Friday, July 31, 2009
For many years, the only option for patients in pain from failed shoulder replacements has been to grin and bear it. But a newer procedure, the reverse total shoulder, approved by the FDA in 2004, offers these patients pain relief and improved shoulder mobility.
According to orthopedic surgeon E. Rhett Hobgood, MD, who has been doing the reverse shoulder procedure since 2006, this implant reverses the normal anatomy of the shoulder joint. “In a standard shoulder replacement, we resurface the socket of the scapula and replace the ball at the top of the humerus. In the reverse shoulder, the ball part of the joint is placed on the scapula, and the socket is created at the top of the humerus.”
A standard shoulder replacement can fail for many reasons, which usually results in implant loosening and significant bone loss of the scapula and humerus. Because of this bone loss, the standard shoulder replacement usually cannot be repeated. “For a patient in pain and with limited movement from a failed shoulder replacement, the reverse procedure provides an option for pain relief and better motion and shoulder function,” says Dr. Hobgood.
The primary indication for the reverse shoulder procedure is shoulder arthritis due to a chronic rotator cuff tear (rotator cuff arthropathy). Because of the absence of rotator cuff function, the shoulder joint is unstable in the upward direction. When the patient tries to lift the arm overhead, the joint slides upward and impinges on the undersurface of the overlying acromion, preventing forward elevation of the arm. This “paralysis” can be corrected with a reverse total shoulder replacement.
“For standard shoulder replacement surgery to work appropriately, a patient must have a functioning rotator cuff,” explains Dr. Hobgood. “This is what is traditionally done for patients with osteoarthritis of the shoulder.” However, for patients without a functioning rotator cuff, the standard shoulder replacement cannot be performed.
A French surgeon named Paul Grammont developed the reverse replacement in the early 1980s, and the procedure has been available in Europe since that time. It gained FDA approval for use in the United States in late 2003, and the first reverse shoulder was implanted in March 2004.
According to Dr. Hobgood, the ideal patient is age 70 or older. “This is a relatively newer implant and significant long term follow up data is not yet available. It is therefore recommended for lower-demand patients,” he explains. “The overall health status of the patient is most important. I’ve done a reverse replacement on a 94 year old.” Like the standard shoulder replacement surgery, the reverse procedure takes about two hours to perform.
Dr. Hobgood has seen the best results in patients who have not had previous shoulder replacement surgeries. “The best results are in a primary patient,” he said. “Complication rates are higher in patients who are being revised from a failed standard total replacement to a reverse. But it offers a solution for these patients when before there was not a good option at all.” The most common complication, when it occurs, is instability.
Recovery from the reverse shoulder procedure is similar to the standard shoulder replacement. The patient does most therapy at home under the direction of a physical therapist. “Rehab is not more difficult than standard replacement,” says Dr. Hobgood. “It just has a different focus. It takes about 12 weeks post-operative to release the patient with no restrictions.”
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