One area patients seek out Doctor Shelden Martin are those needing to have a reverse shoulder arthroplasty.
A reverse shoulder arthroplasty conducts the opposite functions of conventional replacement by relying on arm movement of the deltoid muscle in the shoulder– instead of the rotator cuff– to balance the joint.
Good candidates for this type of procedure include patients who have had unsuccessful rotator cuff and shoulder replacement surgeries and elderly patients that suffer with severe fractures.
Doctor Martin is committed to helping each of his patients get back to their daily activities as soon as possible.
The reverse shoulder arthroplasty or reverse total shoulder replacement is one of the most revolutionary technologies in shoulder surgery in recent decades. This is a special shoulder replacement intended for patients with very complex shoulder problems, specifically those patients having both arthritis and extensive rotator cuff tendon tears. Until the development of this technology in Europe in the mid-1980s and the approval by the FDA in 2003 for use in the United States, previous treatment options for these patients were limited with mediocre outcomes. Now with over 10 years of experience and excellent early outcomes, we continue the relentless pursuit to improve upon this amazing technology with patient specific implantation techniques.
Conventional or anatomic total shoulder arthroplasty or replacement is an extremely successful surgery for patients with shoulder, or glenohumeral arthritis, secondary to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis. This surgery replaces a patient’s humeral head or “ball” of the ball and socket shoulder joint. The native cartilage has been worn away and is therefore replaced with a metal spherical surface placed on top of a metal stem that is secured inside the humeral shaft, typically by a press fit method or with bone cement. The cartilage surface of the socket, called the glenoid, is smoothed or reamed to flat surface onto which a plastic liner is placed. The liner is secured with bone cement, press fit techniques, or with screwed in metal backed components. The rotator cuff tendons must be functioning normally and very carefully repaired during this surgery in order for these components to function properly.
A reverse shoulder arthroplasty essentially switches the ball and the socket components of an anatomic or conventional total shoulder arthroplasty by placing a plastic liner component on top of the humeral stem. The ball component is called the glenosphere and attaches to a metal baseplate, which is secured to the glenoid or socket with a central post or screw and surrounding peripheral screws. With this configuration, there is no need for rotator cuff tendons to balance the prosthesis, and allows the deltoid shoulder muscle to provide shoulder motion.
The primary indication for a reverse shoulder arthroplasty is rotator cuff arthropathy, which is a shoulder with massive, non-repairable tears of the rotator cuff tendons and arthritis of the ball and socket joint. Patients with both glenohumeral arthritis and extensive, non-repairable rotator cuff tears are not candidates for conventional shoulder replacement surgery. As our early experience here in the US with this prosthesis has shown excellent outcomes, indications have expanded to include fractures, other failed surgeries such as rotator cuff repair surgery, or failed arthroplasties including hemi and total shoulder arthroplasty. The best candidates are elderly, low demand patients over the age of 65 who are looking for decreased pain and improved function with activities of daily living.
So what should you do if you suspect if you have shoulder arthritis? It is critical to seek evaluation by a shoulder specialist. First a complete history of your symptoms will be obtained, asking many detailed, specific questions about the onset, duration, and location of your symptoms, as well as what treatments you have received. Next, a complete physical examination will be performed of the cervical spine and the painful shoulder, as well as the contralateral shoulder for comparison. A complete set of x-rays will usually be obtained, which typically show joint space narrowing between the ball and the socket and the formation of osteophytes or bone spurs. Occasionally, in the setting of advanced arthritis, additionally a CT scan will be obtained to better evaluate the bone stock of the glenoid or socket to ensure suitability for resurfacing of the socket. Treatments will be discussed which include both non-operative and surgical. If a reverse shoulder arthroplasty is appropriate, the surgery will be discussed in detail. You will be scheduled for surgery and will need to complete preoperative medical surgical clearance including blood draw, EKG, primary care visit and possible medical specialist clearance such as cardiologists or pulmonologists if you have other medical problems, as well as dental clearance.
If you have been scheduled for surgery, you will be asked to arrive at the surgical facility 1-2 hours prior to your surgical time. An IV line will be established, the anesthesiologist will visit you and discuss the anesthetic portion of the procedure. Dr. Martin will visit you to review any final questions, mark the operative site and review your medical chart and surgical consent forms. The anesthesia is a combination of general anesthesia along with a preoperative regional nerve block. This is an ultrasound-guided injection of a cocktail of long acting local anesthetic medications that will provide complete sensory block to the operative shoulder and arm for typically 12-24 hours. Additionally, Dr. Martin augments the peripheral nerve block by injecting a similar long acting cocktail of local anesthetic medications intraoperatively throughout the surgical wound. Surgery typically takes 1-2 hours. Postoperative oral narcotics, nerve pain medications and non-steroidal anti-inflammatory medications, as well as IV narcotics are used postoperatively.
Most patients typically spend 1 night in the hospital and discharged home the next day wearing a sling and performing home exercises. The sling will be continued approximately 4-6 weeks after surgery. Outpatient physical therapy may be utilized at that time to help patients work on regaining range of motion and strength in the operative arm. Patients will reach most of their improvements in 3-4 months after surgery, although most patients will continue to make small improvements in strength up to 6-12 months after surgery. Dr. Martin will see you periodically in the office throughout your recovery period to ensure appropriate recovery. Typically, after the first year of surgery you will need to see Dr. Martin every 1-2 years for x-rays looking for any signs of early component problems and to follow the longevity and survivorship of the prosthesis.
If you are diagnosed with rotator cuff arthropathy and a reverse shoulder arthroplasty is a surgical option for you, you will want to know your surgeon’s experience with this newer technology. What is his or her training in this procedure and how many procedures are performed annually? You will want to know about the recovery period and what are the average outcomes for your surgeon’s patients. What is your surgeon’s experience with and plan if complications arise.
Early outcomes have been extremely favorable. When performed properly by experienced surgeons, this procedure is incredibly successful at relieving pain caused by arthritic shoulders that are unbalanced due to massive rotator cuff tendon tears. Studies show that on average, patients gain approximately 130°-140° of forward elevation of the arm, which allows a person to get their hand behind their head and allows overhead use of the upper extremity, outcomes that far exceed surgical treatments that were utilized prior to the reverse shoulder arthroplasty.
Unfortunately, as with any surgery, complications can arise. Dislocations, nerve injuries, arterial injuries, infections, stiffness, early component failure, fractures, anesthetic complications and medical complications can all occur. Any of these complications and others can be devastating and require further surgeries and significant morbidity or disability. It is estimated that 80% of all of these procedures are performed by surgeons that perform fewer than 10 annually. There is good evidence to show that patients have better outcomes with surgeries performed by high volume surgeons at high volume surgical facilities. Therefore, you will want to discuss these possible complications with your surgeon.
This technology is the newest advancement in reverse shoulder arthroplasty surgery. Prior to surgery, a CT scan is obtained of the patient’s shoulder. This scan produces a 3-dimensional x-ray image of the patients shoulder. Dr. Martin is then able to digitally determine the precise position and size of the components to be used at the time of surgery. The manufacturer then manufactures a PSI glenoid bone model and PSI instrument guides that are used intra-operatively to reproduce exactly the templated positioning of the components to improve precision and accuracy of component placement. This technology has been shown to be more precise at placing the socket component in the appropriate position compared to the more conventional technique based on the surgeon visually estimating at the time of surgery. We believe this new technology will help prevent early and long-term failure of the socket component, which can lead to catastrophic and devastating complications.
The PSI technology has been shown to improve precision and accuracy of the positioning of the glenoid components, which is critical to the successful outcomes and longevity of the reverse shoulder arthroplasty. The use of the PSI technology is particularly useful in the setting of severe arthritis with deformity of the glenoid, making conventional intraoperative decision-making regarding positioning of the components challenging and unreliable.
Dr. Martin is one of the most experienced surgeons in Arizona utilizing this technology. If you have any questions, or want to schedule an appointment to determine if you’re a candidate for reverse shoulder arthroplasty, call 602-631-3161.