Shoulder Surgery

Reverse Shoulder Replacement

Reverse Shoulder Replacement

Reverse shoulder replacement is ideal for patients with cuff tear arthritis and advanced shoulder joint arthritis with significant glenoid wear. Many patients with shoulder arthritis can be managed without surgery; however, when nonoperative treatment has been exhausted surgery is a reliable option to restore function and relieve pain.

The latest advances with 3D planning and printing, computer navigation, and patient-specific instrumentation allow for accurate placement of components leading to improved outcomes for patients.

A reverse shoulder replacement involves replacing the arthritic shoulder joint surfaces with a highly polished metal ball on the socket side (glenoid) and a plastic socket on the arm side (head of the humerus). 

Essentially the abnormal surfaces (where the cartilage has worn away resulting in arthritis) are removed and replaced with a prosthesis (artificial joint). The normal anatomical arrangement and biomechanics of the shoulder are reversed – hence this is called a reverse shoulder replacement. The greatest advantage of the reverse shoulder replacement is that it does not require an intact rotator cuff to function; however, it does require a well functioning deltoid muscle. 

A reverse shoulder replacement is used for those who have:

  • Massive rotator cuff tendon tears that are irreparable
  • Established cuff tear arthritis (where the ball sits under the acromion)
  • Previous failed rotator cuff repair with significant loss of function
  • Severe osteoarthritis causing abnormal glenoid wear pattern and bone loss
  • Complex fracture and/or dislocation of the shoulder in older patients

 

Medical diagram showing the components involved in a reverse shoulder replacement

Medical diagram showing a reverse shoulder replacement

The decision to have shoulder replacement surgery is unique to each patient. It is a shared decision between you (patient), your family, your local doctor, and your orthopaedic shoulder surgeon. 

There are several reasons why you may be a good candidate and be recommended a shoulder replacement: 

  • Severe shoulder pain that interferes with activities of daily living, such as self-care, shopping, dressing, toileting, reaching up to shelf, and driving
  • Moderate to severe pain at rest; night pain waking you from sleep on a regular basis
  • Loss of motion and/or shoulder weakness leading to loss of independence 
  • Failure of nonoperative treatment to manage your pain

Computer navigation and 3D planning has revolutionised shoulder replacement surgery. It provides improved accuracy and precision during surgery. 

Dr Pant will upload your recent CT scan to a special planning software. Then 3D measurements are taken of your shoulder, the exact wear pattern is analysed, and the correction is planned and the “virtual” prosthesis can be implanted on the computer. 

Essentially the shoulder replacement is done on the computer first. Once Dr Pant is happy with the position of the implants, then custom patient-specific instruments are ordered (from the prosthesis company) for the day of surgery. Because the operation has already been done virtually, most of the workflow during the case is more efficient and predictable; surgery time and blood loss is reduced, and the implant position is more accurate and reproducible, leading to better functional results.

Image showing the computer technology used to plan and perform a total shoulder replacement.

  • The procedure is performed under a General Anaesthetic where you will be positioned on your back
  • Using the pre-operative x-rays and CT scan is carefully reviewed 
  • Using 3D planning software the operation is performed virtually on the computer and Patient Specific Instruments (PSI) is organised. 
  • On the day of surgery – most of the components that will be required have already been selected to streamline your operation. 
  • A 7-10cm incision is made over the front of the shoulder and the shoulder joint arthritis identified
  • The biceps tendon is released from the shoulder joint and later re-anchored to the pectoralis tendon
  • The Subscapularis tendon is then elevated to allow access to the shoulder joint
  • The Humerus (ball) is delivered and resected; The pre-operative planning will guide the appropriately sized implants you will need. The worn-out “ball” is replaced with a “socket” (hence the Reverse Shoulder Replacement)
  • The Glenoid (socked) is exposed. The 3D planning and PSI instruments are used to replicate the planned operation “real-time” in your shoulder. This allows for any deformity/wear to be corrected at this time. The new “ball” is then implanted as sized by the 3D planning into the socket. 
  • The subscapularis tendon is then repaired
  • The wound is finally closed in layers, a waterproof dressing is applied, and your arm is placed in a sling. 
  • Dr Pant will then organise close follow up at regular intervals and liaise with your Physiotherapist to maximise your recovery. 
  • JPL rehabilitation program is commenced from 2 weeks post-surgery

There are three essential components to a good outcome from surgery:

  • Your surgeon
  • You as a patient
  • Your physiotherapist. 

Post-operative physiotherapy

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.

The JPL pathway allows for self-directed, early passive shoulder range of movement: 

  • Passive = assisted with your other arm
  • Active = you move the affected arm independently

Therapy overview 

After the surgery you will be in a sling and protect your shoulder to allow the shoulder to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.

The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the shoulder begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 12 weeks post Reverse Shoulder Replacement surgery. 

Sling

A sling is required for the first 6 weeks after your surgery; the sling is worn for a further 6 weeks outside of the house (to remind others you have had shoulder surgery). The type of sling is selected specific to you and your shoulder surgery:

  • Reverse Shoulder Replacement – Abduction sling

Cropped image of two women showing the different sling types used following reverse shoulder replacement surgery

 

Driving after shoulder surgery

  • After shoulder surgery, you will be in a sling and you may be unable to drive for at least 6 weeks
  • This does vary depending on the complexity of your surgery and the patient. Some patients may be able to drive at 2-4 weeks, and some may not be able to drive for the full 12 weeks. This will be individualised to your situation. 

Showering and getting dressed

  • You may take the sling off to shower
  • Lean forward and allow your arm to “dangle” to wash under your arms
  • The dressings applied are waterproof and you may shower with them on
  • Usually, before you are discharged from Hospital, your dressings are changed after your morning shower.
  • These “new” dressings are then kept intact until your review at 10-14 days
  • If the dressings start to peel at the edges – you may reinforce them
  • If the dressings discolour with discharge (yellow or green) you may have a wound infection; do not be alarmed just yet – please notify SSU (02 9215 6100 or admin@drpant.com.au) and we will give you a plan.
  • When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery.
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 4-6 weeks after surgery. You should keep your sling on while asleep.    

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the sling. The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications. 

When carried out carefully Shoulder Replacement is a safe and reliable procedure. The Sydney Shoulder Unit revision rates are some of the lowest in the world.

The risk of all complications after a Reverse Shoulder Replacement is 2-3 % in the Sydney Shoulder Unit experience. General risks include: 

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating to a Reverse Shoulder Replacement

  • Shoulder joint dislocation 
  • Fracture around the prosthesis (either during surgery or postoperatively)
  • Acromial stress fracture
  • Neurovascular injury during surgery
  • Cutibacterium acnes (formerly Propionibacterium acnes) infection (often presents insidiously) 
  • Prosthesis failure (scapular notching, polyethylene wear, loose prosthesis) 

Patients who smoke, use tobacco products, have diabetes, or elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone healing. Most healthy patients, however, cope well with shoulder replacement surgery and are unlikely to have complications. 

The latest advances in computer navigation, 3D planning and printing, and patient-specific instrumentation allow for accurate placement of components resulting in superior radiographic and functional outcomes for our patients. 

Sydney Shoulder Unit is a high volume shoulder practice that performs a large number of shoulder replacements each year with consistent outcomes for our patients.

When carried out carefully Reverse Shoulder Replacement is a safe and reliable procedure. The Sydney Shoulder Unit revision rates are some of the lowest in the world.

Australian Orthopaedic Association National Joint Replacement Registry Data (Individual Surgeon Reports) shows that Dr Pant’s revision rate for shoulder replacements is currently 0.00% (as of 2021); the national average is 1.06%. This includes Total Shoulder Replacements, Reverse Shoulder Replacements and Shoulder Replacements for fracture.

Patient results

Reverse Shoulder Replacement – Pain

This lovely 80 year old lady I saw every six months for a few years as she coped with her shoulder pain. We tried injections and therapy for some time. Eventually, she could not manage her pain and lost independence – so we proceeded with surgical treatment.

The plain x-ray shows a standard pattern of arthritis; however, a CT scan and 3D planning revealed things were much worse with significant wear in the shoulder (she had a B2 glenoid with 18 degrees of retroversion and 82% subluxation). Her procedure was planned on the computer with 3D software well before her surgery thus allowing her replacement to be done with precision.

She underwent a successful Reverse Shoulder Replacement with augmentation on the socket side to correct the wear and position the implants accurately.

Her postoperative scan shows a well-aligned prosthesis. She underwent JPL rehab and was very happy with her new shoulder. And I have no doubt she is back to picking olives!

Reverse Shoulder Replacement – Shoulder Pain

For patients who have no rotator cuff and advanced arthritis, the Reverse Shoulder Replacement has offered new treatment options. Computer 3D planning and Patient Specific Instrumentation has been the latest innovation.

This 81 year old lady underwent a CT scan with 3D planning and computer navigation prior to surgery. This allows for a detailed understanding of the glenoid wear pattern.

A 3D printed patient specific guide is then used to implant the shoulder replacement with a high level of accuracy. In this case the glenoid bone loss (due to wear) was replaced with a custom bone graft using her own humeral head. She completed her rehabilitation using the JPL method and would like her other side done soon.

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