October 21, 2018

Expanding Solutions for Patients with Damaged Shoulders

By Catherine M. Rapp, MD, Sports Medicine & Orthopaedic Center

 

From its beginnings as a procedure largely for elderly patients, reverse total shoulder replacement has continued to evolve as a surgery that also may help younger, more active patients with certain types of pre-existing shoulder joint damage. 

Since 2003 – when the technique gained FDA approval in the United States – studies to date have shown lasting improvements in shoulder function after 10 to 15 years. This has allowed us to treat many patients with painful, restrictive conditions that often had no previous solution.  

Refinements in prosthetic designs and materials, along with a better understanding of shoulder function to guide surgical methods, should only open this option to more patients in the future. 

Reverse replacements use implants that switch the natural locations of the shoulder’s ball and socket, with the metal ball affixed to the socket and the plastic cup to the upper end of the humerus. Unlike standard surgery, these prostheses do not require the rotator cuff muscles to power and function the joint, instead relying on the deltoid and other muscles. 

A standard replacement does remain the best choice for patients who qualify, as a reverse procedure cannot restore the shoulder’s ability to handle heavy work or most sports. However, reverse replacements can still return clinically beneficial strength, mobility and stability in patients who have: 

• A large rotator cuff tear that can’t be repaired, with resulting severe shoulder pain and/or pseudoparalysis (difficulty lifting their arm above their head or away from their side); 

• Cuff tear arthropathy, a complex form of arthritis arising after a rotator cuff tear; 

• Severe shoulder arthritis with deformity that may preclude a standard replacement;

• Rheumatoid or other inflammatory arthritis;

• Had a previous shoulder replacement that was unsuccessful and are not good candidates for a standard revision;

• Had a complex fracture of the shoulder joint, chronic shoulder dislocation or a tumor in the shoulder joint; 

• Tried other therapies such as rest, medications, cortisone injections and physical therapy for these conditions with no pain relief. 

In general, these patients would not benefit from a standard replacement but may benefit from a reverse shoulder replacement. The best approach must be determined on an individual basis after a complete clinical exam. Recovery may be slightly faster after a reverse surgery, as the procedure does not involve as prolonged a period of protective immobilization to allow the rotator cuff to heal. 

Reverse shoulder replacement is a complex, highly technical surgery, but complications such as nerve damage, infection and dislocation have decreased as it has developed over time. With continued improvements and an aging population, I believe we will see the overall percentage of reverse procedures climb, perhaps moving toward a 50/50 split with the standard approach.  

I look forward to helping a wider variety of patients in our community regain as much of their shoulder function as possible, and to enjoy improved quality of life.

Dr. Rapp recently joined SMOC after completing an Adult Shoulder & Elbow Reconstruction Fellowship at Beaumont Hospital in Michigan. She also served as a general Orthopaedic Surgeon for 4 years in the US Navy. smoc-pt.com.