Reverse total shoulder replacement

Definition

Reverse total shoulder replacement is surgery to replace the damaged parts of the shoulder joint with artificial parts. This type of surgery may be used for people who cannot have regular shoulder replacement surgery or for whom the reverse approach may give a better result.

Alternative Names

Reverse total shoulder arthroplasty; Reverse replacement - shoulder; Reverse arthroplasty - shoulder

Description

You’ll receive anesthesia before surgery. Two types of anesthesia can be used:

• General anesthesia, which means you'll be unconscious and unable to feel pain.
• Regional anesthesia to numb your arm and shoulder area so you don't feel any pain in this area. You'll also be given medicine to help you relax during the operation.

The shoulder is a ball-and-socket joint. The round end of the arm bone fits into the curved surface at the end of the shoulder blade, called the socket. This type of joint allows you to move your arm in most directions.

For a total shoulder replacement, the replacement parts look like the parts of the body they are replacing:

• The round end of your arm bone is replaced with a rounded metal head (ball). The ball sometimes is supported by a stem that goes into the arm bone. It can be held in place with special cement to allow your bone to grow onto it.
• The socket part of your shoulder bone (glenoid) is replaced with a smooth plastic lining (socket) held in place with special cement.

In a reverse total shoulder replacement, the positions of the ball and socket are reversed. The surgeon will:

• Remove the round end of your arm bone and replace it with a socket tray and a stem that goes inside your arm bone.
• Replace the socket part of your shoulder bone (glenoid) with a round metal head (ball) with screws that go into your shoulder blade.
• Place a plastic liner onto the tray that fits in with the round metal head.

This surgery is usually performed when the rotator cuff tendons are severely damaged or there are certain fractures of the shoulder.

For a reverse total shoulder replacement, your surgeon makes a cut over your shoulder joint to open up the area. Then your surgeon:

• Removes the head (top) of your upper arm bone (humerus).
• Places the new metal ball into the shoulder socket. It is usually screwed into the shoulder blade.
• Inserts a tray onto the upper arm bone. The tray usually has a stem that goes into the arm bone that is secured with special cement to allow your bone to grow onto it.
• Locks a plastic liner in place above the tray to fit with the metal ball.
• Closes your incision with staples or sutures.
• Places a dressing (bandage) over your wound.

Your surgeon may place a tube in this area to drain fluid that may build up in the joint. The drain will be removed when you no longer need it.

This surgery normally takes 2 hours.

Why the Procedure Is Performed

A regular anatomic shoulder replacement relies on the rotator cuff to move the arm and shoulder. The muscles and tendons of the rotator cuff hold the ball and socket of the shoulder joint in place.

Reverse total shoulder replacement is usually performed when you have a rotator cuff tear and severe arthritis. With this surgery, the mechanics of the shoulder are changed and the deltoid muscles are now used to move the arm since the rotator cuff is badly damaged. The deltoid muscles cover the front, back, and sides of the shoulder.

Your surgeon also may recommend a reverse total shoulder replacement if you have:

• Had poor results from previous shoulder surgeries
• Very weak rotator cuff strength
• Severe shoulder pain when lifting your arm
• A badly broken bone in the shoulder
• Recurring shoulder dislocation
• A tumor in or around the shoulder

Your surgeon may recommend against this surgery if you have:

• A history of infection, which can spread to the replaced joint
• Severe mental health illness
• Unhealthy skin around the shoulder area
• Very weak (deltoid) muscles that can't be improved with surgery
• Injuries to your axillary nerve that connects to your deltoid muscle

Risks

Risks of anesthesia and surgery in general are:

• Reactions to medicines or breathing problems
• Bleeding, blood clot, or infection

Risks of shoulder replacement surgery are:

• Blood vessel damage during surgery
• Bone break during surgery
• Nerve damage during surgery
• Dislocation of the artificial joint
• Loosening of the implant over time

Before the Procedure

Tell your health care provider what medicines you are taking. This includes medicines, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

• You may be asked to stop taking blood thinners. These include aspirin, ibuprofen (Advil, Motrin), naproxen (Naprosyn, Aleve), warfarin (Coumadin), dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and clopidogrel (Plavix).
• Ask your surgeon which medicines you should still take on the day of your surgery.
• If you have diabetes, heart disease, or other medical conditions, your surgeon will ask you to see the provider who treats you for these conditions to ensure they're under control.
• Tell your surgeon if you've been drinking a lot of alcohol, more than 1 or 2 drinks a day.
• If you smoke, try to stop. Ask your provider for help. Smoking can slow wound and bone healing.
• Let your surgeon know right away if you get a cold, flu, fever, herpes breakout, or other illness before your surgery.

On the day of your surgery:

• You will likely be asked not to drink or eat anything for 6 to 12 hours before the procedure.
• Take the medicines your doctor told you to take with a small sip of water.
• Be sure to arrive at the hospital on time.

After the Procedure

• You may stay in the hospital for 1 to 3 days after your surgery.
• While there, you may receive physical therapy to help keep the muscles around your shoulder from getting stiff.
• Before you go home, the physical therapist will teach you how to move your arm by using your other (good) arm to help.
• Your arm will need to be in a sling for 2 to 6 weeks with no active movement.
• You may start strengthening your shoulder at the 3-month point. Total recovery will take around 4 to 6 months.
• Follow any instructions you're given about how to care for your shoulder at home. This includes activities that you should not do.
• You will be given instructions on shoulder exercises to do at home. Follow these instructions exactly. Doing the exercises the wrong way can injure your new shoulder.

Outlook (Prognosis)

Reverse total shoulder replacement surgery relieves pain and stiffness for many people. You should be able to resume most of your daily activities without much problem.

Your new shoulder joint will last longer if less stress is placed on it. With normal use, a new shoulder joint can last around 10 years.

References

American Academy of Orthopaedic Surgeons website. Reverse total shoulder replacement. orthoinfo.aaos.org/en/treatment/reverse-total-shoulder-replacement/. Last reviewed August 2022. Accessed May 2, 2023.

Duquin TR, Matsen FA, Lippitt SB, Rockwood CA, Wirth MA. Evaluation and management of glenohumeral arthritis. In: Matsen FA, Cordasco FA, Sperling JW, et al, eds. Rockwood and Matsen's The Shoulder. 6th ed. Philadelphia, PA: Elsevier; 2022:chap 60.

Throckmorton TW. Shoulder and elbow arthroplasty. In: Azar FM, Beaty JH, eds. Campbell's Operative Orthopaedics. 14th ed. Philadelphia, PA: Elsevier; 2021:chap 12.