Addressing the Technical Challenges of Reverse Total Shoulder Arthroplasty and Lowering the Risk of Complications

Reverse total shoulder replacement arthroplasty, a technically challenging surgery, is often reserved for patients with serious shoulder pathology that cannot be adequately addressed with more conventional procedures. In patients who present with a massive irreparable rotator cuff tear and arthritis, a reverse total shoulder replacement can dramatically restore function and reduce pain. In the past, there would have been few good options for helping these patients. Nevertheless, according to Hyun-Min (Mike) Kim, M.D., Penn State Hershey Bone and Joint Institute, “Complications are seen in approximately 10 percent of patients who have this procedure done; about half of all complications involve instability. Mechanical impingement between the components and native tissue can contribute to instability and later to scapular notching.” To improve outcomes for these patients, Kim takes specific intra- and post-operative steps aimed at reducing risk of instability.

X-ray images showing pre-operative and post-operative states of a reverse total shoulder replacement.

Preoperative X-ray (top panel) of a 72-year old patient with a massive irreparable rotator cuff tear showing degenerative changes of the acromion and superior migration of the humeral head. The bottom panel shows the postoperative X-ray of the same patient following a reverse total shoulder replacement.

“Beyond choosing an appropriate implant, to guard against instability, I do a very thorough soft tissue release at the inferior portion of the glenoid, which allows me to implant the glenoid component as inferiorly as possible. To achieve an inferior tilt, perform eccentric reaming, removing more bone from the inferior glenoid. I also prefer to use products with a more varus neck-shaft angle. If possible instability is noticed intraoperatively, choose a more constrained polyethylene insert.”

Kim adds that certain key elements of the procedure, such as achieving proper tensioning of the deltoid muscle, can only come with experience. The risk of hematoma and ensuing infection can be higher because this procedure leaves more “dead space” in the shoulder than a conventional shoulder replacement. “To reduce the risk of hematoma, perform very meticulous hemostasis, and then do a layered closure, inserting a drain into the joint,” explains Kim. The recovery process is also slower than with conventional shoulder replacement. Kim says, “I keep the patient’s shoulder immobilized in an arm sling for four weeks and advise them to only do hand, elbow, and pendulum exercises. Physical therapy may begin after four weeks of healing; I think this also helps to prevent instability.” The success seen with reverse total shoulder replacement has led some to consider its use for other indications, including three to four-part humerus fractures in older patients. Kim notes “This is a very intriguing concept change that may help to improve the clinical outcomes and possibly reduce complications associated with such injuries.”

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photo of Mike Kim, M.D.

Hyum-Min (Mike) Kim, M.D.

Hyun-Min (Mike) Kim, M.D.

  • Orthopaedic surgeon, shoulder and elbow surgery
  • Assistant professor, orthopaedics and rehabilitation
  • Phone: 717-531-5638
  • Fellowships: Shoulder, elbow, and sports medicine, Columbia University College of Physicians and Surgeons, New York, New York; Orthopaedic trauma, University of Missouri, Columbia, Missouri; Shoulder and elbow surgery, Barnes-Jewish Hospital, Washington University, St. Louis, Missouri
  • Residency: Orthopaedic surgery, Daegu Fatima Hospital, Daegu, South Korea
  • Internship: General surgery, Daegu Fatima Hospital, Daegu, South Korea
  • Medical School: Kyungpook National University School of Medicine, Daegu, South Korea

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