By: Stephen G. Manifold, MD

The rotator cuff is a group of four muscles and tendons that surround the shoulder joint and provide stability and range of motion of the joint. Degeneration of one or more of these tendons is common with the aging process and in some cases can lead to tearing of the tendons. When symptomatic, this can result in pain and weakness of the shoulder. If nonoperative treatment fails to resolve these symptoms, arthroscopic repair of these tears is often possible and successful. Some tears however, can become very large over time and become irreparable. This can subsequently lead to arthritic changes in the shoulder joint as well which until recently, presented very limited treatment options for the patient and the orthopaedic surgeon. The reverse total shoulder replacement can be an effective treatment for this difficult problem.

Chronic, massive rotator cuff tears are usually retracted and the cuff tissue is atrophied and of poor quality. In some cases, the muscle tissue can be replaced by fatty tissue, a process called fatty degeneration. The situation is worsened when cartilage degeneration, or arthritis, occurs resulting in what is termed rotator cuff arthropathy. When these conditions are present, the cuff loses its function and is considered irreparable. Despite this, some patients have little or no pain and retain remarkably good motion due to compensation from other muscles around the shoulder joint. Other patients however, develop significant pain but still retain good motion. The surgical treatment of this set of patients usually involves partial replacement of the joint, or hemiarthroplasty, to relieve the pain (Figure 1).

A third set of patients develop pain and significant loss of motion of the shoulder, often referred to as pseudoparalysis, due to the inability of the patient to raise the arm. This results in significant functional deficits including dressing and combing hair. Hemiarthroplasty in this set of patients may relieve pain but does not improve motion or function of the arm. The reverse total shoulder replacement was designed for this group of patients.

Standard total shoulder replacement (TSR) refers to replacing the ball and cup portions of the joint. This is performed for osteoarthritis of the shoulder to relieve pain (Figure 2). This procedure is not indicated in patients with rotator cuff arthropathy due to problems with early loosening and failure that result from the absence of a functioning rotator cuff. Reverse TSR reverses the component orientation in an effort to change the biomechanics of the shoulder (Figure 3). The center of rotation of the joint is changed with a reverse TSR so that the deltoid muscle on the outer portion of the arm, and not the rotator cuff, becomes the primary mover of the arm in flexion. This can allow for relief of pain by replacing the arthritic joint as well as improve range of motion and function by essentially replacing the function of the rotator cuff. The goal of the procedure is not to create a “normal” shoulder, but rather provide pain relief and improve function.

The reverse TSR is indicated in older patients, typically over 70 years of age, with rotator cuff arthropathy who have failed nonoperative treatment. Patients are typically discharged after a 1 or 2 day hospital stay and receive physical therapy for early range of motion exercises. No heavy lifting activities are allowed for 3 months. Early 5-year results from the procedure are promising however, longer term results are lacking and as a result, the procedure cannot be recommended in younger patient populations.

In the past, patients with pain and poor shoulder function from rotator cuff arthropathy had very limited treatment options, none of which adequately improved function. The reverse total shoulder re-placement is a significant advancement in the treatment of this difficult problem and can now offer improved quality of life through both pain relief and improvement in arm motion in the properly selected patient.

Dr Manifold is a board certified Orthopaedic surgeon in Dover, Delaware, specializing in knee and shoulder disorders. He completed his fellowship training in knee replacement and reconstruction at The Insall Scott Kelly Institute/Beth Israel Medical Center, New York, and completed an Orthopaedic residency at New York Orthopaedic Hospital/Columbia-Presbyterian Medical Center, New York. He graduated medical school from Temple University School of Medicine, Philadelphia. Dr. Manifold’s office practice is at Tooze, Easter & Manifold, MD, PA 720 S. Queen St. Dover, DE. To schedule an appointment, call 302-735-8700.