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

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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