Shoulder Fracture Treatment: Reverse Joint Replacement

This article covers fractures of the upper arm bone, the humerus, at the shoulder.

There are several options for surgical treatment of a shoulder fracture; this article covers total replacement with a reverse shoulder for a shoulder fracture.

(A separate article covers reverse joint replacement for rotator cuff tears.)

What is a reverse joint replacement?

The shoulder joint is a ball-and-socket joint: there is a ball-shaped part, which is the head of the humerus, and a concave part (the socket), which is the glenoid. This is a total replacement of the joint: both the head of the humerus and the glenoid are replaced. The implant is called a reverse shoulder because the anatomy is reversed – the ball-shaped part, instead of being on the head of the humerus, moves to the glenoid, while the socket moves to the humerus.

When is a reverse joint replacement performed?

The operation is performed for a complex fracture with significant displacement, usually in patients above 75, or at a younger age when the quality of the muscles and bone is poor.

Unlike a partial replacement, which depends on the function of the shoulder muscles, with a reverse replacement the shoulder will function well even if the tendons are damaged.

What is the goal of the operation?

The goal of the operation is to replace the joint in cases of severe fractures and to allow the best possible shoulder function.

This is usually a complex injury, and even after surgery some limitation of shoulder function is expected.

How is the operation performed?

The operation is done with an open technique, that is, through an incision at the front or the side of the shoulder. It is performed under general anesthesia, usually combined with regional anesthesia.

• The first stage of the operation is the approach: through the incision the fracture area is reached and the broken parts are identified.
• The second stage: the head of the humerus is removed and the artificial implant is inserted – a ball-shaped metal implant into the glenoid and a metal implant with a plastic surface into the humerus.
• The third stage: the remaining parts of the tuberosities (the area of bone where the rotator cuff tendons attach) are fixed. Usually sutures are used to stitch the parts into place.
• The fourth stage: the layers and the skin are closed. In certain situations a tube is left to drain blood and fluid from the fracture area. The arm is immobilized in a sling.

What happens after the operation?

Usually the arm is immobilized in a sling for about 3–4 weeks, and then physiotherapy begins.

In the first months function is relatively limited and the movements are mainly passive.

Reasonable daily function can be expected after about 3 months, and relatively good function after about 6 months.

Shoulder function keeps improving during the first year after surgery, and slowly after that as well. Keep in mind that in any case some restriction of movement is expected even at the end of rehabilitation.

What are the risks and complications?

Some complications can occur during the operation: injury to blood vessels, injury to nerves, and complications related to general anesthesia. The risk of an anesthesia complication depends on the patient's underlying illnesses and age.

Late complications include: dislocation of the shoulder, restricted movement after the operation, and infection.

What is the implant made of?

Today most systems are made of a combination of titanium in the part fixed to the bone and a metal head made of a cobalt-chrome alloy. In the humeral part, the piece that attaches to the bone is made of titanium, and the concave surface is made of polyethylene (a hard plastic).

Will the implant set off the alarm at the airport?

It quite possibly will. If it does, show the surgical scar and explain that you have had an operation.

Explanatory video

Reverse shoulder replacement for complex fractures – An explanation of reverse shoulder replacement as a solution for complex fractures in older patients: what the operation involves, who it suits and the recovery process. The video is in Hebrew.

Deltoid strengthening protocol after reverse shoulder replacement – step-by-step exercises for the muscle that moves the reverse shoulder.