Why Should A Person Get A Reverse Prosthesis Instead Of A Standard Shoulder Replacement
A standard total shoulder replacement depends upon muscles and tendons around the shoulder joint to be intact. The muscles attach to the shoulder blade and turn into tendons which attach to the shoulder. These muscles and their tendons function to move the shoulder and are together called the rotator cuff. When these tendons become extensively torn so that they do not attach to the bone any longer, the shoulder often does not function normally. The loss of the rotator cuff can produce pain and also loss of motion. A normal shoulder replacement is designed to work only if those tendons are intact. In contrast, a reverse prosthesis is designed for situations where the rotator cuff is torn or malfunctioning.
Reverse Shoulder Replacement | Q& A with Dr. Edward McFarland
A leading expert in his field, Edward McFarland M.D., explains the difference between Total Shoulder Replacement and Reverse Total Shoulder Replacement. An R-TSR can be the solution to certain conditions that a regular Total Shoulder Replacement cannot resolve.
What Happens After A Reverse Total Shoulder Replacement
Ask your provider about what you should expect after your surgery. In general, after your operation:
- Your operated arm may be numb from the anesthesia. You also may not be able to move your hands or fingers. This will last for several hours.
- You may have some pain, but pain medicines may help as needed.
- You might use a device to keep ice on your shoulder.
- Youll probably need follow-up X-rays to make sure your surgery was successful.
- Your arm will probably be in a sling after the surgery for several weeks.
- You will probably begin physical therapy exercises while you are still in the hospital.
- You should be able to have a normal diet as soon as you can handle it.
- You will probably need to stay in the hospital for 2 to 3 days.
Youll have some pain as you heal after the surgery. But your original shoulder pain should be improved.
Follow all your providers instructions about caring for your shoulder and wound. This might include continued icing of your shoulder and physical therapy. A little bit of drainage from the wound is normal. But let your provider know if it continues to swell and bleed, or if you have a fever or chills.
Your provider can let you know when you will be able to use your hand and arm more fully. You will probably be able to use your wrist and hand soon after your surgery. You wont be able to use your arm for several weeks, though. Most people can return to light work within a few weeks.
How Do I Get Ready For A Reverse Total Shoulder Replacement
Talk with your provider about how to prepare for your surgery.
- Tell your provider about all the medicines you take. This includes over-the-counter medicines such as aspirin and all prescription medicines. It also includes herbs, vitamins, and other supplements.
- Ask if you need to stop taking some medicines before the surgery, such as blood thinners.
- Dont eat or drink after midnight the night before your surgery.
- Follow any other instructions from your healthcare provider.
Before your surgery, you may need imaging tests. These will give your provider more information about your shoulder. These might include:
- CT scan to see the bones in more detail
- MRI to see the soft tissue around the bones in more detail
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What Is The Surgery Like
The surgery experience is very similar to that of a regular shoulder replacement with a few variations. The main factor in the recovery is whether this is the first shoulder replacement for the shoulder or whether an old prosthesis has to be taken out during surgery. When this is done, it is called a revision case and the recovery may be different than when a first time joint replacement is done.
The surgery is typically done with a nerve block of the arm followed by a general anesthetic. The incision is in the front of the shoulder and the surgery takes about two to three hours. Postoperative pain relief is obtained with pain medications orally and by vein if needed. Most patients can begin moving the fingers, wrist and elbow the next day.
Most patients donate a unit of blood prior to surgery which can be given back to them if needed. For first time joint replacements blood is given back to the patient usually only 10 to 20% of the time. For revision cases where the surgery is longer, nearly 80% of cases need a blood transfusion. Similarly, the length of time for surgery is longer for revision cases and the recovery time for gaining function of the arm is longer. Other factors which influence the recovery time include whether bone grafting is done, whether it holds well and how long it takes the bone to heal.
What Is A Reverse Total Shoulder Replacement
A reverse total shoulder replacement is a special type of shoulder surgery. During the surgery, your surgeon removes the damaged parts of the shoulder and replaces them with artificial parts.
The shoulder joint is made up of the upper arm bone and the shoulder blade . The rounded end of the upper arm bone moves inside a shallow socket in the shoulder blade. Because of this, your shoulder normally has a very wide range of motion. Cartilage, tendon, and ligaments around the joint also provide support and help the joint move smoothly.
In a reverse total shoulder replacement, a surgeon removes the rounded head of the upper arm bone. Using screws and special tools, he or she attaches a plastic socket to the remaining bone. The surgeon also removes part of the socket of the shoulder blade. This is then replaced with a metal ball. The metal ball can then move around inside the socket that attaches to the upper arm bone.
This is different from a standard total shoulder replacement. In a standard surgery, the metal ball attaches to the upper part of the humerus. The new socket attaches to the shoulder blade. This more closely follows a persons real anatomy.
Healthcare providers advise reverse total shoulder replacements for certain types of shoulder injuries. The most common type is arthritis with a large rotator cuff tear.
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Phase I Immediate Post Surgical Phase/joint Protection :
Goals:
- Patient and family independent with:
o Joint protectiono Passive range of motion o Assisting with putting on/taking off sling and clothing o Assisting with home exercise program o Cryotherapy
- Promote healing of soft tissue / maintain the integrity of the replaced joint.
- Restore active range of motion of elbow/wrist/hand.
- Independent with activities of daily living with modifications.
- Independent with bed mobility, transfers and ambulation or as per pre-admission status.
Phase I Precautions:
- Sling is worn for 3-4 weeks postoperatively and only removed for exercise and bathing
once able. The use of a sling often may be extended for a total of 6 weeks, if the current
rTSA procedure is a revision surgery.
- While lying supine, the distal humerus / elbow should be supported by a pillow or towel
roll to avoid shoulder extension. Patients should be advised to always be able to visualize their elbow while lying supine.
- No shoulder AROM.
- No lifting of objects with operative extremity.
- No supporting of body weight with involved extremity.
- Keep incision clean and dry No whirlpool, Jacuzzi, ocean/lake wading for 4 weeks.
Acute Care Therapy :
- Begin PROM in supine after complete resolution of interscalene block.
- Forward flexion and elevation in the scapular plane in supine to 90 degrees.
- o External rotation in scapular plane to available ROM as indicated by operative findings. Typically around 20-30 degrees
- No Internal Rotation range of motion .
Day 5 to 21:
3 Weeks to 6 Weeks:
What Results Can I Expect From Reverse Total Shoulder Replacement
The reverse prosthesis is very good at providing pain relief. Studies from Europe indicate that approximately 85-90% of patients who have this procedure obtain excellent pain relief. The degree of pain relief depends largely upon the reason the procedure was done. The degree of pain relief for revision cases is a little lower than for procedures done for the first time, and this is believed to be due to the scar formation and long term damage.
The reverse prosthesis also should restore some range of motion to the shoulder, but the degree of return is not as predictable as pain relief. Most patients obtain the ability to reach the top of their heads without the need to tilt their head. Most patients see improvement of motion in other directions, but if their rotator cuff is torn completely they may not see improvement in the ability to reach out to the side away from the body .
The long term survival rates of the reverse prosthesis have been favorable. The reverse prosthesis has been used in France since the 1980s but was approved by the Food and Drug Administration in the United States in April, 2004. As a result, there are currently no long term studies of its use in the United States. However, the experience of shoulder surgeons and patients from Europe seem to indicate that the prosthesis will last 15 years about 90% of the time.
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How Does It Stay Together
Fortunately the reverse prosthesis can be put into place with screws on the socket side which hold it into the bone of the shoulder blade . The ball then screws into the plate which has been attached to the socket .
The part of the prosthesis placed into the arm bone is secured with cement which bonds the metal to the bone within a few minutes . The plastic socket piece then is press fit into the end of the stem where it is securely fixed by locking into the metal piece. This allows the socket to rotate on the ball so that the shoulder motion can be restored . The muscles around the shoulder also help keep the reverse prosthesis in place.
Phase Iii Moderate Strengthening
Goals:
- Enhance functional use of operative extremity and advance functional activities.
- Enhance shoulder mechanics, muscular strength and endurance.
Precautions:
- No lifting of objects heavier than 2.7 kg with the operative upper extremity
- No sudden lifting or pushing activities.
Week 12 to Week 16:
- Continue with the previous program as indicated.
- Progress to gentle resisted flexion, elevation in standing as appropriate.
Phase IV Continued Home Program :
Typically the patient is on a home exercise program at this stage to be performed 3-4 times per week with the focus on:
- Continued strength gains
- Continued progression toward a return to functional and recreational activities within limits as identified by progress made during rehabilitation and outlined by surgeon and physical therapist.
Criteria for discharge from physio therapy:
- Patient is able to maintain pain free shoulder AROM demonstrating proper shoulder mechanics.
- Typically able to complete light household and work activities.
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Who Should Not Have A Reverse Prosthesis
There are only a few instances where a reverse prosthesis cannot be implanted. The first is if the socket bone is too far gone to allow the component base plate to be able to be fixed with screws to the bone. In some instances bone graft can be added at the time of surgery which makes it possible to place the base plate and screws, or bone graft can be added to allow placement of the base plate at a later date.
Patients with an ongoing infection in the shoulder should not have a reverse prosthesis. However, if the infection can be cleared up then a prosthesis can be inserted. Whenever a shoulder replacement is attempted in a shoulder that has had a previous infection, the post-operative infection rate is higher than if the shoulder never had an infection. This should be discussed in detail with your doctor prior to having this surgery done.
Why Might I Need A Reverse Total Shoulder Replacement
Surgery may be an option for you if you have severe pain that gets in the way of everyday activities. Surgery may also be advised if you have weakness in your shoulder and are not able to move it fully. It may also be advised if your symptoms dont get better with other treatments. These may include medicines, shots , and physical therapy.
Most people get a standard total shoulder replacement. However, reverse total shoulder replacement works better for people with certain injuries, including some rotator cuff injuries. If you have this type of injury, a standard shoulder replacement still might leave you with some pain and limited movement. A reverse total shoulder replacement usually improves these problems. After surgery, instead of using the rotator cuff to lift up your arm, you can use your deltoid muscle. This is a muscle that helps lift the arm up and away from the body.
Healthcare providers also may advise the surgery to people who have already had a standard shoulder replacement for osteoarthritis or other reasons. These people may still have symptoms that a reverse total shoulder replacement can fix.
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What Happens During A Reverse Total Shoulder Replacement
Your healthcare provider can explain the details of your surgery. An orthopedic surgeon will do the surgery aided by a team of specialized healthcare providers. The procedure will take several hours. In general, you can expect the following:
What Shoulder Conditions Warrant Reverse Total Shoulder Replacement
The main reason to consider a reverse prosthesis is when there is arthritis of the shoulder joint and the rotator cuff tendons are torn or gone. This is the most common surgical indication for a patient considering a reverse prosthesis. In this situation this operation will give the patient significant pain relief and may also help with range of motion of the shoulder. While range of motion after a reverse prosthesis may not be completely normal, it is typically improved over the motion previously lost due to the arthritis and pain.
Another reason to have a reverse prosthesis is if the rotator cuff tendons are all torn and one cannot lift the arm high enough to function. Typically in this case the shoulder is not painful but the inability to lift the arm is very disrupting to the ability to function in life. When the patient goes to lift the arm there is a prominence on the front of the shoulder, and this is called an anterior-superior migration or subluxation of the shoulder. In these cases pain may or may not be a major factor for the reverse prosthesis, but the main reason for the replacement is to regain motion and function.
Other reasons to have a reverse prosthesis are some fractures of the shoulder area, particularly ones that involve the proximal humerus where the ball attaches to the shaft of the bone. In some instances, the bone is broken into many pieces or the ball may be split into parts.
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What Are The Risks Of A Reverse Total Shoulder Replacement
Every surgery has risks. Risks for this surgery include:
- Damage to the surrounding nerves
- Break of one of the shoulder bones
- Dislocation of the artificial joint
- Complications from anesthesia
Some of these risks may be higher in people having a repeat surgery. Your own risks may vary depending on the anatomy of your shoulder problem and your general health. Ask your provider about the risks that most apply to you.
Reverse Total Shoulder Replacement Post
*Important rehab guidelines to consider*
- Avoid shoulder Ext past neutral for 12 weeks
- Avoid internal rotation, adduction and extension as patients have a high likely hood of dislocation with combined movements. Such as tucking in their shirt, and performing bathroom/ personal hygiene
- Stability and mobility of the shoulder is now dependent on the Deltoid and periscapular function in patients with a rTSA
- Restoration of Full Normal ROM is NOT expected
- Traditionally rTSA procedure is done via Superior approach, and in these cases
- Early deltoid activity is CONTRAINDICATED
- Use of sling for 4-6 weeks
- No isometrics until 4 weeks
- No AROM Flex for 6 weeks
- No IR until 6 weeks
- No deltoid strengthening for 12 weeks
*Permanent Restrictions*
- No lifting, pushing, pulling more than 25 pounds
- No impact activities
- No shoulder Extension past neutral
- Flex in scapular plane 90 deg
- ER in scapular plane 20-30 deg
- Begin Sub max pain free isometrics
- PROM in a scapular plane
- Flexion to 120 deg
- Begin IR to tolerance NOT to exceed 50 deg
Phase 3
- Begin periscapular and deltoid sub max pain free deltoid isotonic/ PRE exercises
- Begin AROM supine forward flexion with light weights
- Progress GH joint IR ER isotonic ther ex progressing sidelying to standing
12 weeks +
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