Reverse Total Shoulder or Delta Shoulder for Shoulder Arthritis Combined with Massive Rotator Cuff Tear and for Failed Conventional Total Shoulder Replacement

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Last updated: December 12, 2013
Edited by:

Winston J. Warme, M.D.Winston J. Warme, M.D.,
Associate Professor,
UW Orthopaedics & Sports Medicine
Frederick A. Matsen III, M.D.Frederick A. Matsen III, M.D.,
Professor,
UW Orthopaedics & Sports Medicine

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Summary

The reverse total shoulder replacement can restore comfort and function to the arthritic shoulder combined with a massive rotator cuff tear and for failed conventional total shoulder replacement. This combination of conditions can result in major loss of stability and active motion of the shoulder. The reverse total shoulder provides stability of the shoulder joint so that the deltoid muscle can power the shoulder through a useful range of motion. In this procedure the arthritic ball is replaced by a socket fixed to the arm bone (humerus) by a stem that fits within it. A metal ball is fixed to the bone of the arthritic socket with screws. Success requires technical excellence of the surgery and a commitment to a conservative rehabilitation program.

What Are The Key Parts Of The Normal Shoulder Joint?

The ball (humeral head) fits in the socket (glenoid) and is held there by the rotator cuff.

What Is Shoulder Arthritis?

Shoulder arthritis is a condition in which de- generation injury inflammation or previous surgery destroys the normally smooth carti- lage on the ball (humeral head) and socket (glenoid).

How Is Shoulder Arthritis Diagnosed?

Carefully standardized X-rays reveal the loss of the space between the humeral head and glenoid that is normally occupied by cartilage leaving bone on bone contact.

What Is A Conventional Total Shoulder?

In a conventional total shoulder the arthritic surface of the ball is replaced with a metal ball with a stem that is press fit in the inside of the arm bone (humerus) and the socket is resurfaced with a high density polyethylene component.

When Will A Conventional Shoulder Not Work?

When the rotator cuff is sufficiently torn that it no longer provides the necessary stability for the joint the humeral head slides upwards. This results in slackening of the deltoid so that it can no longer raise the hand to carryout nor- mal activities. A conventional shoulder cannot restore the necessary stability in this situation.

What Is A Reverse Total Shoulder?

In a reverse total shoulder the ball is located on the shoulder blade (glenoid) and the socket is located on the arm bone (humerus) exactly the opposite of the situation in a conventional total shoulder. This configuration provides sta- bility because the muscles around the shoul- der compress the ball and socket together.

How Are The Parts Of A Reverse Total Shoulder Hooked To The Bones?

The ball (glenosphere) is screwed to the bone of the shoulder blade. The cup (humeral sock- et) is fixed to a stem that is cemented down the inside of the arm bone (humerus).

What Is The Incision Like?

After a general or regional anesthetic this procedure is performed through an incision between the deltoid and the pectoralis major muscles on the front of the shoulder. It includes release of adhesions and con- tractures and removal of bone spurs that may block range of motion. Our team of surgeons anesthesiologists and surgical assistants usually perform this procedure in less than two hours.

Who Should Consider A Reverse Total Shoulder?

Surgery for shoulder arthritis and rotator cuff deficiency should only be considered when the condition of the shoulder is limiting the quality of the patient’s life and after a trial of physical therapy and mild analgesics to determine if non-operative management is helpful. If severe disability persists patients may consider the reverse total shoulder – no other surgical procedure has the ability to restore the stability needed in the absence of a functioning rotator cuff. The ideal patient is healthy active motivated and committed to complying with the rehabilitation program.

Who Should Probably Not Consider A Reverse Total Shoulder?

This procedure is less likely to be successful in individuals with depression or obesity. Patients who use narcotic medication or who use tobacco may have increased difficult recovering from this procedure. Patients without a functional deltoid are unlikely have a good result from this procedure.

What Are The Keys To Success Of A Reverse Total Shoulder?

Success requires technical excellence of the surgery and a commitment by the patient to follow the rehabilitation program prescribed by the surgeon.

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Normal Shoulder
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Shoulder Arthritis
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Diagnose Shoulder Arthritis
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Conventional Total Shoulder
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rotator cuff is sufficiently torn that it no longer provides the necessary stability for the joint
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Reverse Total Shoulder
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A Reverse Total Shoulder Hooked To The Bones
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An incision between the deltoid and the pectoralis major muscles on the front of the shoulder

 

How Does A Patient Prepare For A Reverse Total Shoulder?

As for all elective surgical procedures the patient should be in the best possible physical and mental health at the time of the procedure. Any heart lung kidney bladder tooth or gum problems should be managed before surgery. Any infection may be a reason to delay the operation. Any skin problem (acne scratches rashes blisters burns etc) on the shoulder or arm should be resolved before surgery. The shoulder surgeon needs to be aware of all health issues including allergies as well as the non-prescription and prescription medications being taken. For instance aspirin and anti-inflammatory medication may affect the way the blood clots. Some of these may need to be modified or stopped around the time of surgery.

What Happens After Surgery?

The reverse total shoulder is a major surgical procedure that involves cutting of skin tendons and bone. The pain from this surgery is managed by the anesthetic and by pain medications. Immediately after surgery strong medications (such as morphine or Demerol) are often given by injection. Within a day or so oral pain medications (such as hydrocodone or Tylenol with codeine) are usually sufficient. The shoulder rehabilitation program is started on the day of surgery. The patient is encouraged to be up and out of bed soon after surgery and to progressively reduce their use of pain medications. Hospital discharge usually takes place on the second or third day after surgery. The arm is kept in a sling for six weeks after the procedure to allow for healing but the patient can use the hand for eating. Driving is not recommended during this time. Thus the patient needs to be prepared to have less arm function for the six weeks after surgery than immediately before surgery. For this reason patients usually require some assistance with self-care activities of daily living shopping and driving. Management of these limitations requires advance planning to accomplish the activities of daily living during the period of recovery.

What About Rehabilitation?

After the six weeks in a sling progressive use of the shoulder for usual daily activities is encouraged. Formal physical therapy is usually not needed.

When Can Ordinary Daily Activities Be Resumed?

The reverse total shoulder is not a procedure that is designed for heavy use or sports. It is designed to help the patient regard the gentle activities of daily living. Every precaution should be taken to avoid falls on the operated shoulder.

What Problems Can Complicate A Reverse Total Shoulder And How Can They Be Avoided?

Like all surgeries the reverse total shoulder can be complicated by infection nerve or blood vessel injury fracture instability component loosening and anesthetic complications. Furthermore this is a technically exacting procedure and requires an experienced surgeon to optimize the bony prosthetic and soft tissue anatomy after the procedure. The procedure can fail if the reconstruction is too tight too loose improperly aligned insecurely fixed or if unwanted bone-to-bone contact occurs.

How Many Reverse Total Shoulders Are Done At The University Of Washington?

We currently perform approximately 35 of these procedures each year on carefully selected patients from across the United States.

What If The Patient Lives A Long Way Away From Seattle?

Patients often come to Seattle from a long distance for the procedure. We are available by appointment in the Shoulder and Elbow Clinic 4245 Roosevelt Way N.E. Seattle on Mondays and Fridays to evaluate individuals with shoulder arthritis to discuss the procedures that might be most ideally suited for them. We perform surgery on Tuesdays and Wednesdays at the University of Washington Medical Center 1959 NE Pacific St Seattle Washington 206 598-4288. We also see patients at the Eastside Specialty Center 1700 - 116th Ave NE Bellevue Washington 425 646-7777. Patients having a reverse total shoulder are often able to return home three days after the procedure. The staples used to close the skin can be removed by a nurse or physician near the patient’s home. Ideally we like to see patients back at six weeks after surgery to assure that satisfactory progress is being made. We request that patients complete questionnaires at 3 6 12 18 and 24 months after surgery so we can track their progress and that the patient obtain and send to us X-rays at 12 and 24 months after surgery if they are unable to return to Seattle for the annual follow-ups. All patients have our personal email and the clinic contact phone numbers to use in contacting us at any time questions arise.

Conclusion

Summary reverse total shoulder replacement for the arthritic shoulder combined with a massive rotator cuff tear. The reverse total shoulder can restore comfort and function to shoulders with arthritis and massive defects in the rotator cuff or in failed conventional total shoulder replacement. In the hands of an experienced surgeon the reverse total shoulder can be an effective method for treating shoulders arthritis and severe rotator cuff deficiency. Pre-planning and persistent rehabilitation efforts will help assure the best possible result for the patient.

Frederick A. Matsen III and Winston J. Warme
Shoulder Surgeons
University of Washington
Department of Orthopaedics and Sports Medicine

References:

Matsen FA 3rd Bicknell RT Lippitt SB. Shoulder arthroplasty: the socket perspective. J Shoulder Elbow Surg. 2007 Sep-Oct;16(5 Suppl):S241-7.

Chebli C Huber P Watling J Bertelsen A Bicknell RT Matsen F 3rd. Factors affecting fixation of the glenoid component of a reverse total shoulder prothesis. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):323-7.

Disclaimer

This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient.