In a “standard” total shoulder replacement, the head (the “ball”) and the glenoid (the “socket”) are replaced so as to mimic the normal anatomy and biomechanics of the glenohumeral joint. More specifically, the humeral head is replaced with a metal implant made of cobalt, chromium or titanium alloys, fixed (either press-fit or cemented) by means of a stem, mimicking the natural head. The articular surface of the glenoid is replaced with a plastic insert (polyethylene), which in turn mimics the size, shape and anatomy of the natural glenoid. This operation is indicated for patients with severe shoulder osteoarthritis but normal rotator cuff function.
Image: The “standard” total shoulder replacement, with the polyethylene insert for the glenoid and the cobalt-chromium alloy prosthesis for the humerus.
Reverse total shoulder replacement is a newer prosthesis that uses a “non-anatomical” philosophy to replace the joint in patients who suffer from severe osteoarthritis and poor rotator cuff function after massive tears, among other causes. In addition, this type of prosthesis can be used to replace a total shoulder replacement after complications such as loosening or infection, or finally for complex fractures in elderly patients that cannot be treated by internal fixation because of bone loss and the poor quality of the remaining bone.
Image: Prostheses from various manufacturers are available, depending on the surgeon’s preference. As shown, the polyethylene is placed on the humeral side, while the “metal ball” is placed on the glenoid.
How does reverse total shoulder replacement work?
Reverse total shoulder replacement was developed in the 1980s in France by Paul Grammont. While it was successful in Europe, it could not be used in the United States until it was approved by the Food and Drug Administration (FDA) in 2004.
In the normal shoulder, the rotator cuff muscles help hold the humeral head on the glenoid by providing a force directed towards the centre of the joint. This force counterbalances the upward force exerted on the shoulder by the deltoid.
The rotator cuff muscles support the elevation and rotation of the shoulder. In patients with rotator cuff damage (e.g. a massive tear), the deltoid muscle pulls the humeral head upwards and off the glenoid, making it impossible to raise the arm. This condition can lead to arthritic changes with specific features (“rotator cuff arthropathy”).
Image
1. Normal anatomy of the rotator cuff: subscapularis (at the front), supraspinatus, infraspinatus and teres minor. These muscles and their tendons keep the head centred on the glenoid.
2. After a rotator cuff tear, as shown on MRI, the patient has difficulty raising and abducting the arm. The tear can cause local irritation and inflammation, with pain on movement. On the MRI, the red arrow shows the fluid replacing the retracted tendon (blue arrow).
3. The humeral head shifts upwards because of the loss of the compressive force normally exerted by the rotator cuff. The X-ray shows the upward migration of the head.
In reverse total shoulder replacement, the humeral head (the ball) is replaced with a concave surface (polyethylene), while the glenoid socket is replaced with a metal ball. This creates a stable fulcrum, so that the patient can use the deltoid to raise the arm without the help of the rotator cuff. The prosthesis is fixed in place with screws on the glenoid side, and with cement or a press-fit stem on the humeral side.
Why can the “standard” or “conventional” total shoulder replacement not be used in some patients?
In some patients, the rotator cuff tendons have suffered a massive tear that cannot be repaired, mainly because of poor tissue quality or because of retraction and degeneration due to the long-standing nature of the damage. Irreparable rotator cuff damage often results from a chronic tear and failed surgical repair, from a fracture or from a failed total shoulder replacement, and must be treated differently.
Image: The X-ray shows the prosthesis (the humeral component) shifted towards the acromion (upwards) because of rotator cuff insufficiency. The purple dashed line shows where the centre of the head should normally be, while the red dashed line shows the actual position of the head.
Pre-operative assessment
Once the decision for surgery has been made, a detailed medical history should be taken, followed by a cardiology and anaesthetic assessment. In most cases a CT or MRI scan is performed before the operation. Finally, it is important to tell the surgeon about any skin infection, any shortness of breath or chest pain.
Surgery and hospital stay
Depending on the case and the surgeon’s preference, the patient receives regional anaesthesia (a nerve block) for additional pain relief. The operation is performed under general anaesthesia and usually takes two hours, but depending on the case it may take longer. This applies mainly to replacement surgery after a failed total shoulder replacement (revision). However, the total time in the operating theatre is longer if the whole process is taken into account (from anaesthesia to the patient’s recovery).
The patient then stays in hospital for about 2–3 days and is discharged depending on the case. The recovery time is determined mainly by the surgeon and the physiotherapist. During the hospital stay, strong painkillers are given intravenously, and after discharge they are taken by mouth. Some patients stop taking medication as early as the first week.
Finally, some patients will need a blood transfusion during or after surgery, depending on the case.
Post-operative course
After meeting the physiotherapist, the patient begins an intensive physiotherapy programme during the first 2 to 6 weeks after the operation. Initially, the patient starts with exercises to restore the shoulder’s range of motion, while strengthening exercises begin 8 weeks after surgery.
During rehabilitation the patient visits the surgeon to make sure progress is as expected.
In addition, the patient should be aware that during the first weeks after the operation they will not be able to look after themselves fully, and should prepare accordingly by letting family or friends know.
Finally, it is advisable for the patient to be followed up by their surgeon every year, or at least every two years.
Long-term results
A large number of patients may have the appropriate indications for reverse total shoulder replacement.
As mentioned above, the strongest indication concerns patients over 70 years of age with severe osteoarthritis and rotator cuff insufficiency. Rarely, it may be used in younger patients, but only as a salvage procedure and when there is no other treatment option to relieve pain and improve joint function.
Reverse shoulder replacement is considered a salvage procedure for young patients with high expectations and demands, because some important limitations apply. All patients are advised not to use the operated arm for high-demand activities, such as weightlifting, carpentry or contact sports. In general, patients should avoid strenuous activities with that arm to prevent early wear of the implant. Limiting activities therefore helps the prosthesis last longer. However, activities such as golf seem to be tolerated quite well.
Contraindications – who should not have a reverse shoulder replacement?
A basic requirement for a successful reverse total shoulder replacement is a functioning deltoid muscle. Patients with nerve damage (particularly of the axillary nerve) or patients who have had previous surgery are not good candidates, since the function of the muscle is not guaranteed.
In addition, patients with severe glenoid bone loss are not good candidates for reverse shoulder replacement, since there may not be enough bone for secure fixation of the glenoid component (the glenosphere). These are usually patients who have had previous operations, or cases of congenital hypoplasia or deformity of the glenoid.
Finally, patients with active infections are not candidates for any joint replacement surgery with prosthetic implants. Only after several months, once the infection has been completely eradicated, can the patient undergo joint replacement.
Alternative options
A limited number of studies have shown that hemiarthroplasty can benefit elderly patients with arthritis and a non-functioning rotator cuff, or patients whose joint replacement operations have failed. Hemiarthroplasty is intended for low-demand patients with poor glenoid bone quality and for cases where every other joint replacement procedure has failed.
The “final” alternative is resection arthroplasty, i.e. removal of all the prosthetic components without replacing them, allowing scar tissue to form. This is a limb-salvage procedure and a “last resort” that is performed very rarely.
Selected references
- Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. The Journal of Bone and Joint Surgery 2007;89:1476–1485.
- Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 2006;88:1742–1747.
- Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Molé D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br 2004;86:388–395.
- Favard L, Levigne C, Nerot C, Gerber C, De Wilde L, Mole D. Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time? Clin Orthop Relat Res 2011;469:2469–2475.
- Melis B, DeFranco M, Lädermann A, Molé D, Favard L, Nérot C, Maynou C, Walch G. An evaluation of the radiological changes around the Grammont reverse geometry shoulder arthroplasty after eight to 12 years. J Bone Joint Surg Br 2011;93:1240–1246.
- Nolan BM, Ankerson E, Wiater JM. Reverse total shoulder arthroplasty improves function in cuff tear arthropathy. Clin Orthop Relat Res 2011;469:2476–2482.
- Roy J-S, Macdermid JC, Goel D, Faber KJ, Athwal GS, Drosdowech DS. What is a Successful Outcome Following Reverse Total Shoulder Arthroplasty? Open Orthop J 2010;4:157–163.
- Austin L, Zmistowski B, Chang ES, Williams GR. Is reverse shoulder arthroplasty a reasonable alternative for revision arthroplasty? Clin Orthop Relat Res 2011;469:2531–2537.
- Boileau P, Chuinard C, Roussanne Y, Bicknell RT, Rochet N, Trojani C. Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm. Clin Orthop Relat Res 2008;466:584–593.
- Cazeneuve J-F, Cristofari D-J. The reverse shoulder prosthesis in the treatment of fractures of the proximal humerus in the elderly. J Bone Joint Surg Br 2010;92:535–539.
- Sadoghi P, Vavken P, Leithner A, Hochreiter J, Weber G, Pietschmann MF, Müller PE. Impact of previous rotator cuff repair on the outcome of reverse shoulder arthroplasty. J Shoulder Elbow Surg 2011;20:1138–1146.
- Riedel BB, Mildren ME, Jobe CM, Wongworawat MD, Phipatanakul WP. Evaluation of the Learning Curve for Reverse Shoulder Arthroplasty. Orthopedics 2010:237–241.
- Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. The Journal of Bone and Joint Surgery 2010;92:2544–2556.
Reverse total shoulder replacement
Professor Salmas was one of the first specialist shoulder surgeons in Athens when, in 1998, he returned from fellowships in Zurich, Switzerland, with the leading shoulder surgeon Christian Gerber, and in Boston with JP Warner, Professor at Harvard University and head of the shoulder service at Mass General Hospital. In those early years, the Professor’s practice was a referral centre for shoulder conditions.
In the early 2010s, Professor Salmas was one of the first to operate, with great success, on patients with a massive irreparable rotator cuff tear and pseudoparalysis using reverse total shoulder replacement.
Since then he has operated on dozens of patients with this procedure, with steadily improving results and a satisfactory return to their everyday activities. He has given a series of lectures on reverse total shoulder replacement.
But let us look at what reverse total shoulder replacement is.
How does reverse total shoulder replacement work?
Image
Surgery and hospital stay
Patients will not need a blood transfusion during or after surgery.
The doctor will examine your case and recommend the right treatment.
Request an appointment210 7793103Frequently asked questions
Reverse total shoulder replacement: frequently asked questions
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Why is it called “reverse”?
Because the normal anatomy is reversed: the ball is placed on the shoulder blade and the socket on the humerus. This allows the deltoid muscle to lift the arm even when the rotator cuff tendons have been destroyed.
Will I be able to raise my arm above my head?
Most patients regain a significant amount of arm elevation and are relieved of pain. The final range of motion depends on the condition of the muscles before the operation.
Patient cases
Patients with reverse total shoulder replacement
Severe shoulder osteoarthritis with a rotator cuff tear – reverse total shoulder replacement
Reverse total shoulder replacement – 1 month after surgery
Shoulder osteoarthritis with a massive rotator cuff tear and humeral shaft fracture – treated with reverse total shoulder replacement and humeral fixation
Reverse total shoulder replacement for rotator cuff tear arthropathy after a massive tear
Reverse total shoulder replacement after a failed repair of a massive rotator cuff tear
Shoulder osteoarthritis with a massive tendon tear – reverse shoulder replacement, 3 months on
Reverse total shoulder replacement – 8 months after surgery
Reverse total shoulder replacement – 6 months after surgery
Reverse total shoulder replacement – 2 weeks after surgery
Pseudoparalysis of the arm from a massive irreparable rotator cuff tear – reverse shoulder replacement
Large (massive) rotator cuff tear (supraspinatus and infraspinatus tendons) – irreparable rotator cuff – treated with reverse shoulder replacement
Appointment
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The doctor will examine your case and explain your treatment options in detail.