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Reverse means the opposite. While non-reverse prostheses are referred to as “anatomical prostheses,” reverse prostheses are considered “non-anatomical” prostheses. In anatomical prostheses, the shoulder joint is completely mimicked or replicated. Despite being anatomical, they depend on the integrity of the rotator cuff muscles’ sleeve to functionally operate the shoulder joint. The humeral head (the ball) is made of cobalt-chromium or titanium, and it is placed into the polyethylene (soft) socket (Figure 1).

In reverse prostheses, the design logic works differently. The main objective of these types of prostheses is to enable the lifting of the arm from the shoulder joint by utilizing the assistance of the deltoid muscle when the rotator cuff, also known as the rotator cuff muscles, is not functioning or has suffered irreparable damage. The humeral head is replaced with the socket of the shoulder, essentially transforming the original socket into the humeral head, and the humeral head becomes the socket of the shoulder.

Reverse prostheses were initially designed as a salvage prosthesis for irreparable tears of the shoulder muscles and permanent degeneration of the shoulder joint in older individuals. However, in recent times, they have also become widely used for severely fragmented fractures of the humeral head in advanced age groups, where repair is not feasible.

Another requirement of reverse prostheses is that previously applied prostheses (partial or total – anatomical) are not functioning properly.

In reverse prostheses, the tension of the deltoid muscle, also known as the lateral muscle of the arm, is of utmost importance.

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When the deltoid muscle is adequately tensioned after reverse prosthesis, patients will be able to lift their arm smoothly over their head.

Reverse prostheses are generally used in patients over 70 years old. Their use is limited in younger patients. This is due to the unknown durability of the prosthesis and the higher risk of complications in this age group due to increased activity levels.

In cases where reverse prosthesis cannot be performed due to reasons such as low bone stock and quality in advanced age or infection, it is recommended to remove the humeral head and leave the shoulder in a flail shoulder state.

Preoperative Preparation and Discharge

After the decision for surgery is made, consultations with other specialists (cardiology, internal medicine, etc.) may be requested by your anesthesiologist. If not already done, a computed tomography (CT) scan of the shoulder will be requested to assess bone stock and for surgical planning. The surgery is performed under general anesthesia and typically takes about 2 hours. This 2-hour period includes the time for induction and preparation (positioning, sterilization procedures, patient draping, etc.), which takes approximately 1 hour, and an additional hour for the awakening period after the surgery. It will generally take about 4 hours for you to leave your room and return to your room. However, if your surgery involves the correction of a previous procedure (revision), it may take significantly longer. Your hospital stay after the surgery will be an average of 2-3 days. During this time, you will be administered strong pain medication, receive ice application, dressing changes, and undergo ambulation. If necessary, blood transfusion may be administered to normalize general parameters. Once your overall condition and wound have improved, you will be discharged and instructed to take oral pain medication and antibiotics while walking.

Postoperative Care after Reverse Prosthesis

Compared to anatomical prostheses, dislocation is more common with reverse prostheses. Therefore, for at least 6 weeks after the surgery, it is important to avoid bringing the arm close to the body and rotating it inward. Rising from a chair with hands placed on the edges should be avoided as an undesirable example. Below are incorrect and correct movements (incorrect – correct) illustrated:

The shoulder-arm sling (with a waist belt) should be used for approximately 3-4 weeks. The link for the use of shoulder-arm sling is provided here: (https://youtu.be/FYqi0wgMQrI) on the side.

Remember to start removing your clothing from the non-operated arm, and lastly, remove the clothing from the operated arm. When putting on clothing, start with the operated arm first and then proceed in the reverse order.

You should have professional dressings done approximately 4-5 times. Within 3-4 days after the surgery, the wound dressing can be washed with lukewarm and gentle water.

During the first 6 weeks, you will have a check-up every 15 days for physical therapy education and wound observation. Afterwards, with the help of X-rays and a physical therapy program, you will gradually transition back to daily activities. The active lifting of your arm, similar to your preoperative movements, surgery, and the subsequent recovery process, will vary from person to person but typically takes an average of 6-8 weeks.

General causes of the tear in your shoulder: the natural loss of strength and degeneration of muscles with advancing age – repetitive strenuous movements due to household chores or work (such as cleaning windows, excessive cleaning efforts, knitting, repetitive heavy lifting, etc.).

Unfortunately, my only recommendation for this would be for the patient to determine the position that they feel most comfortable in. Each individual may have different preferences and comfort levels when it comes to sleeping after surgery. It is important to listen to your body and find a position that minimizes discomfort and supports the healing process.

The tear in your shoulder occurs due to the compression of the shoulder tendons or the abrasive effect of friction and/or inflammatory tissues over time. When a tear occurs, you may experience weakness in shoulder movements, such as dropping objects (e.g., a glass), and especially nighttime pain (inability to sleep on the shoulder and being awakened when changing positions). These are common symptoms associated with a shoulder tear.

rom the first day after surgery, you can comfortably eat your meals with the shoulder sling on.

Considering that you will be using a shoulder sling for approximately 6 weeks and then undergoing about 6 weeks of physical therapy, it is advised not to return to your routine daily tasks until 3-4 months have passed. However, you can still comfortably perform your own light tasks that are not too strenuous (without actively lifting your shoulder)

A tear in the shoulder occurs due to the compression of the shoulder tendons or the friction and abrasive effect of inflamed tissues over time. When a tear occurs, you may experience weakness in shoulder movements, such as dropping objects (e.g., a glass), and especially nighttime pain (difficulty sleeping on the affected shoulder and waking up when changing positions), among other symptoms.

Unless instructed otherwise by your doctor, the shoulder sling will typically stay in place for an average of 6 weeks (1.5 months) following rotator cuff repair. The sling should not be removed for approximately 6 weeks unless your doctor advises otherwise. This period is a standard accepted time frame for the repaired tissue to heal to the bone.

The shoulder-arm sling is often cited as a discomfort by patients. However, this sling helps the anchoring (screw) we use to secure the repaired tendon to the bone during the healing process and also aids in preventing the development of permanent stiffness in the shoulder to some extent. Therefore, unless instructed otherwise by your doctor, the sling should not be removed for approximately 6 weeks.

You will be put under general anesthesia. Your surgery will be performed in a seated position called the beach chair position. After you enter the operating room, the surgery may start approximately 1-1.5 hours later due to the anesthesia and positioning requirements.

After the surgery, ice application for a duration of two days will be started immediately, along with the administration of pain medication. Following a closed or arthroscopic repair, the majority of our patients (unless there is a medical obstacle) can be sent home in the evening of the same day, walking with a shoulder-arm sling. Your wounds will be dressed every other day, or every two days. Generally, stitches will be removed around the 9th-10th day. Subsequently, the post-operative rehabilitation program will be initiated in accordance with your doctor’s recommendations starting around the 4th-5th week. The timeline mentioned above is a standard one and can be modified by your doctor.

The small screws, called anchors, that are placed inside are micro-sized and take up very little space in the bone. These screws serve the purpose of reattaching the torn tendon to its original position on the bone. Due to their small size and remaining within the healed tendon, there is no harm in leaving them in the body. In some cases, absorbable anchors that can dissolve within 6-9 months may be used, depending on the surgeon’s decision.

The topic of re-tear is still controversial. There is a chance of re-tear, especially in individuals of advanced age, with low tissue quality, and those who have accompanying conditions such as diabetes or rheumatism. Smokers and individuals who have experienced a significant shoulder trauma are also at risk of re-tear. It is important to emphasize that smoking, or tobacco use, not only delays the healing of the tear but has also been proven to be a contributing factor in the recurrence of the tear.

 

If you have a tear that is accompanied by symptoms and has been visualized on an MRI, the torn tendon cannot heal on its own. In the future, the tear is highly likely to enlarge. Additionally, scientific studies have shown that this can lead to negative effects on other intact tissues, the continuation and exacerbation of your symptoms, increased weakness, and even calcification in the shoulder joint.

Another point I want to emphasize is that tears that occur especially after trauma (such as falling or sudden movements) tend to rapidly expand within 4-6 months.”

The postoperative physical therapy process is essential for the continuation of your treatment. In other words, the success of your surgery significantly decreases if physical therapy is not performed or cannot be performed. Physical therapy, or postoperative rehabilitation, is applied based on the principles of regaining range of motion and strengthening the shoulder. The stages of rehabilitation follow each other. The patient’s compliance and contribution to rehabilitation are the most important keys to success. Strength training begins after 3 months. Lifting weights and participating in contact sports (such as football or basketball) are strictly prohibited before the 6th month. In conclusion, the rehabilitation program recommended by your doctor plays a key role in the success of your treatment.

In general, most patients experience noticeable improvement in pain and daily activities. In other words, approximately 90% of our patients report significant benefits and satisfaction when asked about their progress one year after the surgery. The restoration of the shoulder’s strength depends on the quality of the tendon, complete healing of the tendon, and the completion of the physical therapy process if required again.

The answer to this question depends on the condition of other shoulder muscles and the age of the patient. Many elderly patients can continue their lives without pain or disability despite having a torn rotator cuff, as they may not experience any symptoms. In a study, although 40% of patients over 70 years old were found to have a rotator cuff tear, no symptoms were observed. However, in younger age groups, especially when the tears occur due to sudden injury, surgical treatment is recommended.

Steroid injections performed in limited numbers (3-4 injections) into the structure known as the bursa are generally safe and often effectively reduce local inflammation (non-infectious inflammatory condition) and pain. These locally administered steroids do not pose the same risks as orally administered steroids, as they are not systemically absorbed by the body. However, repeated steroid injections have been shown to negatively affect the quality of tendons, potentially leading to the need for surgery later on.