Reverse Total Shoulder Replacement: Is It Right for You?

February 21, 2023 | Elbow & Shoulder, IBJI News Room

Q & A with Ryan Harold, MD, Orthopedic Surgeon Specializing in Shoulder & Elbow, and Hand Surgery

As advanced technologies continue to evolve, we now have treatments for shoulder conditions that previously couldn’t be fixed. One of the fastest-growing segments of shoulder surgery is reverse shoulder replacement, a two-decades-old method that has been proven to be a safe and effective shoulder replacement procedure.

According to research from the American Academy of Orthopedic Surgeons, this surgery was originally developed in 1985 in France by Paul Grammont. The Food and Drug Administration (FDA) approved its use in the U.S. in November of 2003, after extensive use in Europe.

Ryan Harold, MD estimates that there are around 80,000 total shoulder replacements performed each year in the U.S. Reverse total shoulder replacement surgery can be extremely beneficial for the right type of patient.

Read on to learn about this specialized surgery, how it differs from traditional shoulder replacement surgery, and who should consider a reverse total shoulder replacement.

What Is Reverse Total Shoulder Replacement?

Dr. Harold: It’s a complete replacement of the shoulder joint, much like a hip or knee replacement. In addition to completely replacing the shoulder joint it‘s a secure fit between the two implants. Because of that, it substitutes for the rotator cuff if needed.

Is a Functional Rotator Cuff Needed?

Dr. Harold: Not only does reverse shoulder replacement completely replace the shoulder joint, but it takes over the job that the rotator cuff does so you don’t need to have a functioning rotator cuff. It is important to note that patients may get better function when some of the rotator cuff is still working. It’s an amazing surgery that can do so much and take care of multiple problems at once for the right patient.

How Does It Work?

Dr. Harold: The normal shoulder joint has a ball on the arm side and a socket on the shoulder blade side. This is an unconstrained joint. This means that the normal shoulder slides around a little bit and it’s the rotator cuff and other supporting structures that keeps the ball centered in the socket.

The natural shoulder has a relatively small and shallow socket and it’s like a golf ball on a golf tee phenomenon: it’s easy to knock the golf ball off the tee if you bump into it. The rotator cuff keeps the ball centered on the socket, and issues can arise when these tendons are torn.

The reverse shoulder replacement reverses the configuration of the shoulder joint. It puts a much deeper socket on the arm bone side and it puts half of a sphere on the shoulder socket side. There’s a plastic liner that goes between and it serves like the new artificial cartilage. The deeper socket is stable and no longer requires the rotator cuff to function. However, it is important to note that patients may get better function when some of the rotator cuff is still working.

How Does This Reverse Shoulder Replacement Improve the Shoulder’s Function?

Dr. Harold: The really important thing is that this reversed configuration of the ball and socket fit together snugly and securely, much more so than the original shoulder.

Because they fit so well together and are so stable, you don’t need the rotator cuff to keep the shoulder stable. We always preserve all of the rotator cuff tendons that are still present, but there are people who come in and nearly all of their rotator cuff tendons are torn; that’s where this implant becomes really important.

Does This Surgery Change Shoulder Mechanics?

Dr. Harold: The reverse shoulder replacement really changes the biomechanics of the shoulder so that the big strong deltoid muscle now becomes the main muscle that lifts the arm and it takes over some of the function that the rotator cuff used to do.

Who Is a Good Candidate for This Surgery?

Dr. Harold: The most common reason to have a reverse shoulder replacement is something called cuff tear arthropathy, which is shoulder arthritis that has developed as a result of a long-standing large rotator cuff tear.

It can be someone who previously had an acute traumatic rotator cuff tear after something like a fall and elected to not have it previously fixed, or a rotator cuff tear that has slowly occurred over time.

If a shoulder has a very large rotator cuff tear, it can go down a very predictable pathway that can turn into cuff tear arthropathy – a specific form of shoulder arthritis. This is a great indication for reverse shoulder replacement surgery.

When a patient has cuff tear arthropathy, it drastically impacts their shoulder. These patients are in a lot of pain. Their shoulder hurts all of the time and when they try to use it, it’s even worse. When you meet someone who has this, it interferes with every aspect of their life – their sleep, activities at home, time with family, hobbies, work, etc. For that reason, this surgery can be life-changing. It drastically changes their pain level and function. It’s really a very satisfying surgery to perform, because of the positive impact you can have on someone’s life.

Figure above: Shoulder x-rays from a 64 year old male patient of Dr. Harold’s that had a reverse total shoulder replacement.

Figure above: Shoulder x-rays from a 76 year old female patient of Dr. Harold’s that had a reverse total shoulder replacement

Does this surgery require a stay overnight in a hospital?

Dr. Harold: This surgery can be done as an outpatient in select patients. That means you go back home on the same day of surgery. However, many patients stay overnight in the hospital and go home around noon the following day.

What Anesthesia Is Used?

Dr. Harold: Most patients will get a nerve block which is an injection in the neck area that numbs the shoulder and the whole arm. When they wake up from anesthesia, they usually don’t have any pain. That typically lasts around 18 hours. After that, they use pill medications for pain control. Anesthesia and our ability to manage pain has made great advances in the past several decades, which helps a lot in the recovery after surgery.

Where Is This Performed as an Outpatient Procedure?

Ravine Way Surgery Center in Glenview or ISMOSC in Morton Grove.

Figure above: This is an example preoperative plan for a patient of Dr. Harold’s with cuff tear arthropathy (which is the combination of shoulder arthritis and a massive rotator cuff tear). This patient had bone wear and loss, which required a special implant to make up for this bone loss. The images above are planning the shoulder socket side of the replacement, which is done prior to surgery to help accurately plan the procedure.

Figure above: This image shows planning the arm bone (humerus) side of the reverse shoulder replacement. This is done prior to surgery and helps accurately plan the procedure.

What Can a Patient Expect Prior to Surgery?

Dr. Harold: They have to see their primary care physician within 30 days of surgery. There are specific lab tests needed. They also need to get a CT scan of their shoulder. The CT scan is used to generate a special 3D model of their shoulder for preoperative planning. This allows the entire surgery to be done virtually ahead of time and precisely plan out many of the details of surgery.

Figure above: This shows both of the two reverse shoulder replacement implants put together. The software then simulates moving the arm and predicts shoulder range of motion. This enables Dr. Harold to evaluate how much the shoulder will move after surgery, and importantly identify and correct any potential issues ahead of time.

What is Required After Surgery to be Safely Discharged Home?

Dr. Harold: Once their pain is controlled, they’re eating and drinking, up and walking, and able to go to the bathroom, then they can go home. This is usually the same day or the next day.

What Is At-Home Treatment Like?

Dr. Harold: Patients are in a sling for three weeks following surgery, and they’re not doing anything with their shoulder. They are taking the sling off three times per day to work on their range of motion with their elbow, wrist, and hand – so these joints keep moving and don’t get stiff. Eating a healthy, well balanced diet after surgery and getting up and walking many times a day is encouraged to stay active.

When Does Physical Therapy Start?

Dr. Harold: Physical therapy starts three weeks after surgery and goes along with when they discontinue thier sling. Physical therapy can typically last for several months, depending on the needs of the patient.

How Does Recovery Compare to Rotator Cuff Surgery?

Dr. Harold: There’s less physical therapy required for a reverse shoulder replacement than a rotator cuff repair surgery. These are really two completely different procedures with two very different recoveries. Many people know someone that has had a rotator cuff repair – a shoulder replacement is very different. Patients are typically in physical therapy for around three or four months after a reverse shoulder replacement, whereas that can be closer to six months after a cuff repair. Rotator cuff repair is also often associated with more discomfort after surgery, as compared to a shoulder replacement.

Many patients, when they think of shoulder surgery, are most familiar with a rotator cuff repair and that recovery can be intimidating. The recovery after shoulder replacement is not fast, but it’s faster than a cuff repair and it’s not easy, but it’s easier than a cuff repair.

How Do Patients Sleep Following Reverse Shoulder Surgery?

Dr. Harold: Patients can sleep however they are comfortable, but most are comfortable sleeping somewhat upright in a recliner or with something called a wedge pillow with the back partly elevated. On average, they may be more comfortable sleeping this way for around six weeks. Some can sleep flat sooner, some a little bit later.

Why Would Someone Need Reverse Total Shoulder Replacement Surgery vs Another Shoulder Procedure?

Dr. Harold: For many patients, this would be the best option for them but there are some people where there may be multiple options. It’s always an individualized decision along with the patient after we talk about all of the options and pros and cons of each. Ultimately the treatment plan has to match up with what the patient is looking for, their goals, and expectations. Each surgical plan is always individualized.

Does Dr. Harold Perform Other Types of Shoulder Replacements?

Dr. Harold: I offer the full range of shoulder reconstruction options. This includes minimally invasive arthroscopic options such as rotator cuff repair, re-do or revision rotator cuff repair, rotator cuff repair with allografts to make up for tissue (tendon) loss. I also offer other options, such as arthroscopically-assisted lower trapezius tendon transfer, latissimus dorsi tendon transfers, pectoralis major tendon transfer, and other less common procedures. In terms of shoulder replacement, I perform both anatomic and reverse shoulder replacement, as well as re-do (revision) shoulder replacement. Although we are discussing and focusing on reverse shoulder replacement today, about half of the shoulder replacements I do are what is called an anatomic shoulder replacement. This surgery too is a great option for the right patient.

Is There Specialized Training for This Procedure?

Dr. Harold: Shoulder and elbow surgery fellowship is the training that focuses on shoulder replacement, complex shoulder surgery, and revision or re-do shoulder replacement surgery.

Is Any Advanced or Custom Surgical Planning Used?

Dr. Harold: I obtain a CT scan of the shoulder of nearly every patient that is having a shoulder replacement. That CT scan is used to build a 3D model of the shoulder, which is then imported into a specialized software to allow customized surgical planning for each individual patient. The software allows selecting the best size and combination of implants for each patient. It also allows precise measurement of any bone wear of deformity, so that it can be corrected during surgery. It also allows me to look at the range of motion of the shoulder, identify any potential issues, and overall provide a more precise surgery. In some cases, I will order custom 3D printed implants or custom 3D printed guides for a patient, if needed for cases of extreme bone loss or revision (re-do) surgery. (see the 3 images above for a sample patient’s shoulder imported into the software for surgical pre-operative planning)

How Successful Is This Surgery?

Dr. Harold: Patients who are in a lot of pain before surgery say that their arthritic pain is typically gone by the time I see them in the office 10-14 days after surgery. At that point, they have some discomfort from the surgery itself which is usually improving day by day and week by week. They generally report that they can do many activities around the house at six weeks, especially lighter activities. They are usually still working on improving shoulder range of motion with physical therapy.

At three months when I see them, they generally report that their function is good or very good, pain is usually low or very low, and physical therapy is usually close to completed. I tell them that at 3 months they are around 75-80% recovered, and that the last 20-25% of improvement will happen slowly on its own over the next 9 months.