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Physicians Update

 
Fall 2010

Reverse Shoulder Replacement Improves Outlook for Patients with Cuff Tear Arthropathy

PU Fall 2010 - Reverse Shoulder ReplacementMany people who suffer from rotator cuff tears may be managed nonsurgically using medications, injections and physical therapy. If the condition does not respond to conservative measures, arthroscopic surgery can be used to repair the tendon in many cases. But for patients with massive, irreparable rotator cuff tearing that results in arthritis (cuff tear arthropathy of the shoulder), the problem is more complex. Reverse shoulder replacement has emerged as a promising solution in recent years.

“We now have an arthroplasty option for cuff tear arthropathy that can reliably give a patient an improvement in range of motion and a dramatic decrease in pain after the operation,” says UCLA orthopaedic surgeon Seth Gamradt, M.D., who specializes in shoulder and knee surgery. “When patients have arthritis alone, we can perform a conventional total shoulder replacement, and when they have a reparable rotator cuff tear alone, we can repair it using arthroscopic techniques,” Dr. Gamradt explains. The combination of the two conditions, however, has been historically difficult to treat, he says.

When the rotator cuff is intact, a conventional shoulder replacement replaces the ball (humeral head) and socket (glenoid) of the shoulder with metal and plastic, which effectively eliminates pain and restores range of motion. In patients with cuff tear arthropathy, however, the rotator cuff muscles fail to hold the shoulder in the socket. The ball rides high in the socket and this eventually leads to arthritis and cartilage erosion over the course of years. In the most severe cases, patients suffer intractable pain and are unable to raise the arm. Conventional shoulder replacement with a hemiarthroplasty (half shoulder replacement) has not been a predictable strategy to address these dual problems, according to Dr. Gamradt.

The reverse total shoulder replacement, approved by the FDA for use in the United States in 2004, is a shoulder prosthesis specifically designed to improve upon the results of conventional shoulder replacement in patients who have a deficient rotator cuff and severe arthritis.

The procedure is performed by implanting a balltype prosthesis to the socket of the shoulder and a socket-type prosthesis to the ball of the shoulder. Together these change the anatomy of the shoulder in such a way that the deltoid muscle has the tension sufficient to power the shoulder. This restores the patient’s ability to raise the arm and reduces the pain from arthritis. The complication rate for the reverse prosthesis is approximately 10 percent in primary surgery and 30–40 percent in revision surgery, Dr. Gamradt says.

“The art of the procedure is deciding who needs it,” he notes. “If patients don’t have much pain or their pain can be managed with medications, I usually don’t recommend this surgery. That is, poor range of motion alone without pain is not enough for me to recommend the surgery because the risk is higher than in conventional arthroplasty. It is nice to have this new option, but we use it conservatively to help only those patients with a combination of severe pain and motion loss who are likely to derive the most benefit.”





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