Published on February 22, 2016

Reversing shoulder pain by reversing the shoulderReversing shoulder pain by reversing the shoulder

Few would share the sense of joy 78-year-old Alyce Day did when she recently raked the leaves in her yard. Day, a Hyannis retiree, was finally rid of chronic shoulder pain and immobility that had plagued her for years.

Ecstatic about her restored function, she credits Jesse Affonso, MD for performing an innovative reverse shoulder joint replacement surgery- a last-chance procedure reserved for patients who do not qualify for the traditional approach.

“Reverse shoulder joint replacement is a surgical procedure like no other,” remarked Dr. Affonso, the chief of Orthopedics at Cape Cod Hospital. “It changes anatomy, rather than replacing what is normally there. No other surgical intervention does this.”

For a brief lesson; a normal shoulder is a ball and socket joint supported by the surrounding rotator cuff tendons and muscles. The ball is located at the tip of the upper arm bone (humerus), which fits snuggly into the opposite facing socket.

In traditional replacement surgery, the diseased joint is removed and replaced with a prosthetic replica. But, in reverse shoulder replacement, the prosthetic joint switches the location of the components: the socket is secured to the top of the upper arm bone (humerus) where the ball once was, and the new ball is where the socket used to be.

“Normally, the rotator cuff provides stability to the joint, keeping the ball centered in the socket. When damaged beyond repair, arm mobility can be severely limited. In these instances, traditional joint replacement surgery isn’t an option,” said Affonso.

Alyce Day was a good candidate for a reverse shoulder replacement. Years of changing bedding and flipping mattresses as a summer housekeeper had taken its toll on her right shoulder. With chronic arthritis and pain, she lost her mobility.

“I stopped being able to do things for myself,” she said. “I couldn’t shampoo my hair very well and couldn’t pack a suitcase. Forget taking my grandchildren bowling!”

The procedure was designed specifically for use in shoulders with extensive and irreparable damage to the rotator cuff. The best candidates have the following profile:

  • 60 plus years in age
  • Limitations in mobility and weakness
  • Large rotator cuff tears where conventional joint replacement surgery is not an option
  • Previous failed joint replacement or rotator cuff repair
  • History of certain types of complex fractures, where conventional joint replacement surgery isn’t an option.

The reverse shoulder prosthetic uses a deeper socket to stabilize the joint and compensate for the loss of the rotator cuff function. The mechanics of joint movement is shifted so that the deltoid becomes the prime elevator of the shoulder instead of the rotator cuff.

“The forces aren’t natural. But, by switching the position of the ball and socket we are able to engage the strength of the deltoid (the large muscle on the outside of the upper arm). This becomes the new driving force to move the arm and regain stability,” said Dr. Affonso. “This is really a salvage procedure, where all other conventional options have been exhausted. Without it, patients are left with no alternative but to live in pain with restricted shoulder function for life.”

The actual procedure takes 90 minutes to two hours and is done with the patient sitting upright in a chair. Afterwards, most patients are hospitalized for one to two days, and may be discharged directly home, depending upon the amount of help available there. Otherwise, a two-week stay in a skilled nursing facility is typical.

Because the mechanics of the shoulder are altered, a very careful postoperative rehabilitation plan protocol is developed. Rehabilitation is guided by Dr. Affonso to ensure a successful outcome.

For people living an active lifestyle, there are new limitations after the surgery.

“Weight bearing is a problem,” cautioned Dr. Affonso. “Because of the new mechanics, we recommend that there is no more pressure put on this arm forever.”

Alyce Day was in such agony, the notion of replacing her shoulder with an artificial one that reversed natural anatomy hardly interested her. “I didn’t give it a single thought,” she said. “I would have done anything to get rid of my pain.”

Two months after her surgery, she began to notice the difference. Her mobility returned and over the course of the following year, her pain was gone.

“These are my happiest patients,” said Dr. Affonso. “They are so miserable and in so much pain, with no mobility. All they want to be able to do is simple, daily tasks like brush their hair and put their dishes away on a shelf.”

Day is so happy with her result that in September she has another appointment with Dr. Affonso. She would like to have her second shoulder done.