During a total shoulder replacement the surgeon cuts or reams away the diseased head of the humerus (the ball) and glenoid (socket). The head is replaced with a metal ball that is usually cemented into the humerus. The glenoid (socket) is resurfaced with a plastic liner that is cemented to the underlying bone. After shoulder replacement limitations are placed on the patient’s activities. For example, heavy weight lifting will cause abnormal wear on the joint and could lead to early failure of the implant. With appropriate care, shoulder replacements are expected to last approximately 15 years in 9 out of 10 patients. After that it is not uncommon for results to deteriorate and revision surgery to be considered.

Shoulder Arthroplasty

What is a reverse shoulder replacement?

Just as it sounds the ball and socket components are reversed and the ball becomes the socket and the socket becomes the ball. The rotator cuff is very important to maintain the normal anatomy of the shoulder. When there is a massive rotator cuff tear the head of the humerus starts to migrate upward and will no longer stay in joint even if a shoulder replacement is done. The rotator cuff is also important to initial lifting of the arm, and without it this cannot be done. The reverse shoulder replacement changes the biomechanics of the shoulder so that the deltoid muscle can lift the arm without the help of the rotator cuff. The outcomes of this surgery are improving every year but so far are not as consistent as standard total shoulder replacement. It is expected that 9 out of 10 patients will achieve 10 years with this surgery prior to deterioration of function and consideration of revision surgery. For this reason, the patients that are considered for reverse shoulder replacement are ideally close to or over 70 years of age.

Shoulder unbalanced deltoid

Shoulder with lack of Rotator cuff, and upward migration of the humeral head due to unbalanced deltoid pull upward

How do you know if you need a reverse shoulder replacement?

Those patients who present with shoulder arthritis may not know they have a large rotator cuff tear, but if their imaging is like that of the shoulder above in which the humeral head has moved upward this is an indication. Another sign is the inability to independently lift the arm up, also called pseudoparalysis. The nerves are working so it is not a true paralysis, but you are unable to elevate the arm due to the massive rotator cuff tear. In these patients a regular shoulder replacement will not work.

Intra-operative decision

Sometimes these signs are not demonstrated preoperatively. When performing the surgery it may be found that the rotator cuff is not sufficient to support a regular shoulder replacement and the surgery will be converted to a reverse replacement.


Surgery

  • You will be in the hospital overnight, you will likely go home postoperative day 1
  • If you smoke, now is a good time to stop. This will reduce the risks of complications
  • You will be given a general anesthetic (put to sleep) for the procedure
  • In addition you will be offered a nerve block by the anesthetist:
    • This involves freezing the nerves to the arm
    • This can last anywhere from 6 – 18 hours
    • Usually with replacement surgery they leave a catheter in place to help with the pain overnight
    • It is important that you take pain medications post operatively while the catheter is in place as it will wear off
  • Do not eat or drink anything after midnight the day of your surgery

Post Operative

You will be given written instructions by your surgeon before or after surgery.

Medications – You will be provided with analgesic medication to help manage your pain in the first several weeks. You can taper off of the medication as soon as your pain starts improving. Tapering down from the narcotic medication onto Tylenol and/or anti-inflammatory medications (such as Advil/Ibuprofen, Aleve/Naproxen or Celebrex) after the first several days is a good way of avoiding some the side effects of narcotic pills (such as constipation and drowsiness)

Ice – It is extremely helpful to ice the shoulder after surgery. This can be done with bags of ice or ice packs on the shoulder. A very useful device for icing is an automatic ice machine (e.g. Cryocuff, Polar care) which is used to help ease the pain and speed the recovery. These can be purchased prior to surgery if you wish. Any further questions regarding these products can be obtained from your surgeon or their office assistant.

Sling – You will be in a sling for 6 weeks. You may wish to consider a more robust sling than those offered to patients in the hospital. You will not be able to drive while in the sling.

 

Dressing & Wound – You will have a bulky dressing on your shoulder when you leave the hospital. Leave this dressing alone after a shoulder replacement unless your surgeon has told you otherwise.If you notice signs of infection such as fevers, chills, or increasing redness around the wound you should see your family doctor, contact your surgeon’s office or go to the emergency department.

Physiotherapy – Physiotherapy is crucial after any surgery. You will need to attend physiotherapy and if done outside of the hospital the government does not cover this cost. Depending on patient volumes you may be able to get into Lions Gate for outpatient physiotherapy. If you do not have insurance (e.g. extended benefits) and cannot get into Lions Gate outpatient physiotherapy you will need to save money to allow you to attend. A physiotherapy prescription will be given to you when you leave the hospital or at your first postoperative visit. Typically after shoulder surgery physiotherapy is begun between 2-6 weeks after surgery.

Return to Work – Everyone is different and every job is different. You should expect to take 10-14 days off of work if you have a ‘desk-type’ job. You may need more time off depending on how extensive your surgery is and how much discomfort you have postoperatively. Patients with more labor intensive jobs will require at least 4-5 months off of work prior to returning to their regular duties.

Follow-up Appointments – You will need to make a follow up appointment for 2 weeks after surgery. Typical visits will be at the 2, 6 and 12 week marks to check on your progress and answer questions. Most of your visits will be in the cast clinic and it will be very busy. It is not uncommon for the clinic to run significantly behind schedule.

What are expected outcomes and activities after surgery?

Although each patient is unique and recovery different there are average expected outcomes. Those who get a regular shoulder replacement usually attain about 140deg of forward elevation, whereas with a reverse shoulder replacement the average elevation is about 90 deg.

Activities that are recommended after full recovery of a shoulder replacement include; walking, hiking, swimming, cycling, aerobics and golfing. Other activities that patients previously engaged in such as skiing and tennis may be attainable as well.


Surgeons