MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

(iv) Reverse shoulder Function of the rotator cuff

In order to understand the design rationale for RSR we must first
replacement consider the biomechanics of the rotator cuff and the reason why
poor function is observed after conventional arthroplasty in cuff
James C Beazley deficient shoulders. The rotator cuff muscles provide a balanced
force couple that keeps the humeral head centred on the glenoid
Gev Bhabra
throughout its range of motion. The joint is balanced in the axial
Tom Lawrence plane anteriorly by subscapularis and posteriorly by infra-
spinatus and teres minor. In the coronal plane supraspinatus
completes the compressive force that counteracts the deltoid
Abstract
Arthritis of the glenohumeral joint in the presence of a deficient or poorly
vector of pull.4 These coronal and axial force couples provide a
functioning rotator cuff is common and debilitating, particularly in the
stable centre of rotation, eliminating shear and allowing efficient
elderly population. Shoulder arthroplasty in this patient group has histor-
function of the deltoid. The rotator cuff is also pivotal in con-
ically performed badly with poor function and limited pain relief. In an
trolling internal and external rotation.
effort to combat the challenges faced when treating these patients,
In the setting of a massive rotator cuff tear, the proximal
reverse polarity shoulder replacements were introduced, and the design
humerus migrates superiorly (Figure 1) and the force couple
of these implants has evolved over the last 30 years. The relative success
balance is lost. The humeral head is no longer centred on the
of reverse shoulder replacements in these patients has led to their use for
glenoid, and without a stable fulcrum, deltoid loses its ability to
other indications including trauma and massive cuff tears without
provide rotational torque leaving the patient unable to elevate
arthritis. In this review we present the biomechanical principles that un-
their arm.
derlie the design of the reverse shoulder replacement, and outline the
evolution of the design in recent times. We also discuss surgical tech- Biomechanics of reverse shoulder replacement
nique and review the clinical outcomes and complications associated
To compensate for the loss of the stable fulcrum and balanced
with the procedure.
force couple in patients with rotator cuff deficiency, Grammont
Keywords arthroplasty; biomechanical phenomena; prosthesis design; introduced the reverse shoulder concept in 1985 based on several
replacement/methods; rotator cuff/surgery; shoulder joint/surgery key principals; (1) the centre of rotation should be medialised to
increase the deltoid lever arm and minimize stress at the implant-
bone junction, (2) the centre of rotation is moved distally to in-
crease deltoid tension, and (3) the implant is semi-constrained
Introduction providing a fixed stable fulcrum to allow the deltoid to exert
Improvements in pain and function have been reliably reported rotational torque. Although modern RSRs may differ in some
in patients with shoulder arthritis and an intact rotator cuff un- respects from the Grammont’s original design, the core principals
dergoing anatomic shoulder arthroplasty.1 However, in patients remain unchanged.
with a non-functioning rotator cuff, conventional arthroplasty Medialisation of the centre of rotation (COR) relative to the
has failed to provide significant functional benefit.2 In the 1980s native shoulder increases the lever arm of the deltoid (Figure 2a
the reverse shoulder replacement (RSR) concept was developed and b). The abduction and flexion moment arm of the middle
to allow restoration of joint stability and function in patients with deltoid have been shown to increase by an average of 17.2 mm
a deficient rotator cuff. Originally intended for patients with ro- and 14.8 mm respectively,5 increasing torque by up to 40%.6
tator cuff arthropathy, the breadth of indications increased to Medialising the COR directly on to the glenosphere-bone
include massive irreparable rotator cuff tears without arthritis, interface also reduces torque and shear forces generated at this
revision arthroplasty and trauma. In 2011 RSR accounted for interface (Figure 3a and b). Placing the centre of rotation further
42% of all primary shoulder arthroplasty performed in the USA.3 distal (inferior) also has an advantage in that it tensions the
This article reviews the evolution and the biomechanical prin- deltoid and improves the clearance of the humeral prosthesis
ciples behind RSR design, indications, outcomes, surgical tech- inferiorly, reducing the incidence of inferior impingement and
nique and complications. notching.

Advances in RSR design

James C Beazley MBChB MSc FRCS (T & O) Registrar University Hospitals In recent years several modifications have been made to reverse
Coventry and Warwickshire, Coventry, West Midlands, UK. Conflict of shoulder implants to reduce complications such as scapular
interest: none declared. notching and base-plate failure, seen with earlier aspects of the
design.
Gev Bhabra MBChB MD FRCS (T & O) Shoulder and Elbow Fellow, University
Although the anatomical neck-shaft angle of the humerus is
Hospitals Coventry and Warwickshire, Coventry, West Midlands, UK.
135-140 , Grammont’s original prosthesis was designed with a
Conflict of interest: none declared.
more horizontal inclination (155 ) to place the humerus in an
Tom Lawrence MBChB MSc MD FRCS (T & O) Consultant Shoulder and Elbow infero-medial position allowing increased length and tension of
Surgeon, University Hospitals Coventry and Warwickshire, Coventry, the deltoid muscle.7 However, recent biomechanical studies have
West Midlands, UK. Conflict of interest: none declared. shown that a lower inclination angle reduces the adduction

ORTHOPAEDICS AND TRAUMA 29:5 305 Ó 2015 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

Baseplate design has also seen subtle changes geared towards

reducing micro-motion and thereby increasing osseo-integration.
Stabilization screws have increased in diameter and some de-
signs feature a central screw rather than the traditional peg
design to increase baseplate compression and minimize failure.

Indications and outcomes for reverse shoulder replacement

Whilst RSR was originally designed for patients with rotator cuff
arthropathy, the indications for RSR have expanded significantly
in recent years.

Cuff tear arthropathy

Cuff tear arthropathy is a combination of massive rotator cuff
tear and glenohumeral arthritis with a prevalence of 2% in pa-
tients over 80 years of age.9 Neer developed the term “cuff tear
arthropathy” in 1981 to describe proximal migration of the hu-
merus and acetabularization of the acromion10 (Figure 5). The
exact aetiology of cuff tear arthropathy is not known. Various
theories regarding its aetiology include a calcium-phosphate
crystal mediated pathway, and a cuff tear theory in which both
mechanical factors and cartilage nutritional factors contribute to
arthropathy.11
Figure 1 Massive rotator cuff tear with superior migration of the humeral RSR for cuff tear arthropathy has been shown to reliably
head (red arrow). improve pain and function.12,13 Nolan et al.12 report a substantial
improvement in Constant-Murley and American Shoulder and
deficit, inferior impingement and therefore scapular notching.8 In Elbow scores after RSR in patients with cuff tear arthropathy.
addition a lower inclination angle lateralizes the humeral Active forward flexion improved from 61 pre-operatively to 121
component which may optimize tension on the anterior and post-operatively.12 This series demonstrated no improvement in
posterior cuff to improve internal and external rotation. Newer external rotation after RSR, although others have noted that lat-
designs have therefore introduced humeral prostheses with a eralized stems demonstrate a greater improvement in external
more anatomical neck shaft angle (Figure 4a and b). These newer rotation than medialised prostheses.13
implants are typically platform designs that allow conversion of
anatomic total shoulder to RSR without the need to change the Massive irreparable cuff tear without glenohumeral arthritis
stem. These employ an onlay technique whereby the humeral Massive irreparable cuff tears in patients without glenohumeral
articulation, consisting of a tray and bearing, lies on top of the arthritis present a challenging problem. Surgical treatment op-
neck cut. This differs from the traditional implants that consist of tions are limited but include biceps tenotomy, subacromial
an inlay technique, requiring reaming of the epiphysis, in which decompression or arthroscopic debridement. Although these
the humeral articulation lies inside the humerus (Figure 4). procedures can offer some pain relief, they do not reliably restore

Figure 2 Schematic diagrams showing the effect of medialisation of centre of rotation on the deltoid lever arm. Medialisation of the COR increases the
lever arm of the deltoid (D) in the RSR (a) vs. the native shoulder (b).

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 MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

Figure 3 Schematic diagrams showing the effect of medialising the centre of rotation on to the native glenoid surface. Movements of the shoulder
produce a resultant force vector (Fv) which is composed of compressive forces (Fc) and shear forces (Fs). Early RSR designs had a COR lateral to the
glenoid surface (a). This generated a moment (M) at the bone-implant surface which changed the resultant force vector acting to destabilize the gle-
nosphere. Grammont’s hemisphere design (b) placed the COR directly on to the bone-implant surface, to reduce torque at this interface.

function.14 Tendon transfers have shown to provide some In a study of 72 shoulders with irreparable cuff tears and no
improvement in active range of motion but the ideal candidates glenohumeral arthritis, RSR significantly improved pain and
are young patients with an irreparable cuff tear complaining of functional scores at an average follow up of 52 months.16 Active
weakness primarily.15 Therefore RSR is being increasingly per- forward elevation improved from 53 to 134 , and active abduc-
formed in elderly patients with painful massive irreparable cuff tion from 49 to 125 . However, there is some evidence to suggest
tears and significant shoulder dysfunction. that there is a greater improvement in outcome after RSR in

Figure 4 (a) A prosthesis based on Grammont’s original concepts, with a horizontal neck-shaft angle and an inlay design such that the neck of the humeral
component lies within the humerus. (b) An X-ray of a contemporary RSR implant with a more anatomical neck-shaft angle and an onlay stem.

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 MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

glenoid retroversion or a biconcave glenoid undergoing

anatomic total shoulder replacement (TSR).21 RSR may offer a
more reliable alternative to anatomic TSR in these patients. In a
series of 27 patients who underwent RSR for primary gleno-
humeral osteoarthritis with a biconcave glenoid, Mizuno et al.
reported a mean Constant score increase from 31 to 76 points
with a revision rate of 3.7% at a mean follow-up of 54
months.22
Finally, RSR may be indicated for chronic shoulder disloca-
tions, post traumatic sequelae, and tumours that require signifi-
cant bone and soft tissue resection.

Surgical technique
Approach
The majority of surgeons use a standard deltopectoral approach
Figure 5 Cuff tear arthropathy with proximal migration of the humerus, although the superolateral approach has also been advocated.
acetabularization of the acromion and glenohumeral arthritis. Proponents of the superolateral approach argue that preservation
of subscapularis and the anterior capsule accounts for lower
patients with cuff tear arthropathy compared with RSR in patients post-operative instability.23,24 The main disadvantage of the
with an irreparable cuff tear and no glenohumeral arthritis.13 superolateral approach is difficulty in inferior access, with a risk
of improper baseplate positioning and deltoid dehiscence.
Proximal humeral fractures
The skin incision for the deltopectoral approach begins just
Comminuted proximal humeral fractures in the elderly that are
superior and lateral to the coracoid process and runs infero-
not reconstructable have traditionally been treated with hemi-
laterally towards the proximal humeral shaft. The cephalic vein
arthroplasty(HA).17 Failure of tuberosity healing and poor cuff
defines the interval between deltoid and pectoralis major and can
quality in this population are the main reasons for unsatisfactory
be mobilized medially or laterally. The coracoid process and
outcomes following hemiarthroplasty and therefore the use of
conjoined tendon are defined by incising the clavipectoral fascia.
RSR has recently gained popularity.
Retracting the deltoid laterally reveals the subscapularis muscle,
Sebastia-Forcada et al.18 performed a randomised controlled
with the biceps tendon in its groove. The subscapularis tendon is
trial comparing RSR and HA for the treatment of proximal hu-
divided close to its humeral attachment and reflected medially.
meral fractures in patients over 70 years. At a mean follow-up of
The capsule is released off the humeral neck protecting the
28 months RSR patients had significantly higher mean University
axillary nerve.
of California-Los Angeles and Constant scores, forward elevation
For the superolateral approach the incision begins 1 cm
(120 vs 80 ) and abduction (113 vs 79 ). Forty-month survival
medial to the anterior part of the acromio-clavicular joint, and
was 96.8% in the RSR group and 80.0% in the HA group.
continues laterally to the edge of the acromion and then longi-
Revision procedures tudinally in the direction of the deltoid fibres.24 It should extend
The most frequent indications for revision of shoulder arthro- no more than 4 cm lateral to the acromion in order to preserve
plasty are rotator cuff deficiency, infection, aseptic loosening and the axillary nerve. The deltoid is split between the anterior and
instability. Late rotator cuff tear is a recognized complication middle thirds, and the anterior deltoid released from the anterior
after total shoulder arthroplasty, with rates approaching 45% at acromion and tagged to facilitate repair at the end of the
10 years post-operatively.19 RSR is being increasingly used as a procedure.
treatment option for salvage of failed arthroplasty.
Humeral preparation
In a systematic review Randelli et al.20 pooled the results of 10
Once the humerus has been exposed and dislocated, the head is
case series examining the outcome of RSR for failed shoulder
excised with the aid of a resection guide and a version rod
arthroplasty with cuff insufficiency. 226 patients with a mean
aligned with the forearm (Figure 6a and b). The angle of incli-
follow-up of 3.8 years were included in the analysis. The pooled
nation for the cut depends on the prosthesis being used. The
results showed significant improvements in Constant score, but
angle of version of the cut remains controversial. It is important
the values were well below age-related norms and those
to be aware that increasing retroversion will increase external
observed after primary RSR. The reoperation rate ranged from 13
rotation with proportional loss of internal rotation. Less retro-
to 42%. The authors concluded that clinical outcomes are less
version has the reverse effect. Traditionally with the use of
predictable and complications and revision rates are higher in
Grammont-style implants the cut is made more towards neutral
patients undergoing revision RSR than in patients treated with a
version. With the more recent platform implants, cuts are made
primary RSR procedure.20
towards the anatomic 30 of retroversion. Once the neck has
Primary osteoarthritis with biconcave glenoid been cut the medullary canal of the humerus is entered and
High rates of postoperative posterior instability and premature prepared using the appropriate broaches or reamers, using a
glenoid failure have been found in patients with significant guide rod to maintain correct version (Figure 7).

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 MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

Figure 6 Intra-operative photographs. (a) The humeral head is dislocated and is “bald” with no attached of rotator cuff tendons. (b) The resection guide
for the humeral neck cut is attached, and the version rod is aligned with the forearm.

Glenoid preparation (Figure 9). After drilling, central and peripheral (non-locking or
After adequate glenoid exposure, the glenoid surface is prepared locking) screws are inserted. After baseplate fixation, the gleno-
for fixation of the baseplate. Experimental and clinical studies sphere is impacted onto the baseplate and secured with either a
have shown that inferior placement of the baseplate reduces single screw or a morse taper, depending on the implant design
inferior impingement and notching.8,25,26 The guidewire should (Figure 10). Most manufactures have the option of two gleno-
therefore be placed just inferior to the centre point of the glenoid sphere sizes and some allow the option to offset the component
surface (Figure 8). inferiorly to further minimize notching.
With the guidewire in situ, cannulated reamers are used to The soft tissue tension and stability can be altered by the
prepare the glenoid surface and the baseplate is impacted thickness of the polyethylene insert (Figure 11). Trial inserts are

Figure 8 The glenoid guidewire is inserted inferior to the centre of the

Figure 7 The humeral canal is prepared with broaches and reamers, using glenoid surface. In this instance a glenoid “sizer” is placed at the inferior
a guide rod aligned to the forearm to maintain version. margin of the glenoid to help to direct correct placement of the guidewire.

ORTHOPAEDICS AND TRAUMA 29:5 309 Ó 2015 Elsevier Ltd. All rights reserved.
 MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

Figure 9 The glenoid baseplate in situ. This particular design has a central Figure 11 The polyethylene insert is attached to the humeral component.
compression screw and four peripheral screws which can be locking or Trial inserts of varying thickness can be used to alter soft tissue tension
non-locking. and stability.

used to determine the correct size. Too little tension may Instability
compromise stability whereas over-tensioning increases the risk Instability was the most common complication reported by
of acromial fractures, neurological injury and deltoid fatigue. Zumstein et al.27 in a systematic review of 782 RSRs. It occurred
Once the definitive implants have been inserted (Figure 12) in 4.8% of cases, with the incidence of instability being signifi-
closure is performed. The subscapularis can be repaired provided cantly higher (9.4%) in those patients receiving a RSR for a failed
it is not excessively tight. primary arthroplasty.27 Careful attention to surgical technique
including correct tension and orientation of the prosthesis will
Complications minimize instability.
Early series of RSRs reported high level of complications. Some of
the early complications have been overcome with improvements Scapular notching
in implant design and surgical technique. The main complica- Scapular notching is the erosion and radiographic lucency seen at
tions to be aware of are discussed below. In the future, data the inferior scapular neck and is a complication unique to RSR. It
collection through national joint registries will provide useful is thought to be caused by a mechanical impingement between
information regarding data complications and implant survival
rates.

Figure 10 The glenosphere in situ. Depending on prosthesis design, this Figure 12 The joint is reduced and checked for range of movement, sta-
can either be secured with a central screw or a morse taper. bility and impingement.

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 MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

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