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Reconfigured and Reconstructed: Reverse Total Shoulder Replacement


By Alexander Germanis

The English language is fairly unique when compared to many of its European cousins in that the word order in a sentence does not always matter. Often, an opening phrase or two can be repositioned toward the end of a sentence and it will still all work as a whole. Despite these supposedly lackadaisical grammatical restrictions, however, a speaker still needs to know how and when such alterations can be made.

Surprisingly, the shoulder joint has something in common with sentence construction. With a regular total shoulder replacement, “all of the muscle and tendons and regular structures are intact, they’re just arthritic,” says Dr. Joseph Norris, a surgeon at McLean County Orthopedics. “Therefore you replace the ball and socket — a new metal ball where there was bone and a new plastic socket where there was a socket; all the other parts stay there and they still function the same way. You just don’t have a rough surface rubbing on a rough surface.”

“A reverse total shoulder comes into play when you have the same arthritic conditions but there’s no rotator cuff available or there’s a chronic tear associated with arthritis,” Dr. Norris continues. “Then you use the physics of the shoulder to allow someone who has what I call ‘pseudo-paralysis’ — where they cannot move their arm or function [due to] the pain from their arthritis and absence of rotator cuff — and adapt the way you put in the implant. So, in the socket side you put a ball and in the ball side you put in a socket.”

Just as with reconfiguring the order of words in a sentence, there is always the matter of the requisite know-how to make it work. “[A reverse total shoulder] changes the vectors on which the deltoid [shoulder] muscle works to be able to forward elevate and abduct the arm. It’s a pretty ingenious design… but it’s very technically demanding as you can imagine — getting the tension the right way and making sure it’s working appropriately without a good rotor cuff but still functioning well as a shoulder.”

Reverse total shoulder replacements are fairly rare, however. Even a regular shoulder replacement does not occur with the prevalence of hip and knee replacements for one main reason: “Arthritis of the shoulder joint is not quite as common because it’s not a weight-bearing joint,” Dr. Norris explains.

But arthritis of the shoulder can have its origins in an unexpected way, according to the doctor. “If you have a rotor cuff tendon tear and that tear is not fixed, over time that can lead to arthritis because the rotator cuff is not providing the compression to lever the ball into the socket.”

These two issues — a rotator cuff tear combined with debilitating arthritis — combine to form a condition known as rotator cuff arthropathy. For this condition, a reverse total shoulder replacement is the only treatment that can restore normal mobility.

Initially developed in the 1970s by the French physician Dr. Paul Grammont, the reverse total shoulder was “designed for patients over 70, who have a rotator cuff tear, but they’re still very functional and they want to live on their own,” Dr. Norris says.

The doctor goes on to outline other instances in which a reverse total shoulder replacement can be utilized: “An older person has a bad fracture and you worry about the rotator cuff healing back to the bone. You can do it in a traumatic scenario — a fracture of the proximal humerus. It can provide better function long-term.”

But the procedure comes with a caveat. “If you have a failed reverse total shoulder replacement,” Dr. Norris warns, “it’s a bit of an endgame.” Therefore, before he engages in either form of shoulder replacement, he “always tries conservative treatments first. I’d never do surgery unless I’ve first tried injections, medicine by mouth, and, in some cases, therapy.”

Furthermore, for those who do undergo the procedure, there is “the long-term lifting restriction,” the doctor adds. “Because of the physics of how the construct works, there’s a lot of force and torque, so I don’t have people lift more than a gallon milk (approximately eight pounds) after that surgery, which turns a lot of people away.”

When confronted with the alternative, Dr. Norris explains that the benefits of replacing the joint in such a way can far outweigh the single lifting restriction. “You can take a person who is in pain and cannot even move their arm away from their body to a person who has little to no pain and can start using it for daily activities and function again.”

For more information about joint pain, cartilage restoration, arthroscopic surgery or other orthopedic questions, you may
contact Dr. Norris at McLean County Orthopedics, 309-663-6461 or visit his website He specializes in complex arthroscopic surgeries.

Photo credit: monkeybusinessimages/iStock