Shoulder Replacement Surgery: Indications, Types, and Recovery Overview

Shoulder arthroplasty (replacement) is a highly successful procedure for end-stage shoulder arthritis and complex fractures, with >90% patient satisfaction at 10 years. Understanding indications, implant options, and the recovery trajectory helps patients make informed decisions and optimize outcomes.

Primary Indications

• Osteoarthritis (primary or post-traumatic): Most common; pain, stiffness, functional loss unresponsive to non-operative care
• Rheumatoid/inflammatory arthritis: Synovial destruction; often younger patients
• Rotator cuff tear arthropathy: Massive irreparable cuff tear + superior migration + arthritis
• Proximal humerus fractures: 3-4 part fractures in elderly; reverse TSA preferred for poor bone/soft tissue
• Avascular necrosis: Post-steroid, trauma, sickle cell, idiopathic
• Failed prior surgery: Failed hemiarthroplasty, failed fixation, infection (staged revision)

Implant Types: Anatomic vs. Reverse

Feature	Anatomic TSA	Reverse TSA (rTSA)
Mechanism	Replicates native anatomy: humeral head + glenoid component	Reverses ball-and-socket: glenosphere on glenoid, humeral cup
Rotator cuff	Requires intact, functional cuff	Functions WITHOUT rotator cuff (deltoid-powered)
Primary indication	OA with intact cuff, inflammatory arthritis	Cuff tear arthropathy, massive cuff tears, revision, fractures, failed hemi
Range of motion	Excellent if cuff intact	Reliable forward elevation; limited internal rotation/behind-back
Longevity	15-20+ years (glenoid loosening main failure)	10-15 years (baseplate loosening, acromial stress fracture)
Age typical	<70-75	>70-75 (increasingly used younger for cuff tear arthropathy)

Hemiarthroplasty

Humeral head replacement only. Indications: young high-demand patients with OA (glenoid preservation), fracture with intact glenoid cartilage, some cuff tear arthropathy. Higher revision rate than TSA.

Preoperative Optimization

• Smoking cessation ≥4-6 weeks (critical for healing)
• Glycemic control (HbA1c <7-8%)
• Nutritional optimization (protein, vitamin D)
• Dental clearance (reduce hematogenous seeding risk)
• Prehab: scapular strengthening, range of motion exercises
• Medication review: hold anticoagulants, immunosuppressants per protocol

Surgical Overview

• Anesthesia: General + interscalene block (gold standard for postoperative analgesia)
• Approach: Deltopectoral (standard) or superior (for rTSA)
• Duration: 1.5-3 hours
• Hospital stay: Outpatient (increasingly) to 1-2 nights

Recovery Timeline

Phase	Timeline	Goals	Precautions
Immediate	0-2 weeks	Pain control, wound healing, sling immobilization, pendulums, elbow/wrist/hand AROM	Sling 24/7 except hygiene/exercises; no active shoulder motion; no lifting
Early	2-6 weeks	Passive/active-assisted ROM (forward elevation to 140°, ER to 30-45°), scapular stabilization	No active IR/extension; no lifting >1 lb; sling weaning
Intermediate	6-12 weeks	Active ROM, progressive strengthening (isometric → isotonic), functional tasks	No heavy lifting (>5-10 lbs); avoid forced IR/extension
Advanced	3-6 months	Full strengthening, sport/work-specific training, return to golf/tennis/swim	Gradual return; monitor for pain/swelling
Long-term	6-12+ months	Maximal improvement; continued strength gains	Lifelong: avoid repetitive heavy overhead loading; antibiotic prophylaxis for dental? (controversial)

Outcomes and Complications

• Success rates: 90-95% pain relief; functional improvement correlates with preoperative status and rehab adherence
• Complications (1-5% each): Infection (1-2%), instability (dislocation), periprosthetic fracture, nerve injury (axillary most common), loosening, glenoid wear (anatomic), acromial/spine fracture (reverse), component malposition
• Revision indications: Infection, instability, aseptic loosening, component wear, periprosthetic fracture

Choosing a Surgeon

• Fellowship-trained in shoulder/elbow or sports medicine
• High volume (>50 shoulder arthroplasties/year)
• Experience with both anatomic and reverse
• Published outcomes or registry participation (AJRR, national registries)
• Multidisciplinary team (PT, pain management, anesthesia)

Medical Disclaimer: This overview is educational only. Surgical candidacy, implant selection, and rehabilitation protocols are highly individualized. Consult a board-certified orthopedic surgeon specializing in shoulder reconstruction for personalized evaluation and treatment planning.