Reverse Total Shoulder Replacement

How reverse shoulder replacement works

In a reverse replacement, a metal ball is attached to the glenoid side of the joint and a polyethylene socket is placed on the humeral side. This configuration changes the center and mechanics of rotation. The deltoid can then compensate for some of the lifting function that would normally be provided by the rotator cuff. A reverse implant does not require a normal rotator cuff, but a successful result still depends on the deltoid, nerve function, remaining muscles and tendons, bone quality, implant fixation, and appropriate tension and alignment.

When is reverse replacement considered?

Common indications include rotator cuff tear arthropathy, an irreparable rotator cuff tear with substantial weakness or loss of active elevation, advanced arthritis with severe glenoid deformity or bone loss, selected complex proximal humerus fractures, fracture nonunion or malunion, and failure of an anatomic replacement, hemiarthroplasty, or previous reverse replacement. Reverse replacement is not automatically the correct choice because a patient is older. The procedure should be selected because the anatomy, soft tissues, and diagnosis make it the most reliable reconstruction.

Patient-specific CT planning and mixed reality

Reverse replacement is highly sensitive to component position, sizing, fixation, and soft-tissue balance. Dr. Knudsen obtains a CT scan and performs three-dimensional computer templating for every case. The plan evaluates glenoid version and inclination, bone loss, screw trajectories, baseplate position, humeral size, implant configuration, potential impingement, and the expected effect on stability and motion. Augmented- and mixed-reality applications can provide intraoperative access to the digital plan and support precise placement of the implants. These tools help translate the preoperative strategy into the operating room while preserving the surgeon's ability to adapt to the actual anatomy.

Evaluation and recovery

Evaluation includes a detailed history, examination of active and passive motion, assessment of deltoid and nerve function, X-rays, and CT-based planning. MRI or ultrasound may be useful in selected primary cases. Blood testing and aspiration may be required when a previous replacement is being revised. The arm is protected in a sling during the initial phase. Motion and strengthening progress according to the diagnosis and the tissues repaired. Pain relief often occurs before strength and endurance return. Improvement commonly continues for many months and may continue for a year or longer.

Risks and realistic expectations

Potential risks include infection, instability or dislocation, fracture, nerve or blood-vessel injury, stiffness, persistent pain, acromial or scapular stress fracture, implant wear or loosening, and revision surgery. Rotation may remain limited even when elevation and pain improve. The goal is a comfortable, dependable shoulder for daily function. Work, lifting, golf, tennis, swimming, and other activities are discussed individually because repetitive heavy loading or high-risk activity may need to be modified.

Selected References

1. Galvin JW, et al. Outcomes and complications of primary reverse shoulder arthroplasty with minimum of 2 years' follow-up: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022;31(11):e534-e544.
2. Godlewski M, Knudsen ML, Braman JP, Harrison AK. Perioperative Management in Reverse Total Shoulder Arthroplasty. Curr Rev Musculoskelet Med. 2021;14(4):282-290.
3. Obana KK, Chen JY, Weiss DL, Luzzi AJ, Knudsen ML, Jobin CM, Levine WN. Outcomes of reverse total shoulder arthroplasty in patients ≤65 years old. J Shoulder Elb Arthroplast. 2026;10(3):100041.
4. Obana KK, Weiss DL, Luzzi AJ, LeVasseur MR, Knudsen ML, Jobin CM, Levine WN. Reverse total shoulder arthroplasty is safe and effective in patients ≥90 years old. JSES Int. 2026;10(1):101374.

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