Reverse Shoulder Replacement

An older man holding his shoulder in pain.

Total shoulder replacement surgery is a proven way to relieve pain and stiffness in advanced shoulder arthritis or to treat a severe shoulder fracture. But for some people who have a current or prior rotator cuff injury, a traditional shoulder replacement may not be optimal. For these patients, a special procedure known as a reverse total shoulder replacement is often the best option.

What is a reverse total shoulder replacement?

A reverse total shoulder replacement is a surgical procedure used to treat severe shoulder problems. The surgery involves removing the damaged parts of the shoulder joint and replacing them with a specially designed artificial joint. This surgery is different from a regular shoulder replacement and is typically recommended for people who have certain shoulder conditions, such as massive rotator cuff tears. This new joint allows the shoulder to move more effectively, even if the rotator cuff muscles are not working properly.

What is the difference between reverse shoulder replacement and regular shoulder replacement?

The main difference is how the artificial joint is positioned in the shoulder. In a regular shoulder replacement (called an anatomic shoulder replacement), the damaged parts of the shoulder joint – the ball and socket – are replaced with artificial ones in the same positions as the natural joint. In a reverse shoulder replacement, the positions of the ball and socket are switched. The artificial ball is attached to the socket side of the joint and the artificial socket is placed where the natural ball used to be.

By reversing the positions of the ball and socket, the surgery allows different muscles to take over the function of the damaged ones, improving the shoulder's movement and stability. This changes how the shoulder rotates at its center and utilizes different muscles, such as the deltoid, to provide better stability and movement, especially for individuals with compromised rotator cuff muscles or complex shoulder conditions.

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X-ray showing severe arthritis of the shoulder area with complete tear of the rotator cuff. X-ray after reverse shoulder replacement.
Figure 5 (left) X-ray showing severe arthritis of the shoulder area with complete tear of the rotator cuff. Figure 6 (right) Postsurgical X-ray after replacement using the Comprehensive Reverse Shoulder System designed by HSS surgeons.

Video: Reverse shoulder replacement animation

What type of implant is used for reverse shoulder replacement?

  1. In a reverse shoulder replacement, the implant consists of two main components: The glenosphere and the humeral component.
  2. The glenosphere is the artificial ball component. It is made of metal – usually a metal alloy or titanium – and has a smooth surface to allow it to move freely. It replaces the damaged natural socket (glenoid) of the shoulder joint.

The humeral component is the artificial socket. and it is made of a durable plastic material called polyethylene. This component replaces the damaged natural ball – the humeral head (head of the humerus bone) – of the shoulder joint.

The materials used for the implant components are typically durable and biocompatible, meaning they are well-tolerated by the body and can withstand the stresses of everyday activities. Orthopedic surgeons choose the appropriate size and type of implant based on the patient's specific shoulder anatomy and the severity of their shoulder condition.

Who is a good candidate for reverse shoulder replacement?

Conventional shoulder replacement is commonly used for people with problems like arthritis or injury to help reduce pain and improve movement. A reverse shoulder replacement is usually recommended for people who have more complex shoulder issues. Some common indications for a reverse shoulder replacement include: a massive rotator cuff tear or arthropathy, a failed previous replacement or a complex fracture.

Massive rotator cuff tears

If a person has a large and irreparable tear in the rotator cuff, it can lead to significant pain and loss of shoulder function. In such cases, a reverse shoulder replacement may be considered as it relies on different muscles (such as the deltoid) to move the arm, rather than the damaged rotator cuff muscles.

Rotator cuff arthropathy

This is a condition where there is both a massive rotator cuff tear and arthritis in the shoulder joint. Reverse shoulder replacement is often chosen for patients with this condition because it can address both problems and provide pain relief and improved function.

Failed previous shoulder replacement

If a previous shoulder replacement has been unsuccessful or has led to complications, a reverse shoulder replacement might be recommended as an alternative solution.

Complex fractures

In some cases of severe shoulder fractures that cannot be repaired using conventional methods, a reverse shoulder replacement may be considered.

It's essential for individuals considering this surgery to undergo a thorough evaluation by an orthopedic surgeon to determine if they are a suitable candidate for a reverse shoulder replacement. Factors like the individual's overall health, age, bone quality, and shoulder function will be taken into account to make an informed decision about the most appropriate treatment option. As with any surgery, there are risks and benefits, and the decision should be made collaboratively between the patient and their medical team.

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Who is not a good candidate for reverse shoulder replacement?

While reverse shoulder replacement can be beneficial for many individuals with specific shoulder conditions, there are certain situations where it may not be the most suitable option. Individuals who have good rotator cuff function, an active infection, severe osteoporosis, poor general health, or unrealistic expectations for the outcome may not be good candidates for a reverse shoulder replacement.

Good rotator cuff function

If the rotator cuff muscles are functioning relatively well and can adequately move the arm, a reverse shoulder replacement may not be necessary. In such cases, a regular shoulder replacement can be considered, if the patient has painful arthritis and a functional rotator cuff. Or, other less invasive treatments may be more appropriate in patients who have not tried more conservative treatments.

Active infections

Active infections in the shoulder joint or surrounding tissues can increase the risk of complications after surgery. Infections need to be treated and resolved before considering any joint replacement procedure.

Severe osteoporosis

Severe osteoporosis or significant bone loss in the shoulder area may compromise the ability to anchor the artificial components securely. In such cases, the stability of the implant might be compromised, leading to an increased risk of failure or increased risk of a stress fracture around the shoulder blade.

Poor general health

Individuals with other serious medical conditions that make surgery risky or difficult to recover from (such as severe heart or lung disease) may not be good candidates.

Unrealistic expectations

Patients who have unrealistic expectations about the outcome of the surgery or those who are not committed to participating in postsurgical rehabilitation and physical therapy may not be suitable candidates.

What are the potential risks of reverse shoulder replacement?

Reverse shoulder replacement, like any surgical procedure, carries certain risks and potential complications. Some of the potential risks associated with a reverse shoulder replacement include: infections, implant loosening or dislocation, shoulder fracture, persistent pain, limited range of motion, allergic reaction to a prosthesis, nerve or blood vessel damage, and anesthesia-related complications.

Infection

There is a risk of infection at the surgical site, which can lead to pain, swelling, and, in severe cases, may require additional treatment or even revision surgery.

Implant loosening or dislocation

The artificial components used in the reverse shoulder replacement can potentially loosen or dislocate over time. This may cause instability and affect the functioning of the shoulder joint. This often may require revision surgery to address this.

Fracture

Fractures can occur around the implant site or around the shoulder blade during or after the surgery, especially in individuals with weaker bones or compromised bone structure.

Persistent pain

Some patients may experience persistent pain or discomfort following the surgery, which may require further evaluation and management.

Limited range of motion

While reverse shoulder replacement can improve shoulder function, some patients may still have limitations in their range of motion, particularly in certain directions like behind the back.

Allergic reaction

In rare cases, patients may experience an allergic reaction to the materials used in the implant.

Nerve or blood vessel injury

During the surgery, there is a slight risk of damaging nearby nerves or blood vessels, which can lead to weakness, numbness, or circulation problems in the arm. Surgery also increases the risk of developing blood clots, which can be dangerous if they travel to other parts of the body, causing blockages. This risk is higher in people who have a prior history of blood clots or a family history of blood clots.

Complications with anesthesia

General anesthesia carries its own set of risks, including adverse reactions and breathing difficulties.

It's important to note that while these risks exist, many people undergo reverse shoulder replacement successfully with positive outcomes and without complications. The decision to proceed with the surgery should be made after thorough discussions with the patient’s orthopedic surgeon, who will carefully assess the patient’s overall health and specific shoulder condition and weigh the potential risks against the benefits of the procedure.

How long does it take to recover from reverse shoulder replacement?

The recovery time for a reverse shoulder replacement can vary depending on several factors, including the individual's age, overall health, the extent of the shoulder damage, and their commitment to post-operative rehabilitation. Both anatomic and reverse shoulder replacements require rehabilitation afterward to regain strength and mobility in the shoulder.

Generally, the recovery process can be broken down into several phases:

  1. Hospital stay: After reverse shoulder replacement, patients typically stay in the hospital overnight for one night for close monitoring and initial recovery.
  2. Early recovery (1 to 6 weeks): During the first few weeks after surgery, patients focus on pain management, wound healing, and gradually regaining shoulder movement. Physical therapy sessions are started to improve range of motion and strengthen the surrounding muscles.
  3. Mid recovery (6 weeks to 3 months): At this stage, patients continue with physical therapy to enhance shoulder strength, stability, and mobility. They may start using the arm for everyday activities with some restrictions and gradually increase their activity level.
  4. Late recovery (3 to 6 months): Around three months post-surgery, many patients experience significant improvement in shoulder function. Physical therapy, which can include home exercises, typically intensifies, focusing on building muscle strength and coordination for more complex movements and functional activities.
  5. Full recovery (6 to 12 months): By six months to a year after the surgery, most patients have achieved a significant recovery and can perform daily tasks with improved shoulder function. However, full recovery can continue beyond the one-year mark, with ongoing improvements in strength and range of motion.

It's important to note that individual recovery times can vary, and some people may take longer to reach their maximum potential. In order to maximize recovery potential, patients should adhere to the recommended rehabilitation program and follow the advice of the medical team. During the recovery period, patients should avoid heavy lifting, high-impact activities, and movements that put excessive strain on the shoulder joint. Following the surgeon's and physical therapist's instructions is essential to ensure a successful outcome and minimize the risk of complications.

What is the success rate of reverse shoulder replacement?

The success rate of reverse shoulder replacement is generally high, with many patients experiencing significant improvement in pain relief and shoulder function. The procedure has been particularly successful in treating certain shoulder conditions, such as massive rotator cuff tears and rotator cuff arthropathy, where traditional shoulder replacements may not provide satisfactory results.

The success rate can vary depending on factors such as the patient's age, overall health and the specific shoulder condition being treated. However, research and clinical studies have shown favorable outcomes for many patients who undergo reverse shoulder replacement. According to some studies, the long-term survival rate of reverse shoulder replacements is around 85% to 90% at 10 years after the surgery. “Survival rate” means that the implant is still functioning well in the majority of patients at that time point. Newer advancements in implant design and surgical techniques continue to improve outcomes and longevity. Patient satisfaction rates after reverse shoulder placement have been reported as high as 90% to 95% at 10 years after their shoulder replacement.

What are the limitations after reverse shoulder replacement?

After a reverse shoulder replacement, patients may experience certain limitations, especially during the initial stages of recovery. These limitations can vary depending on individual factors such as the patient's age, overall health, the specific shoulder condition being treated, and the success of the surgery. Some common limitations include:

  1. Limited range of motion: While a reverse shoulder replacement can improve shoulder function, some patients may still experience limitations in their range of motion, particularly in certain directions. It may take time and consistent physical therapy to regain full shoulder mobility and, sometimes, complete restoration of range of motion may not be achieved.
  2. Weight restrictions: Patients are often advised to avoid heavy lifting or activities that put excessive strain on the shoulder joint, especially during the early stages of recovery. Following the surgeon's weight restrictions is essential to prevent potential complications or implant damage.
  3. Strength and endurance: It can take several months to regain full shoulder strength and endurance after the surgery. Physical therapy and exercises are essential to help build and strengthen the surrounding muscles gradually.

It's important for patients to have realistic expectations about the limitations and recovery process after reverse shoulder replacement. Working closely with the orthopedic and physical therapy team, adhering to postoperative instructions, and maintaining a healthy lifestyle can help optimize the outcomes and minimize potential limitations. Each patient's experience is unique, and regular follow-up appointments with their orthopedic surgeon can address any concerns and ensure that the recovery is progressing as expected.

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Dr. Gabriella Ode is a board certified orthopedic surgeon specializing in sports medicine and shoulder surgery in the HSS Sports Medicine Institute with offices in Manhattan and Brooklyn. Her clinical practice specializes in shoulder and knee arthroscopy injuries. Dr. Ode has a particular interest in women's sports medicine and is a team orthopedic surgeon for the New York Liberty of the WNBA.

Authors

Gabriella E. Ode, MD
Assistant Attending Orthopedic Surgeon, Hospital for Special Surgery
Assistant Professor of Orthopedic Surgery, Weill Cornell Medical College

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References

  • Brusalis CM, Taylor SA. Periprosthetic Fractures in Reverse Total Shoulder Arthroplasty: Current Concepts and Advances in Management. Curr Rev Musculoskelet Med. 2020 Aug;13(4):509-519. doi: 10.1007/s12178-020-09654-8. PMID: 32506260; PMCID: PMC7340687.
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  • North D, Hones KM, Jenkins P, Sipavicius E, Zermeño Salinas JL, Hao KA, Schoch BS, Wright TW, Gulotta LV, King JJ. How common is nerve injury after reverse shoulder arthroplasty? A systematic review. J Shoulder Elbow Surg. 2023 Apr;32(4):872-884. doi: 10.1016/j.jse.2022.10.022. Epub 2022 Nov 24. PMID: 36427756.
  • Rauck RC, Swarup I, Chang B, Ruzbarsky JJ, Dines DM, Warren RF, Henn RF 3rd, Gulotta LV. Preoperative patient expectations of elective reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2019 Jul;28(7):1217-1222. doi: 10.1016/j.jse.2018.12.008. Epub 2019 Mar 20. PMID: 30904239.
  • Rossi LA, Tanoira I, Ranalletta M, Kunze KN, Farivar D, Perry A, Chahla J. Cemented vs. uncemented reverse shoulder arthroplasty for proximal humeral fractures: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022 Mar;31(3):e101-e119. doi: 10.1016/j.jse.2021.10.011. Epub 2021 Nov 2. PMID: 34737086.

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