Bilateral Reverse Total Shoulder Arthroplasty for 2 Different Etiologies
A 76-year-old female patient presents with a 3-year history of progressive bilateral shoulder pain, right greater than left. Non-operative management is no longer an option. Will bilateral reverse total shoulder arthroplasty offer pain relief and return to function in both shoulders?
Daniel E. Davis, MD, MS
Reverse total shoulder arthroplasty (RTSA) was originally designed for the treatment of end-stage rotator cuff arthropathy. Prior to its development, the best option for patients with this disease was a hemiarthroplasty, which helped with pain relief but was not as reliable for restoring shoulder function.
The rate of shoulder arthroplasty overall has increased steadily since approval of the RTSA implant by the US Food and Drug Administration (FDA) in 2004.  Indications for RTSA have rapidly expanded, with the procedure considered to be a viable treatment option for: 
- Irreparable rotator cuff tears
- Revision shoulder arthroplasty
- Acute and chronic proximal humerus fractures
- Malunited proximal humerus fractures
- Chronic shoulder instability
- Salvage procedures about the shoulder
Reverse total shoulder arthroplasty has been shown to reliably improve functional outcomes and relieve pain in the appropriately indicated situations. Certain functional outcomes, such as forward elevation and internal rotation behind the back, have been identified as limitations of RTSA. The limitation of internal rotation is a potential downside for patients who may require bilateral RTSA. However, reasonable outcomes have been described. 
This article reviews the case of a patient who underwent bilateral RSA for different diagnoses in each shoulder in close temporal sequence.
A 76-year-old female patient presents with a 3-year history of progressive bilateral shoulder pain, right greater than left. She has received multiple cortisone injections that provided some relief for the left shoulder but not for the right.
She has no history of right shoulder trauma but says she sustained a proximal humerus fracture on the left shoulder 5 years prior. The fracture was treated non-operatively. She also has a known chronic rotator cuff tear on the right shoulder.
- Height: 5 feet, 1 inch; weight: 115 pounds; BMI: 22
- No ecchymosis or swelling of either shoulder
- No tenderness over the acromioclavicular joints bilaterally; pain anteriorly along the joint line, right greater than left
- Range of motion: In both shoulders, active and passive forward elevation to 120°, external rotation to neutral, and internal rotation to the sacrum; significant crepitus and pain with range of motion in the right shoulder, less crepitus and less pain due to a recent cortisone injection in the left shoulder
- Strength and special testing: Positive Jobe’s test of both shoulders, with significant pain and 3/5 strength; external rotation strength 3/5 bilaterally, pain related; positive abdominal compression test on right for pain and weakness, on left for pain
Imaging: Plain Radiographs
Right Shoulder: Grashey View
- Complete loss of the glenohumeral joint space with subchondral collapse of the humeral head
- Superior humeral migration with narrowing of the acromiohumeral interval and acetabularization of the acromion
- Moderate inferior humeral osteophyte and inferior glenoid osteophyte (Figure 1)
Right Shoulder: Axillary Lateral View
- Complete loss of glenohumeral joint space without subluxation or wear of the anterior or posterior glenoid (Figure 2)
Figure 1 and 2. Anteroposterior Grashey (left) and axillary lateral (right) views of the right shoulder demonstrate advanced rotator cuff arthropathy.
Left Shoulder: Grashey View
- Complete loss of glenohumeral joint space with subchondral sclerosis of the humeral head and glenoid
- Slight superior migration of the humeral head
- Approximately 30° varus malunion of the humeral head (Figure 3)
Left Shoulder: Axillary Lateral View
- Loss of glenohumeral joint space
- Approximately 20° retroversion malunion of the humerus, with the head well centered on the glenoid
- No significant glenoid bone loss (Figure 4)
Figure 3 and 4. Anteroposterior Grashey (left) and axillary lateral (right) views of the left shoulder demonstrate advance post-traumatic arthritis with varus and retroverted malunion.
- Right shoulder rotator cuff arthropathy with end-stage glenohumeral changes
- Left shoulder post-traumatic arthritis with varus malunion
The patient’s symptoms were progressing in the right and left shoulders. At initial presentation, the patient was experiencing less pain in her left shoulder than in her right due to cortisone injections in the left shoulder. However, that lasted only 3 weeks.
A discussion was then initiated about surgical management of both shoulders with RTSA, as the patient had exhausted non-operative management. This discussion included the risks and benefits of the surgical procedure, as well as 2 factors important to bilateral shoulder replacement:
- Timing. We discussed spacing the operations by a minimum of 3 months to allow full recovery of the first operation before undergoing the second.
- Range of motion. We discussed the potential loss of internal range of motion on both shoulders, making it challenging for self-care after toileting.
Understanding these possible limitations, the patient wished to move forward with RTSA of the right shoulder first.
- The patient was positioned in a beach chair positioner, sitting upright at approximately 60°.
- A standard deltopectoral approach was performed, taking the cephalic vein laterally with the deltoid. The biceps tendon was tenodesed to the pectoralis major tendon.
- The subscapularis, which was intact but attenuated, was peeled from the lesser tuberosity.
- The humeral head was osteotomized at 135° inclination and 20° retroversion with an extra-medullary cutting guide. The superior rotator cuff was found to be chronically torn.
- The glenoid was then exposed while identifying and protecting the axillary nerve. The biceps stump and labrum were circumferentially removed.
- A guide pin was placed with a guide at 10° of inferior tilt.
- A uniblock screw-in baseplate was secured with 4 peripheral locking screws. A 32-mm glenosphere with 6 mm of lateralization was secured to the baseplate.
- The humerus was then delivered from the wound and the canal was prepped. The metaphysis was reamed to accept a monoblock metaphyseal-fitting stem, which was implanted with press-fit fixation.
- After trialing of a standard-size polyethylene, the final polyethylene was impacted onto the stem.
- The incision was closed in a standard fashion and the patient was placed in an abduction sling.
This process was repeated 3 months later for the left shoulder. The main difference was the larger amount of proximal humerus that was resected due to malunion. Thus, a larger polyethylene insert was used on the humeral component to gain better stability of the implant.
For both operations, the patient was seen at 2 weeks postoperatively for wound evaluation and advancement of activity. In each case, the abduction brace was discontinued at this visit and the patient was advanced to passive and active assisted range of motion with limits to 140° in forward elevation and 40° of external rotation. She was instructed not to attempt internal rotation behind the back or pushing up from a seated position for 6 weeks postoperatively.
At the 6-week follow-up visit, the patient rated her right shoulder at 80% of a normal shoulder. She had forward elevation of 120° and external rotation of 30°. She was very happy with her progress but wished to work on advancing her range of motion and strengthening during outpatient physical therapy.
At the 3-month follow-up visit, the patient’s right shoulder was pain free and she had forward elevation to 140°, external rotation to 40°, and internal rotation to the mid-lumbar spine. She had 4/5 strength with resisted external rotation and Jobe’s test.
The left shoulder continued to deteriorate, and she agreed to move forward with replacement on that side.
By 6 months after right shoulder surgery, she had forward elevation to 140° and external rotation to 40° with no right shoulder pain. She had internal rotation to the mid-lumbar spine.
At 6 weeks after surgery, the patient’s progress with her left shoulder was less advanced than it had been with her right shoulder: Forward elevation was 90°, with mild pain. She started outpatient physical therapy after the 6-week follow-up visit.
By 3 months postoperatively, the patient reported no shoulder pain, with forward elevation to 140° and external rotation to 40°. She had internal rotation to the mid-lumbar spine.
At the 1-year follow-up visit for both shoulders, the patient had maintained the same range of motion and pain relief and rated each shoulder at 100%. Radiographs showed that both components were in position, with good bony integration and no scapular notching (Figures 5-8).
Figures 5–8. Anteroposterior Grashey and axillary lateral views of the right (top) and left (bottom) shoulders demonstrate well-positioned implants at the 1-year follow-up visit. Note the slightly increased joint space in the left shoulder: A larger polyethylene was used after slightly more bone was resected due to malunion.
Reverse total shoulder arthroplasty has contributed to the increase in the number of shoulder arthroplasties performed in the US since approval of the RTSA implant by the FDA.  It has proven to be a reliable method of managing not only rotator cuff arthropathy, but also other shoulder pathologies – including bilateral shoulder disease – that were challenging to treat with established procedures. 
Bilateral RTSA is not a unique concept and has been reported in multiple studies. Levy et al  described a group of 19 patients who had undergone bilateral RTSA and who had excellent functional outcomes at an average 18-month follow-up. In addition, all patients regained the ability to perform perineal care. 
Similar results were found by Mellano et al,  who reported on 50 bilateral RTSA patients with an average 61-month follow-up. Again, pain and functional outcomes were significantly improved, with few patient reporting difficulties with perineal care. The complication profile was similar to that of unilateral RTSA at 5%. 
Berglund et al  compared the difference between the first and second operated shoulders after staged bilateral RTSA. They found that the second shoulder had slightly worse functional capabilities preoperatively than the first shoulder. However, both shoulders improved at an expected rate postoperatively,  the reason likely being that the second shoulder bears a heavier burden while the first recovers.
The present case report describes a patient who presented with significant bilateral shoulder pain caused by 2 different etiologies. She underwent bilateral RTSA and experienced very good results at 1 year for both shoulders. Although this is not a unique case, it suggests several valid learning points:
- It is important to note the time needed between procedures. A gap of 3 months is usually the minimum amount of time for the first shoulder to recover enough to proceed with the second shoulder.
- This case is interesting in that the pathology of each shoulder was different and thus required a slightly different surgical technique and implant to achieve optimum outcomes. The difference likely contributed to the slower recovery of the right shoulder compared with the left. Understanding this can be helpful in counseling patients with similar shoulder issues.
- Although it is usually not a problem (and was not in this case), counsel patients on the possibility of not being able to perform proper perineal care after bilateral shoulder arthroplasty.
Understanding these variables, the surgeon should be able to appropriately counsel and guide patients to recovery after undergoing bilateral RTSA. Patients should be expected to have significant improvements in pain and function and, thus, quality of life.
Daniel E. Davis, MD, MS, is an orthopaedic surgeon with The Rothman Institute, Philadelphia, Pennsylvania. He specializes in the treatment of shoulder and elbow conditions.
Shoulder and Elbow Editor, Rothman Institute Grand Rounds
Disclosures: Dr. Davis has no disclosures relevant to this article.
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