What are the indications for reverse total shoulder replacement?

Indications for Reverse Total Shoulder Arthroplasty

Reverse total shoulder arthroplasty is indicated for patients with massive, unrepairable rotator cuff tears who have pseudoparalysis and have failed conservative treatment, as well as for rotator cuff tear arthropathy (the combination of massive rotator cuff tear with glenohumeral arthritis). 1, 2

Primary Indications

Massive, Unrepairable Rotator Cuff Tears with Pseudoparalysis

• Patients must demonstrate arm elevation less than 90° at the shoulder, with or without anterosuperior escape, after failing at least 6 months of nonoperative treatment 3
• The rotator cuff tear must involve at least two tendons and be deemed irreparable 3
• Pseudoparalysis (inability to actively elevate the arm) is the key functional deficit that makes these patients candidates for reverse arthroplasty 1, 2

Rotator Cuff Tear Arthropathy

• This represents the combination of massive rotator cuff tear with glenohumeral joint arthritis 2, 4
• Patients with primary rotator cuff tear arthropathy achieve the best outcomes among all indication groups 4
• After failure of conservative treatment, reverse shoulder arthroplasty improves patient-reported outcomes in this population 1

Expanded Indications

Irreparable Rotator Cuff Tears Without Arthritis

• Patients with Hamada stage 1,2, or 3 changes (no or minimal arthritis) can be considered when non-arthroplasty options have failed or have low likelihood of success 3
• Pain combined with functional limitation is the primary driver, even in patients who retain greater than 90° of elevation 3
• This indication shows 90.7% survivorship at intermediate-term follow-up (mean 52 months) 3

Other Complex Shoulder Pathologies

• Primary osteoarthritis with concurrent rotator cuff tear (these patients achieve better outcomes than revision or post-traumatic cases) 4
• Failed anatomic total shoulder arthroplasty or hemiarthroplasty in rotator cuff-deficient shoulders 5, 6, 4
• Acute proximal humerus fractures and their sequelae 5
• Inflammatory arthropathy including rheumatoid arthritis 5, 7

Critical Patient Selection Factors

Age Considerations

• Age under 50 years is a significant concern due to potential risks of increased prosthetic loosening and decreased survivorship 2, 8, 9
• The procedure was originally designed for older adults with rotator cuff deficiency, though indications have expanded to younger populations with severe pathology 9
• The average age in successful series is approximately 73 years 4

Absolute Contraindications

• Severely impaired deltoid function is an absolute contraindication, as the deltoid muscle must power shoulder motion in the reverse design 2
• The reverse prosthesis inverts normal anatomy, placing a metal ball on the glenoid and cup on the humerus, allowing the deltoid to compensate for absent rotator cuff function 2

Prognostic Considerations

Best Outcomes Expected In:

• Primary rotator cuff tear arthropathy 4
• Primary osteoarthritis with rotator cuff tear 4
• Massive rotator cuff tears without prior surgery 4, 3

Higher Complication Rates Expected In:

• Revision arthroplasty cases (higher complication rate than primary procedures) 4
• Post-traumatic arthritis (less improvement compared to other etiologies) 4
• Patients with prior surgical procedures on the same shoulder 3

Common Pitfalls to Avoid

• Do not perform reverse arthroplasty in patients with inadequate deltoid function, as this will result in failure 2
• Avoid multiple steroid injections in rotator cuff tears, as these may compromise cuff integrity and affect subsequent repair or arthroplasty outcomes 1
• Be cautious in patients under 50 years old due to longevity concerns with the prosthesis 2, 8, 9
• Recognize that revision cases and post-traumatic arthritis have higher complication rates (dislocation and infection being most common) and potentially less functional improvement 4