Thousands of people undergo conventional anatomic shoulder replacements each year for relief from arthritis pain, but for those who also have rotator cuff tears, the conventional procedure may not be the best option. A reverse total shoulder replacement can relieve arthritis pain in these patients and may provide better outcomes following surgery.
"A reverse total shoulder replacement doesn't replace the rotator cuff. It is designed to accommodate for the lack of a rotator cuff," says Wayne McGough, MD, of Andrews Sports Medicine & Orthopaedic Center. "With the reverse shoulder replacement, you can knock out two birds with one stone. It is a complete shoulder replacement, so it will alleviate the arthritis pain, and it is potentially more successful in patients with rotator cuff issues because it relies on different muscles to move the arm and it is intrinsically more stable than an anatomic total shoulder."
According to the American Academy of Orthopaedic Surgeons, the conventional shoulder replacement device mimics the normal anatomy of the shoulder: a plastic cup is fitted into the glenoid, and a metal ball is attached to the top of the humerus. It also uses the rotator cuff muscles to function properly.
In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the socket, and the plastic cup is fixed to the upper end of the humerus. In a patient with a large rotator cuff tear and cuff tear arthropathy, these muscles no longer function. The reverse total shoulder replacement relies on the deltoid muscle, instead of the rotator cuff, to power and position the arm.
"The surgery typically is done on patients with significantly limited shoulder motion due to a large irreparable rotator cuff tear. A person can have arthritis in the shoulder and a functioning rotator cuff and still sometimes maintain a reasonable range of motion. If a person has a large cuff tear, however, he or she will usually have a very limited range of motion," McGough says. "I tell my patients to pursue this surgery if their primary goal is pain relief with a secondary goal of range of motion. If they don't have much pain but want more range of motion and function, they may not be as happy with the outcome. Studies show that most people end up with slightly less range of motion than with an anatomic replacement."
The FDA approved reverse total shoulder replacement surgery in 2003. With people staying more active as they age, reverse total shoulder replacement has become a more popular procedure in recent years.
"Our population is living longer and staying active longer than ever before," McGough says. "Given the high incidence of rotator cuff tears in the elderly population, this surgery gives patients an ability to stay active whereas they may previously have had to give up their recreational activities because of a lack of a good surgical option. Generally, people aren't willing to try a newer procedure, but as patients' reported outcomes improve I believe that word-of-mouth discussions are leading to an increase in volume for this procedure."
McGough says that like any surgery, the reverse total shoulder replacement comes with unique risks. "Nerve injury is possible but not common, and because of the lack of a rotator cuff, dislocation can occur in some cases," he says. "Also, the ball could come loose or the shoulder blade could fracture. It has a higher complication rate than the anatomic procedure, but it doesn't mean it isn't a good surgery."
Dot Ray is a believer in the reverse total shoulder procedure. She injured her shoulder during a landscape project in her yard. Her doctor diagnosed her with arthritis in the shoulder and gave her a cortisone injection. However, the pain worsened, and she started to lose function in her left shoulder and arm so she went to an orthopedist.
"He confirmed that the cartilage was gone in my left shoulder and that it was bone on bone. He recommended a cortisone injection for short-term relief and a total shoulder replacement as my only long-term option," Ray says. "I decided I needed a second opinion. Some of our friends recommended Dr. Sam Goldstein. When I called Dr. Goldstein's office at Andrews Sports Medicine, they told me that Dr. Wayne McGough performs most of the total shoulder replacements at Andrews."
After reviewing her medical records, McGough recommended a reverse total shoulder replacement because she had severe osteoarthritis and rotator cuff disease. "Dr. McGough performed my surgery on May 2nd. Three months later, I am totally surprised with how well I am recovering," Ray says. "I appreciate Dr. McGough for helping give me back my quality of life."
MGough is happy to be able to offer this surgical option to his patients. "I think this is game-changing surgery, because there is a unique population with rotator cuff tear arthropathy who have significant pain and 'pseudo paralysis' and can't lift their arm. If someone has a problem that sounds like rotator cuff tear arthropathy, they should contact a surgeon who has experience with this procedure," he says. "I do a lot of different types of surgeries in my practice, and I can tell you that these are some of my happiest patients."