Clinical Orthopaedics and Related Research®

, Volume 469, Issue 9, pp 2440–2451 | Cite as

How Reverse Shoulder Arthroplasty Works

  • Matthew Walker
  • Jordan Brooks
  • Matthew Willis
  • Mark Frankle
Symposium: Reverse Total Shoulder Arthroplasty



The reverse total shoulder arthroplasty was introduced to treat the rotator cuff-deficient shoulder. Since its introduction, an improved understanding of the biomechanics of rotator cuff deficiency and reverse shoulder arthroplasty has facilitated the development of modern reverse arthroplasty designs.


We review (1) the basic biomechanical challenges associated with the rotator cuff-deficient shoulder; (2) the biomechanical rationale for newer reverse shoulder arthroplasty designs; (3) the current scientific evidence related to the function and performance of reverse shoulder arthroplasty; and (4) specific technical aspects of reverse shoulder arthroplasty.


A PubMed search of the English language literature was conducted using the key words reverse shoulder arthroplasty, rotator cuff arthropathy, and biomechanics of reverse shoulder arthroplasty. Articles were excluded if the content fell outside of the biomechanics of these topics, leaving the 66 articles included in this review.


Various implant design factors as well as various surgical implantation techniques affect stability of reverse shoulder arthroplasty and patient function. To understand the implications of individual design factors, one must understand the function of the normal and the cuff-deficient shoulder and coalesce this understanding with the pathology presented by each patient to choose the proper surgical technique for reconstruction.


Several basic science and clinical studies improve our understanding of various design factors in reverse shoulder arthroplasty. However, much work remains to further elucidate the performance of newer designs and to evaluate patient outcomes using validated instruments such as the American Society for Elbow Surgery, simple shoulder test, and the Constant-Murley scores.


Rotator Cuff Shoulder Arthroplasty Reverse Shoulder Arthroplasty Glenoid Component Reverse Total Shoulder Arthroplasty 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Anglin C, Wyss UP, Pichore DR. Shoulder prosthesis subluxation: theory and experiment. J Shoulder Elbow Surg. 2000;9:104–114.PubMedCrossRefGoogle Scholar
  2. 2.
    Bayley J, Kessel L. The Kessel total shoulder replacement. In: Bayley I, Kessel L, eds. Shoulder Surgery. New York: Springer-Verlag; 1982:160–164.Google Scholar
  3. 3.
    Bobyn JD, Toh K-K, Hacking SA, Tanzer M, Krygier JJ. Tissue response to porous tantalum acetabular cups: a canine model. J Arthroplasty. 1999;14:347–354.PubMedCrossRefGoogle Scholar
  4. 4.
    Boileau P, Chuinard C, Roussanne Y, Bicknell RT, Rochet N, Trojani C. Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm. Clin Orthop Relat Res. 2008;466:584–593.PubMedCrossRefGoogle Scholar
  5. 5.
    Boileau P, Chuinard C, Roussanne Y, Neyton L, Trojani C. Modified latissimus dorsi and teres major transfer through a single delto-pectoral approach for external rotation deficit of the shoulder: as an isolated procedure or with a reverse arthroplasty. J Shoulder Elbow Surg. 2007;16:671–682.PubMedCrossRefGoogle Scholar
  6. 6.
    Boileau P, Watkinson DJ, Hatzidakis A, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg. 2005;14(Suppl S):147S–161S.PubMedCrossRefGoogle Scholar
  7. 7.
    Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. Near Award 2005: The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006;15:527–540.PubMedCrossRefGoogle Scholar
  8. 8.
    Boulahia A, Edwards TB, Walch G, Baratta RV. Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear. Orthopedics. 2002;25:129–133.PubMedGoogle Scholar
  9. 9.
    Chacon A, Virani N, Shannon R, Levy JC, Pupello D, Frankle M. Revision arthroplasty with use of a reverse shoulder prosthesis-allograft composite. J Bone Joint Surg Am. 2009;91:119–127.PubMedCrossRefGoogle Scholar
  10. 10.
    Chebli C, Huber P, Watling J, Bertelsen A, Bicknell RT, Matsen F 3rd. Factors affecting fixation of the glenoid component of a reverse total shoulder prosthesis. J Shoulder Elbow Surg. 2008;17:323–327.PubMedCrossRefGoogle Scholar
  11. 11.
    Chou J, Malak SF, Anderson IA, Astley T, Poon PC. Biomechanical evaluation of different designs of glenospheres in the SMR reverse total shoulder prosthesis: range of motion and risk of scapular notching. J Shoulder Elbow Surg. 2009;18:354–359.PubMedCrossRefGoogle Scholar
  12. 12.
    Cofield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg Am. 1984;66:899–906.PubMedGoogle Scholar
  13. 13.
    Coventry MB, Beckenbaugh RD, Nolan DR. Ilstrup DM. 2,012 total hip arthroplasties. A study of postoperative course and early complications. J Bone Joint Surg Am. 1974;56:273–284.PubMedGoogle Scholar
  14. 14.
    Cuff D, Pupello D, Virani N, Levy J, Frankle M. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint Surg Am. 2008;90:1244–1251.PubMedCrossRefGoogle Scholar
  15. 15.
    De Wilde LF, Van Ovost E, Uyttendaele D, Verdonk R. Results of an inverted shoulder prosthesis after resection for tumor of the proximal humerus [in French]. Rev Chir Orthop Reparatrice Appar Mot. 2002;88:373–378.PubMedGoogle Scholar
  16. 16.
    Dorr LD, Wan Z. Causes of and treatment protocol for instability of total hip replacement. Clin Orthop Relat Res. 1998;355:144–151.PubMedCrossRefGoogle Scholar
  17. 17.
    Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am Acad Orthop Surg. 2007;15:340–349.PubMedGoogle Scholar
  18. 18.
    Favard L, Lautmann S, Sirveaux F, Oudet D, Kerjean Y, Huguet D. Hemi-arthroplasty versus reverse arthroplasty in treatment of osteoarthritis with massive rotator cuff tear. In: Walch GBP, Mole D, eds. 2000 Prostheses…2 to 10 Year Follow-up. Paris, France: Sauramps Medical; 2001:261–268.Google Scholar
  19. 19.
    Favre P, Loeb MD, Helmy N, Gerber C. Latissimus dorsi transfer to restore external rotation with reverse shoulder arthroplasty: a biomechanical study. J Shoulder Elbow Surg. 2008;17:650–658.PubMedCrossRefGoogle Scholar
  20. 20.
    Field LD, Dines DM, Zabinski SJ, Warren RF. Hemiarthroplasty of the shoulder for rotator cuff arthropathy. J Shoulder Elbow Surg. 1997;6:18–23.PubMedCrossRefGoogle Scholar
  21. 21.
    Frankle M. Rationale and biomechanics of the reverse shoulder prosthesis: the American experience. In: Frankle M, ed. Rotator Cuff Deficiency of the Shoulder. New York: Thieme; 2008:76–104.Google Scholar
  22. 22.
    Frankle M, Levy JC, Pupello D, Siegal S, Saleem A, Mighell M, Vasey M. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients surgical technique. J Bone Joint Surg Am. 2006;88(Suppl 1):178–190.PubMedCrossRefGoogle Scholar
  23. 23.
    Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am. 2005;87:1697–1705.PubMedCrossRefGoogle Scholar
  24. 24.
    Frankle MA, Siegal S, Pupello DR, Gutierrez S, Griewe M, Mighell M. Coronal plane tilt angle affects risk of catastrophic failure in patients treated with a reverse shoulder prosthesis. J Shoulder Elbow Surg. 2007;16:e46.CrossRefGoogle Scholar
  25. 25.
    Frankle MA, Teramoto A, Luo Z-P, Levy JC, Pupello D. Glenoid morphology in reverse shoulder arthroplasty: classification and surgical implications. J Shoulder Elbow Surg. 2009;18:874–885.PubMedCrossRefGoogle Scholar
  26. 26.
    Gagey O, Hue E. Mechanics of the deltoid muscle. A new approach. Clin Orthop Relat Res. 2000;375:250–257.PubMedCrossRefGoogle Scholar
  27. 27.
    Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg Am. 2006;88:113–120.PubMedCrossRefGoogle Scholar
  28. 28.
    Gerber C, Pennington SD, Lingenfelter EJ, Sukthankar A. Reverse Delta-III total shoulder replacement combined with latissimus dorsi transfer. A preliminary report. J Bone Joint Surg Am. 2007;89:940–947.PubMedCrossRefGoogle Scholar
  29. 29.
    Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993;16:65–68.PubMedGoogle Scholar
  30. 30.
    Gutiérrez S, Comiskey CA, Luo Z-P, Pupello DR, Frankle MA. Range of impingement-free abduction and adduction deficit after reverse shoulder arthroplasty. Hierarchy of surgical and implant-design-related factors. J Bone Joint Surg Am. 2008;90:2606–2615.PubMedCrossRefGoogle Scholar
  31. 31.
    Gutiérrez S, Greiwe RM, Frankle MA, Siegal S, Lee WE 3rd. Biomechanical comparison of component position and hardware failure in the reverse shoulder prosthesis. J Shoulder Elbow Surg. 2007;16:S9–S12.PubMedCrossRefGoogle Scholar
  32. 32.
    Gutiérrez S, Keller TS, Levy JC, Lee WE 3rd, Luo Z-P. Hierarchy of stability factors in reverse shoulder arthroplasty. Clin Orthop Relat Res. 2008;466:670–676.PubMedCrossRefGoogle Scholar
  33. 33.
    Gutiérrez S, Levy JC, Lee WE 3rd, Keller TS, Maitland ME. Center of rotation affects abduction range of motion of reverse shoulder arthroplasty. Clin Orthop Relat Res. 2007;458:78–82.PubMedGoogle Scholar
  34. 34.
    Gutiérrez S, Luo Z-P, Levy J, Frankle MA. Arc of motion and socket depth in reverse shoulder implants. Clin Biomech. 2009;24:473–479.CrossRefGoogle Scholar
  35. 35.
    Effects of tilt and glenosphere eccentricity on baseplate/bone interface forces in a computational model, validated by a mechanical model, of reverse shoulder arthroplasty journal of shoulder and elbow surgery. J Shoulder Elbow Surg. 2011 Jan 31 [Epub ahead of print].Google Scholar
  36. 36.
    Harman M, Frankle M, Vasey M, Banks S. Initial glenoid component fixation in ‘reverse’ total shoulder arthroplasty: a biomechanical evaluation. J Shoulder Elbow Surg. 2005;14:162S–167S.PubMedCrossRefGoogle Scholar
  37. 37.
    Harris TE, Jobe CM, Dai QC. Fixation of proximal humeral prostheses and rotational micromotion. J Shoulder Elbow Surg. 2000;9:205–210.PubMedCrossRefGoogle Scholar
  38. 38.
    Hopkins AR, Hansen UN, Bull AMJ, Emery R, Amis AA. Fixation of the reversed shoulder prosthesis. J Shoulder Elbow Surg. 2008;17:974–980.PubMedCrossRefGoogle Scholar
  39. 39.
    Humphrey CS, Kelly JD 2nd, Norris TR. Optimizing glenosphere position and fixation in reverse shoulder arthroplasty, Part Two: the three-column concept. J Shoulder Elbow Surg. 2008;17:595–601.PubMedCrossRefGoogle Scholar
  40. 40.
    Jasty M, Bragdon C, Burke D, O’Connor D, Lowenstein J, Harris WH. In vivo skeletal responses to porous-surfaced implants subjected to small induced motions. J Bone Joint Surg Am. 1997;79:707–714.PubMedGoogle Scholar
  41. 41.
    Karduna AR, Williams GR, Williams JL, Iannotti JP. Glenohumeral joint translations before and after total shoulder arthroplasty. A study in cadavera. J Bone Joint Surg Am. 1997;79:1166–1174.PubMedGoogle Scholar
  42. 42.
    Lévigne C, Boileau P, Favard L, Garaud P, Molé D, Siveaux F, Walch G. Scapular notching in reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2008:17:925–935.PubMedCrossRefGoogle Scholar
  43. 43.
    Levy J, Frankle M, Mighell M, Pupello D. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture. J Bone Joint Surg Am. 2007;89:292–300.PubMedCrossRefGoogle Scholar
  44. 44.
    Levy JC, Virani N, Pupello D, Frankle M. Use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty in patients with glenohumeral arthritis and rotator cuff deficiency. J Bone Joint Surg Br. 2007:89:189–195.PubMedCrossRefGoogle Scholar
  45. 45.
    Lippitt SB, Vanderhooft JE, Harris SL, Sidles JA, Harryman DT II, Matsen FA III. Glenohumeral stability from concavity-compression: a quantitative analysis. J Shoulder Elbow Surg. 1993;2:27–35.CrossRefGoogle Scholar
  46. 46.
    Long BW, Rafert JA. Orthopaedic Radiography. Philadelphia: WB Saunders; 1995:189–199.Google Scholar
  47. 47.
    Malik A, Maheshwari A, Dorr LD. Impingement with total hip replacement. J Bone Joint Surg Am. 2007;89:1832–1842.PubMedCrossRefGoogle Scholar
  48. 48.
    Matsen F, Lippitt S. Principles of glenohumeral stability. In: Matsen F, Lippitt S, DeBartolo S, eds. Shoulder Surgery: Principles and Procedures. Philadelphia: WB Saunders; 2004:83.Google Scholar
  49. 49.
    Matsen F, Lippitt S. Principles of glenoid concavity. In: Matsen F, Lippitt S, DeBartolo S, eds. Shoulder Surgery: Principles and Procedures. Philadelphia: WB Saunders; 2004:89.Google Scholar
  50. 50.
    Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65:1232–1244.PubMedGoogle Scholar
  51. 51.
    Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64:319–337.PubMedGoogle Scholar
  52. 52.
    Norris TR, Kelly JDI, Humphrey CS. Management of glenoid bone defects in revision shoulder arthroplasty: a new application of the reverse total shoulder prosthesis. Tech Shoulder Elbow Surg. 2007;8:37–46.CrossRefGoogle Scholar
  53. 53.
    Nyffeler RW, Werner CML, Gerber C. Biomechanical relevance of glenoid component positioning in the reverse Delta III total shoulder prosthesis. J Shoulder Elbow Surg. 2005;14:524–528.PubMedCrossRefGoogle Scholar
  54. 54.
    Nyffeler RW, Werner CML, Simmen BR, Gerber C. Analysis of a retrieved Delta III total shoulder prosthesis. J Bone Joint Surg Br. 2004;86:1187–1191.PubMedCrossRefGoogle Scholar
  55. 55.
    Pollock RG, Deliz ED, McIlveen SJ, Flatow EL, Bigliani LU. Prosthetic replacement in rotator cuff-deficient shoulders. J Shoulder Elbow Surg. 1992;1:173–186.CrossRefGoogle Scholar
  56. 56.
    Roche C, Flurin P-H, Wright T, Crosby LA, Mauldin M, Zuckerman JD. An evaluation of the relationships between reverse shoulder design parameters and range of motion, impingement and stability. J Shoulder Elbow Surg. 2009;18:734–741.PubMedCrossRefGoogle Scholar
  57. 57.
    Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone Joint Surg Am. 2001;83:1814–1822.PubMedGoogle Scholar
  58. 58.
    Sirveaux F, Favard L, Oudet D, Huguet D, Lautman S. Grammont. Inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive and non repairable cuff rupture. In: Walch G, Mole D, eds. 2000 Shoulder Prostheses . . . Two to Ten Year Follow-up. Montpellier: Sauramps Medical; 2001:247–252.Google Scholar
  59. 59.
    Shon WY, Baldini T, Peterson MG, Wright TM, Salvati EA. Impingement in total hip arthroplasty: a study of retrieved acetabular components. J Arthroplasty. 2005;20:427–435.PubMedCrossRefGoogle Scholar
  60. 60.
    Simovitch RW, Helmy N, Zumstein MA, Gerber C. Impact of fatty infiltration of the teres minor muscle on the outcome of reverse total shoulder arthroplasty. J Bone Joint Surg Am. 2007;89:934–939.PubMedCrossRefGoogle Scholar
  61. 61.
    Simovitch RW, Zumstein MA, Lohri E, Helmy N, Gerber C. Predictors of scapular notching in patients managed with the Delta III reverse total shoulder replacement. J Bone Joint Surg Am. 2007;89:588–600.PubMedCrossRefGoogle Scholar
  62. 62.
    Visotsky JL, Basamania C, Seebauer L, Rockwood CA, Jensen KL. Cuff tear arthropathy: pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am. 2004;86(Suppl 2):35–40.PubMedGoogle Scholar
  63. 63.
    Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am 2007;89:1476–1485.PubMedCrossRefGoogle Scholar
  64. 64.
    Warner JJ. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect. 2001;50:63–71.PubMedGoogle Scholar
  65. 65.
    Werner CML, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87:1476–1486.PubMedCrossRefGoogle Scholar
  66. 66.
    Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff-deficient shoulders. J Shoulder Elbow Surg. 1996;5:362–367.PubMedCrossRefGoogle Scholar
  67. 67.
    Zuckerman JD, Scott AJ, Gallagher MA. Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg. 2000;9:169–172.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Matthew Walker
    • 1
  • Jordan Brooks
    • 2
  • Matthew Willis
    • 1
  • Mark Frankle
    • 1
  1. 1.Florida Orthopaedic InstituteTampaUSA
  2. 2.Foundation for Orthopaedic Research and EducationTampaUSA

Personalised recommendations