The Procedure
A reverse total shoulder replacement (RTSR) is where the shoulder joint is replaced with a prosthesis, however instead of the ball of the humeral head being replaced with a ball and the socket of the glenoid being replaced with a socket, the humeral head is replaced with a socket and the glenoid with a ball called a glenosphere. Hence the shoulder joint is in a sense reversed, which is why it’s called a reverse shoulder replacement. In Australia, 80% of all shoulder replacements performed are reverse total shoulder replacements and reverse shoulder replacements out last all other types of shoulder replacements in terms of longevity.
Shoulder replacement surgery is performed as an open procedure. I typically book 3 hours of theatre time for the surgery.
The reverse shoulder replacement was originally designed to replace the shoulder that had become arthritic due to a chronic rotator cuff tear, a condition called cuff arthropathy. Conventional or anatomic shoulder replacements don’t work for this condition and it wasn’t until reverse shoulder replacements became available that the condition could be successfully treated. The first reverse shoulder replacement was performed in Australia by Professor David Sonnabend in Sydney in 1999. Since then, due to their success, the indications for reverse shoulder replacements have broadened dramatically. Reverse shoulder replacements are now performed on patients with irreparable rotator cuff tears, severe arthritis, avascular necrosis and severe fracture cases.
Around 80% of all shoulder replacements in Australia are performed as RTSRs, and the reverse shoulder replacements are the longest lasting of all the shoulder replacement types. I typically use the Stryker, Tornier Ascend Flex or Medacta shoulder prostheses. These prostheses have established track records in the Australia Shoulder Registry with excellent performance and longevity.
Pre Op
If you are undergoing a joint replacement, I will ask you to see a physician prior to your surgery to ensure that any underlying medical issues are identified and treated. It has been consistently shown that patients undergoing prosthetic joint replacement surgery experience fewer complications and better outcomes following their surgery if they have been reviewed by a physician preoperatively. Joint replacement surgery places a significant stress on the body. Any unrecognised and untreated medical conditions have a tendency to present issues during such surgery. The physician review is aimed at identifying any unrecognised health issues and optimising you from a medical standpoint for the upcoming surgery. You will also need to have a blood test for your general blood health. These steps before surgery have a proven record of reducing the rate of surgical complications and infections and improving the outcome of your surgery.
Other things to do include:
- Speak to your health fund to confirm if the hospital fee for your surgery is covered on your policy. This is particularly important when considering prosthetic joint replacement surgery as many health policies do not include joint replacement cover. If your policy does not cover joint replacement surgery, you may need to upgrade your cover and wait the 12 month qualifying period before you are covered for your surgery.
- Speak to your anaesthetist to confirm their fees
- Register your details with the hospital
- Read through, complete and return your paperwork to our office
- Plan your transport to and from the hospital. You won’t be able to drive yourself home after the surgery, so make sure you have a travel plan in place
- If required, arrange any recommended pre op physio appointments
- If required, get any pre op pathology tests (e.g., blood tests)
- Use benzoyl peroxide 5% wash on your shoulder for 5 applications: twice a day for two days, and then again on the morning of the surgery. This will help reduce your risk of infection from Cutibacterium acnes.
- You will need to shower using chlorhexidine cloths the night before and the morning of surgery. This dramatically reduces the total number of bacteria you carry on your body and helps reduces the risk of bacterial infection.
- You will be given a script for mupirocin nasal ointment to be applied to both your nostrils twice a day for five days before surgery. Mupirocin ointment is very effective at eradicating bacteria from the nasal passage, including Staphylococcus aureus (aka. Golden staph), dramatically reducing the risk of a staph wound infections by more than 80%.
- Pack a bag for your hospital stay including regular medications in the original packaging, a loose button-up shirt to wear after surgery, nightwear, personal items including toiletries. If you have sleep apnoea, you must bring your CPAP machine.
- If you are on any blood thinners ring my office and confirm when to stop taking them before the operation.
- If you are on any diabetic tablet medications ring your anaesthetist and confirm whether you need to stop taking them before the operation
- Confirm your admission details with my office one to two business days prior to surgery
Though this can seem overwhelming, you will be provided with detailed instructions on what needs to be done so your surgery journey can be as smooth as possible.
Complications
RTSR is a significant surgery similar to a hip or knee replacement, and there are risks, including:
- Infection: for RTSR, the risk of infection is around 1%. It’s quite unusual and rare for an infection to develop, however they can occur.
- Dislocation: around 1%
- Prosthesis failure: the artificial joint will have a lifespan of up to 20 years, however a second joint replacement surgery may be required
- Bruising & haematoma: this will vary between each person, however bruising is a normal side effect of surgery and will usually resolve within a short time. A haematoma may require a return to theatre for drainage.
- DVT and PE: deep vein thrombosis and pulmonary embolism are blood clots that form in either the lower limbs or your lungs. If left untreated, DVT and PE can have serious effects, however if treated promptly, the risks are significantly lowered. More information can be found here
- Anaesthetic risks: as RTSR is performed under a general anaesthetic (GA), there are the usual risks associated with this. In Australia, the risk of mortality from GA is around 1 in 100,000. Fortunately, Australia is one of the safest places to undergo a GA. For context, the risk of death in a car accident in Queensland is around 1 in 10,000 per year.
- Wound issues: some superficial issues can develop on the wounds after surgery, however most will require a small intervention to resolve the problem.
- Instability and dislocation: instability occurs in about 1% of patients undergoing reverse shoulder replacement in Australia and typically occurs in the first year. It will usually require relocation of the joint and immobilisation in a sling for some weeks. If a recurring problem, a revision of the shoulder prosthesis will be required.
- Stiffness occurs in a small number of cases.
- Prosthesis failure: the artificial joint will reasonably have a lifespan of up to 20 years. If the shoulder replacement wears out, a revision joint replacement surgery may be required. To give you something to consider, the AOA NJRR reported in 2024 that at 14 years, 7% of reverse total shoulder replacements had been revised meaning that 93% still had not been revised. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) gives the most relevant information regarding shoulder joint outcomes in Australia and you can access the results of shoulder joint replacement surgery in Australia here: https://aoanjrr.sahmri.com/
Day of Surgery
Your admission details will be confirmed one to two business days prior to surgery. You will need to make note of your admission time and your fasting time. Your admission time may be as early as 6am. If you aren’t local to Brisbane, it is usually recommended that you stay the night before in case your admission is early.
When you arrive at the hospital, you will go through the admissions process and then be taken through to the surgical waiting area. Your anaesthetist will have a short consultation with you before you go into theatre and under general anaesthetic. I will say hi to you before the surgery in the anaesthetic bay of the operating theatre and mark your operation site with you.
Your hospital stay will usually be two nights. You will be discharged usually around 10am on the second day postop. I will see you before your discharge. I will provide you with a folder containing a detailed postoperative pack including a letter telling you what I found at surgery and exactly what I did in your operation along with information about your rehabilitation and postoperative care. Remember to have someone available to take you home from the hospital.
Post Op Recovery & Healing
On day 1 post-operatively, an X-Ray and CT scan will be performed to check the position of the prosthesis and physiotherapy will commence. You need to take time off work and driving, as well as other recreational physical activities, to allow adequate rest and healing to occur. Exact durations are variable, however three months is quite a reasonable expectation.
A review with me will be organised at around 6 weeks post-op. Usually, you will have reviews with me and the shoulder physio at 6 weeks, 12 weeks, 12 months post-op. Final checks and scans (XRays and a CT scan) are performed at 12 months post-op. These appointments can be either in person or by telehealth video consultation (either Facetime or WhatsApp). Just let my office know which you prefer.
Rehabilitation
As it is a joint replacement, RTSR rehab involves both resting and gradually increasing physical therapy during recovery after surgery.
Normally, a sling is worn for three weeks after surgery, and then gradually weaned off from four weeks. At six weeks, it is normal for there to still be some soreness and aches, and your range of motion will still be limited, however a gradual increase in exercises will help to improve movement.
By 12 weeks after surgery, the range of motion will be improved, and activities of daily living and other physical activities can be performed. Strengthening exercises will begin at this point and will continue until an appropriate level of function is achieved.
Full recovery and return to normal physical activities including strenuous exercises like sports is achieved at around 6 to 12 months.
Physiotherapy Guidelines
Day 1 Physio Guidelines
The hospital physio will demonstrate how to fit your sling and how to eat, shower & dress whilst in your sling. Please make sure you go through these things with the physio so that you get them really clear in your mind before you leave hospital.
Goal:
- Protect healing of the arthroplasty
- Maintain GH (glenohumeral) Joint range of motion within certain limits
- Protect any tendon repairs
Sling:
- Worn 3-4 weeks post operatively (defer to op record)
- Can come out of sling for showering, eating, sitting quietly
- Check fit, demonstrate activities of daily living (showering, dressing etc)
- The sling is fitted to you in theatre with you lying prone. For the sling to be fitted properly you need to be standing and the physio will do with you the first moning after your surgery. I like the sling to be long enough to reach your metacarpophlangeal joints, the knuckles at the base of your fingers. If it is too short, the physio can arrange a larger size sling for you while you are in hospital.
Precautions:
- No active use of operated shoulder
- Consider any SSC (subscapularis) repairs, No shoulder extension, HBB (hand behind back), Weight Bearing
Therapy:
- Ensure appropriate sling fit, good posture in sling and scapula awareness.
- Patient independent in Don/doff sling and self cares
- Chest and mobility check as appropriate
- GHJ (glenohumeral joint) passive ROM (range of motion) exercises: Circular pendulums, Stick ER(0) external rotation in neutral) to 20-30 degrees, forward lean flexion to 120 degrees. Progress to AA/AROM (active-assisted/active range of motion) once out of sling.
- Maintain range of motion of adjacent joints
- Oedema control, effleurage as required
Follow up:
- With local therapist at the two week mark, earlier if any concerns with swelling/stiffness/pain
- Week 6 with me and the shoulder physio, progression of rehabilitation will be outlined then
Results After Surgery
Following RTSR and adhering to rehabilitation protocols, most patients will experience a dramatic improvement in pain relief and shoulder function. Many patients have a return to normal or near normal levels of physical activity, and the range of motion is increased after surgery. The joint replacement surgery is particularly good at relieving the aching pain at night that disrupts the sleep of so many patients and keeps them awake at nighttime
The RTSR joint prosthesis lasts for maybe 20 years, with many patients experiencing much longer use than this.