shoulder arthroplasty & physiotherapy

SHOULDER ARTHROPLASTY

Dr.Satyendra Nath Bhattacharyya

Asst. Professor BIMLS, Burdwan

HISTORY

Developments

The first shoulder arthroplasty is thought to have been

carried out in 1894 (Hamblen 1984) but it was in 1951

that the modern story of shoulder replacement began.

In 1951 Charles Neer developed a hemi-arthroplasty,

primarily for the reconstruction of severe proximal

humerus fractures. However, it was also used for people

suffering from osteoarthritis, with surprisingly good

results. In 1973 Neer redesigned the humeral component

and added a glenoid to make the first unconstrained

Total shoulder arthroplasty (TSR) - known as

the Neer II.

FACTORS INFLUENCING OUTCOME OF SHOULDER ARTHROPLASTY(MAINLY IN RA)

Factors affecting outcome of prosthetic shoulder reconstruction. Pathology

Rotator cuff disease

Glenoid erosion bone loss

Humeral bone loss

Bone density Surgical technique

Prosthetic placement

Prosthetic-cement-bone interface

Soft-tissue balancing Prosthetic design

Size selection

Glenoid

Humeral head

Humeral stem

Material properties Rehabilitation programme

Range of motion

Strength

Stability

PRIMARY OSTEOARTHRITIS (OA)

This is the indication for TSR from which the best results can be expected. Godeneche et al. (2002) reviewed a series of 267 operations for osteoarthritis and found that 77% of them had results which were classed as good or excellent. They found that the result was dependent on the severity of the degenerative changes that had taken place prior to surgery. It seems, therefore, that for patients who have primary osteoarthritis without gross soft-tissue damage or loss of bone, we can expect to achieve near-normal range of movement and strength. Patients who start off with rotator cuff disease or glenoid erosion should have less high expectations

RHEUMATOID ARTHRITIS (RA)

People with RA who undergo shoulder arthroplasty are

likely to have a number of the adverse pathological factors . The expected results will depend on how many and how severe they are. People with rheumatoid arthritis do not tend to be referred for replacement arthroplasty until these factors are fairly advanced, so the results are generally not as good as in osteoarthritic patients. The surgical approach and basic postoperative management are the same.

In advanced disease of either the OA or RA type it is not always possible to insert a glenoid component. If there is gross bone loss around the glenoid fossa, it is not possible to attach the implant securely enough.

Also the lack of rotator cuff function causes the humeral head to 'rock' the glenoid component, causing loosening. The problem of glenoid fixation is one of the ongoing dilemmas in shoulder arthroplasty.

COMPLEX FRACTURE

Following a complex fracture it is normally a hemiarthroplasty that is performed as the glenoid is intact. The operation can be performed either acutely as the primary treatment for the fracture or later as a secondary procedure. The results are better if it is performed acutely. This is a different operation from the

one performed as an elective procedure as there is disruption of the tuberosities to which the rotator cuff

muscles are attached. The challenge to the surgeon is to

restore the anatomy to as close to normal as possible

PROCEDURE

The most common surgical approach is known as the

'deltopectoral approach'. The incision passes between

the deltoid and pectoralis major, and access to the

shoulder joint is via the subscapularis muscle and the

anterior part of the capsule. Thus the subscapularis

muscle is the only active structure which will need to be

protected in the early postoperative period.

GETTING TO THE JOINT

The patient is first taken into the operating room and positioned on a special operating table as though lounging in a beach chair. The arm is placed on a board that will allow the surgeon to move it up or down as necessary during the surgery. Anesthesia is given and, when it has taken effect, the skin around the shoulder and upper arm is thoroughly scrubbed and sterilized with an antiseptic liquid.

An incision about six inches long is then made over the shoulder joint. The incision is gradually made deeper through muscle and other tissue until the bones of the shoulder joint are exposed.

SHOULDER JOINT EXPOSED

Replacing the Socket Portion of the Joint The implant that replaces the socket consists of a durable

plastic insert with a very smooth, cupped surface. Implant to Replace Socket in Shoulder Blade

REMOVING THE SURFACE OF THE SOCKET

The arm is maneuvered until the humeral head is dislocated from the socket.

Special precision instruments are then used to remove the damaged cartilage and bone surface from the glenoid, and to shape the socket so it will match the shape of the implant that will be inserted. Holes are then drilled into the socket to accommodate the fixation pegs on the implant. These pegs help stabilize the implant.

SOCKET PREPARED FOR IMPLANT

INSERTING THE IMPLANT

The socket implant is attached by using a special kind of cement for bones. The cement is pressed into the holes. The implant is then inserted.

GLENOID IMPLANT

REPLACING THE BALL PORTION OF THE JOINT

The implant that replaces the ball consists of a long metal stem that fits down into the humerus. A metal head in the shape of a partial sphere is mounted on top of this stem. This head contacts the socket implant in the shoulder blade.

METAL IMPLANT TO REPLACE BALL PORTION OF SHOULDER JOINT

PREPARING THE HUMERAL CANAL

The upper arm bone has relatively soft, porous bone tissue in the center. This part of the bone is called the "canal."

Special instruments are used to clear some of this soft bone from the canal.

Using a precision guide and saw, the damaged rounded portion (ball) of the humerus is removed.

HUMERAL HEAD (BALL) IS REMOVED

INSERTING THE IMPLANT

The metal stem implant may be held in place by either using the special bone cement, or by making it fit very tightly in the canal. The surgeon will choose the best method, depending on the patient's age and expected activity level.

If cement is used, it is injected into the canal first, and then the implant is inserted into the canal. If cement is not used, the implant is simply inserted into the canal.

On some implants, the stem and partial sphere are one piece. On others, they may be two separate pieces. If the partial sphere is a separate piece, it is usually secured to the top of the stem after the stem has been inserted.

STEM IMPLANT WITH PARTIAL SPHERE (HEAD)

SHOULDER IMPLANTS AFTER INSERTION

CLOSING THE WOUND

When all the implants are in place, the surgeon places the new ball that is now part of the upper arm bone into the new socket that is part of the shoulder blade. If necessary, the surgeon may adjust the ligaments that surround the shoulder to achieve the best possible shoulder function.

When the ligaments are properly adjusted, the surgeon sews the layers of tissue back into their proper position. A plastic tube may be inserted into the wound to allow liquids to drain from the site during the first few hours after surgery. After the tube is inserted, the edges of the skin are sewn together, and a sterile bandage is applied to the shoulder. Then, the patient is taken to the recovery room

BIGLIANI/FLATOW® THE COMPLETE SHOULDER SOLUTION

The Bigliani/Flatow Shoulder allows for the restoration of shoulder joint function in cases of shoulder replacement surgery. Backed by the clinical expertise of surgeons and decades of experience, the Bigliani/Flatow Shoulder System is designed to replicate the natural shoulder's mobility, balance, and stability with a multitude of component sizes.

Anatomical Shoulder™ System Traditionally, patients undergoing shoulder reconstruction

faced two postoperative tasks. First, they had to let the shoulder tissues recover, as would be expected. Then they had to adapt to anatomical changes imposed by a first- or second-generation implant that offered nothing more than an approximate fit.

But now, with the modular Anatomical Shoulder System, the shoulder implant can be tailored to each patient’s individual anatomy.

This allows a more advanced rehabilitation and an expanded radius of movement while placing fewer demands on the soft tissues and on the anchoring of the prosthesis.

The surgeon enjoys a simple operating technique that places fewer limiting factors on the success of the surgery. The design of the Anatomical Shoulder prosthesis truly sets the new standard for third-generation shoulder arthroplasty.

ANATOMICAL SHOULDER™ INVERSE/REVERSE SYSTEM FROM ANATOMICAL TO INVERSE/REVERSE

With the Anatomical Shoulder System and now with the innovative Anatomical Shoulder Inverse/Reverse system, Zimmer offers surgeons a complete Shoulder solution with the possibility to change a done hemi- and total shoulder arthroplasty with the current implanted cemented or press-fit stem into an inverse/reverse shoulder solution.

This design allows the surgeon the opportunity to revise a primary anatomical prosthesis to the inverse/reverse components, without the need for stem removal. Such revision might be necessary in the setting of irreparable rotator cuff tear. This greatly simplifies and shortens revision surgery since the need to remove a well-fixed stem is eliminated.

FEATURES OF ANATOMICAL SHOULDER INVERSE/REVERSE SYSTEM

Option to convert to inverse/reverse without stem removal

Designed for flexibility and stability by using either a  press-fit or cemented stem

Infinite variable settings of the humeral head Utilizes polyaxial locking screws, variable angulations to

a maximum of 30º in all directions

REHABILITATION PROTOCOLAFTER SHOULDER ARTHROPLASTY

Phase 1: Weeks 0 - 6 RestrictionShoulder motion Week 1 120 degrees of forward flexion 20 degrees of external rotation with the arm at the side 75 degrees of abduction with 0 degrees of rotation • Week 2 • 140 degrees of forward flexion. • 40 degrees of external rotation with the arm at the

side. • 75 degrees of abduction with 0 degrees of rotation. • No active internal rotation. • No backward extension.

Immobilization • Sling • After 7-10 days, sling used for comfort only. Pain Control • Reduction of pain and discomfort is essential for

recovery • Medications • Narcotics-for 7-10 days following surgery. • NSAIDs-for patients with persistent discomfort

following surgery. • Therapeutic modalities • Ice, ultrasound, HVGS. • Moist heat before therapy, ice at end of session.

Motion: Shoulder • Goals • 140 degrees of forward flexion. • 40 degrees of external rotation. • 75 degrees of abduction. • Exercises • Begin with Codman pendulum

exercises to promote early motion. • Passive ROM exercises (see next slide)

Forward flexion External rotation with the arm at the side

External rotation with the arm in 90 degrees of abduction Cross-body adduction

• Capsular stretching for anterior, posterior, and inferior capsule, by using the opposite arm to assist with motion

• Active-assisted motion exercises (see next slide)

• Shoulder flexion. • Shoulder extension. • Internal and external rotation. • Progress to active ROM exercises.

Exercises to regain motion. Active-assisted ROM exercises using a pulley system and a dowel stick

Motion: Elbow • Passive-progress to active • 0 to 130 degrees of flexion • Pronation and supination as

toleratedMuscle Strengthening • Grip strengthening only

Phase 2: Weeks 6-12 Criteria for Progression to Phase 2 Minimal pain and tenderness. Nearly complete motion

Intact subscapularis without evidence of tendon pain

on resisted internal rotation. Restrictions • Increase ROM goals • 160 degrees of forward flexion • 60 degrees of external rotation with the arm at the

side • 90 degrees of abduction with 40 degrees of

internal and external rotation

Immobilization None Pain Control• NSAIDs-for patients with persistent

discomfort following surgery.• Therapeutic modalities • Ice, ultrasound, HVGS. • Moist heat before therapy, ice at end of

session.

Motion: Shoulder• Goals • 160 degrees of forward flexion. • 60 degrees of external rotation with the arm at

the side. • 90 degrees of abduction with 40 degrees of

internal and external rotation.• Exercises • Increase active ROM in all directions. • Focus on passive stretching at end ranges to

maintain shoulder flexibility (see next slide). • Utilize joint mobilization techniques for capsular

restrictions,especially the posterior capsule (see 2nd next slide)

Forward flexion External rotation with the arm at the side

External rotation with the arm in 90 degrees of abduction Cross-body adduction

Stretching of the posterior capsule

Muscle Strengthening• Rotator cuff strengthening:

Only three times per week to avoid rotator cuff tendinitis, which will occur with overtraining

• Begin with closed-chain isometric strengthening (see

next slide) • External rotation. • Abduction.

Closed-chain shoulder exercises. 1. Isometric strengthening of the rotator cuff in abduction (pushing out against the wall). 2.Isometric strengthening of the rotator cuff in external rotation.

• Exercises performed with the elbow flexed to 90 degrees.

• Starting position is with the shoulder in the neutral position of 0 degrees of forward flexion, abduction, abduction,and external rotation.

• Exercises are performed through an arc of 45 degrees in each of the five planes of motion.

• Six color-coded bands are available; each provides increasing resistance from 1 to 6 pounds, at increments of one pound

• Progression to the next band occurs usually in 2to 3-week intervals. Patients are instructed not to progress to the next band if there is any discomfort at the present level.

• PROGRESS TO OPEN-CHAIN STRENGTHENING WITH THERABANDS

Open-chain isotonic strengthening of the rotator cuff (internal rotation) using Theraband tubing

• Theraband exercises permit concentric and eccentric strengthening of the shoulder muscles and are a form of isotonic exercises (characterized by variable speed and fixed resistance)

• External rotation. • Abduction. • Forward flexion.• Progress to light isotonic dumbbell exercises • External rotation (see next slide). • Abduction. • Forward flexion.

external rotation strengthening

• Scapular stabilizer strengthening • Closed-chain strengthening exercises (see

next three slides) • Scapular retraction (rhomboideus,

middle trapezius). • Scapular protraction (serratus anterior). • Scapular depression (latissimus dorsi,

trapezius,serratus anterior). • Shoulder shrugs (trapezius, levator

scapulae).

Closed-chain strengthening exercises of the scapula stabilizers. A, Scapular protraction. B and C, Scapular retraction.

Additional closed-chain scapular stabilizer strengthening. A, Start. B, Finish (the right arm is the focus of rehabilitation).

Closed-chain strengthening of the scapular stabilizers. A, Start. S, Finish.

Phase 3: Months 3 -12Criteria for Progression to Phase 3 • Full painless ROM. • Satisfactory physical examination. Goals • Improve shoulder strength, power, and

endurance. • Improve neuromuscular control and

shoulder proprioception. • Prepare for gradual return to functional

activities.

• Home maintenance exercise program

• ROM exercises two times a day

• Rotator cuff strengthening three times a week

• Scapular stabilizer strengthening three times a week

Motion • Achieve motion equal to contralateral side. • Utilize both active and passive ROM

exercises to maintain motion.

Muscle Strengthening

• Shoulder

• Begin internal rotation and extension strengthening

• First closed-chain isometric strengthening and advance to Theraband and light weight isotonic strengthening.

• Scapular stabilizers

• Progress to open- and closed-chain strengthening

(see next 4 slides).

Open-chain strengthening exercises of the scapula stabilizers without dumbbells

Open-chain strengthening exercises of the scapula stabilizers with lightweight dumbbells.

Additional closed-chain scapular stabilizer strengthening. A, Start. B, Finish (the right arm is the focus of rehabilitation).

Open-chain strengthening of the scapular stabilizersusing Theraband tubing.

• Deltoid strengthening • Eighr to 12 repetitions for each exercise, for three sets. • Strengthening only three times per week to avoid rotator cuff tendinitis.

Strengthening of the anterior deltoid. A, Closed-chain isometric. B, Open-chainisotonic.

Isotonic deltoid strengthening with light dumbbells. A, Start. B, Finish.

Functional Strengthening • Plyometric exercises (see next slide). Maximum improvement by 12-18 month. Warning Signs • Loss of motion. • Continued pain. Treatment of Complications • These patients may need to move back

to earlier routines. • May require increased use of pain

control modalities as outlined above.

Plyometric shoulder strengthening exercises using Theraband tubing (A) and an exercise ball (B).

REFERENCES

Clinical Orthopaedic Rehabilitation 2nd edition Zimmer Implants Catalouge

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