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Orthopedics

Reverse Total Shoulder Arthroplasty Requires Precision Good Indications

Curtis R. Noel, M.D., Co-Director, Cleveland Akron Shoulder & Elbow Fellowship, Orthopaedic Focus Winter 2011

Although not as common as total knee and total hip replacement surgery, total shoulder replacement surgery is a very successful procedure for those individuals suffering from shoulder arthritis. However, there are certain shoulder conditions that traditional total shoulder arthroplasty cannot treat. In 2004, Food and Drug Administration approved the reverse total shoulder, giving orthopaedic surgeons a powerful tool to treat many of these conditions. But enthusiasm must be tempered with good indications and precise techniques.

Reverse Total Shoulder ArthroplastyTraditional Shoulder Arthroplasty (figure 1)
The traditional or unconstrained total shoulder arthroplasty was initially developed in the 1950s.  Through the decades, its design has been refined so the current third generation of total shoulder replacements allows the surgeon multiple options to accurately recreate a patient’s normal anatomy. This unconstrained shoulder arthroplasty has proven to be a reliable and durable treatment option for glenohumeral arthritis, rheumatoid arthritis and avascular necrosis. But it requires that the patient’s rotator cuff be intact in order to give it stability and function. For patients who lack a functioning rotator cuff, a traditional total shoulder is contraindicated, and orthopaedic surgeons did not have a good treatment option for these patients prior to the advent of the reverse total shoulder.

Reverse Total Shoulder Arthroplasty 2Reverse Total Shoulder Arthroplasty (figure 2)
The current reverse or constrained total shoulder designs trace its roots back to Europe in the 1980s. Compared with traditional total shoulder arthroplasty, the reverse shoulder switches the ball from the humerus and places it onto the glenoid, where it becomes the glenosphere. The socket is then placed on the humeral side and becomes the humeral cup. When reduced, the humerus becomes constrained or locked underneath the glenosphere. This lowers and medializes the center of rotation of the shoulder improving the deltoid’s mechanical advantage to raise and rotate the arm.


Indications

Reverse Total Shoulder Arthroplasty 3

The reverse total shoulder was designed specifically to treat rotator cuff tear arthropathy (CTA). With CTA, the shoulder becomes unstable and arthritic because of the loss of rotator cuff function. Patients often present with pain and with loss of shoulder motion, especially active elevation, and when this loss is severe it is termed pseudoparalysis.

Radiographs will show arthritic changes in the joint along with superior migration of the humerus that narrows the normal distance between the acromion and the humeral head (figure 3). When conservative treatment fails, the reverse total shoulder can provide patients with reliable pain relief and improvement in shoulder function.

Reverse Total Shoulder Arthroplasty 4The reverse design brings the humerus down off the acromion and medializes the center of rotation allowing the deltoid to elevate and rotate the shoulder without the need for the rotator cuff (figure 4).

The indications for using the reverse total shoulder are expanding. Besides treating CTA, reverse total shoulder replacements are also helpful to treat shoulder fractures in the elderly, the third most common fracture in the elderly. Proximal humerus fractures can be difficult to treat and outcomes are not always that predictable with fixation or hemiarthroplasty.

The reverse provides us another option to help improve function in patients suffering from proximal humerus fractures, either initially or in revision situations. Similarly, for those who continue to have pain and loss of motion after unsuccessful shoulder surgeries, the reverse total shoulder may provide improved function and pain relief.

The reverse total shoulder is not without its complications, however. Some of these complications include dislocations, infections and scapular fractures. In addition, the longevity of the prosthesis is not fully known and, therefore, a reverse total shoulder is usually reserved for those over the age of 65.

For these reasons, the reverse total shoulder should only be used by physicians with extensive training and experience in shoulder arthroplasty surgeries according to the fairly narrow guidelines.

The reverse total shoulder is an exciting and powerful addition to the orthopaedic armamentarium, but its use should be restricted to those physicians with appropriate training and understanding of its indications.

Patients who were told in the past that there was no treatment for their current shoulder condition should consult with an orthopaedic shoulder surgeon to discuss the potential risk and benefits of a reverse total shoulder replacement.

The reverse total shoulder is an exciting and powerful addition to the orthopaedic armamentarium, but its use should be restricted to those physicians with appropriate training and understanding of its indications.

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