Reversing a Shoulder: Innovative Shoulder Surgery

Approximately 80% of patients undergoing reverse shoulder replacement surgery return to full daily functioning after surgery

Shoulder pain is the most common problem in orthopedics, following back problems and injuries. The shoulder is the most complex joint in the body. It is built of four joints that allow maximal ranges of motion in a number of ways:

Joint one: Between the humeral head (the ball) and the glenoid cavity – the surface of the scapula (the socket).

Joint two: Between the clavicle and the acromion process (a projection of the scapula).

Joint three: Between the rib cage and the scapula.

Joint four: Between the humeral head and the inferior surface of the acromion process, separated by a tendon.

The ordinary motion of raising the hand involves the integrated movement of all these joints at once.

The shoulder itself is stabilized through ligaments (in the first layer) and muscles and tendons (in the second layer). An injury to any of these layers causes restricted movement and pain.

"Usually," said Dr. Gil Laufer, senior orthopedic surgeon and specialist in shoulder medicine in the Orthopedics B Department at Hillel Yaffe Medical Center, "people with shoulder injuries that require excessive surgical intervention such as reverse shoulder replacement surgery are those over 65, who put the shoulder under excessive strain over time, so much so that abrasion occurs, imbalance between the muscles, and tearing of the tendons in the rotator cuff, resulting in significant reduction of motion. There is a strong tendency towards these injuries in people worked or work in manual labor that requires lifting of the arms above shoulder height such as porters, mechanics and hair stylists."

These people suffer severe pain in the shoulder and arm for a prolonged period that is aggravated by sleep (and which can even awaken them). Examination shows tearing of the rotator cuff tendons, which sometimes cannot be repaired at that stage. Sometimes the patient defers the decision to repair the tendon and reaches the point where it is difficult to perform trivial actions such as dressing and undressing.

Tendon is the tissue that connects muscle to bone. This is tissue that does not contract, which has uniform, permanent length and range. One of the most common problems of the shoulder is tendonitis. Inflammation occurs when there is an imbalance between the shoulder muscles and weakness in the rotator cuff muscles.
When the inflammation is not treated properly, the tendon can tear as the result of abrasion digestion by substances secreted as a result of the inflammation.

"The conservative treatment for torn tendons," explained Dr. Laufer, "is physical therapy, anti-inflammatory pills, etc. When conservative treatment is not effective, the tendon is usually repaired in orthopedic surgery, either endoscopic or standard (depending on the injury). "

When should the reverse shoulder replacement surgery be performed?

If the patient has large and significant tearing which cannot be "repaired" by the standard surgical procedure, that is, the shoulder tendons are completely destroyed and the hand has very limited function because there are no tendons to stabilize the movement, and it will aid in raising the hand, reverse shoulder replacement surgery is performed.

The procedure combines use of a prosthesis, part of which consists of a special circular structure that changes the structure of the shoulder and actually inverts it. Inversion causes the ball and socket to exchange positions, such that the ball lies on the scapula and the socket lies on the humerus, instead of the other way around.

Restructuring the shoulder enables stabilizing it and strengthening the power of the deltoid muscle (the shoulder muscle responsible for raising the hand). With this new positioning the patient regains full range of motion in the shoulder, using only the deltoid and not the rotator cuff (the torn ligaments).

"The operation eliminates the need for using the torn tendons, and even promotes greater muscle strength and motion than before," stated Dr. Laufer. "Simply put, following the operation, the patient, who could hardly move his hand before, can move as he did in the past, sometimes even more easily."

The success rates Dr. Laufer reports are very high - about 80% of the patients return to full daily functioning and almost complete disappearance of pain. The remaining 20% of the patients reported suboptimal motion, but a significant reduction in pain. Recovery time from the surgery is about six months and is accompanied by the appropriate physical therapy and monitoring by an orthopedist.

That said, there is no doubt the essential change lies in the quality of life for patients who suffered very limited motion, and can now return to their daily routine and full function.