Total Shoulder Replacement: What to Expect During Surgery

What Is Total Shoulder Replacement?

Total shoulder arthroplasty (TSA) is a surgical procedure in which the damaged surfaces of the shoulder joint — the ball (humeral head) and the socket (glenoid) — are replaced with metal and plastic prosthetic implants. It is a highly effective operation for end-stage shoulder arthritis, with excellent pain relief and functional outcomes.

Types of Shoulder Arthroplasty

Total shoulder arthroplasty (anatomic TSA): Replaces both the ball and socket with components that mirror normal anatomy. Requires an intact rotator cuff — if the cuff is severely deficient, anatomic TSA may fail.

Reverse total shoulder arthroplasty (rTSA): Reverses the normal ball-socket geometry — a metal ball is fixed to the glenoid (socket), and a socket cup replaces the humeral head. Designed for patients with massive rotator cuff tears and cuff tear arthropathy; allows the deltoid muscle to compensate for absent cuff function.

Hemiarthroplasty: Only the humeral head (ball) is replaced; the glenoid is left intact. Less commonly performed today.

Who Is a Candidate?

End-stage shoulder osteoarthritis (severe joint space loss, osteophytes, pain)
Rheumatoid arthritis of the shoulder
Rotator cuff tear arthropathy (massive cuff tear + arthritis) — usually treated with rTSA
Failed prior shoulder surgery or fracture malunion
Avascular necrosis of the humeral head

Surgical candidates have:

Disabling shoulder pain unresponsive to conservative treatment
Functional limitations significantly impacting quality of life
Adequate bone stock for prosthesis fixation
Intact deltoid function

Pre-Operative Preparation

Medical clearance (cardiac, pulmonary evaluation as needed)
Blood work and EKG
Dental evaluation (dental infection can seed prosthetic joints — address dental issues before surgery)
Discontinue NSAIDs and blood thinners as directed
Pre-operative shoulder X-rays and possibly CT scan for implant sizing
Arrange 6+ weeks of assistance at home
Prepare a recliner or wedge pillow for post-op sleeping

Day of Surgery

Anesthesia

Most shoulder replacements are performed under general anesthesia plus an interscalene nerve block. The nerve block provides 12–18 hours of post-operative pain control and reduces narcotic requirements.

Surgical Steps (2–3 hours)

Positioned in beach chair position (semi-seated upright)
Deltopectoral incision: 6–8 inch incision along the shoulder front between the deltoid and pectoralis major muscles
Subscapularis tendon divided or split to enter the joint
Humeral head dislocated anteriorly and removed with a saw
Glenoid is prepared and a plastic socket (glenoid component) is cemented into place (anatomic TSA)
The medullary canal of the humerus is prepared and a metal stem is implanted (press-fit or cemented)
A metal or cobalt-chromium ball attaches to the stem
The joint is reduced (ball placed back into socket), stability and range of motion checked
Subscapularis tendon repaired
Closure in layers; drain may be placed

Recovery Room

1–2 hours post-operatively. Most patients are admitted overnight; some centers perform same-day discharge for appropriate patients.

Risks and Complications

Prosthesis loosening: Long-term complication, may require revision
Glenoid component wear or failure (anatomic TSA specific)
Instability/dislocation: Particularly relevant for rTSA
Infection: Deep periprosthetic joint infection (<1–2%)
Nerve injury: Axillary nerve most at risk
Stiffness: If subscapularis healing is inadequate
Periprosthetic fracture: Fracture around the stem (uncommon)
Implant failure requiring revision surgery

What to Bring

Button-down or snap-front shirts
Slip-on shoes
Abduction sling (surgeon may provide; confirm in advance)
Phone, charger, entertainment for hospital stay
Arrange home help for at least 4–6 weeks post-op