A reverse total shoulder replacement reverses the normal arrangement of the shoulder joint. Instead of a ball on the arm bone and a socket on the shoulder blade, a socket is fitted to the top of the arm bone and a metal ball, called a glenosphere, is fitted to the shoulder blade.
That change matters because it alters which muscle does the lifting. A standard anatomic replacement relies on a working rotator cuff, so it does not work where the cuff is worn away. A reverse replacement allows the deltoid, the large muscle over the outside of the shoulder, to raise the arm instead. According to the Australian shoulder registry, reverse replacements now account for approximately 80% of all shoulder replacements performed in Australia. The first was performed in Australia in 1999.
The procedure
The operation is performed through an incision at the front of the shoulder, and approximately three hours of theatre time is booked. The worn humeral head is removed and a socket component is fitted to the top of the arm bone. The glenoid on the shoulder blade is prepared and the glenosphere is fixed to it. Where the subscapularis tendon can be repaired, it is repaired at the end of the operation.
The prostheses used are made by Stryker, Tornier (Ascend Flex) or Medacta. Australian registry data record low revision rates for these implants.
A reverse replacement was originally designed for cuff tear arthropathy, the pattern of joint destruction that follows a long-standing rotator cuff tear. It is now also used for irreparable rotator cuff tears, severe shoulder arthritis, avascular necrosis, and severe fractures of the upper arm bone.
Risks and complications
All surgery carries risk. The risks below are the ones that matter most for this operation, and the ones that apply to you are discussed with you in consultation before any decision is made.
General surgical risks
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Bruising and haematoma. The amount of bruising varies from patient to patient. Bruising is a normal consequence of surgery and usually settles within a short time. A haematoma is a collection of blood that occasionally needs to be drained in theatre.
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Deep vein thrombosis and pulmonary embolism. Blood clots can form in the veins of the leg and can travel to the lung. The risk of serious harm is significantly reduced when a clot is recognised and treated promptly.
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Anaesthetic risks. These are discussed with your anaesthetist before surgery. The risk of death from a general anaesthetic in Australia is approximately 1 in 100,000.
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Wound problems. Superficial wound problems can occur. Most need only a small intervention.
Risks specific to this procedure
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Infection. Infection occurs in approximately 1% of reverse total shoulder replacements. A superficial infection is usually treated with antibiotics. A deep infection involving the prosthesis is more serious and can require the implant to be removed and replaced.
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Dislocation and instability. The socket can come off the glenosphere in approximately 1% of cases, most often within the first year after surgery. This usually requires further surgery.
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Stiffness. Some patients do not regain full movement. A reverse replacement normally gives less rotation than a natural shoulder, particularly reaching behind the back.
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Failure of the prosthesis. A shoulder replacement does not last indefinitely. It can loosen or wear and may eventually need revision surgery. The Australian Orthopaedic Association National Joint Replacement Registry reports that, at 14 years, approximately 7% of reverse total shoulder replacements had been revised. Registry data are published at aoanjrr.sahmri.com. Individual results vary.
Before surgery
Published studies report that patients whose medical conditions are identified and treated before an operation have fewer complications. You will be asked to see a physician beforehand so that any underlying medical problem can be found and managed, and to have a general blood test.
You will also be asked to start physiotherapy before surgery. Working on the shoulder and on your general conditioning beforehand makes the early weeks of rehabilitation easier.
Administration and planning
- Confirm with your health fund that the hospital fee is covered. Many policies exclude joint replacement, and upgrading a policy usually involves a 12-month waiting period before joint replacement is covered.
- Confirm the anaesthetist’s fees.
- Register your details with the hospital.
- Read, complete and return the paperwork to the office.
- Plan your transport to and from hospital. You cannot drive yourself home.
- Attend any recommended pre-operative physiotherapy and complete any requested pathology.
- Confirm your admission details with the office one to two business days before surgery.
Skin and nose preparation
These steps reduce the number of bacteria on your skin and in your nose before the operation, which lowers the risk of a wound infection.
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Benzoyl peroxide 5% wash on the operative shoulder, five applications in total: twice daily for two days, then once more on the morning of surgery. This targets Cutibacterium acnes, a bacterium that lives in the skin around the shoulder.
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Chlorhexidine cloths. Shower with these the night before surgery and again on the morning of surgery. This reduces the number of bacteria on your skin.
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Mupirocin nasal ointment applied to both nostrils twice daily for the five days before surgery. Published studies report that nasal mupirocin reduces the risk of staphylococcal wound infection by more than 80%.
Packing and medications
- Pack your regular medications in their original packaging, a loose button-up shirt, nightwear and toiletries. Bring your CPAP machine if you have sleep apnoea.
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Blood thinners. Call the office to confirm when to stop these before surgery.
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Diabetes tablets. Call your anaesthetist to confirm whether to stop these.
The day of surgery
Your admission details are confirmed with the office one to two business days beforehand. Note both your admission time and your fasting time. Admission can be as early as 6am, so patients who live outside Brisbane are usually advised to stay in Brisbane the night before. See accommodation for options near the hospital.
After the admissions process you wait in the surgical waiting area. You have a short consultation with your anaesthetist before your general anaesthetic, and Dr Cutbush greets you in the anaesthetic bay and marks the operation site.
The hospital stay is usually two nights, with discharge around 10am on the second day. You are reviewed before discharge and given a folder containing a letter describing the findings and the operation performed, together with your rehabilitation and post-operative care information. You will need someone to take you home.
Recovery and healing
On day one you have an X-ray and a CT scan to check the position of the prosthesis, and physiotherapy begins.
You will need time off work, driving and recreational activity. Three months is a reasonable expectation, although this varies with the individual and with the type of work involved.
Reviews with Dr Cutbush and the shoulder physiotherapist are at 6 weeks, 12 weeks and 12 months. A final X-ray and CT scan are taken at 12 months. Reviews can be in person or by video call, and the office will ask which you prefer.
Rehabilitation
Recovery combines rest with gradually increasing physiotherapy. The sling is worn for approximately three weeks and is then weaned from about week four. At six weeks, some soreness and aching is normal and range of motion is still limited; exercises are increased gradually. By 12 weeks range of motion has improved, daily activities and other physical activity can be resumed, and strengthening begins and continues until an appropriate level of function is reached. Full recovery, including a return to strenuous activity and sport, is generally reached at around 6 to 12 months.
Day one
The hospital physiotherapist sees you the morning after surgery and again before discharge. They fit the sling and show you how to eat, shower and dress while wearing it. The goals at this stage are to protect the healing joint replacement, to keep shoulder movement within set limits, and to protect any tendon repair that was performed.
The sling is worn for three to four weeks after surgery, and the instruction in your operation record takes precedence over the general guideline. It is fitted in theatre while you are lying face down, then refitted standing up on the first morning after surgery. It should reach the knuckles at the base of your fingers; if it is too short, a larger size can be provided in hospital. It can be removed for showering, eating and sitting quietly.
Exercises and precautions
Precautions during this phase:
- No active use of the operated shoulder.
- No shoulder extension.
- No hand-behind-back movement.
- No weight bearing through the operated arm.
- Where the subscapularis tendon was repaired, this is taken into account in your protocol.
Passive glenohumeral range of motion exercises:
- Circular pendulums.
- Stick-assisted external rotation, from neutral to 20 to 30 degrees.
- Forward lean flexion, to 120 degrees.
These progress to active-assisted and then active range of motion once you are out of the sling. Alongside them, the physiotherapist checks your sling fit, posture in the sling and scapular awareness, makes sure you can put the sling on and take it off independently and manage your own self-care, carries out a chest and mobility check as appropriate, maintains movement in the neighbouring joints, and controls swelling with effleurage as required.
Follow-up
- See your local therapist at two weeks, or sooner if you have concerns about swelling, stiffness or pain.
- Attend the week six review with Dr Cutbush and the shoulder physiotherapist, where the next stage of rehabilitation is outlined.
Results after surgery
With surgery and adherence to the rehabilitation protocol, most people experience a substantial reduction in pain and an improvement in shoulder function, and range of motion is increased after surgery. Many people return to normal or near-normal levels of physical activity. Aching pain at night that disturbs sleep often improves.
Rotation, particularly reaching behind the back, is usually more limited after a reverse replacement than after an anatomic one. Australian registry data record that approximately 7% of reverse total shoulder replacements had been revised at 14 years. Individual results vary.
Next steps
This page is general information about a surgical procedure and is not a recommendation that you have it. Whether surgery is appropriate for you can only be determined after assessment. All surgery carries risk; the risks relevant to you are discussed in consultation before any decision is made.
