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 doctors are often asked by their patients. 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 bone (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).
When should I have shoulder or elbow replacement?
The main reason for shoulder or elbow replacement is painful arthritis. Less frequently a replacement may be carried out to deal with fractures close to the joints. 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 contraction of the soft tissues 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 needs to advise you.
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, for example paracetamol, and anti-inflammatory drugs, for example diclofenac. If you have rheumatoid arthritis, disease-modifying drugs may be used. Injections of steroid and other drugs into the joint can 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, which is useful for some people. Physiotherapy can often be of great benefit to people with problems in either joint. If these treatments do not relieve the pain then surgery may be considered.
There are other surgical 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). The lining of the joint can be removed if very inflamed (synovectomy) – this is usually only carried out on the elbow joint. Occasionally part of the bone at the elbow (the radial head) is 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 GP, physiotherapist or nurse) as well as 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. S/he 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?
In most cases the surgery is done from the front of your shoulder. The surgeon will decide beforehand whether one or both sides of the joint needs replacing (Figure 7). 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).
This operation is done with a cut along the back of the elbow. Both sides of the joint are replaced, either with or without cement (Figure 8). The humeral (upper arm) and ulnar (forearm) components are made of both metal and plastic. 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).
How long does it take?
The operations usually take between one and two 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 four or five 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 (see Figures 9 & 10). 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 one or two days – this can be done on the ward.
How long will it be before the joint works again?
It will take three to six months before you get the full benefit of the surgery. You should feel a noticeable improvement by six weeks from 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 or ‘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 the pain to go or be much reduced, and this should happen soon after the operation once the wound has settled down. Increasing the range of movement can take longer and any increases you achieve will usually only be because the joint is less painful. 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 it go wrong?
Shoulder and elbow joint replacements are very successful and most people who have them are delighted with the operation and are glad they had it done. Like any operation a very small number of people can have a problem. The main problems with the shoulder are infection, loosening of the replaced parts (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 and 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 the possibility of problems with your surgeon before your operation.
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 a further operation will be required.
Can I work and drive afterwards?
You will be able to return to work after your joint replacement, but this may take up to three months depending on the type of work you do. Heavy manual activities are not recommended 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 after about six months.
Are there any other varieties of joint replacements used in the shoulder and elbow?
For specific disease of the radial head in the elbow and following some fractures, a metal radial head replacement may be used. This kind of replacement leaves the rest of the elbow joint unchanged.
How long will my joint replacement last?
There is a very good prospect that your shoulder or elbow replacement will last for ten 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 is also a more difficult operation to do from the surgeon’s point of view.