Reverse Shoulder Replacement Surgery - Its Implications and Potential Risks

Introduction:

Conventional total shoulder replacements are done for patients with shoulder arthritis. However, this is not as beneficial for large rotator cuff tears leading to cuff tear arthropathies. Conventional total shoulder replacement surgeries may result in pain and limited motion, and thus in these cases, reverse total shoulder replacement surgery is a better option.

How Does Conventional and Reverse Shoulder Replacement Differ?

• A conventional shoulder replacement mimics the normal anatomy of the shoulder, whereas a reverse total shoulder replacement depends upon different muscles to move the arm.

• A plastic "cup" is fitted into the glenoid in conventional shoulder replacement surgery, and a metal ball is attached to the humerus.

• In case of a reverse shoulder replacement surgery, the socket and metal ball positions are interchanged. The rotator cuff helps position and power the arm during a range of motion to function correctly. However, in a patient with an extensive rotator cuff injury or damage or cases of cuff tear arthropathy, these muscles lose their normal function. Reverse shoulder replacement thus relies upon the deltoid muscle.

What Is the Purpose of Shoulder Replacement Surgery?

Shoulder replacement surgery aims to alleviate pain and other symptoms caused by shoulder joint damage. Various conditions can lead to this damage:

1. Osteoarthritis: Also known as wear-and-tear arthritis, osteoarthritis affects the cartilage covering the ends of bones, causing joint movement to become less smooth.

2. Rotator Cuff Injuries: These injuries can sometimes result in damage to the cartilage and bone in the shoulder joint. The rotator cuff comprises muscles and tendons surrounding the shoulder joint.

3. Fractures: Fractures of the upper end of the humerus may necessitate replacement due to the injury itself or failed prior surgery for fracture fixation.

4. Rheumatoid Arthritis: Inflammation associated with rheumatoid arthritis, caused by an overactive immune system, can damage the cartilage and, occasionally, the underlying bone in the joint.

5. Osteonecrosis: Certain shoulder conditions can disrupt blood flow to the humerus, leading to bone collapse when the bone is deprived of blood.

What Are the Suitable Cases for Reverse Shoulder Replacement?

Reverse total shoulder replacement surgeries are recommended in the following cases;

• A complete or partial rotator cuff injury that is beyond repair.

• Arthropathies that result from torn or injured rotator cuffs.

• A failed shoulder replacement surgery.

• Severe shoulder pain

• Difficulty lifting the arm.

• Complex fractures at the shoulder joint.

• Chronic shoulder dislocation.

• Tumor or growth in the shoulder joint.

• Failure of other pain management therapies.

How Is the Patient Prepared Preoperatively?

The consultant orthopedic surgeon is responsible for the shoulder surgery by following the successive steps;

• Medical Examination of the Patient: A primary care doctor evaluates the patient before surgery to ensure a successful surgery and complete recovery. Before a surgical procedure, a relevant specialist must assess patients with chronic medical conditions.

• Medications: The orthopedic surgeon should be informed about the medications taken by the patient, as some medicines have to be stopped before a surgical procedure can be conducted. Medications such as Aspirin, Ibuprofen, Naproxen, arthritis medications, and blood thinners will be advised to stop at least two weeks before surgery.

• Modification of Everyday Activity: Simple changes at home prior to the surgery can make the recovery phase easier, as, during the first several weeks, it will be hard to reach higher areas. Postoperatively, the patient will require help for a few weeks with some daily tasks.

How Is the Surgical Procedure Conducted?

• Preoperative Patient Preparation: The patient is advised to wear loose-fitting clothes, and a button-front shirt as the patient needs to wear a sling to immobilize the affected arm. The patient is then taken to the preoperative preparation area. An anesthesiologist and the operating surgeon will discuss the type of anesthesia necessary, whether general anesthetic, a regional anesthetic, or a combination.

• Surgical Procedure: The procedure usually requires about two to three hours. An incision on the shoulder is made. The damaged bone is removed and reshaped as necessary, and the prosthetic components are placed to restore function to the affected shoulder.

What Are the Complications of Reverse Shoulder Replacement?

Reverse shoulder replacement surgery is highly technique sensitive and requires expert surgical skills. Hence the surgeon must inform the patient of the potential postoperative risks.

Postoperative risks may include the following;

1. Bleeding at the surgical site.

2. Nerve damage to the surgical site.

3. Infection of the surgical site.

4. Dislocation: The new joint's ball might come out of its socket.

5. Fracture: Bones like the humerus, scapula, or glenoid can break during or after surgery.

6. Implant Loosening: Even though shoulder replacement parts are strong, they might loosen or wear out over time. Sometimes, another surgery is needed to fix this.

7. Rotator Cuff Failure: The muscles and tendons around the shoulder joint, called the rotator cuff, can wear out after surgery.

Complications may occur that are specific to the joint itself, which include the following;

1. Wearing of the prostheses.

2. Loosening of components

3. Dislocation of the replaced shoulder components.

If any of these occur, the surgery might need to be revised or repeated depending upon the extent of the complication.

How Does the Patient Recover Postoperatively?

The patient is prescribed several doses of antibiotics to reduce the risk of infection. Pain medication must be prescribed to manage postoperative pain. Solid food and a regular diet, and getting out of bed are almost always possible on the day following the procedure. The patient is usually discharged on the second or third day.

Pain Management: Pain is a natural part of the healing process. Medications are prescribed for short-term pain relief. The types of pain management medicines include;

1. Opioids.

2. Nonsteroidal anti-inflammatory drugs (NSAIDs).

3. Local anesthetics.

A combination of the medications mentioned above is used to improve pain relief as well as minimize the need for opioids, as they are a narcotic and can lead to dependence or addiction.

Postoperative Rehabilitation: The arm is immobilized using a sling immediately after the surgery. A gentle range of motion exercises to enhance mobility and endurance may be prescribed. A formal physiotherapy program may also be recommended to strengthen the shoulder and improve flexibility. Follow-up office visits and postoperative X-rays may be needed to monitor the shoulder up to a specific period.

What Are the Steps to Be Followed by the Patient During the Postoperative Recovery Phase?

1. Following the home exercise program.

2. Avoid extreme arm positions for the first four to six weeks.

3. Avoid overdoing strenuous exercises.

4. Pushing oneself up out of a chair or bed is strictly forbidden to avoid forceful muscular contractions.

5. Refrain from repetitive heavy lifting after shoulder replacement.

What Are the Long-Term Effects of Reverse Shoulder Replacement?

After rehabilitation, the patients can usually lift their arms just above shoulder height. The elbow can be bent to reach the top of the head. Reverse total shoulder replacement provides excellent pain relief. Patient satisfaction is typically very high. Several early and mid-term studies of the results of this surgery have shown promising results. However, very few long-term studies exist and thus can be an area for future research.

Conclusion

Conventional total shoulder replacement surgeries may result in pain and limited motion, and thus in these cases, reverse total shoulder replacement surgery is a better option. A primary care doctor evaluates the patient before surgery to ensure a successful surgery and complete recovery.