Reverse Total Shoulder Arthroplasty

Reverse Total Shoulder Arthroplasty

Mitchel D. Armstrong MD BMSc FRCSC Bandar M. Assiry MBBS SB‐orth and Ryan T. Bicknell MD MSc FRCSC

Division of Orthopaedic Surgery, Department of Surgery, Queen’s University, Kingston, ON, Canada

Clinical scenario

  • A 75‐year‐old woman who is living independently is seen with complaints of right shoulder pain and loss of motion.
  • She has no history of trauma and the pain has been progressive over the past 2–3 years.
  • On examination, she has very limited active movement and crepitus. She is neurovascularly intact.

Relevant anatomy

A rotator cuff tear can be classified as acute (no irreversible muscular fatty atrophy and generally reparable) or chronic (with irreversible muscular fatty atrophy and generally irreparable). Instability of the glenohumeral joint due to a long‐standing irreparable rotator cuff tear often occurs in an anterior and superior direction, called anterosuperior escape, often leading to a pseudoparalysed shoulder, generally defined as a loss of active forward elevation with maintained passive movement. These abnormalities can eventually lead to arthritic changes at both the glenohumeral and acromiohumeral articulations.

Importance of the problem

Shoulder arthritis can include osteoarthritis, rheumatoid arthritis, post‐traumatic arthritis, and cuff tear arthropathy. Each type of arthritis is not infrequently seen in combination with a rotator cuff tear. A conventional anatomic total shoulder arthroplasty (TSA) is used to relieve pain and improve function in arthritic shoulders. The articular surfaces are unconstrained and allow the healthy rotator cuff and extrinsic shoulder muscles to restore shoulder function. In most arthritic shoulders, with or without a rotator cuff tear, the ball‐and‐socket biomechanics of the glenohumeral joint are maintained. However, each type of arthritis may present in combination with rotator cuff dysfunction and loss of the normal biomechanics, often leading to instability and pseudoparalysis. In this situation, the outcome of a traditional shoulder arthroplasty is substantially compromised.13

The incidence of rotator cuff tear dysfunction in the population of shoulder arthritis patients is difficult to determine, but occurs in a minority of patients. Although shoulder arthritis is much less common than hip or knee arthritis, the incidence and indications for shoulder arthroplasty continue to increase.

Top three questions

  1. Among patients with shoulder pain and dysfunction, which indications, compared to others, are most relevant for reverse total shoulder arthroplasty (rTSA)?
  2. In patients undergoing rTSA, do some surgical techniques, compared to others, result in better outcomes?
  3. In patients undergoing rTSA, what are the clinical outcomes?

Question 1: Among patients with shoulder pain and dysfunction, which indications, compared to others, are most relevant for reverse total shoulder arthroplasty (rTSA)?


In general, rTSA is an implant that provides increased stability for a shoulder that has lost, or is at increased risk of losing, its normal ball‐and‐socket function. This most commonly occurs due to soft tissue (usually rotator cuff) or bony deficiency. However, as experience with this implant increases and with newer research, the indications for rTSA are expanding.

Clinical comment

The traditional indication for rTSA has been rotator cuff tear arthropathy with pseudoparalysis in elderly low demand patients. However, indications have rapidly expanded to now include younger high demand patients, other causes of arthritis, cuff insufficiency, or impending insufficiency, as well as some types of proximal humerus fractures.

Available literature and quality of the evidence

  • Level I: 1 randomized control study.4
  • Level II: 1 nonrandomized control study5 and 2 economic analyses.6,7
  • Level III: 1 case‐controlled study8 and 2 retrospective cohorts.9,10
  • Level IV: 2 systemic reviews11,12 and 4 case series.1316


Cuff tear arthropathy

RTSA may be considered when the patient presents with a clinically symptomatic, irreparable rotator cuff tear associated with anterosuperior escape and an irrecoverable pseudoparalysis. However, deltoid function must be preserved and there must be adequate glenoid bone stock to allow secure glenoid component fixation.17,18

Rheumatoid arthritis

RTSA in patients with rheumatoid arthritis is considered a reliable treatment option, with similar results to rTSA in rotator cuff arthropathy without a higher complication rate.11

Cuff tear arthropathy in younger patients

The use of rTSA for cuff tear arthropathy in patients younger than 65 years of age generates some treatment controversy. However, rTSA is now emerging as a reasonable treatment option for these patients, providing subjective functional improvements, but with higher complication rates and implant longevity concerns.91316

Failed arthroplasty

RTSA is also used as a revision procedure for shoulder arthroplasty associated with instability, this is associated with reasonable survival rates and higher complication rates than other indications. Instability can still remain an issue for one in seven patients.10

Proximal humerus fractures

RTSA can be used for the treatment of complex proximal humerus fractures in elderly patients. Patients show better forward flexion and abduction, with lower revision rates when compared with hemiarthroplasty.4,12,19,20 RTSA has also been shown to be more cost‐effective when compared with hemiarthroplasty.7

Resolution of clinical scenario

  • In patients greater than 70 years of age, rTSA can be considered when rotator cuff dysfunction leads to anterosuperior humeral escape and shoulder pseudoparalysis.
  • However, when all other options are exhausted, rTSA may also be considered in patients with rheumatoid arthritis, cuff tear arthropathy in patients less than 65 years of age, failed anatomic TSA, and complex proximal humerus fractures in the elderly.

Question 2: In patients undergoing rTSA, do some surgical techniques, compared to others, result in better outcomes?


There has been a dramatic increase in rTSA implant design and surgical techniques over the past 10 years. This has led to debate within the literature regarding many factors, including optimal positioning of the glenosphere and baseplate and humeral stem as well as size and design of the glenosphere. The effects of subscapularis muscle repair also show discordance within the literature.

Clinical comment

rTSA has enjoyed tremendous success considering its relatively short proliferation. This implant design provides a surgical option in difficult situations that previously were inadequately addressed with other surgical options. However, the pain and functional outcomes, survival, and complication rates have been somewhat inconsistent and concerning long term. As a result, authors have searched for implant design and technique methods to optimize the outcomes.

Available literature and quality of the evidence

  • Level I: 4 randomized controlled trials.2124
  • Level II: 1 prospective case series.25
  • Level III: 5 retrospective cohort designs, 2 prospective case‐control studies, and 2 retrospective case‐control studies.2634
  • Level IV: 1 systematic review and 3 retrospective case series.3538
  • Level V: 4 biomechanical studies.3941


Humeral component neck‐shaft angle

Utilizing a lower neck‐shaft angle (135°) on the humeral component leads to a greater impingement free range of motion (ROM) and decreases the rate of scapular notching when compared with a higher angled (155°) design (p = 0.0081).30,39,40 The neck‐shaft angle does not appear to affect the rate of postoperative dislocation.35

Larger diameter glenosphere

Use of a larger diameter glenosphere (>42 mm) decreases the rate of scapular notching (p <0.001) and improves ROM (forward flexion and external rotation) (p <0.05).31,33 However, both the size of the glenosphere and the presence of notching does not appear to affect the clinical outcome at short‐term follow‐up.22,29,32

Inferior glenoid component tilt and positioning

Inferior glenoid tilt of >10° does not reduce the rate of scapular notching and does not appear to confer a clinical benefit.23,30 Inferior glenoid positioning is desirable to decrease the rate of scapular notching and may improve clinical outcome scores.22,25,41,42

Glenoid lateralization

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Reverse Total Shoulder Arthroplasty

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