Reverse total shoulder arthroplasty

Changed by Domenico Nicoletti, 9 Feb 2024
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Disclosures - updated 29 Aug 2023: Nothing to disclose

Updates to Article Attributes

Body was changed:

Reverse total shoulder arthroplasties (RTSA) or replacements (RTSR) are a variant on the standard total shoulder replacement (TSR). It is often the preferred method when there has been advanced damage to the rotator cuff as seen in rotator cuff tear arthropathy.

Prosthetic components

Humeral components

  • proximal cup-shaped portion is a radiolucent polythene insert that articulates with the glenosphere

  • metal stem in the proximal humeral shaft

Glenoid components

  • glenosphere is the rounded metal ball of the prosthesis that attaches to a baseplate (metaglene)

  • baseplate (metaglene) is specially coated metal plate that is attached to the native glenoid fossa with bicortical screws

Procedure

The reverse total shoulder arthroplasty flips the normal mechanical arrangement of the shoulder's ball-and-socket joint. Instead of the humeral head fitting into the glenoid, a rounded hemispheric glenoid prosthesis articulates with a socket on the humeral head prosthesis.

Advantages and disadvantages

Reversing the ball and socket arrangement, the point of rotation is moved more medially, aiding the deltoid muscle which, without an intact rotator cuff, will provide most of the early adduction for the upper extremity after the surgery. Internal and external rotation are more limited in this arrangement, however.

The indications for reverse total shoulder replacement are expanding and include

  • osteoarthritis in patients with a degenerate rotator cuff

  • irreparable massive cuff tear

  • replacement after tumour surgery

  • complex fractures in elderly patients where the greater and lesser tuberosity fragments are involved 

  • failed standard total shoulder replacement

Axillary nerve dysfunction is a contraindication for reverse total shoulder replacement. 

The design is thought to have relatively good short and medium-term outcomes compared with other types of total shoulder replacements, with improved recovery time and pain scores 3. Long-term outcomes remain poorly defined.

Radiographic features

Plain radiograph
CT

  • better for evaluation if there is a suboptimal radiograph

  • as on conventional radiography, >2 mm of lucency around the prosthetic component is concerning for loosening

MRI
Ultrasound

  • useful for imaging the rotator cuff musculature, evaluating the prosthesis dynamically, and evaluating for joint effusion

  • cannot be used to evaluate for component loosening

Complications

The overall complication rate for all forms of total shoulder arthroplasty is ~15%. Complications include:

  • aseptic loosening of the glenoid component: most common complication (~30% of all shoulder replacements, but decreased with reverse total shoulder replacements 5)

  • aseptic loosening of the humeral component

  • dislocation

  • periprosthetic fractures

  • acromial/scapular spine fracture, most commonly a stress fracture 6

  • hardware failure

  • axillary nerve palsy

  • infection (uncommon)

  • scapular notching

    •

History and etymology

French surgeon Paul-Marie Grammont (1940-2013) designs a clinically successful reverse prosthesis (where other reverse designs have failed) for arthritic shoulders with massive rotator cuff tear in 1985, in which normal anatomical prostheses could not solve the problem of restoring both joint stability and mobility 7,8.

The idea of reverse total shoulder arthroplasty thought by Grammont was an important step forward in the field of shoulder arthroplasty in fact the previous constrained prostheses (spherical or inverted spherical designs) all failed because their centre of rotation remained lateral to the scapula, limiting movement and producing excessive torque at the prosthesis-bone interface of the glenoid component, thus leading to premature loosening 7,8.

See also

  • +<li><p><a href="/articles/scapular-notching" title="scapular notching">scapular notching</a></p></li>

References changed:

  • 1. Sanchez-Sotelo J. Total Shoulder Arthroplasty. Open Orthop J. 2011;5(1):106-14. <a href="https://doi.org/10.2174/1874325001105010106">doi:10.2174/1874325001105010106</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21584206">Pubmed</a>
  • 9. Castagna A, Borroni M, Dubini L, Gumina S, Delle Rose G, Ranieri R. Inverted-Bearing Reverse Shoulder Arthroplasty: Consequences on Scapular Notching and Clinical Results at Mid-Term Follow-Up. JCM. 2022;11(19):5796. doi:10.3390/jcm11195796 - Pubmed
  • 1. Sanchez-Sotelo J. Total Shoulder Arthroplasty. Open Orthop J. 2011;5(1):106-14. <a href="https://doi.org/10.2174/1874325001105010106">doi:10.2174/1874325001105010106</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21584206">Pubmed</a>

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