Shoulder Replacement — Procedure Guide, Recovery & Risks | MyMedicPlus

Shoulder replacement (total shoulder arthroplasty, TSA) is a major orthopaedic procedure that resurfaces or replaces the damaged glenohumeral joint — the ball-and-socket articulation between the humeral head (upper arm ball) and the glenoid (shoulder socket) — with prosthetic metal and polyethylene components. It is one of the fastest-growing orthopaedic procedures globally, with over 70,000 performed annually in the United States and rising rates across Europe, Asia, and Australia.

Three main types of shoulder arthroplasty address different pathologies: (1) Total shoulder arthroplasty (TSA) — anatomic replacement with a metal humeral stem and head and a polyethylene glenoid component, for glenohumeral arthritis with an intact rotator cuff; (2) Reverse total shoulder arthroplasty (rTSA) — in which the ball and socket are switched (metal ball on the glenoid, socket on the humerus), transferring power to the deltoid and bypassing the rotator cuff, for massive rotator cuff tears with arthritis or failed prior surgery; and (3) Hemiarthroplasty — replacing only the humeral head without a glenoid component, for proximal humeral fractures or isolated humeral head avascular necrosis.

The reverse shoulder prosthesis, originally developed by Paul Grammont in France in the 1990s, has transformed the treatment of massive cuff-tear arthropathy — a condition previously without satisfactory surgical solutions. rTSA now accounts for over 50% of all shoulder replacements in many centres.

Total shoulder arthroplasty (TSA) is indicated for patients with glenohumeral osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, or avascular necrosis of the humeral head causing severe, constant shoulder pain significantly impairing daily activities and quality of life, who have failed non-surgical management including analgesics, anti-inflammatory medications, physiotherapy, and intra-articular corticosteroid or hyaluronic acid injections. A functioning rotator cuff is required for TSA.

Reverse total shoulder arthroplasty (rTSA) is the preferred procedure for cuff-tear arthropathy (severe arthritis combined with massive rotator cuff tear causing a 'pseudoparesis' — inability to actively elevate the arm); irreparable massive rotator cuff tears in patients over 65; failed conventional TSA with rotator cuff failure; complex proximal humeral fractures in elderly osteoporotic patients; and glenohumeral arthritis in the context of chronic instability.

Hemiarthroplasty remains indicated for three- and four-part proximal humeral fractures in elderly patients where osteosynthesis (internal fixation) is unlikely to succeed due to poor bone quality, and for isolated humeral head avascular necrosis with an intact glenoid cartilage. Contraindications include active infection, absent deltoid function (rTSA), and insufficient bone stock.

The procedure is performed under general anaesthesia with an interscalene brachial plexus nerve block providing 12–18 hours of post-operative analgesia. The patient is positioned in the beach-chair position (upright, 70 degrees) to maintain normal anatomical orientation.

A deltopectoral approach — an 8–12 cm incision in the groove between the deltoid and pectoralis major muscles — provides the standard access. The cephalic vein is preserved and retracted laterally. The conjoined tendon (short head biceps and coracobrachialis) and subscapularis tendon are managed: for TSA, the subscapularis is divided from the lesser tuberosity and meticulously repaired at closure; for rTSA, the subscapularis may be repaired or sacrificed depending on tissue quality and surgeon preference.

The humeral head is excised with a calibrated cutting guide at the appropriate angle and height. The medullary canal is reamed and broached to accept the humeral stem, which is implanted in the correct version (retroversion for TSA, less retroversion for rTSA). For TSA, the glenoid is prepared by reaming to expose subchondral bone and a polyethylene glenoid component cemented into place. For rTSA, a titanium baseplate is impacted and screw-fixed to the glenoid; a metal hemisphere (glenosphere) is then attached, and the humeral component accepts a matching polyethylene cup. Soft tissue balancing and component stability are confirmed through full range-of-motion assessment. The subscapularis is repaired with transosseous sutures, wound layers are closed, and a drain is placed. Operative time is approximately 90–150 minutes.

The arm is immobilised in a sling for 4–6 weeks post-operatively. Pendulum exercises and passive range-of-motion begin the day after surgery to maintain mobility and prevent stiffness while the subscapularis repair heals. Formal physiotherapy is commenced at 2 weeks, progressing to active-assisted exercises at 6 weeks when healing of the subscapularis repair permits. Strengthening begins at 3 months with resistance-band exercises for the deltoid and periscapular muscles.

Return to driving is typically at 6–8 weeks when the sling is discarded and the arm can safely control the vehicle. Most patients achieve functional independence (dressing, personal hygiene, light cooking) by 6–8 weeks. Heavy lifting (greater than 5 kg) is restricted for 3 months. Return to recreational activities including golf, swimming, and cycling occurs at 4–6 months. Racquet sports and overhead throwing are generally discouraged after TSA due to glenoid loosening risk but are often permitted after rTSA.

The majority of functional gain occurs in the first 6 months, with continued improvement to 12–18 months. Annual radiographic assessment monitors prosthetic stability and glenoid component wear over time.

Glenoid component loosening is the most common long-term complication of total shoulder arthroplasty, occurring in 5–10% at 10 years, presenting as pain and progressive radiolucency around the glenoid pegs on radiograph. Revision surgery for symptomatic loosening requires glenoid revision or conversion to reverse TSA. Humeral loosening is significantly less common (less than 2%).

Periprosthetic joint infection occurs in 0.7–1.5% — low compared to hip and knee arthroplasty — but is treated with two-stage revision and prolonged antibiotic therapy. Cutibacterium acnes (Propionibacterium acnes) is the most common organism, particularly in men with oily skin, and may present as indolent infection up to 2 years post-operatively.

Instability (prosthetic dislocation) occurs in 1–5% of rTSA (less common in TSA). Neurological injury including axillary nerve neuropraxia occurs in approximately 1–2% and usually resolves spontaneously within 3–6 months. Rotator cuff failure after TSA may necessitate revision to rTSA. Periprosthetic fracture (rare, 1–2%) requires operative management. Scapular notching — inferior glenoid notching from impingement of the humeral cup — is common radiographically in rTSA (25–50%) but rarely clinically significant.

Shoulder replacement delivers excellent pain relief in over 90% of appropriately selected patients, with pain scores (VAS, ASES) improving by 60–80% from pre-operative levels. Forward elevation, which is often severely restricted by cuff-tear arthropathy, improves from an average of 60–80 degrees pre-operatively to 120–150 degrees after rTSA.

The Oxford Shoulder Score and Constant-Murley Score both show clinically meaningful improvement at 12-month follow-up, maintained at 5-year review. Implant survivorship is excellent: 15-year prosthetic survival for TSA exceeds 85%, and early 10-year data for rTSA shows survivorship of 90–95% at experienced centres.

The transformative impact on quality of life is frequently described by patients as life-changing: the ability to sleep through the night without pain, to dress independently, to participate in recreational activities, and to return to light work. Patient satisfaction rates exceed 85–90% for both TSA and rTSA in series with appropriate patient selection. For the elderly patient with cuff-tear arthropathy who was previously unable to lift the arm above the waist, rTSA restores functional independence that significantly reduces carer dependence.