Standard Shoulder Replacement vs Reverse Shoulder Replacement
What’s the difference between a standard total shoulder replacement and a reverse total shoulder replacement?
First, let’s review the anatomy of the shoulder. Similar to the hip joint, the shoulder is a large ball and socket joint. It is made up of bones, tendons, muscles and ligaments, which hold the shoulder in place but also allow movement. Bones of the shoulder joint include: the clavicle (collar bone), scapula (shoulder blade), and humerus (upper arm bone). The clavicle attaches the shoulder to the rib cage and holds it out away from the body. The rounded head of the humerus rests against the glenoid cavity (socket) of the shoulder blade.
In standard total shoulder replacement surgery, a metal ball is used to replace the head of the humerus. A high-strength plastic implant is used to replace the socket of the shoulder blade.
In reverse total shoulder replacement surgery, the location of the new ball and socket are on the opposite sides of a normal shoulder. Their positions are ‘reversed.’ A new metal hemisphere is used to replace the socket of the shoulder blade and a metal and high-strength plastic socket is used to replace the head of the humerus.
What are the causes of shoulder pain?
Shoulder pain can be the result of arthritis or bone fracture. These events change the surfaces of the joint. Pain can also be the result of a rotator cuff tear. Some patients develop both severe arthritis and large rotator cuff tears. When these two problems occur together, the result is severe pain and significant loss of function, particularly in patients’ ability to raise their arm overhead.
Which type of total shoulder replacement surgery is the best option for which type of shoulder problem?
The primary goal of both approaches is to relieve pain. Secondary goals are to improve motion, strength and function. Before any decision is made regarding the type of surgery, all nonsurgical approaches are tried first. Medications and physical therapy are tried first. If the pain is still not significantly reduced, total shoulder replacement surgery is considered.
The degree of damage to the rotator cuff is one of the key factors in deciding which type of total shoulder replacement surgery is the better option. Although standard shoulder replacement surgery reduces or eliminates pain and improves function, success depends on the condition of the rotator cuff. The more intact the rotator cuff, the better the outcome.
Reverse total shoulder replacement surgery is the best option for patients with severe arthritis and a large rotator cuff tear. Despite the large rotator cuff tear, the change in position of the joint improves shoulder function and replacing the joint removes any arthritis. More than 90% of patients experience significant improvement in both shoulder pain and function, including the ability to raise their arm overhead.
The use of reverse total shoulder replacement surgery is expanding to include other situations in which there is significant rotator cuff damage. These include:
- Failure of a prior shoulder replacement either from damage to the rotator cuff itself or because bone loss that has led to damage or destruction of the rotator cuff’s bony attachment sites on the humerus
- Fractures to the humerus that require shoulder replacement
In both of these expanded uses, surgical treatment can be difficult, and standard shoulder replacement may not reliably improve pain and function. Reverse total shoulder replacement has shown promise in more reliably improving shoulder function in these difficult cases.
A summary of the similarities and differences between the two types of total shoulder replacement surgeries is shown in the table.
|Total Shoulder Replacement Surgery: Comparing Reverse and Standard Approaches |
| ||Reverse total shoulder replacement ||Standard total shoulder replacement |
|Typical indication for surgery ||Massive rotator cuff tear that cannot be repaired with or without shoulder arthritis |
Nonsurgical methods were tried and were unsuccessful
|Shoulder arthritis without a rotator cuff tear |
Nonsurgical methods were tried and were unsuccessful
|Most common patient characteristics ||Males and females age >= 60 Can walk/move about without assistance ||Males and females age >= 50 Can walk/move about without assistance |
|Typical outcomes ||Outstanding pain relief, improvement in overhead function and overall shoulder range-of-motion |
(may not gain as much overhead function as standard replacement, and some weakness related to rotator cuff tear may persist)
|Outstanding pain relief, improvement in overhead function and overall shoulder range-of-motion |
|Life span of implant ||Approximately 9 out of 10 implants last 10 years (longer-term follow-up not yet available) ||Approximately 9 out of 10 implants last 15 years |
What tests will I need to have to help determine what type of surgery is best for me?
Tests include a series of x-rays, a physical examination and a thorough review of your medical history.
- X-rays can usually reveal bone spurs, damaged joint surfaces and any narrowed joint spaces.
- The physical exam will help determine the source of pain with motion and also the degree of loss in range of motion.
- The medical history and description of your shoulder problem, such as degree of pain with activity, any limitations in use, loss of motion or pain at rest, can add useful information when developing a treatment plan.
You, your surgeon and your family are all active participants in selecting the most appropriate treatment.
- Ricchetti E. Hand and Upper Extremity Center. Cleveland Clinic, Cleveland, Ohio
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