Reverse Total Shoulder Replacement
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It is a type of shoulder replacement done for patients who have developed rotator cuff arthropathy which is arthritis of the shoulder joint which develops because of a massive rotator cuff tear that is no longer repairable. Patients with rotator cuff arthropathy have significant loss of function of the affected shoulder and often are unable to lift their arm even to shoulder height. This inability to lift the arm to even shoulder height is called pseudo-paralysis of the shoulder.
The position of the ball and socket is changed so that the ball is on the socket side of the joint and the socket is on the ball side
Figure 1: Radiograph of a normal shoulder the humeral head (“ball’) centered on the glenoid (“socket”) process of the scapula. The center of the humeral head (blue dot) is level with the center of the glenoid (red dot).
Figure 2: Radiograph of an individual with rotator cuff arthropathy. Note the superior position of the humeral head on the glenoid, with the center of the humeral head (blue dot) no longer being aligned with the center of the glenoid (red dot). This prevents normal function of the shoulder.
In the normal shoulder, the rotator cuff helps the large deltoid muscle to elevate the arm. When the rotator cuff is completely torn and non-functional the humeral head “escapes” superiorly (as seen in X-ray image above), and the deltoid is then unable to lift the arm by itself. By reversing the position of the ball and socket the loss of the normal rotator cuff is compensated for and the deltoid muscle can then once again raise the arm.
Figure 4: After implantation of a reverse total replacement which reverses the position of the “ball” and “socket.”
Significant pain and disability is often associated with rotator cuff arthropathy. Individuals often have difficult with simple daily activities such as feeding themselves, getting dressed and combing their hair because of a significant loss of shoulder motion and strength. There is often associated pain, especially at night-time which interferes with normal sleep. Pseudo-paralysis and rotator cuff arthropathy can be seen in older patients with a degenerative massive rotator cuff tear. Other causes of cuff arthropathy include prior failed rotator cuff repairs, or individuals with prior failed shoulder replacement surgery. A reverse shoulder replacement can also be useful in the cases of severe fractures of the proximal humerus (shoulder joint) in older individuals.
In individuals with a massive rotator cuff tear that is not repairable, an initial trial of physical therapy may help restore function to an acceptable levels. If however significant functional loss and associated pain persist despite a course of conservative therapy, reverse arthroplasty is often the only surgical option.
The surgery is done as an in-patient procedure and usually involves a hospital stay of two nights. An interscalene nerve block is done to numb the shoulder and arm, and general anesthesia may also be used. An incision is made over the front of the shoulder and all arthritic bone, and any bone spurs, as well as tight scar tissue is removed and a reverse shoulder replacement is implanted.
Physical therapy is initiated during the hospital stay. The patient is taught a simple set of exercises that they can do on their own at home. Typically full recovery is achieved by 3-4 months post-operatively. A reverse shoulder replacement can significantly decrease pain and improve function for patients and contribute significantly to an improved quality of life.
The University of Maryland Orthopaedics Difference
The University of Maryland is a tertiary referral center for complex shoulder problems and as such, we are specifically equipped to handle this type of complex operation. Patients benefit from our multidisciplinary approach to the treatment of shoulder disorders and have access to a full range of care. Our experienced team of physicians, certified physical therapists, and support staff all work together to help patients achieve success. In addition, our affiliated occupational and physical therapists are specially trained in rehabilitation of the shoulder and elbow prior to and after surgical reconstruction.