Scott Davenport Daniel Woodward Amy Monroe Reverse Total Shoulder Replacement The Surgery The Rehab Protocol A Clinical Case
Aug 07, 2015
Scott Davenport
Daniel Woodward
Amy Monroe
Reverse Total Shoulder ReplacementThe Surgery
The Rehab ProtocolA Clinical Case
DescriptionReverse Total Shoulder Arthroplasty
Joint replacement procedure where the ball and socket articulations of the glenohumeral joint are reversed
Received FDA approval for use in the US in 2004
DescriptionProsthesis design alters the
center of rotation by moving it medially and inferiorly
This increases the deltoid moment arm and deltoid tension
Enhanced mechanical advantage of deltoid compensates for the deficient rotator cuff
Deltoid becomes the primary elevator of the shoulder joint
1. Achieve functional range of motion while allowing for adequate soft tissue healing
2. Maximize use of upper extremity for daily activities at or above shoulder height
3. Educate patient to safely manage their rehabilitation and use of their arm throughout post-operative rehabilitation
Goal of Procedure
Glenohumeral joints with severe arthropathy and severe rotator cuff deficiency or a joint in which a previous TSA has failed (also with cuff deficiency)
Joint must be structurally and anatomically suited to receive deviceCementless metaglene component
Functional Deltoid
Indications for RTSA
Any active infections be it local or systemicInadequate bone density to appropriately
support the new prosthesisSevere deformityMuscle, nerve, or vascular diseaseObesity, drug abuse, mental incapacity
Contraindications for RTSA
Osteoporsis or poor bone stock for acceptance of prosthesis
Metabolic disorder or systemic pharmacological treatments leading to progressive deterioration of bone support for the implante.g. DM, steroid therapies, immunosuppressive
therapies, etc.Hx of general or local infectionsDeformities leading to impaired
fixation/positioning of implant
Precautions
Tumors of the supporting bone structuresAllergic reactions to implant materials
e.g. bone cement, metal, polyethyleneTissue reactions to implant corrosion or
debris due to wearDisabilities of other joints
Precautions (cont.)
Any change in position of prosthesisAny infection, looseningTemporary inferior subluxation which will
usually diminish as muscle tone is regainedCardiovascular disorder
e.g. thrombosis, pulmonary embolism, MI Hematoma and/or delayed healingPneumoniaSubluxation/dislocation of replaced joint
Adverse effects
Prosthetic ComponentsHumeral Components:1. Epiphysis: Upper part of the prosthetic humeral stem
2. Diaphysis: Lower portion of the humeral stem
3. Polyethylene Cup: Becomes the socket of the new ball & socket joint
Glenoid Components:1. Metaglene: Specially coated metal plate that is attached to the glenoid fossa with screws
2. Glenosphere: Half globe metal piece that is attached to the metaglene
The Surgical Approach1,3,6,8
Delto-pectoralIncision begins inferior to the clavicle & extends 1 cm lateral to the coracoid tip
Advantages:a) More traditional & very familiar to most
surgeons
b) Allows clear view of the glenoid & therefore facilitates accurate implantation of the glenoid components of the prosthesis
c) Minimizes surgical trauma to the anterior deltoid
d) Easier identification of the axillary nerve
e) Good for revision surgery
Disadvantages:f) Subscapularis is incised & repaired (if
possible) following implantationa) Some have reported higher rates of
dislocation
The Surgical Approach6,8
Superior lateral Incision begins at the level of
the AC joint & extends 4cm inferiorly
Advantages:a) Subscapularis muscle is not
inciseda) Lower rates of dislocation
Disadvantages:b) Limited visualization leading
to less ideal component positioning
c) Decreased external rotation postoperatively (compared with the deltopectoral approach)
d) Deltoid muscle is disrupted
The Surgical Approach5
Anterosuperior Anterior deltoid is divided from the
anterior edge of the acromioclavicular arch, allowing exposure to the glenoid for glenosphere implantation
Advantages:a) Ease of axial humerus preparationb) Quality of exposure of the glenoidc) Increased post-op stability as
compared with the deltopectoral approach
Disadvantages:d) Disrupts the deltoid musclee) Risk of inaccurate glenoid
positioningf) Axillary nerve palsy
The Surgical Approach4
Latissimus Dorsi (LD) Tendon Transfer
For cases where the Teres Minor is deficient
LD tendon is transferred to the top & back of the humeral head
LD is well suited for transfer due to:
a. Large surface areab. Good strengthc. Good vascularity
LD: Humeral extensor → Humeral stabilizer with an external rotation moment
If subscapularis function is deficient, the procedure is of questionable benefit & probably should not be used
The Surgical Procedure at a Glance
The Approach Resection of humeral head
Diaphyseal Preparation
Preparation of the Glenoid
Insertion of Metaglene
Glenosphere Placement
Insertion of Humeral Implant
“Reverse Total Shoulder Arthroplasty – from the Most to the Least Common Complication”The most frequent complication is Scapular
NotchingErosion of the scapular neck related to
impingement by the medial rim of the humeral cup during ADD
Pre-Op findings associated w/ Scapular NotchingRTC ArthropathyFatty Infiltration of InfraspinatusNarrowed Acromiohumeral DistanceSuperiorly Oriented Glenoid
Surgical Complications2
Scapular Notching
Surgical Complications2,7
AnesthesiaInfectionFractureDislocation/
InstabilityLooseningNerve or Blood
Vessel InjuryHematomaPoor Screw
Placement
Precautions
NO extension past neutral x6 weekso At 6 weeks progress 10° per week into extension with arm at 15-30° abduction
NO combined humeral IR and extension x12 weekso Tucking in shirt or bathroom personal hygiene with operative arm are specifically
dangerous activities NO horizontal Adduction past neutral x6 weeks
o At 6 weeks progress 10° per week into with AROM. No overpressure Avoid “cocking position” or “throwing position” of 90° abduction with end
range ER If subscapular repair then ER will be limited x6 weeks with specifics from
surgeon Post-operative brace/sling with abduction pillow should be worn at all times
x4 weeks and then progressive weaning from device based on patient tolerance.
Post-operative Rehab Protocol
Goals of Rehabilitation
Focus should be on:o Full ROM in scaption progressing then to flexion and
abductiono Shoulder stabilityo AAROM in scaption, flexion, and abduction progressing to
AROM as patient tolerateso Scapular neuromuscular control and stabilityo Realize that ER will be and is expected to be very weak. Do
not overload this tissue as likely the only remaining external rotator is teres minor.
Post-operative Rehab Protocol
Acute Care Therapy (Days 1-4)
Begin PROM supine and in scapular plane to 90° keeping elbow bent ER in available range with arm in 30° abduction and forward flexion
(30-30 position)o Typically 20-30°
Gripping and hand dexterity Wrist and Elbow AROM 4-5x daily 3 point pendulums/Codman’s (front-back-horizontal abduction)
PROM and AROM Neck ROM and stretching to trapezius and levator scapulae Brace/sling education and management OT evaluation for dressing may be indicated at this time
Post-operative Rehab Protocol
Outpatient Therapy Phase I (Day 10-21)
PROM in scaption, flexion and abd to 120°. No overpressure at end range. o Limit ER to 45° and perform at 30-30 position
AAROM pulleys with focus on scapular plane but also flexion and abductiono AAROM using non operative hand
Deltoid and shoulder isometrics – submaximalo Recommend use of theraband with patient positioned in desired plane and moving
away from anchor point of theraband. Gentle resisted exercise of elbow, wrist and hand AROM in scapular plane working from gravity reduced position to full
gravity/AROMo Continue AROM 3 point pendulumso Consider ball on mat table pendulums
Scapular AROM – scapular clocks UE weight bearing stability exercises (limit weight bearing to 25%)
o Examples include mat UE walking in flexion/scaption, “window washing”, etc.
Post-operative Rehab Protocol
Phase II (3 – 6 weeks)
Continue above where deficits persist PROM working to 150° scaption, flexion and abduction
o Continue to limit ER to 45° and perform at 30-30 position AROM working to decrease substitution patterns UBE/Arm bike – ensuring no extension past neutral and providing pt has
motion to allow. Keep rotation neutral Isometric push downs progressing to light resistance
o Goal is to initiate scapular depression and scapular stability Shoulder stability exercises progressed to include
o Alternating isometrics (sub max)o Ball on wall cross and circleso Ball on wall stability with therapist perturbations
Progress scapular stability to include rows (NO humeral extension)
Y-T scapular exercises on Swiss ball. NO “W” (YTW). NO resistance
Post-operative Rehab Protocol
Criteria for progression to phase III
AROM above 90° in scaption, flexion and abduction Activation of all components of the deltoid as well as
scapular musculature with stability exercises (with arm in scapular plane)
No increased pain with PROM, AAROM, or shoulder/scapular stability exercises
Post-operative Rehab Protocol
Phase III (6-12 weeks)
Full PROM in scaption, 160-170° Flexion, 150° abduction Begin ER with arm in slight flexion and 60° abduction Begin ER with arm in slight flexion and 90° abduction (limit 45° ER) AROM in scaption, flexion and abduction progressing as tolerated by patient Continue with shoulder and scapular stability progressing as tolerated Shoulder strengthening to include:
o Push downso Theraband scaption (full can) , flexion, abduction, IR o Extension to allowable ROM (see precautions)o ER strengthening with care not to overload teres minor
Scapular strengthening to include:o Gradual addition of light weight with rows into allowable extensiono Y-T-W on Swiss ball using care in “W” position to avoid excessive ER
UBE/Arm bike with resistance increasing as patient tolerates Serratus, latissimus dorsi, and gentle pectoral strengthening
o Press up with a pluso Serratus puncho Pull downs (begin with theraband and progress to cable column)
Post-operative Rehab Protocol
66 y.o. male, R rTSA on 10/3/14Post-op days 1-3, seen as inpatient
PROM shoulder flexion & scaption to 90°PROM shoulder ER to 15° at 0° ADD & 30/30Shoulder IR full to stomach
Closed reduction on 10/15/14Dislocation likely occurred while sleeping
Return to outpatient clinic on 10/29/14PROM shoulder flexion 136°PROM shoulder ER to neutralPROM shoulder ABD 102°Shoulder IR to stomach w/ slight forward flexion
Clinical Case
7 Weeks Post-opAROM shoulder flexion (sitting) 137° PROM shoulder flexion (supine) 155° PROM shoulder ER (supine) 42° PROM shoulder ABD (supine) 115°
Weak Shoulder EROnly Teres Minor for ER
Scapular control is improving, but still has difficulty w/ scapular depression.
Use of substitution is decreasing.Shoulder musculature fatigues quicklyNo c/o pain
Clinical Case
1. Edwards TB, Williams MD, Labriola JE, Elkousy HA, Gartsman GM, O’Connor DP. Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty. J Shoulder Elbow Surg.2009;18:892–896. doi: 10.1016/j.jse.2008.12.013.
2. Farshad, Mazda, and Christian Gerber. "Reverse Total Shoulder Arthroplasty-from the Most to the Least Common Complication - Springer." Reverse Total Shoulder Arthroplasty-from the Most to the Least Common Complication - Springer. Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008 Zürich, Switzerland, 01 Dec. 2010. Web. 23 Nov. 2014. <http://dx.doi.org/10.1007%2Fs00264-010-1125-2>.
3. Frankle, Mark A. Rotator Cuff Deficiency of the Shoulder. 1st ed. New York: Thieme, 2008. Web. 21 Nov. 2014.
4. 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. doi: 10.2106/JBJS.E.00282.
5. Molé D, Wein F, Dézaly C, Valenti P, Sirveaux F. Surgical Technique: The Anterosuperior Approach for Reverse Shoulder Arthroplasty. Clinical Orthopaedics and Related Research 2011;469(9):2461-2468. doi:10.1007/s11999-011-1861-7.
6. Nam D, Kepler CK, Neviaser AS, Jones KJ, Wright TM, Craig EV, et al. Reverse total shoulder arthroplasty : c0 urrent concepts, results, and component wear analysis. J Bone Joint Surg Am 2010;92 Suppl 2:23-35.
7. "Reverse Shoulder Arthroplasty." Houston Methodist Orthopedics & Sports Medicine. Houston Methodist Orthopedics & Sports Medicine, n.d. Web. 23 Nov. 2014. <http://www.methodistorthopedics.com/reverse-shoulder-arthroplasty>.
8. Walch G, Wall B, Mottier F. Complications and revision of the reverse prothesis: a multicenter study of 457 cases. In: Boileau P, editor. Reverse shoulder arthroplasty. Nice: Sauramps; 2006. p. 335-52
9. Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2011;20:146–157
References