But what about patients with orthopedic complications that make a successful outcome an iffy proposition? Specifically, what do you suggest when a 67-year old with severe degenerative arthritis and chronic rotator cuff problems comes to you with a shoulder that is too painful to move? What do you do when an 18-year-old trauma patient comes in with shoulder bones so broken they can never be put together again?
This is when a 180 degree turnaround in approach could make all the difference—a reverse total shoulder arthroplasty.
“Reversing the mechanics of the system takes the responsibility off the rotator cuff,” Jason Cobb, MD, of Alabama Orthopedic Surgeons said. “The socket is on the arm side and the ball is on the scapula side. It’s designed for more stability, and biomechanically it relies on the deltoid muscle rather than the rotator cuff.”
Cobb became interested in the reverse shoulder option in 2003 when he was training in trauma and performed several of the procedures shortly after it was approved by the FDA. The procedure was introduced in Europe in the 1980s and was building a track record for success in cases that were difficult to correct with conventional surgery.
“It was a good alternative when there were major shoulder injuries or severe deterioration from arthritis,” Cobb said. “The design has continued to evolve and improve. The system we have now is more streamlined, with better components and precision tools.
“In non-trauma cases, the reverse total shoulder procedure is most commonly used when there is both arthritic deterioration in the ball and socket joint, and rotator cuff tears involving at least two tendons. These tears allow increasing micro-motion, which accelerates wear in the shoulder joint as arthropathy symptoms become worse.
“What I particularly like about the reverse procedure is that in addition to helping patients achieve good pain control, it gives them an excellent range of shoulder motion—at least 105 to 110 degrees, and 120 to 130 degrees is common,” Cobb said. “Compare that to other procedures where anything over 90 degrees is considered acceptable.”
Because of the positive results, indications for choosing the reverse procedure are becoming broader. With the rotator cuff essentially retired from use, another advantage is that the procedure eliminates the risk of shoulder failure from a future rotator cuff injury, reducing the odds that a revision surgery might be needed.
Among orthopedic surgeons, there has been a growing interest in performing the procedure, although there is a learning curve.
“Primarily, it’s a matter of learning the right placement, so there is no risk of impingement,” Cobb said. “The exposure is similar, but the incision is smaller, usually 10 to 12 centimeters or possibly less. We push the muscles out of the way to work. Patients receive a multimodal cocktail to control pain, and preop and postop antibiotics to reduce the risk of infection. In most cases, we usually see a phenomenal recovery, with only an overnight hospital stay. The patient goes home the next day with a sling.”
Passive motion begins right away, with light outpatient rehab sessions weekly and training in follow-up exercises the patient does at home as they regain strength, full function and range of motion.
“We’ve had great results with reverse total shoulder arthroplasty. Patients usually experience immediate relief and excellent stability. There’s a lower failure rate; lower than a standard total shoulder replacement, and much lower than hemiarthroplasties,” Cobb said.
“When working with a patient who might have impaired healing—someone who smokes, or a diabetic, for example—the reverse shoulder procedure may be a good option to consider, particularly in trauma situations where a bone fragment may not heal properly.”
The shoulder is one of the hardest working joints in the body. Good function is necessary to the work of everyday living. The shoulder is also the joint with the widest range of motion, and this mobility puts it at risk of wear and injury. According to the American Academy of Orthopedic Surgeons, about 53,000 shoulder replacements are performed in the US every year. The increase in the number of replacements since the introduction of the reverse procedure is attributed in part to being able to help more difficult cases and in part to an aging population whose shoulders have more years of wear.
“As time goes on, I think we’ll be seeing the reverse total shoulder procedure used more often,” Cobb said.