Reverse shoulder replacement: who it is for, risks and recovery

The shoulder is a ball and socket joint: the ball at the top of the arm bone (humerus) fits into the socket (glenoid) on the shoulder blade, and the group of muscles and tendons called the rotator cuff keeps the ball centred and helps lift the arm. East Kent Hospitals explains that when the rotator cuff is completely lost, a traditional shoulder replacement leads to a poor result and early failure, because the implant moves abnormally and unusual forces act on the artificial joint.

A reverse replacement was designed for this situation. Oxford University Hospitals says it is called reverse because the surgery reverses the normal ball and socket arrangement, with the ball on the shoulder blade side and the socket on top of the arm bone, and that this reversal has been found to improve the function of the muscles that move the arm. East Kent adds that the large deltoid muscle, which forms the shape of the shoulder, then works better so that a person can lift their arm over their head to compensate for the torn rotator cuff.

The Oxford booklet says arthritis, either osteoarthritis or rheumatoid arthritis, is the most common reason for replacing the shoulder joint, and that it may also be necessary after a fracture or damage to the rotator cuff tendons. East Kent describes osteoarthritis with rotator cuff disease as causing pain, difficulty sleeping on the affected side, catching, popping or clicking, weakness and loss of movement.

Before surgery, East Kent lists treatment options: painkillers such as paracetamol or codeine, anti-inflammatories such as ibuprofen, changes to daily routine, physiotherapy exercises and a steroid injection to keep pain under control temporarily. Surgery becomes an option when none of these work well enough.

East Kent says that patients who can have this surgery have significant pain from shoulder osteoarthritis, a rotator cuff tear that cannot be repaired or rotator cuff muscles that do not work, and a working deltoid muscle, and that people without this combination can usually have other surgeries. It stresses that patients should discuss all of their options with their orthopaedic surgeon.

Expectations should be realistic. The main goal is pain relief, with improved movement a secondary benefit, and the amount of movement regained depends on the state of the muscles before surgery.

The Oxford booklet says surgery is usually carried out under a general anaesthetic, together with a nerve block, an injection of local anaesthetic around the nerves at the side of the neck given under ultrasound guidance, which blocks pain signals for additional pain relief during and after surgery. The arm feels numb and weak for 12 to 48 hours afterwards.

East Kent describes the surgeon making a cut of around 10 to 12cm at the side of the shoulder, and notes that most prostheses have a special coating that allows bone to bond onto them over 12 weeks, avoiding bone cement. East Kent also describes implant designs that include traditional stemmed components and bone-preserving short-stem or stemless ones, and mentions that computer-assisted surgery is occasionally used.

The Oxford booklet lists risks with approximate frequencies: deep infection, rare and affecting fewer than 1 in 100 people; ongoing stiffness or pain in 1 to 20 in every 100 people; nerve and blood vessel damage, fewer than 1 in 100; DVT or pulmonary embolism, fewer than 1 in 100; dislocation, estimated at between 1 and 5 in 100; further surgery in 5 to 10 in every 100 people after 10 years; and loosening of the implants, generally considered rare and not likely for several years.

East Kent lists infection, bleeding, blood clots, soft tissue injury, continued pain and complex regional pain syndrome, stiffness that may cause frozen shoulder, numbness or tingling, fracture of the surrounding bones, dislocation, loosening and wear, and that the surgery may not be successful. It advises that if the artificial ball comes out of the socket, you should go to the emergency department.

• Increasing redness, swelling, heat or discharge from the wound.

• A sudden change in how the shoulder looks or a feeling that it has slipped out.

• Calf pain and swelling, or sudden breathlessness.

• Numbness or colour change in the hand.

The Oxford booklet describes four phases. In hospital, you are one-handed and need help with dressing, bathing and meals. Over the first 6 weeks pain gradually reduces and you wean out of the sling. From 6 to 12 weeks you begin lifting your arm in the air when sitting or standing. After 12 weeks more vigorous stretches begin. It says to avoid putting the arm behind the back and pushing inwards, and pushing up from a chair, for 6 weeks, not to lift anything heavier than a cup of coffee for 6 weeks, to avoid moving the arm out to the side and twisting behind for 8 weeks, and to avoid pushing down on the operated arm for 12 weeks.

Oxford says you may be off work for 6 to 8 weeks depending on the job, with lifting, overhead or manual work avoided for 3 to 6 months, and that it is likely to be 6 to 8 weeks before you can drive, or 8 to 12 weeks with a manual car. East Kent says you will not be able to drive for about eight weeks and that gentle swimming can start 4 to 6 weeks after surgery. Yearly follow-up is described to check the joint.

Both leaflets stress that recovery is not a quick fix. Even if muscles are badly damaged and do not work properly, Oxford says the pain should be much less than before surgery.

Reverse shoulder replacement is provided by specialist upper limb surgeons in NHS and private hospitals, usually after a period of physiotherapy and injections have been tried. Ask your surgeon how many of these operations they do, which implant is planned, how long you are likely to stay in hospital and what follow-up will be arranged.