Shoulder and Elbow Joint Replacement
An Information Booklet
What is in this booklet?
The aim of this booklet is to provide information for people who are considering a shoulder or elbow joint replacement. It includes the sorts of questions people often ask their doctors. Many of the questions and answers apply to both shoulder and elbow replacement. However, there are differences between the two operations and these will be highlighted.
What is joint replacement?
Replacement of the shoulder joint and elbow joint are procedures where the surfaces of the joint, normally made of bone covered with cartilage, are replaced with parts made of metal and plastic. The operation is sometimes called arthroplasty. In the shoulder, often only the upper arm (humeral) side of the joint is replaced. This is called hemiarthroplasty, meaning replacement of part of the joint. With the elbow, both sides of the joint are replaced (total arthroplasty). Figure 1 shows the bones of the shoulder. Figure 2 shows the bones of the elbow joint.
When should I have a shoulder or elbow joint replacement?
Painful arthritis is the main reason for shoulder or elbow replacement. Shoulder and elbow joints which are affected by arthritis can become painful, swollen and difficult to move. The lack of movement can be caused by the joint surfaces not moving smoothly on each other, or by contraction of the soft tissues (tendons, ligaments) around the joint. The joint may be too painful to allow you to move it. In a joint where pain cannot be relieved by other methods such as drugs, splints, injections or physiotherapy, and the pain is interfering with your quality of life, a joint replacement may be considered. A surgeon who performs these operations will advise you. Less frequently a replacement may be carried out to deal with fractures close to the joints.
What are the alternatives to joint replacement?
Most people with arthritis of the shoulder or elbow joint will receive other treatments from either their family doctor (GP) or a rheumatologist before they see a surgeon for a joint replacement. In general, drug treatment will consist of painkillers such as paracetamol, and anti-inflammatory drugs such as diclofenac. If you have rheumatoid arthritis, disease-modifying drugs may be used. Injections of steroid and other drugs into the joint can also be helpful in the early stages of joint pain. Some of the nerves that transmit pain from the shoulder can be numbed with injections of local anaesthetic, and some people find these help. Physiotherapy can often be of great benefit to people with problems in either joint. However, if these treatments do not relieve the pain then surgery may be considered.
There are other operations available which, in some cases, are more helpful than joint replacement. These include making the joint solid and immoveable (arthrodesis) or cleaning it out (debridement). If the lining of the joint is very inflamed it can be removed (synovectomy) – this is not usually carried out on the shoulder joint. Occasionally part of the bone at the elbow (the radial head) may be removed.
Will an unoperated joint get worse?
The arthritis of the joint tends to get worse over time, but not at a steady rate. Your surgeon will be able to advise you if waiting would be harmful or make the situation more difficult to deal with in the future.
Should I have a joint replacement?
Deciding to have a joint replacement should be considered carefully in consultation with your surgeon and any other health professionals who are helping you (such as a GP, physiotherapist or nurse) and with your family and friends. There is always the option of not having surgery. The benefits need to be weighed against the risks. Your surgeon will be able to advise you of the pros and cons of having an operation.
What will a surgeon do in clinic?
Your surgeon will discuss your symptoms and the problems they cause you, and will examine your joints. X-rays will probably be taken. Your surgeon will discuss the possible courses of action which could be taken, what you can expect from these courses of action, what the risks are, and what alternatives there are.
What does the operation involve?
Shoulder replacement
The shoulder is a ball-and-socket type joint. Often only the ball part of the joint (the humeral head) needs to be replaced, but sometimes the socket (glenoid) is also replaced (see Figure 3). The surgeon will decide beforehand whether you need to have one side of the joint, or both sides, replaced. The operation will be carried out using a general anaesthetic (in which case you will be asleep) and/or a local anaesthetic (which numbs the nerves to the arm and shoulder). The shoulder joint is normally opened from the front and the muscles pulled out of the way (retracted). The damaged bone of the humeral head is removed. The humeral component usually has a stem or shaft, in which case the bone needs to be prepared so that the stem can be inserted. Sometimes, however, the surgeon may decide to resurface the joint, using a component that fits over the humeral head like a cap. Much less bone is removed in a resurfacing operation. Figures 4 and 5 are x-rays showing the two types of humeral component in place. Usually neither type of humeral component is cemented, other than following a fracture. When a glenoid component is used it may be either cemented or uncemented.
Elbow replacement
Both sides of the joint are replaced, either with or without cement. The upper arm (humeral) and forearm (ulnar) components are made of both metal and plastic (see Figure 6). The operation will be carried out using a general anaesthetic (in which case you will be asleep) and/or a local anaesthetic (which numbs the nerves to the arm and shoulder). The elbow joint is usually opened from the back and the muscles retracted. The damaged joint surfaces are removed and the shafts of the ulna and humerus prepared to accept the components, which are usually cemented in. Some designs have a pivot between the two halves while others rely on the muscle tension to hold the two parts in contact. Figures 7 and 8 are x-rays showing the two types in place.
How long does it take?
The operations usually take 1–2 hours. Giving the anaesthetic takes about half an hour, and recovery before going back to the ward another half an hour to an hour.
How long will I be in hospital?
You will usually be in hospital for 4–5 nights after your surgery. During this time medical, nursing, physiotherapy and occupational therapy staff will be involved in your care. A couple of days after your operation x-rays of your new joint will be taken. Your arm will be in a sling or splint to protect it. If a tube was placed in the wound during the operation to allow blood to drain out, it will be removed after 1–2 days (this can be done on the ward).
How long will it be before the joint works again?
It will take 3–6 months before you get the full benefit of the surgery. You should feel a noticeable improvement by about 6 weeks after the operation, and steady further improvement from then on.
Will it hurt?
A number of methods will be available after your operation to help keep your arm as free from pain as possible. These may include local anaesthetic, 'patient-controlled analgesia' (PCA – a system where you can control your own supply of painkiller going into a vein by pressing a button), or other injections and tablets.
Will I have physiotherapy?
You will need to do exercises given by the physiotherapist, both while you are in hospital and after you get home. These will be reduced as time goes by following your operation. The physiotherapist’s job is to help you get your joint moving and build its strength by getting you to do particular exercises and movements.
What can I expect from my new joint?
For either the shoulder or the elbow the aim of joint replacement surgery is to help with pain. In most cases you can expect that the pain will be gone or much reduced, and this should happen soon after the operation – once the wound has settled down. Because the joint is less painful, you will probably find that the range of movement in the joint increases, although this will take longer. With the shoulder you will often be able to get the arm up to a height where the elbow is level with the shoulder, but not above this. With the elbow there will be some improvements in both straightening and bending the joint. You should discuss with your surgeon beforehand how much improvement in movement s/he expects you to get from the operation.
Can the operation go wrong?
Shoulder and elbow joint replacements are very successful and most people who have them are delighted with the operation and glad they had it done. As with any operation, a very small number of people may have problems. The main problems with the shoulder are infection, loosening of the components, or fracture of the bone during the operation. With the elbow, the main problems are infection, wound problems such as it not healing, temporary bruising of the ulnar nerve, loosening of the replaced parts, or fracture of the bones. The risks of these problems need to be taken into account when deciding whether to have the operation. You should discuss this with your surgeon beforehand.
What happens if it does go wrong?
If you are unlucky enough to have problems then talk to your surgeon, who will be able to advise you. In some circumstances you may need to have a further operation.
Can I work and drive afterwards?
You will be able to return to work after your joint replacement, but this may take up to 3 months depending on the type of work you do. Heavy manual activities are not recommended at any time following shoulder or elbow replacement, particularly after elbow replacement. Heavy activity tends to loosen the replaced parts in the bone.
You will be able to drive after your joint replacement as long as you can safely control the vehicle and do an emergency stop. It is important to check with your insurance company, and to be confident that you can adequately control the vehicle if the unexpected were to happen.
Will the surgeon follow me up in clinic?
Your surgeon will see you fairly regularly after the operation, but less frequently from about 6 months after the operation.
Are any other types of joint replacement used in the shoulder and elbow?
If the disease is affecting only the radial head in the elbow a metal radial head replacement may be used. This operation leaves the rest of the elbow joint unchanged. This may also be used for some fractures.
How long will my joint replacement last?
There is a very good prospect that your shoulder or elbow replacement will last for 10 years. After this time it may loosen and wear out. The old parts can then be replaced if required. However, second-time (revision) surgery is likely to be more difficult for you as a patient than the first time around, and it is also a more difficult operation to do from the surgeon’s point of view. In a revision operation the original components will need to be removed, along with any cement which may have been used. The shaft of the humerus will often have become thinner by the time revision surgery is needed and, because further bone is removed during the operation, the humerus is more prone to fracture. Again, you should discuss the risks with your surgeon. If revision surgery is needed following a resurfacing operation, the resurfacing component is usually replaced with a stemmed component. This is less difficult technically, because less bone will have been removed in the first operation, but you should still talk to your surgeon if you have any worries.
Useful addresses
The Arthritis Research Campaign (arc)
PO Box 177, Chesterfield
Derbyshire S41 7TQ
Phone: 0870 850 5000
www.arc.org.uk
As well as funding research, we produce a range of free information booklets and leaflets. Please contact the address above for a list of titles or, on this website, see Publications for People with Arthritis.
Arthritis Care
18 Stephenson Way
London NW1 2HD
Phone: 020 7380 6500
Helplines: 020 7380 6555 (10am–4pm Mon–Fri)
or freephone: 0808 800 4050 (12pm–4pm Mon–Fri)
www.arthritiscare.org.uk
Offers self-help support, a helpline service (on both numbers above), and a range of leaflets on arthritis.
