Reverse Shoulder Arthroplasty

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Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today we’re talking remotely with Professor Angus Wallace. Professor Wallace is a professor of orthopaedic surgery at the University of Nottingham in the United Kingdom. Professor Wallace is an expert on shoulder reconstruction. Thanks for joining us, Professor Wallace.

Professor Wallace: Lovely to be with you tonight, Randale.

Dr. Sechrest: Well, Professor Wallace, what I thought we would discuss today is a relatively new procedure which is used for very specific problems in the shoulder that require an artificial shoulder replacement, but problems that don’t normally lend themselves to utilization of a normal artificial shoulder replacement. Now the type of procedure that we’re talking about is sometimes referred to as a reverse shoulder arthroplasty and this procedure was really developed because of the shortcomings in some conditions, some very specific conditions of the shoulder that are regular shoulder arthroplasty set of implants, a socket, the glenoid component, and the ball portion or the humeral head component simply don’t work because the shoulder is too damaged in order to have these two components function. So today I thought we would go through some of the information that’s coming out of this new procedure and hopefully have you walk us through this procedure: the risks, the benefits of the procedure, the differences in this procedure over the normal shoulder arthroplasty that’s been done for several decades now and try to help patients understand better exactly what we’re trying to accomplish with this new procedure. So first, tell us a little bit about the reverse shoulder arthroplasty and what types of conditions this is used in.

Professor Wallace: Yes, this was developed in France by Professor Grammond who we owe a real debt to because he produced this shoulder and at the time was criticized fairly severely for bringing out a design which everybody thought was going to fail. The design is the wrong way around so that if we look at the normal shoulder it’s got a ball at the top of the arm, and I’m demonstrating that for you here, Professor Grammond said that if we put a socket, and there is a socket, instead of the ball then perhaps we will be able to cope with the situation where the ball is no longer stable. The thing that makes the ball stable is the rotator cuff tendon and this rotator cuff tendon goes all the way around rather like the cuff on your sleeve holding the ball on the socket. Now a group of patients tear this sleeve and the ball becomes unstable and tends to move up. The design that Professor Grammond demonstrated is a design which is pretty impressive in that it maintains the stability and holds down the shoulder. I’ll show you what this looks like in a model and I brought here for you, a model of the shoulder and here you can see that the socket is now on the arm and the ball is on the shoulder blade and that articulation means that the humerus, the arm bone, cannot ride up because it’s stopped by the ball. So from the point of view of having a stable shoulder, this stops the up-riding that we see in patients who have torn rotator cuff tendons.

Dr. Sechrest: Yeah, I think that’s pretty clear. I like the model in terms of showing us how this works, and I think we ought to point out to patients that, in the normal situation, the socket is actually in the scapular area and is actually exactly opposite in terms of the reverse shoulder arthroplasty and that’s why we call it a reverse shoulder arthroplasty is that where the ball normally is, we placed a socket, and where the socket normally is we’ve turned around and placed a ball there for that socket now to fit into and articulate or move against. So it is something that was probably a pretty interesting design when it first came out and most orthopaedic surgeons and most orthopaedic procedures are really designed to reproduce the normal anatomy. We think like that. We think about restoring what was there before and simply resurfacing our joint and keep it working the same way. So this whole notion of reversing the whole process clearly was a genius sort of idea that Dr. Grammond had.

Professor Wallace: I call this the upside-down shoulder because it’s the wrong way around and actually my patients understand it better calling it an upside down rather than an inverse shoulder, so it’s upside down in the ball and socket or the wrong way around. It really has been a huge innovation within shoulder surgery. It allows us now to treat some patients who previously were untreatable, where we were getting poor results using a conventional shoulder replacement, and because of that we actually stopped offering them surgery for a while because our results were so poor.

Dr. Sechrest: One thing we ought to probably discuss for patients and that is how you decide whether a patient needs a regular shoulder arthroplasty, a regular artificial shoulder, or when their condition may require them to consider a reverse shoulder arthroplasty or this upside-down shoulder arthroplasty that you’ve termed it. Can you elaborate a little bit on when a patient comes to you what sort of symptoms are they having that sort of keys in your mind that notion that they’re not the typical patient and they may be better served with a reverse shoulder arthroplasty?

Professor Wallace: Patients typically have a condition called pseudoparalysis. That means that with the rotator cuff tear they can’t lift their arm up. What happens when they lift their arm up or try to lift their arm up is that the shoulder comes up and the shoulder comes up because the rotator cuff muscles are not working and they feel that they can’t get their arm, their hand, where they want to get it to. When I learned about the function of the shoulder, the shoulder’s main function is to position the hand where you want to use it and that may be for having a drink. It may be for combing your hair. It may be for scratching the back of your neck. So the shoulder is there to get your hand in the right place. These patients who have pseudoparalysis cannot get their hand up. In fact, some can’t even get it up to their mouth and it can be very disabling and they certainly can’t comb their hair or brush their hair, and it’s intriguing to see how clever they are at getting around this because I’ve seen some of my patients sit in a seat, bend forward, put their head between their knees, and comb their hair that way because that means that you’re using the rest of your body to put the head in the right position. But they manage and it is incredible that they develop methods of getting around their disability.

Dr. Sechrest: Now I think you mentioned that the primary problem that causes pseudoparalysis is not paralysis as we normally would think of, with a nerve injury or something like that. But these patients really don’t have rotator cuff function and those rotator cuff tendons have torn away from the bone of the shoulder and no longer are either keeping the shoulder together holding that humeral head into the socket of the glenoid so that the larger muscle, the deltoid, can actually do most of the work of raising the shoulder or raising the arm. I guess some patients would just say, “Well, why can’t you just simply repair those tendons and then proceed on with a regular artificial shoulder?” Why is that not possible?

Professor Wallace: One of the difficulties we have as you get older is that these rotator cuff tendons have a poor blood supply and they’ve got a poor healing ability. The tendons, there are actually 4 of them, and the 2 that give us most trouble are called the supraspinatus and the infraspinatus. We’re showing these on the following diagram. Now these tendons are primarily responsible for allowing you to lift outwards and turn the hand upwards, and if the supraspinatus is damaged and torn, you can’t lift up that way. If the infraspinatus is torn, you can’t lift that way. In fact one of the signs that we have for the torn infraspinatus is the bugle sign where you can’t lift the hand up because the elbow drops.

Dr. Sechrest: One of the things that I think we ought to point out to patients, and I think patients all the time hear about rotator cuff repairs where we, as orthopaedic surgeons, will go in and repair a torn rotator cuff. I think one of the things patients sometimes don’t understand is that these tendons, as we age, as you said they’ve got poor blood supply, sometimes these tendons contract. They pull back so that they’re too short to repair. Sometimes they simply dissolve almost – the tear has been there for so long that it is actually worn away portions of that tendon. The patient that says, “Why can’t you repair these tendons?” I don’t think they often understand that sometimes these tendons are simply un-repairable and that function cannot be regained without either replacing that muscle with a muscle transfer or doing something that’s fairly heroic. And part of the problem I think that patients don’t always understand is that unless you can get those rotator cuff tendons repaired in a way that can function, the artificial shoulder joint, the normal artificial shoulder joint is not very successful in being able to provide people with better function. It may help with pain relief but not with increased function so that they can lift their arm. So I think that’s a key point that I see patients sometimes not understanding because they’ve heard about rotator cuff repair and they’re just not clear why we can’t always go in and repair these tendons. I don’t know if that’s your observation, but I’d be interested in hearing your opinion about that.

Professor Wallace: I agree entirely, Randale, with that. In general, we’ve become very clever now at fixing the small and medium sized rotator cuff tears, and we have very good keyhole surgery that will do that. But once you get to the large tears, the tears that measure about 5 even 6 centimeters, they’re a real problem. Although we feel as surgeons feel it should be possible to go in and repair these tears, we now know from scientific studies, from looking at follow-up of patients, that about 30-50% of these large and massive tears, when we repair them, actually fall apart. So, no, the inverse or upside-down shoulder, is giving us an opportunity of giving patients function that really isn’t possible with a large and massive rotator cuff tear.

Dr. Sechrest: Well, let’s move on and talk a little bit about how you evaluate a patient. When a patient is referred to you or shows up in your office with shoulder pain. How do you go about determining what’s going on with that patient and then what sort of operative procedures are most appropriate in that case?

Professor Wallace: Well, the most important thing is to establish whether they’ve got arthritis and whether the rotator cuff tendons are working or not. Interestingly, there are a group of patients with arthritis in their shoulder, where the shoulder creaks. These patients usually have no rotator cuff tears and they are candidates for a conventional shoulder replacement. But if you’ve got patients who have a shoulder that they can’t lift and doesn’t creak, and they’re weak, these are the indications that there may be a torn rotator cuff. Pain, weakness, and inability to lift the arm. Now as a surgeon, I want to know whether the rotator cuff tendons are torn or not, and I have a number of simple tests that I do to see whether these tendons are working. One test is to push the arm outwards from the side, and that test I call the supraspinatus test, and if the patient is able to do that with good strength then the supraspinatus is probably working. But if they are weak and they cannot push against my hand, pushing against their elbow, that alerts me to the possibility that the tendon is torn. In the same way, looking at the infraspinatus, the infraspinatus twists the arm outwards in that direction, and if you resist that movement and that movement is weak, that tells me as an orthopaedic surgeon that the infraspinatus is probably torn. Interestingly, patients develop supraspinatus tears that get bigger and move into infraspinatus and the most important indication for me considering an inverse shoulder replacement is weakness of outward rotation – twisting the arm outwards. If they can’t do that or it’s very weak, then that makes me think, “Ah, perhaps this is a candidate for an inverse shoulder.”

Dr. Sechrest: Now once you’ve done your history and you’ve done your physical examination and you’ve got at least some idea of what’s going on in the person’s shoulders, what type of imaging studies would you normally suggest at that point in order to evaluate the situation. Are you getting plain x-rays? Is now the time that you move on to an MRI scan or some type of CT scan to try to further assess what’s going on in the shoulder? How do you approach that?

Professor Wallace: Well, I’m a simple Scotsman and the cheapest image is a simple x-ray, and that’s where I start. I always have a simple x-ray of the shoulder, a front AP view and a top-down axial view, and that allows me to see the bones. I can tell from the bones whether the rotator cuff is likely to have a big tear, but I can’t be sure, and so we move on to the MRI scan. The two main specialist scans are CT scans that show the bones, and MRI scans that show the soft tissues. So for rotator cuff tear patients it’s an MRI scan. So we send them for an MRI scan and that tells me two things: Is there a tear and how big is it? And what is the condition of the muscles? Because when you have a big rotator cuff tear, the muscles start deteriorating and getting what we call ‘fatty degeneration’. In other words, what was a muscle and perhaps you can think of this as a good bit of steak develops fat within and becomes weaker as the result of the muscle dissolving into fat.

Dr. Sechrest: Now once you have this information I’m assuming at that point you’ve got a pretty good idea of whether the patient may be a candidate for a routine shoulder arthroplasty or a reverse shoulder arthroplasty. Is there any sort of conservative care that you would offer the patient? Is there anything that patients can do short of surgery that may help in terms of treatment of their pain and may increase their function and allow them to postpone surgery?

Professor Wallace: Physiotherapy has a very real place for patients who have a large rotator cuff tear. My main indication for a shoulder arthroplasty, an inverse shoulder replacement, is a painful shoulder with a torn rotator cuff. If the shoulder is painless, but weak, the physiotherapists are able to develop the muscles that are still working to compensate for the muscles that are torn, and as a consequence, you’ll end up with physiotherapy improving the strength of the shoulder, and you can avoid shoulder replacement in some of these patients. I would say about a third of the patients will respond well to physiotherapy and as a consequence of responding well, they won’t need the inverse shoulder replacement. So it’s worthwhile starting with a course of fairly intensive physiotherapy exercises and that’s mainly a home exercise program, and then reevaluating the patient after, say, 2-3 months to see how they’ve got on. If they’ve responded, then I actually wouldn’t do a shoulder replacement. If they don’t respond, then we’re really into that patient requiring an inverse shoulder replacement.

Dr. Sechrest: Now, when you sit down and have this discussion with patients, and you’re ready to sort of say, “You know, I think it’s time for consideration of a reverse shoulder arthroplasty.” How do you counsel that patient? At that point in time what are you wanting that patient to know in terms of what you’re going to do, what they should be expecting, and what they should be expecting in terms of results and the rehabilitation process after the surgery? How do you have that discussion with your patients?

Professor Wallace: Well, it’s very important, in my opinion, as a surgeon, that the patient understands all the risks. This is higher risk surgery than carrying out a conventional shoulder replacement and, therefore, I have a responsibility as a surgeon to explain to the patient, that if we move onto an inverse or reverse shoulder, then that shoulder replacement roughly has double the risks and double the complications of a conventional shoulder replacement. But remember, we’re offering this to patients who do badly with a conventional shoulder replacement. So what do I say to them? I explain that we have a design of shoulder replacement that works for their shoulder. But it is likely that with this shoulder replacement, they’ll be able to lift their arm up to shoulder level. I don’t promise them anymore that although some do get a bit higher. One of the problems with the inverse shoulder is that the outward movement, that movement where you get your hand behind your head, is actually a movement which is rarely achieved with an inverse shoulder replacement. Quite different from a conventional shoulder replacement where it’s quite common to be able to get behind your head, and this is due to the fact that this movement of outward external rotation, that movement is caused by the infraspinatus muscle and that muscle and tendon is torn. So we do our best to give the patients as much of that movement as possible, but we warn them that they are going to have a problem brushing their hair, getting their hand up to behind their head and neck, and this is a recognized problem with that design of shoulder.

Dr. Sechrest: Now if I could summarize. It sounds to me like there’s two things here that patients, real take-home messages for patients. One is that the reverse shoulder doesn’t necessarily function completely normally or completely like the normal shoulder and probably not quite as well as a regular shoulder arthroplasty or artificial shoulder replacement simply because of the design. And I think I also heard you say that the reverse shoulder arthroplasty also has about twice the percentage or twice the chance of a complication or potentially something going wrong during the procedure. Can you elaborate on that a little bit in terms of what sorts of things do you see in the reverse shoulder arthroplasty that lead to this two-times complication rate?

Professor Wallace: I think it’s probably best to go back to our model and explain the weak points of the reverse shoulder replacement. Here’s the shoulder replacement. I emphasize that it stops the humerus riding up. In order to do that, that ball attached to the shoulder blade with four screws, that ball has enormous forces generated on the ball, and that ball can sometimes loosen on the shoulder blade; and the reason why it’s prone to loosen is that many of these patients have a bit of osteoporosis, their bones are a bit soft, a bit brittle, and therefore getting a good fix of that ball is crucially important and there are always that it’s going to loosen. Now that loosening rate probably is of the order of about 2% per year, and in a conventional shoulder, you’re talking about a loosening rate of 1% a year. So that’s the first complication that we need to explain to the patient. The ball works loose and then what happens? Well, what happens is that the patient gets pain similar to the pain that we started off with, and the surgeon is in a situation where they have to do something about it and this means a revision operation. They have to go back in and try and fix it. This is where high stakes come into the whole equation because fixing a loose ball in a reverse shoulder is really difficult, and often you have to think about doing it in two stages. In other words, you have to go in first, take the ball out, put in some bone graft and then go in later and re-do it. So it is high stakes when you get that complication. The second complication that we now recognize as being a significant problem is infection. Infection after conventional shoulder replacement occurs at a rate of about 1%. In other words, if you have 100 patients having a shoulder replacement, one of them gets a deep infection. In the reverse shoulder replacement, it’s about 3%. It’s a lot higher, and again, if it gets infected, what happens is that everything comes loose, and again the surgeon has to go in, take everything out, clean it out, and do a two stage operation to rebuild the shoulder again. I am very much an advocate now of the reverse shoulder replacement, but, the surgeon has the responsibility to explain to the patient that there are some high stakes involved and that there is a bit of a gamble and the patient has to share that gamble. But, if I had a large or a massive rotator cuff tear, and I was over 65, I would be prepared as a surgeon to take that gamble. If I was 50, I would not be prepared to take that gamble because if you’re younger, your muscles are stronger, the forces are greater and you use your shoulder more. So I would actually avoid having this operation until I am older and less mobile and I’m not using the arm as much.

Dr. Sechrest: If I might, I’m assuming that the reason you would avoid it at age 50 is that the chances of loosening is actually higher because you’re putting more force across the shoulder. Is that correct?

Professor Wallace: Very significantly and the problem is that with the larger forces you tend to land up causing more bone damage making a revision operation even more difficult.

Dr. Sechrest: Now a question about infection. Do we have any indication why the infection rate is essentially three times? I think we ought to point out to patients that we’re really talking about very low numbers. We’re not talking about half of these things failing. We’re talking about 1 in 100, 3 in 100 becoming infected. That’s still a very low rate. But do we have any reason or any idea of what’s causing this increased infection rate?

Professor Wallace: Well, Randale, we think, and we haven’t proven this, it’s due to the fact that there is a lot of what we call ‘dead space’. There’s a lot of gap above the shoulder replacement that after an operation fills with blood. That collection of blood is lying quite close under the skin surface and therefore bugs can more easily get into this big collection under the skin surface and we suspect that that is one of the factors. It’s very difficult to prove that’s the case. All that we can do is to monitor, as we are doing, how many infections we are getting, and this is the result of studies carried out in France, more recently in America, and now in the United Kingdom, and we are confirming that this infection risk is there. It is higher and it is a problem.

Dr. Sechrest: Are there any other complications or potential things that could go wrong that you worry about as a surgeon during this procedure that you’ll discuss with the patient before surgery?

Professor Wallace: Yes, we have one particular nerve which is at risk during the operation. That nerve is called the axillary nerve and we’ve got a picture of that now up on the screen for you. That nerve is at risk. It’s close to where the operation is being carried out. The problem with the reverse shoulder replacement is at the end of the operation you are very dependent on one muscle, the deltoid muscle. That’s the muscle that forms the roundness of your shoulder and that muscle is supplied by the axillary nerve and if it’s stretched or damaged or cut at the time of operation then you will land up with a shoulder replacement that does not work because the muscles no longer work.

Dr. Sechrest: Now any ideas about the incidence of that. What percentage of patients may have that complication? Oh, it’s small. We are talking about under 1%. If you were gambling on the horses it’s a risk that you wouldn’t be too concerned about, but it’s there, and 1% doesn’t sound much. 1 in a 100. But if you happen to be the unfortunate patient who is that 1, then you get pretty upset, and that’s why it is so important for surgeons to explain to the patients that these things and they do happen at regular rates. And even though we’re the most brilliant surgeon in the world, we still have complications and our patients need to understand that these risks exist. We don’t have these problems on purpose. We try very hard to avoid them, but they occur.

Dr. Sechrest: Yeah, very well said. I think that patients need to go into any operation with eyes wide open and understand that these things are sometimes beyond anybody’s control and they’re going to happen. Let’s move on now a little bit to talk about the procedure itself. When you sit down and discuss the situation with a patient in terms of what to expect during the surgery – how long you’re going to be in the hospital, what types of anesthesia to expect, and when you can get out of the hospital and what’s done at that point in time? How do you have that discussion with patients?

Professor Wallace: That’s very important and the way that we do it in the United Kingdom is probably different from the United States. We have waiting lists so the patient will probably wait from the time I see them and decide on their surgery, they’ll wait for about 10-12 weeks before they have their operation. Because of that delay we have a system where I see them 3 weeks before their operation and we go through everything with them. I explain at that stage the kind of anesthesia that’s available, how the anesthesiologist will help them with the operation, and we have two major and different techniques now. You can either have an operation when you’re fast asleep with a general anesthetic or you can have an operation when you are awake and we carry out the operation under a block so that your arm and shoulder are paralyzed; and that means that you are awake or partially awake during the operation. You don’t need such a big anesthetic and a lot of patients appreciate that. At the moment in U.K. for the inverse shoulder replacement about 80% have general anesthetics and 20% have regional blocks. The arm is numbed. But I think over the next 5 years we’ll see that percentage change because patients don’t want the risks of a general anesthetic which does involve chest problems, occasional heart problems, and regional blocks are becoming really popular.

Dr. Sechrest: Now in terms of the operation itself, is the reverse shoulder arthroplasty, is that an operation that takes longer for you as the surgeon to actually complete than a normal shoulder arthroplasty or are they pretty comparable?

Professor Wallace: In my hands, reverse shoulder arthroplasty is a bit quicker. Not a lot quicker. That’s because in most patients I do it from a superior approach. That means I go into the shoulder from the top down. Now the reason I do that is that if you go from the top into the shoulder, you’re actually going through the area where the rotator cuff is torn so you don’t have to do very much surgery to get into the shoulder. It’s already torn. It’s opened up for you to get in there and you don’t have to damage any more of the tissues very much. The difficulty with going in from the top is that the view is not so good, and you’ve got to be pretty sure that you’re putting all the bits of the shoulder in the right place. So some surgeons will tend more to put it in from the front. They’ll have a scar at the front of the shoulder in this area here, and they’ll open up the shoulder from the front. That takes longer. It’s a slightly more difficult opening into the shoulder but once you’re there it’s actually a bit easier from the front. So some surgeons will go from the top, some will go from the front. Neither is absolutely right, and I sometimes go from the front because there are technical problems and I think it’s better to go from the front in that situation. The two scars are different and this is important. The scar, particularly for ladies on the front of the shoulder if you are 70 or over, is usually a very nice cosmetic scar. However the scar over the top of the shoulder can look a bit thickened. It’s not as attractive and if you have off the shoulder dresses, then it’s not an attractive scar. So I think it’s important for the surgeon to speak to the patient and explain, “There are two scars I could use. Which one would you prefer?” And the surgeon can actually do the operation through either of the scars it’s just they’ve got to think a bit carefully about how they do it.

Dr. Sechrest: Professor Wallace, I think that outpatient surgery is all the rage these days, and I think that we’ve seen lots of different procedures that we used to do in the hospital, with the patient in the hospital for several days, move to the point to where they can be done now as an outpatient procedure. What you’re describing to me sounds like, as least in the United Kingdom, that most of these arthroplasties are done as inpatients. This is not, I’m assuming, an outpatient procedure.

Professor Wallace: You’re quite right, Randale. This is still an inpatient procedure although the system in the United Kingdom, the costs are important. Our patients are not admitted the night before. They come in at 7am for an operating list that starts at 8:30am. We go and see the patients on the admission ward at 7:30 in the morning and make sure that we’ve got them teed up to start at 8:30 and then work through the day. They stay in for anything between 48 hours and 5 days. Now that’s a huge change from 5 years ago where they would actually stay in for anything up to 10-14 days. So we’ve cut the hospital stay fairly dramatically. But I know in the United States they tend to discharge their patients from hospital more around the 48 hour time than the 5 day time. Our difficulty in the United Kingdom is that we have a lot of patients who have social problems. There is very little help for them now and we’ve got to sort out their social problems and make sure that they’re safe to go home, look after themselves, cook meals, etc., and when you’ve actually operated on their arm, and if it’s their right arm, then they are pretty incapable of doing things for the first week and therefore they need help. We don’t have relations in the United Kingdom looking after our patients nowadays. Relations sort of vanish. They often disappear. They’re there at visiting time, but as soon as we discuss discharging the patient they don’t appear on the scene, and this is a problem for us in the United Kingdom. I don’t what things are like in America.

Dr. Sechrest: Well, I’m not certain that we have that similar problem. It tends to be a pretty heterogeneous group. I mean some folks have family but, you know, the trend is that families don’t live in the same town anymore for several generations so I think you clearly have the situation where we have our elderly here in the United States that simply don’t have any family around that are capable of taking a week off and sort of nursing the patient. So I suspect it’s probably very similar although I can’t really speak to that.

Professor Wallace: Yeah. I think there’s probably an element of it. It does vary and I’m being unkind to some people because we do have some lovely families where we’ve had daughter flying back from Australia to look after their mothers who come out after shoulder replacements so I don’t want to generalize too much. But it is a problem for some of our patients.

Dr. Sechrest: Professor Wallace, two things I think that patients are always worried about after an operation, and one is pain. They’re always asking, “How much pain am I going to have?”, and I think for any arthroplasty or any sort of artificial joint replacement that’s one of the things that keeps patients from having this procedure earlier because they just have this perception that they’re going to be in an enormous amount of pain. The second thing that people always worry about, I think, is what’s going to happen to me after surgery from the standpoint of physical therapy, what are people going to make me do. Those sorts of things. So first, if you could at least comment on the amount of pain after this procedure and perhaps how you deal with it while the patient’s in the hospital.

Professor Wallace: Pain after the operation during the first 24-48 hours can be a significant problem, and that’s why we are not unhappy about keeping patients in for 48 hours. We give them strong painkillers and these painkillers are very effective nowadays. So the pain problem is not the sort of problem should stop patients from considering having a reverse shoulder replacement. What is surprising is that once you get beyond 48 hours pain becomes very minimal, and these patients main problem is getting the shoulder moving. It’s not pain, and often they will say to me 2 days after the operation, “Oh, you know that nasty arthritic pain I had before the operation is gone. You’ve given me a new pain but it’s not nearly as bad as that arthritic pain I had before the operation.” And some patients who are very lucky wake up after the operation and say, “Oh, my pain is gone. This shoulder feels so good. I wish I’d had the operation years ago.” So you can’t predict exactly how the patient will feel but, in general, severe pain after a reverse shoulder replacement is uncommon and patients tend to get a quick recovery and they loose their pain very quickly.

Dr. Sechrest: Now you mentioned getting the shoulder moving which I think every orthopaedic surgeon over the last 20 years has just been, I think, inculcated with the notion that the faster we get motion in anything the better off we are. So I’m assuming that your patients are being seen by a physical therapist and are starting some exercises fairly quickly while they’re in the hospital. What’s your protocol with the reverse shoulder arthroplasty in terms of getting that shoulder moving?

Professor Wallace: The shoulder in one day and I go around to 8:30 the following morning, see the patients, and that’s when they start their therapy. The physiotherapist gets them out of their arm immobilizer or their arm sling and gets them moving straight away. What has been very surprising how quickly patients with reverse shoulders are able to get that shoulder moving, and it is quite clear that the recovery time after reverse shoulder is faster than the recovery time after a normal or anatomic design of shoulder replacement. In other words, the patient gets their movement back quicker and they seem to need less physiotherapy. Our physiotherapy practice is to actually train the patients during the first 48 hours to do their own shoulder exercises at home. So they have a sling initially, take their arm out of the sling and use pulleys and the pulleys are their main exercise at home. They do a combination of pulleys where the good arm is pulling down and the bad arm is going up. The pulley exercises are combined with pendulum exercises and in Scotland that’s called ‘stirring the porridge’. You bend over, forwards, and stir the porridge around, around, and around in the porridge bowl. So the combination of these exercises is what the patient does at home. The amount of hospital physiotherapy that they have is not very great. So we would expect them perhaps to be seen a couple of times the first week and then weekly after that with them doing the home exercises themselves. This is significantly different from a conventional shoulder replacement where more physiotherapy is required.

Dr. Sechrest: Now how do you advise patients in terms of when they’re going to be through they’re going to be through this process? Because I think all of us want to know when can I, in some ways, put this behind me? I’m through with rehabilitation. My shoulder is healed completely and I’m pretty much in a steady state to where I can do the activities that I want to with this shoulder and not necessarily worry about continuing to do rehabilitation or continuing to come back for doctor’s visits. How long is that in your mind?

Professor Wallace: Well, there are two questions they ask. The first one is, “When can I get back to driving?” That’s crucial in the United Kingdom because that gives the elderly patient their independence and the rules are that as soon as you are functioning well enough to control a motor vehicle then that’s fine. That’s when you can return to driving. The second thing they want to know is when the physiotherapy can end. When can we give up the exercises and I usually say to them, “Look, by the time you’ve got to 3 months you have attained almost the best you can get.” And therefore my advice is work hard up to 3 months and then the exercises can fall off. Then you can cut down on the exercises and get back to leading a normal life again.

Dr. Sechrest: I think most patients are always concerned especially if they’ve had a major operation like an artificial shoulder replacement. They want to know what they should look for in terms of things that might indicate that something’s going wrong. Are they having a fever? Do they have something coming from the wound? Any sort of signs of infection? And in some cases, especially with artificial joints, what should they look for in terms of the joint dislocating or having a problem with the joint itself? How do you advise patients in terms of what they should call you as the surgeon for and when they should seek some care or ask people is this okay?

Professor Wallace: It is very important for patients to know that if they’ve got a fever, I want to know about that fever. I want them to phone my secretary, phone my nurse, tell the nurse they’re not right, and come back and see me. I know it’s sometimes a pain, but it’s very important that they do that because some complications can be treated and, if they’re treated promptly, you can avoid a really bad long-term problem. I expect the wound, when they’re discharged from hospital, to be covered with a light dressing. I’m for the patient to change that dressing. If the wound becomes red and discharges they come back to see me immediately. If the wound remains nice and normal color, that’s fine. If there’s a lot of bruising and it goes purple, that’s fine. But red and angry and a discharge is bad and I must see them because they need antibiotics and they may need to have some further surgery but that indicates to me that there’s an early infection. Initially a superficial infection which may be treated very easily and may be cured. But if they don’t come and seek treatment then we can land up with a much more serious problem. The one thing I don’t want patients to do, if they get a red wound, is just take antibiotics because you can hide or mask a deep infection with antibiotics. I want to see the problem and I want to be able to deal with it early.

Dr. Sechrest: What about any sort of problems with the shoulder itself outside of infection? Do you worry about these types of implants, these reverse shoulder arthroplasties, do you worry about them dislocating?

Professor Wallace: Dislocation was a problem with the early designs. It’s very rare now and of the patients who I have discharged and in my practice I have done over 100 of these shoulders. The patients that I have discharged only one has sustained a dislocation after discharge from hospital. So it’s now pretty uncommon and the sign is that the shoulder stops working and becomes painful. So somebody has gone home with a shoulder that they’re able to lift up, get the hand above shoulder level, and then suddenly they find it’s become painful and they can’t lift their arm up. I want to know about that because that could be a dislocation.

Dr. Sechrest: Anything else that patients should watch for in the postoperative period once they’ve left the hospital that you want them to either call your office, go to the emergency room or make an appointment to come back in and see you?

Professor Wallace: Some patients do get a badly swollen arm and it’s important if the arm is swollen that it’s kept up. That can be done with a temporary sling or it can be done simply by resting the arm on pillows. But if that swelling is significant than I would prefer to check the arm, make sure there’s nothing serious going on. There are rare cases of blood clots occurring in the veins in the arm and I need to be absolutely sure that that hasn’t occurred in these cases of swollen arm and therefore they may need investigating. So call your surgeon, explain the problem, and have a low threshold for coming back and having it looked at.

Dr. Sechrest: Well, Professor Wallace, I think we’ve pretty much covered all of the information that I think that I would want to know as a patient undergoing a reverse shoulder arthroplasty. Is there anything that you can think of that we have not discussed that you feel patients need to know about this procedure?

Professor Wallace: I do feel that the younger patients need to be carefully canceled. We need to explain to them that this is not an operation that is readily available for younger patients. But if they were to have it and they do use it sometimes on the younger patient, there are additional risks that they need to recognize and need to accept before we go ahead. The other situation that we are seeing is that more of the inverse shoulder operations or reverse shoulder operations are being done for fractures. At the moment, the jury is out in relation to whether that is a better or a worse treatment than using a conventional anatomical shoulder replacement. And again that’s a situation where the surgeon and the patient need to have a discussion and the surgeon needs to explain why this form of treatment is being considered and, that if you’re putting in a reverse shoulder for a fracture, that you’re putting it in recognizing that there are additional risks.

Dr. Sechrest: Well, this has been a great discussion and I think that it’s going to be a great amount of information that will clarify the difference between reverse arthroplasties or the reverse artificial shoulder from the traditional artificial replacement. So I want to thank you for joining us today. I look forward to having further discussions on additional shoulder topics in the future, and would invite you back to the show anytime.

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