of the humerus fits into a socket in the scapula. The second, smaller joint in the shoulder is called the acromioclavicular joint.bony1

Both joints in the shoulder can be affected by arthritis. However, when we talk about arthritis of the shoulder, they are usually referring to the large ball-and-socket joint.  The bone ends are usually covered in cartilage. This acts as a cushion and gives bone ends a smooth surface, allowing them to move easily over one another. The main shoulder joint is enclosed in a fibrous capsule that contains lubricating fluid which also provides nutrition to the cartilage.
Arthritis destroys the cartilage covering the ends of bones. The normally smooth joint surfaces become rough and uneven. As a result, the joint does not move smoothly. The joint becomes stiff and painful at rest, with movement being limited and painful.

Shoulder Joint Replacement
Shoulder joint replacement is a major surgical procedure to remove the damaged joint and replace it with an artificial joint. The surgeon may replace or resurface the head of the humerus leaving the natural socket, or replace both the head of the humerus and the socket. This depends on the extent of damage to the joint but most commonly only the ball of the joints is resurfaced or replaced.

Prosthesis:
The artificial shoulder joint is called a prosthesis. The prosthesis is designed to function like a normal joint. As shown in the figure, the rounded head of the humerus is replaced with a metal ball or more recently a carbon-fibre ball. This ball may be fixed to a metal stem that is inserted into the bone cavity of the humerus. However it is also common to simply cover the worn ball with a smooth metal eggshell-type implant.  The artificial socket for the scapula is made of plastic and may be attached to the bone with special synthetic cement.

Surgical Procedure:
An incision about 20 centimetres long is made across the front of the shoulder. Nerves, blood vessels and muscles are carefully moved aside, and the joint capsule is opened. The humerus is taken out of its socket. The head of the humerus is removed or prepared.  Tools are used to prepare the bone cavity of the humerus so that a secure fit is achieved if a metal stem is inserted.  The head of the humerus is not removed if a resurfacing implant is being used.  If the socket needs to be replaced, a small drill is used to remove damaged cartilage from the surface. Small stems on the outside of the artificial socket are plugged into holes drilled in the scapula. The humerus is fitted into the new socket, and the shoulder is tested to make sure that the pieces fit together properly. Sometimes bone cement or screws are used to anchor the prostheses. The joint capsule is closed with stitches that dissolve. The procedure is completed with the stitching of the skin incision. The procedure usually takes one hour.

Arthroscopy
Using a thin instrument called an arthroscope, it is possible to look inside the damaged joint. The arthroscope contains a miniature video camera and light source. These are linked to a television monitor.  The arthroscope is inserted through a small incision at the back of the shoulder. A second incision may be made to introduce a tube into the joint space. Dilute saline is gently pumped through the tube to fill and swell the joint space, making the surgical field easier to see. Working through another incision and watching the procedure on the television monitor, the surgeon may use surgical instruments to repair the damaged joint.
Various instruments are used to smooth rough surfaces, remove loose and damaged tissue, and shave away torn cartilage; this is called debridement and chondroplasty. The joint is then washed out with saline until blood and loose particles of bone and cartilage are removed.  If damage to the joint surface is marked then arthroscopy may not improve symptoms of pain and will aid principally in determining which shoulder implant would be best suited to your shoulder.
The incisions are stitched or closed with small adhesive strips, and a dressing is applied. Arthroscopy usually takes less than 30 minutes.

Arthrodesis (Fusion)
For certain patients with degenerative or rheumatoid arthritis or shoulder paralysis, the surgeon may recommend an arthrodesis procedure of the shoulder joint instead of joint replacement surgery or arthroscopy. Arthrodesis surgery results in significant loss of flexibility of the joint but usually increased strength and less pain.

Before Surgery
You will have a physical examination to test the range of movement and muscle strength in the shoulder. An X-ray examination is done to see how much joint damage is present. Other joints may be examined for signs of arthritis. An MRI may also be performed.
 .
You may be advised to stop taking anti-inflammatory medicine seven to 10 days before surgery. A physiotherapist may assess your condition and discuss an exercise program to assist rehabilitation after surgery. Your physiotherapist may have suggestions about how to make day-to-day activities at home easier after surgery.
 .
I need to know your medical history to plan the best treatment. Please fully disclose any health problems you may have had. Some may interfere with surgery, anaesthesia or aftercare.
 .
Before surgery, please tell me if you have had:
  • An allergy or bad reaction to antibiotics, anaesthetic drugs or other medicines, surgical tapes or dressings
  • Prolonged bleeding or excessive bruising when injured
  • Previous problems with blood clots in the legs or lungs recent or long-term illness
  • Keloid (raised) scars or poor healing of scars after previous surgery.
 .
To detect problems that could complicate surgery or anaesthesia, blood tests may be taken. Chest X-ray examinations and electrocardiograph (ECG) tests may be needed to assess your suitability for general anaesthesia.
 .
Please provide me with a list of ALL medicines that you are taking or have recently taken. Include prescription medicines and those bought “over the counter”, without prescription. Include medicines such as insulin, warfarin and contraceptive pills that are taken for long-term treatments.  Prior to surgery you maya be referred to a physician for a full assessment of your fitness for surgery.
 .
Do not take aspirin, medicines containing aspirin (such as cough syrups), large amounts of vitamins (particularly Vitamin E), or anti-inflammatory medicines for at least 7 days prior to surgery. These may increase the risk of excessive bleeding during and after your surgery.

Smoking
If you smoke please stop at least two weeks prior to your surgery. Smoking increases surgical and anaesthetic risk and impairs wound healing.

Recovery After Arthroscopy and Shoulder Joint Replacement
Immediately after surgery, you will be transferred to the recovery ward. Nursing staff will monitor your recovery.
 .
Arthroscopy: You will be given painkillers and anti-inflammatory tablets to use immediately, with instructions for further use over the next few days. You can probably go home the same day, or you may have to stay in hospital overnight. You cannot drive for a few days, so arrange for someone to drive you home. It is normal to feel a slight grinding sensation in the joint for a day or two after the operation.
The shoulder dressing is usually kept on for 7-10 days. Keep the dressing dry. You will have a follow-up outpatient appointment with me approximately seven to ten days after your surgery.
Both your physiotherapist and I may instruct you on:-
  • Exercises to help strengthen muscles around the joint.
  • Movements to avoid.

You will be told when you can use the joint normally and return to normal activities.

 

Joint Replacement Surgery: After shoulder joint replacement, you will have a bulky dressing on your shoulder. Your arm will be in a sling. This is to protect the shoulder and to keep it in the correct position.

A drainage tube may extend from your wound underneath the dressing. If you have such a tube it will be removed after one day.

Most patients have some pain and discomfort while tissues around the new joint heal. A pain reliever can be taken for this. The pain from the operation usually lasts for a few weeks before it starts to improve.

An exercise program is an important part of your recovery. It usually starts with gentle exercises the day after surgery. These exercises are important to help prevent stiffness and regain shoulder movement. As the tissues heal, your physiotherapist tests the strength in your shoulder and surrounding muscles. An exercise program will be designed for you. Strength and flexibility of your shoulder should steadily improve over the next six to 12 months.

Most patients go home two to three days after surgery, with specific instructions on daily activities. You may be allowed to resume driving in about 3 to 6 weeks, depending on your recovery.

Stitches may are usually under the skin and will dissolve in time leaving a faint scar. You may have regular X-ray examinations to detect any changes such as loosening in the artificial joint. It takes time to recover from joint replacement surgery, and you will need help when you return home. Arrange for a responsible adult to stay with you for several weeks after surgery.

Some patients may have difficulty sleeping on their operated shoulder due to pain during the recovery phase. Most shoulder joint replacements are successful in relieving pain and improving flexibility to a lesser extent if at all. Improved materials and advances in surgical techniques have extended the length of time a joint replacement can last in excess of 10-15 years.

 

Osteoarthritis of shoulder joint

Metal humeral head resurfacing

Post operative shoulder resurfacing

Post operative shoulder resurfacing

Avascular necrosis of humeral head

Pyrocarbon humeral head replacement

Post operative shoulder hemiarthroplasty

Post operative shoulder hemiarthroplasty

Possible Complications Of Surgery

As with all surgical procedures, arthroscopy and joint replacement surgery do have risks, despite the highest standards of practice. Whilst every attempt is made to minimise risks, complications can occur that may have permanent effects.The following possible complications are listed to inform and not to alarm you.

General Risks Of Surgery

Possible complications of any surgery may include:-

  • Pain and discomfort around the incisions
  • Wound infection and treatment with antibiotics
  • Nausea (typically from the anaes¬thetic; this usually settles down quickly)
  • Bleeding from the incisions
  • Keloid scars (most scars fade and flatten, but some may become “keloid” and remain raised, itchy, thick and red. A keloid can be annoying but is not a threat to health.)
  • Slow healing (most likely to occur in smokers and people with diabetes)
  • allergies to anaesthetic agents, antiseptic solutions, suture material or dressings.

Specific Risks Of Arthroscopy
  • A build-up of fluid in the shoulder joint that requires drainage.
  • Cartilage damage.
  • Temporary joint stiffness.
  • Temporary injury to nerves close to the surgical area.
  • Infection
Serious complications after shoulder arthroscopy are unusual and occur in much less than one patient in every 100.

Specific Risks Of Shoulder Joint Replacement
  • The risk of infection is about one patient in every 200. Infection may occur up to several months after the operation. Infection can spread from any part of your body to the area of the new joint. To help prevent this, you may need to take antibiotics before and after other surgery or dental work. Infrequently, the infection may be resistant to treatment, and a second operation is needed to remove the prosthesis, followed by a third operation to replace it.
  • The artificial joint may become loose where the metal or cement meets the bone. This causes pain and eventually another operation will be needed.
  • The artificial shoulder joint can dislocate, that is, the ball comes out of the socket. This risk is most likely soon after surgery while the tissues around the new joint are still healing. If it happens more than once, another operation may be needed.
  • As the surgery is performed close to the nerves to the arm, permanent nerve damage is possible. Minor nerve injuries usually heal well over time, and the nerves may recover completely.
  • The main arterial blood supply to the arm is also potentially at risk during surgery but injury of the vessels is uncommon.


Please Report To Me 

Please contact me through any of the above numbers or via your General Practitioner at once if you develop any of the following problems:

  • Temperature higher than 38C or chills.
  • Severe pain or tenderness in the shoulder.
  • Heavy bleeding from your wound.
  • Redness around an incision that is spreading.
  • Worsening flexibility or inability to move the shoulder.