The Procedure
An anatomic total shoulder replacement (ATSR) is a surgery where the shoulder joint is replaced with a prosthetic joint. The prosthesis consists of two components, a metal ball to replace the humeral head, and an artificial socket. These two components are secured to either side of the shoulder joint, to the humerus and glenoid respectively. Shoulder replacement surgery is performed as an open procedure. I typically book 3 hours of theatre time for the surgery.
The ATSR is usually performed for patients with severe osteoarthritis in the glenohumeral joint.
Pre Op
If you are undergoing a joint replacement, I will ask you to see a physician prior to your surgery to ensure that any underlying medical issues are identified and treated. It has been consistently shown that patients undergoing prosthetic joint replacement surgery experience fewer complications and better outcomes following their surgery if they have been reviewed by a physician preoperatively. Joint replacement surgery places a significant stress on the body. Any unrecognised and untreated medical conditions have a tendency to present issues during such surgery. The physician review is aimed at identifying any unrecognised health issues and optimising you from a medical standpoint for the upcoming surgery. You will also need to have a blood test for your general blood health. These steps before surgery have a proven record of reducing the rate of surgical complications and infections and improving the outcome of your surgery.
Physiotherapy Prehab is very helpful to do in preparation for your upcoming joint replacement surgery. Your physio will be able to do the prehab with you.
Other things to do include:
- Speak to your health fund to confirm if the hospital fee for your surgery is covered on your policy. This is particularly important when considering prosthetic joint replacement surgery as many health policies do not include joint replacement cover. If your policy does not cover joint replacement surgery, you may need to upgrade your cover and wait the 12 month qualifying period before you are covered for your surgery
- Speak to your anaesthetist to confirm their fees
- Register your details with the hospital
- Read through, complete and return your paperwork to my office
- Plan your transport to and from the hospital. You won’t be able to drive yourself home after the surgery, so make sure you have a travel plan in place
- If required, arrange any recommended pre op physio appointments
- If required, get any pre op pathology tests (e.g., blood tests)
- Use benzoyl peroxide 5% wash on your shoulder for 5 applications: twice a day for two days, and then again on the morning of the surgery. This will help reduce your risk of infection from Cutibacterium acnes.
- You will need to shower using chlorhexidine cloths the night before and the morning of surgery. This dramatically reduces the total number of bacteria you carry on your body and helps reduce the risk of bacterial infection.
- You will be given a script for mupirocin nasal ointment to be applied to both your nostrils twice a day for five days before surgery. Mupirocin ointment is very effective at eradicating bacteria from the nasal passage, including Staphylococcus aureus (aka., Golden staph), dramatically reducing the risk of staph wound infections by more than 80%.
- Pack a bag for your hospital stay including regular medications in the original packaging, a loose button-up shirt to wear after surgery, nightwear, personal items including toiletries. If you have sleep apnoea, you must bring your CPAP machine.
- If you are on any blood thinners, ring my office and confirm when to stop taking them before the operation.
- If you are on any diabetic tablet medications, ring your anaesthetist and confirm whether you need to stop taking them before the operation
- Confirm your admission details with my office one to two business days prior to surgery
Though this can seem overwhelming, you will be provided with detailed instructions on what needs to be done so your surgery journey can be as smooth as possible.
Complications
General risks of surgery include:
- Bruising & haematoma: this will vary for each patient. Bruising is a normal side effect of surgery and usually resolves in a short time. Haematoma is a collection of blood in the wound and may occasionally require a return to theatre for drainage.
- Infection: infection is a rare but possible risk that occurs in less than 1% of cases in my experience. If infection does occur, it may be treated with antibiotics. In severe cases, removal and replacement of the shoulder prosthesis may be required.
- DVT and PE: deep vein thrombosis and pulmonary embolism are blood clots that form in either the lower limbs or lungs. If left untreated, DVT and PE can have serious effects, however if treated promptly, the risks are significantly lowered. More information can be found here (hyperlink to UC Health Blood Clot pamphlet)
- Anaesthetic risks: general anaesthetic (GA) carries a number of risks, which will be discussed in detail with your anaesthetist prior to surgery. Fortunately, Australia is one of the safest places to undergo a GA. In Australia, the risk of mortality from GA is around 1 in 100,000. For context, the risk of death in a car accident in Queensland is around 1 in 10,000 per year.
- Wound issues: some superficial issues can develop in surgical wounds postoperatively. Most resolve without issue, however occasionally they may require a small intervention to resolve the problem.
ATSR is a significant surgery, similar to a hip or knee replacement, and there are risks, including:
- Instability and dislocation
- Stiffness
- Prosthesis failure: the artificial joint will reasonably have a lifespan of up to 20 years. If the shoulder replacement wears, out a revision joint replacement surgery may be required. To give you something to consider, the AOA NJRR reported in 2024 that at 14 years, 17.4% of standard (stemmed) anatomical total shoulder replacements had been revised, meaning that 82.6% still had not been revised. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) gives the most relevant information regarding shoulder joint outcomes in Australia and you can access the results of shoulder joint replacement surgery in Australia here: https://aoanjrr.sahmri.com/
Day of Surgery
Your admission details will be confirmed one to two business days prior to surgery. You will need to make note of your admission time and your fasting time. Your admission time may be as early as 6am. If you aren’t local to Brisbane, it is usually recommended that you stay the night before in case your admission is early.
When you arrive at the hospital, you will go through the admissions process and then be taken through to the surgical waiting area. Your anaesthetist will have a short consultation with you before you go into theatre and under general anaesthetic. I will say hi to you before the surgery in the anaesthetic bay of the operating theatre and mark your operation site with you.
Your hospital stay will usually be two nights. You will be discharged usually around 10am on the second day postop. I will see you before your discharge. I will provide you with a folder containing a detailed postoperative pack, including a letter telling you what I found at surgery and exactly what I did in your operation along with information about your rehabilitation and postoperative care. Remember to have someone available to take you home from the hospital.
Post Op Recovery & Healing
On day 1 post-operatively, an X-Ray and CT scan will be performed to check the position of the prosthesis and physiotherapy will commence. You need to take time off work and driving, as well as other recreational physical activities, to allow adequate rest and healing to occur. Exact durations are variable, however three months is quite a reasonable expectation.
A review with me will be organised at around 6 weeks post-op. Usually, you will have reviews with me and the shoulder physio at 6 weeks, 12 weeks, 12 months post-op. Final checks and scans (X-rays and a CT scan) are performed at 12 months post-op. These appointments can be either in person or by telehealth video consultation (either Facetime or WhatsApp). Just let my office know which you prefer.
Rehabilitation
As it is a joint replacement, ATSR rehab involves both resting and gradually increasing physical therapy during recovery after surgery.
Normally, a sling is worn for six weeks after surgery to protect the repair of the subscapularis rotator cuff tendon. At six weeks, it is normal for there to still be some soreness and aches, and your range of motion will still be limited, however a gradual increase in exercises will help to improve movement.
By 12 weeks after surgery, the range of motion will be improved, and activities of daily living and other physical activities can be performed. Strengthening exercises will begin at this point and will continue until an appropriate level of function is achieved.
Full recovery and return to normal physical activities including strenuous exercises like sports is achieved at around 6 to 12 months.
Physiotherapy Guidelines
Day 1 Physiotherapy Guidelines
The hospital physio will see you the morning after surgery and the following morning before you discharge. They will demonstrate how to fit your sling and how to eat, shower & dress whilst in your sling. Please make sure you go through these things with the physio so that you get them really clear in your mind before you leave hospital.
Goals:
- Protect healing of the arthroplasty
- Maintain GH (glenohumeral) Joint Range of motion within certain limits
Sling:
- Usually worn for the first 6 weeks post operatively
- Can come out of sling for showering, eating, sitting quietly
- Check fit, demonstrate activities of daily living (showering, dressing etc)
- The sling is fitted to you in theatre with you lying prone. For the sling to be fitted properly, you need to be standing and the physio will do this with you the first morning after your surgery. I like the sling to be long enough to reach your metacarpophlangeal joints, the knuckles at the base of your fingers. If it is too short, the physio can arrange a larger size sling for you while you are in hospital.
Precautions:
- No active use of operated shoulder
- No shoulder extension, HBB (hand behind back), Weight Bearing
Therapy:
- Ensure appropriate sling fit, good posture in sling and scapula awareness.
- Patient independent in don/doff sling and self-cares
- Chest and mobility check as appropriate
- GHJ (glenohumeral joint) passive ROM (range of motion) exercises: Circular pendulums, Stick ER (0) (external rotation in neutral) to 20 degrees, forward lean flexion to 120 degrees
- Maintain range of motion of adjacent joints
- Oedema control, effleurage as required
Follow up:
- With local therapist at the two-week mark, earlier if any concerns with swelling/stiffness/pain
- Week 6 with me and the shoulder physio, progression of rehabilitation will be outlined then
Results After Surgery
Following ATSR and adhering to rehabilitation protocols, most patients will experience a dramatic improvement in pain relief and shoulder function. Many patients have a return to normal or near normal levels of physical activity, and the range of motion is increased after surgery. The joint replacement surgery is particularly good at relieving the aching pain at night that disrupts the sleep of so many patients and keeps them awake at night time.