A reverse total shoulder arthroplasty is a procedure considered for
patients whose shoulder problem cannot be effectively managed with a
conventional total shoulder replacement. The reverse total shoulder prosthesis
is based on a concept introduced by Professor Paul Grammont, in which a convex
articular surface is fixed to the glenoid and a concave articular surface is
fixed to the proximal part of the
humerus1
(Fig. 1). This prosthesis
addresses some of the limitations of conventional arthroplasty. To understand
the role of the reverse total shoulder arthroplasty, one must first understand
the limitations of conventional arthroplasty.
A conventional or anatomic shoulder arthroplasty is the replacement of
damaged joint surfaces with prosthetic components that approximate the normal
joint surfaces and are stabilized by mechanisms similar to those stabilizing a
native glenohumeral joint. In performing a conventional arthroplasty, the
surgeon is faced with the following limitations.
Limited Ability to Manage Glenohumeral Translation
The normal glenohumeral joint consists of a small, shallow concave glenoid
with a compliant rim for articulation with a spherical humeral head. The small
articular surface and minimal constraint of the glenoid allow a large range of
rotational motion before the humeral neck abuts on the glenoid rim. They also
allow small physiologic translations of the humeral head on the glenoid in
response to loads that are applied tangential to the glenoid joint surface.
Translation also occurs at the extremes of glenohumeral motion, permitting a
greater range of motion than would be possible if the humeral head did not
translate.
While the compliant rim of the normal glenoid enables full surface contact
during small humeral translations, this attribute is not replicated by the
much less compliant polyethylene joint surface of a conventional shoulder
arthroplasty. If the prosthetic glenoid surface conforms exactly to the
humeral head (i.e., if each has the same radius of curvature), no translation
can occur without loading of the polyethylene glenoid rim. Rim loading is
associated with markedly diminished contact area, increased contact pressure
(load per unit contact area), and cold flow of the rim. Rim loading also
challenges glenoid component fixation through the socalled rocking-horse
mechanism. A prosthetic glenoid surface that does not conform exactly to the
humeral head (i.e., has a radius of curvature that is larger than that of the
humeral head) allows translation but also diminishes contact area, increases
local contact pressure, and increases the risk of polyethylene failure.
Limited Fixation of the Glenoid Component to Bone
The normal glenoid joint surface is well fixed to the subjacent glenoid
bone. This fixation is critical for the management of tangential humeral loads
that are directed off-center to the glenoid center line. In conventional
arthroplasty, the polyethylene glenoid surface can be fixed to the bone with
bone cement or with screws and tissue ingrowth through a metal back. With the
repeated application of off-center loads, bone-cement fixation is at risk of
failing as a result of cement fatigue and bone resorption. While metal backs
can be secured to bone, the fixation of the polyethylene to the metal back is
also at risk of failing.
Limited Intrinsic Stability
The normal glenohumeral joint is stabilized by the concavity compression
mechanism, in which the joint forces compress the humeral head into the
glenoid fossa. These compressive forces are due to the combined action of
muscular and capsuloligamentous restraints. A loss of any of the normal
osseous, capsuloligamentous, or muscular constraints leads to glenohumeral
instability and a loss of normal shoulder function. Anterior instability
results from defects in the subscapularis, anterior aspect of the capsule,
glenoid labrum, anterior glenoid bone, rotator cuff, or posterior humeral
articular surface. Posterior instability results from glenoid dysplasia;
posterior glenoid erosion or fracture; and defects in the posterior aspect of
the labrum, posterior aspect of the capsule, posterior aspect of the rotator
cuff, or anterior humeral articular surface. Superior instability results from
loss of the compression and spacer effect of the normal supraspinatus. Upward
displacement of the humerus slackens the deltoid so that it is less effective
in humeral elevation. If the deltoid cannot compensate for this slack, the
humerus cannot be elevated, a situation known as pseudoparalysis. The
coracoacromial arch serves as a backstop limiting upward translation of the
humeral head with rotator cuff deficiency. Deficiency of the coracoacromial
arch, from wear, fracture, or surgical acromioplasty, can allow the humeral
head to slip out from underneath it, a condition known as anterosuperior
escape, which compounds the pseudoparalysis.
Conventional arthroplasty can be used in some patients with arthritis and
glenohumeral instability. When arthritis is coupled with instability resulting
from deficiencies of the humeral head, the full articular surface can be
restored by a humeral component. When the glenoid is deficient, its contour
can be restored by a glenoid prosthesis as long as the bone beneath it offers
sufficient support. When arthritis is coupled with instability resulting from
acute reparable rotator cuff tears, stability may be restored by cuff repair
in association with conventional shoulder arthroplasty. When arthritis is
coupled with instability resulting from excessive capsular laxity, capsular
tightening or the use of a larger humeral head component may restore the
capsular tension needed for stability. When the cuff is deficient and the
upwardly displaced humeral head is stabilized by an intact coracoacromial arch
and the deltoid has not been slackened to the point where it is unable to
raise the arm, a conventional or extended-articularsurface humeral
hemiarthroplasty may enhance shoulder comfort and function.
Conventional arthroplasty usually cannot be used to manage instability
resulting from unreconstructable soft-tissue or osseous deficiencies, such as
severe posterior glenoid bone deficiency. If the posterior aspect of the
capsule and rotator cuff have been lost as a result of trauma or previous
surgery, conventional arthroplasty cannot restore posterior stability.
Similarly, in the presence of anterosuperior escape and pseudoparalysis of the
shoulder, resurfacing of the humeral head and glenoid cannot restore shoulder
stability or deltoid function.
Limited Ability to Compensate for Deltoid Dysfunction
Conventional shoulder arthroplasty can only minimally modify the tension
and moment arm of the deltoid. Deltoid tension can be adjusted by raising and
lowering the humeral component, but such changes may adversely affect the
alignment of the humeral and glenoid articular surfaces. With a conventional
arthroplasty, the center of rotation of the humeral head cannot be medialized
to increase the deltoid moment arm.
Limitations of Any Type of Shoulder Reconstruction
Conventional shoulder and reverse shoulder arthroplasty are limited by the
same factors that limit any surgical reconstruction. Shoulders with skin,
vascular, lymphatic, or osseous deficiency may be at excessive risk when
treated with reconstructive
surgery1. Patients
who have fragile bone or general medical, emotional, motivational, or social
health issues are usually not candidates for any type of shoulder
arthroplasty. Deltoid deficiency, limited scapular mobility, and infection
usually preclude effective
reconstruction2.
Glenohumeral Translation
In reverse total shoulder arthroplasty, the deep, conforming concavity of
the humeral articular surface does not permit glenohumeral translation. While
this constraint reduces the range of motion before contact occurs between the
humeral and glenoid elements, it eliminates the possibility of rim loading and
the resulting problems of cold flow of the rim polyethylene and the creation
of eccentric forces that can contribute to component loosening. Full surface
contact is maintained during the allowed range of the
articulation3-6.
Fixation of the Glenoid Component
In reverse total shoulder arthroplasty, a metal "metaglene," or
base-plate, is fixed to a prepared glenoid with locking and nonlocking screws
along with a press-fit hydroxyapatite-coated central peg. No bone cement is
used. The spherically convex glenoid articular surface, the
"glenosphere," is fitted to the metaglene and held in position
with use of a Morse taper and screw. The glenoid component does not have a
polyethylene element, therefore avoiding the challenges associated with
securing a polyethylene surface to a metal-backed glenoid fixation system. The
geometry of the glenoid prosthesis medializes the center of rotation of the
glenoid prosthesis on the osseous surface of the glenoid, so that
eccentrically applied loads have a small lever arm, reducing the moments that
challenge glenoid fixation.
Intrinsic Stability
One of the measures of the intrinsic stability of an articulation is the
balance stability angle—i.e., the maximal angle that the net joint
reaction force can form with the concavity before dislocation occurs. In most
conventional shoulder arthroplasty systems, the net humeral joint-reaction
force must be directed within =30° of the glenoid center line to avoid
dislocation. In reverse total shoulder arthroplasty, the glenosphere is
stabilized in the humeral socket as long as the net joint-reaction force
exerted by the glenoid convexity is within 45° of the center of the
humeral articular concavity. Because the center line of the humeral concavity
forms an angle of 155° with the long axis of the humeral shaft, the joint
is stable against forces applied to it by the deltoid, although these forces
may be parallel to the surface of the osseous glenoid. This high degree of
intrinsic stability frees the reverse total shoulder prosthesis from
dependence on soft-tissue constraints and the coracoacromial arch for
stability. It can also provide stability when there is glenoid osseous
deficiency, as long as there is sufficient bone stock for glenoid
fixation.
Compensation for Deltoid Dysfunction
In contrast to conventional arthroplasty, reverse arthroplasty provides the
opportunity to restore tension to the deltoid by moving the deltoid insertion
distally and provides an increased deltoid lever arm by increasing the
perpendicular distance from the center of rotation (on the osseous surface of
the glenoid bone) to the deltoid muscle. Finally, the intrinsic stability of
the reverse total shoulder prosthesis allows for humeral elevation by the
lateral deltoid even in the presence of an anterior deltoid defect that may
have resulted from injury or previous surgery.
Reverse total shoulder arthroplasty is considered when rehabilitation has
not satisfactorily addressed, and conventional surgical reconstruction methods
cannot satisfactorily manage, shoulder pain and loss of function. Because of
the magnitude and potential risks of the reverse shoulder arthroplasty,
nonoperative means of improving the patient's quality of life merit a
dedicated trial prior to surgery. The patient should be treated initially with
a specific exercise program and analgesics before any surgery is
considered.
The reverse total shoulder arthroplasty may be considered for the
management of a patient with refractory rotator cuff tear arthropathy,
especially with anterosuperior escape and pseudoparalysis; a failed prosthetic
reconstruction with superior, anterior, or posterior instability; or a failed
reconstruction for a traumatic injury with pseudoparalysis and instability. As
is the case with any major surgical procedure, the surgeon must consider the
adequacy of the skin, bone, and deltoid muscle. When the procedure is being
done as a revision of a previous operation, consideration must be given to the
possibility of occult infection with organisms such as Pseudomonas
acnes or Staphylococcus epidermidis. The surgeon needs to assess
the patient's physical, emotional, and social situation to determine if those
factors favor a successful outcome. Finally, the surgeon needs to be confident
of his or her ability to manage the complex intraoperative decision-making and
any complications that may arise with this procedure.
There are now a number of different reverse total shoulder arthroplasty
systems and many variations on the technique. The following is an example of a
reverse total shoulder arthroplasty technique involving use of the Delta
Reverse Shoulder Prosthesis (DePuy, Warsaw, Indiana). It is beyond the scope
of this article to present each of these methods and perhaps too soon to
understand their relative advantages and disadvantages. The presentation of
this example provides the opportunity to describe some of the key principles
and technical aspects of the procedure.
Preoperative planning is critical. The surgeon must consider the osseous
anatomy, the reconstructability of the soft tissues, and the alterations
resulting from previous injury and surgery. An anteroposterior radiograph made
in the plane of the scapula and a transparent glenoid template are used to
estimate the most inferior position of the glenoid that will result in the
inferior screw being contained in the thick bone of the scapular axillary
border. An anteroposterior humeral radiograph is used to estimate the size and
fit of the diaphyseal and metaphyseal humeral components.
Although the deltopectoral approach may be associated with an increased
prevalence of instability, it is often used because it is familiar, safe, and
versatile. Any adhesions are lysed and bursal tissue is removed while the
deltoid, the acromion, and any residual rotator cuff tissue are protected. The
rotator cuff tear is examined to verify that it cannot be repaired, and, if it
cannot, useless tendon tissue is resected. The glenohumeral joint is opened by
incising the subscapularis and capsule from their insertion on the lesser
tuberosity. The surgeon should preserve as much length of the subscapularis as
possible. The inferior aspect of the capsule is released from the humerus, and
the axillary nerve is identified. The subscapularis is dissected so that it is
freed circumferentially. It will be repaired to the humerus later.
The humeral head is removed first to expose the glenoid. Final preparation
of the humerus is deferred until the glenoid prosthesis is in place. The
humeral resection guide stem is inserted into the medullary canal
(Fig. 2), and the humeral head
is resected in 0° of retroversion. When the arm is pulled distally, the
plane of the humeral cut should pass just below the inferior aspect of the
glenoid face.
Secure fixation of the all-metal glenoid component to the bone of the
glenoid is one of the unique features of the reverse total shoulder
arthroplasty. This secure fixation depends on proper preparation of the bone,
positioning of the component, and screw placement.
The surgeon should be sure to identify and protect the axillary nerve.
First, the capsule is dissected from the anterior aspect of the glenoid down
to and around the inferior pole so that the superior aspect of the axillary
border of the scapula can be palpated and seen. The origin of the long head of
the triceps is released as necessary. All abnormal glenoid anatomy is
identified. The surgeon should note the amount of overhang of the inferior
aspect of the glenoid with respect to the axillary border of the scapula. The
labrum and cartilage are removed from the glenoid. A point is marked 13 mm
anterior to the posterior rim of the glenoid and 19 mm superior to the
inferior glenoid rim, and a guidewire is drilled into the glenoid at this
point (Fig. 3). The metaglene
is placed over this guidewire (with the peg laterally) to verify the
appropriateness of this center point. If the metaglene rim is flush with the
extrapolated axillary border, the metaglene is removed and the central hole is
drilled with a step drill. The glenoid is reamed conservatively, with removal
of only enough bone to make the surface relatively flat; and the surgeon makes
sure that the reamer handle remains perpendicular to the face of the glenoid.
Bone graft harvested from the humeral head is added to any defects in the
osseous glenoid, and the metaglene peg is inserted into the central peg
hole.
The anterior and posterior aspects of the axillary border of the scapula
are palpated, and the metaglene is rotated so that the inferior hole is
centered over the axillary border. With use of a drill guide, the hole is
drilled for the inferior locking screw. (The inferior locking screw makes a
16° angle with the central peg.) The surgeon should check frequently to
ensure that the drill is in bone by pushing on the drill while it is not
rotating. A 2-mm drill bit is used unless the bone is unusually hard. At least
36 mm of intraosseous drilling is recommended. If this is not achieved, the
rotation of the metaglene with respect to the axillary border of the scapula
should be reexamined. Once an adequate hole has been made, the inferior
locking screw is inserted. A similar technique is used to drill the hole for
and insert the superior locking screw. Then the hole for the anterior
nonlocking screw is drilled and the screw is inserted into the best bone
available, with the orientation guided by palpation of the anterior aspect of
the glenoid neck. The posterior nonlocking screw is then inserted, again in
the best bone accessible. A trial glenosphere is inserted into the metaglene
and the inferior aspect of the glenoid is inspected, with removal of bone that
may abut against the humeral polyethylene component. Any axillary glenoid bone
is resected as necessary. The adequacy of the bone resection can be verified
by placing a trial polyethylene component over the glenosphere and making sure
that it can be adducted fully, while recalling that the humeral cup makes a
155° angle with the humeral shaft.
The final preparation of the humerus must preserve humeral bone stock while
optimizing the height, version, and fixation of the humeral component. The
humeral canal is prepared by inserting progressively larger reamers until
cortical contact is first achieved (Fig.
4). The trial stem is inserted with the metaphyseal reamer guide
in 0° of retroversion, and the metaphysis is reamed until bone purchase is
achieved.
The trial humeral component is assembled and is inserted in 0° of
retroversion. A 3-mm trial plastic cup is used, and the joint is reduced. The
surgeon checks for medial abutment of the polyethylene against the axillary
border of the glenoid, for stability, and for range of motion. There should be
<2 mm of distraction when distal traction is applied to the arm. If the
joint cannot be reduced, the surgeon should consider lowering the humeral
component by sequentially resecting small amounts of humeral bone.
The glenosphere should be inserted before the humeral component. The
glenosphere is inserted into the metaglene, with the surgeon making sure that
there is no soft tissue interposed between them, that the glenosphere is
aligned to avoid cross-threading, and that it is fully seated.
Positioning of the humeral component and selection of the humeral
polyethylene cup are the definitive steps for adjusting the deltoid tension.
The definitive humeral component is securely assembled with a strong crescent
wrench on the stem and the component inserter on the metaphysis. The humeral
medullary canal is brushed and irrigated. A cement restrictor is inserted 13
mm distal to the lateral aspect of the humeral cut. Six drill holes and
number-2 nonabsorbable sutures are placed in the anterior neck cut for later
attachment of the subscapularis. The assembled humeral component is cemented
in 0° of retroversion without the polyethylene insert. Different heights
of polyethylene liners, starting with 3 mm, are tried to discover the height
that allows reduction of the shoulder but <2 mm of distraction with
traction. The surgeon checks again for abutment of polyethylene against the
lateral aspect of the glenoid inferiorly with the patient's arm adducted.
Finally, the surgeon places the definitive polyethylene component, making sure
that it is inserted straight. The subscapularis is repaired to the humerus
with the sutures that had been previously placed at the anterior neck cut. A
postoperative radiograph is recommended
(Fig. 5).
This is a major operation on individuals who are usually older and less
robust than those treated with conventional arthroplasty; thus, rehabilitation
is gentle and gradual. The arm is rested in a sling for thirty-six hours.
Hand-gripping exercises are started immediately. Hand-to-mouth exercises are
started after thirty-six hours, and physical activity is limited to gentle
activities of daily living, with a lifting limit of 1 lb (0.45 kg) until six
weeks after the surgery. Activities are progressed from that point, with the
range of motion limited to 0° of external rotation and 90° of
elevation for three months.
A retrospective study including all reverse shoulder prostheses implanted
over a ten-year period at three shoulder centers was conducted in France. Of
the original group of 457 patients, 242 (53%) had a rotator cuff lesion: 149
had cuff tear arthropathy, forty-eight had a massive cuff tear, and forty-five
had failed rotator cuff surgery. Ninety-nine patients (22%) had a revision of
a previous prosthesis, sixty (13%) had fracture-related problems, twenty-six
(6%) had osteoarthritis, and 2% each had rheumatoid arthritis, a tumor, or
another condition. Three hundred and eighty-nine shoulders (85%) were
available for follow-up more than two years postoperatively. The average age
at the time of follow-up was 75.6 years (range, twenty-two to ninety-two
years). The average duration of follow-up was 43.5 months (range, twenty-four
to 142 months).
Significant improvement was noted in the mean Constant scores for pain
(from 3.5 points preoperatively to 12.1 points at the time of follow-up),
activity (from 5.8 to 15.1 points), mobility (from 12.1 to 24.5 points), and
strength (from 1.3 to 6.1 points) (p < 0.0001). Active elevation improved,
but active internal and external rotation did not. The operations for the
treatment of cuff tear arthropathy had the best results, whereas the revision
procedures had the worst outcomes. A young age, preoperative stiffness, teres
minor deficiency, tuberosity nonunion, and pain rather than loss of function
as the preoperative symptom tended to be associated with inferior results. The
deltopectoral approach tended to result in greater active elevation but also a
greater risk of instability. Survivorship to the end points of revision and
loosening was better for patients with rotator cuff problems than for those
with a failed prior hemiarthroplasty. The functional results were noted to
deteriorate progressively after six years in the group treated for a cuff
tear, after five years in the group treated with a revision of a prior
hemiarthroplasty, after three years in the group with osteoarthritis, and
after one year in the group managed with a revision of a total shoulder
arthroplasty.
Reverse total shoulder arthroplasty is a new, unconventional approach to
the treatment of a variety of difficult shoulder conditions in older
individuals. Thus, it is not surprising that it would be associated with
frequent and substantial complications. Indeed complication rates as high as
60% with revision rates as high as 50% have been
reported2.
Complications are more frequent and more serious when reverse total shoulder
arthroplasty is used to revise a failed prior arthroplasty.
Humeral cortical perforations, shaft fractures, or tuberosity fractures may
occur during surgery. Intraoperative humeral fractures are most commonly
associated with revision of a prior humeral arthroplasty, with a rate as high
as one in four. Prevention requires careful removal of the prosthesis and
respect for the thin bone that is often encountered in candidates for reverse
shoulder arthroplasty. These fractures can often be treated at the time of the
surgery with a longer stem and cerclage wires or tension band wire fixation.
The surgeon performing a reverse total shoulder arthroplasty must be prepared
and equipped for these eventualities. Furthermore, humeral fractures may
increase the risk of subsequent humeral loosening.
Intraoperative glenoid fracture may involve the rim, major portions of the
glenoid surface, or the glenoid neck. These fractures occur during glenoid
reaming or during tightening of glenoid screws. Prevention requires respect
for the osteopenic bone of older patients and gentle reaming of the glenoid by
hand. Rim fractures can often be stabilized by the metaglene. If fixation is
questionable, placement of the humeral component can be delayed until fracture
consolidation is achieved. If the central peg of the metaglene cannot be
secured to intact bone, a staged reconstruction with bone graft should be
considered.
Postoperative hematomas are common and may be prevented by careful
hemostasis, the use of drains, and delaying motion of the shoulder for several
days after the surgery. Large hematomas may require surgical drainage.
A humeral shaft fracture is another relatively common postoperative
complication. These fractures usually are due to a fall or to abrupt passive
elevation or rotation of the arm. They often occur at the tip of the
prosthesis, probably because of the abrupt transition between the stiff
cemented segment of the humerus containing the prosthesis and the osteopenic
bone distal to it. Treatment may include bracing, additional fixation, or
revision to a longer component.
Loosening of the humeral component is uncommon and usually is associatd
with a fracture or infection. Unscrewing of the junction between the
metaphyseal and diaphyseal portions of the humeral component can be avoided by
vigorous tightening at the time of the surgery and by maintaining tuberosity
support for the metaphysis.
Loosening of the glenoid component results when the component is insecurely
anchored, because of either glenoid bone deficiency or suboptimal positioning,
or it occurs secondary to trauma in which the force on the arm is transmitted
directly to the glenoid fixation. The risk of glenoid loosening can be
minimized by ensuring that (1) the glenoid component is positioned low on the
glenoid bone so that upwardly directed forces on the glenosphere can be
resisted by compression of the superior aspect of the metaglene against solid
glenoid bone and (2) the fixation screws are securely anchored in the best
scapular bone available. Secure anchoring is particularly important for the
inferior screw, which must resist pull-out when inferiorly directed loads are
applied to the glenosphere.
Infection is a relatively frequent and serious complication of reverse
total shoulder arthroplasty. Contributing causes include hematoma formation,
revision of a previous arthroplasty, the magnitude of the surgery, and the
compromised general health of some patients. Infection with persistent
low-virulence organisms, such as Propioni-bacterium acnes and
Staphylococcus epidermidis, are particularly prevalent in patients
treated with revision arthroplasty. Prevention is optimized by obtaining
culture specimens in a thorough fashion at the time of the revision surgery
and maintaining the cultures for several weeks to allow growth of these
slow-growing organisms. Once a specific organism is identified,
culture-specific treatment should be employed. The inclusion of appropriate
antibiotics in the cement is recommended.
Dislocation is a relatively common complication, especially after the
revision of a previous arthroplasty, when the osseous and soft-tissue anatomy
has been distorted by prior trauma, when components are malpositioned, or when
the humeral component levers against glenoid bone. Instability can be
prevented by careful intraoperative examination to ensure full motion, proper
version, absence of abutment, and no separation (pistoning) of the components
when traction is applied to the humerus, combined with repairs of the
subscapularis and other soft tissues. If there is any question about the
intrinsic stability, delaying shoulder motion for six weeks after the surgery
may allow healing of the soft-tissue envelope around the reconstruction. If
the components have been properly positioned with adequate soft-tissue tension
and without medial glenohumeral abutment in adduction, an early postoperative
dislocation may be managed with closed reduction and immobilization with the
arm at the side in a sling. If instability results from component
malpositioning, osseous abutment, or inadequate soft-tissue tension, revision
surgery may be required.
Fractures of the acromion occur commonly as a result of a preexisting
acromial lesion, overtensioning of the deltoid, or osseous fatigue from
loading of an osteopenic acromion. Distal acromial fractures with inferior
angulation usually require only treatment of symptoms. However, fractures of
the scapular spine may cause clinically relevant pain and loss of function.
Anteroposterior, axillary and scapular Y radiographs as well as computed
tomography scans may be used to evaluate patients with unexpected pain or poor
function after a reverse total shoulder arthroplasty. Internal fixation should
be considered for such patients, despite the difficulties presented by poor
bone and substantial loads.
Neurological injuries include axillary nerve damage from surgical
dissection or traction injuries from excessive tension resulting from
lengthening of the arm. These injuries are most common in revisions with
difficult surgical exposures.
Reverse total shoulder prostheses and the support for their application
tend to be expensive. Being that this prosthesis is generally recommended for
individuals sixty-five years of age and older, the cost of its implantation
may substantially exceed a medical center's reimbursement from Medicare and
other insurance programs. However, there are many individuals whose comfort,
function, and quality of life are compromised by severe rotator cuff lesions
and failed surgical reconstructions who could potentially benefit from this
procedure. Finally, the substantial risks of the procedure create the need for
informed consent and assessment of the total context in which the patient will
live after this reconstruction.
Reverse total shoulder arthroplasty is a powerful and technically demanding
tool for managing problems in relatively older, less active patients who
previously had no solution for these problems. It is tempting to expand its
application to an increasing number of conditions in younger and more active
individuals, such as irreparable rotator cuff tears, severe proximal humeral
fractures, and complex instability patterns. This temptation needs to be
balanced by an awareness of the complications, cost, and potential for
deteriorating function with time after this method of reconstruction.
Note: The authors thank Steven B. Lippitt, MD, for his
artwork.
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