Post on 24-Mar-2020
7/14/2014
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Reverse Total Shoulder ArthroplastyOptimizing Outcomes
Kim Kraft, PT, DPT, CHT
Reverse Total Shoulder Arthroplasty
How is it different than a normal shoulder replacement?
What are the therapy precautions?
What should patients and therapists expect as the course of treatment?
How do you plan valuable therapy programs?
Introduction
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Shoulder Arthroplasty HistoryTotal
Shoulder Arthroplasty
• First shoulder arthroplasty was documented in 1893 in Paris by the surgeon Paen
Reverse
Shoulder Arthroplasty
• Introduced by Grammont in 1987
• Design exchanges the convex and concave surfaces
• Reduces loosening of the proximal scapular component, the glenosphere
Comparison : TSA vs RTSATraditional Total Shoulder
Arthroplasty(Total, TSA)
Reverse Total Shoulder Arthroplasty
(Reverse, RSA or RTSA)
Reverse Total Shoulder Arthroplasty
Indications
• Glenohumeral osteoarthritis with massive rotator cuff tear
• Rheumatoid arthritis with massive rotator cuff tear
• Proximal humeral nonunion or malunion
• Massive chronic irreparable rotator cuff tear
• Acute complex fracture in elderly person
• Fixed glenohumeral dislocation in elderly person
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Reverse Total Shoulder Arthroplasty Indication
Massive Irreparable RC TearCuff Tear Arthropathy
Allows the deltoid to raise the arm in the absence of any rotator cuff muscles
Cuff Tear Arthropathy
Acetabularization
Reverse Total Shoulder Arthroplasty Indication
Complex 3 & 4 Part Humeral Fracture
In cases of : inadequate bone stock (osteopenia or bone loss) or compromised blood supply
Gaunt and McCluskey 2012. A Systematic Approach to Shoulder Rehabilitation. Human Performance and Rehabilitation Centers, Inc. Columbus GA.
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Proximal Humeral Fracture With Bone Loss
Shoulder Arthroplasty 2008, Gary M. Gartsman & T. Bradley Edwards Saunders Elsevier Philadelphia
RTSA Contraindications
• Unaddressed health problems
• Active infection
• Axillary nerve palsy
• Deltoid insufficiency
• Osteopenia of the glenoid or humerus
• Fused shoulder (ankylosed or arthrodesed)
• Upper motor neuron lesion
• Poor motivation
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RTSA: Meet the Components
• Glenosphere
• Humeral Cup
• Humeral Stem
• Missing: Rotator Cuff
RTSA Alternatives
1. Ream and run with humeral hemiarthroplasty
2. Glenoid resurfacing
shoulderarthritis.blogspot.ca
Frederick Matsen III
Rehabilitation Concepts
• Understand prosthesis mechanics
• Maximize deltoid elevation
• Manage therapist and patient expectations
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RTSA Procedure
RTSA Procedure Video
By Dr. Mark A. Frankle
Pioneer
Search YouTube “Reverse Shoulder Prosthesis Implant Procedure”
47:05 in length
Tampa General Hospital
RTSA Procedure Reference
Shoulder Arthroplasty 2008,
Gary M. Gartsman
T. Bradley Edwards
Saunders Elsevier
Philadelphia
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DeltoPectoral Incision
humerus to prevent shoulder extension reducing anterior shoulder tension and
support under forearm to support the weight
http://strumentistaso.altervista.org/Ortopedia/frattura-testa-omerale.html
Beneath the Skin
Large RCT
• Release of coracoacromial ligament
• Large rotator cuff tear reveals the glenohumeral joint beneath
Gartsman & Edwards 2008
Exposure of the Proximal Humerus
Gartsman & Edwards 2008
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Prep and Ream Humeral Canal
Gartsman & Edwards 2008
A Little BLUE Glue
Cementing prevents subsidence
Gartsman & Edwards 2008
Humeral Component Insertion
Gartsman & Edwards 2008
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Glenoid Reaming and Glenosphere Prep
Gartsman & Edwards 2008
Glenosphere Insertion
Gartsman & Edwards 2008
Humeral Spacer Trial / Stability Test
Gartsman & Edwards 2008
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Subscapularis Muscle RepairedIf Present
1. Limit ER to 20 degrees for 4 weeks
2. No abduction with external rotation for 6 weeks
3. No resistance to IR for 12 weeks
Gartsman & Edwards 2008
RSA PRECAUTIONS
RSA IMPLANTATION HAS PRECAUTIONS ASSOCIATED WITH BONE FIXATION, INFECTION, AND SOFT TISSUE HEALING
Arthrokinematics ● PROM ● Notching
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ArthrokinematicsThe Story of the Golf Ball and the Tee
http://bleacherreport.com/articles1499870-dwight-howards-shoulder-injury-why-his-torn-labrum-may-linger-until-
offseason
• Arthrokinematics are joint motions
• Roll, Glide, and Spin• Native shoulder joint
follows “Convex on Concave Rule”
• Roll and glide happen in opposite directions to maintain contact of the joint surfaces
RTSA Arthrokinematics
• Roll and glide in the same direction
• Increased translation
• Reduces PROM available
• Humeral component can abut scapula inferiorly (notching) or superiorly (scapular spine fracture)
The Story of the Golf Ball and the Tee
Notching
• Edge of the humeral component abuts the scapular neck
• Limits PROM
• Cause: Translation
J Bone Joint Surg Br 2004;86[3]: 388-395.
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Notching
http://shoulderarthritis.blogspot.com/2012/04/radiographic-analysis-of-effects-of.html
RTSA PROM : Factors
RSA has a wide variation of potential PROM based on component size, shape,
and surgical procedure.
RTSA PROM
Research: PROM will be limited by surgical components and procedure.
Maximum Flexion 145⁰
Maximum IR/ER Total of 120⁰
Virani NA, Cabezas A, Gutiérrez S, Santoni BG, Otto R, Frankle M.
Reverse shoulder arthroplasty components and surgical techniques that restore glenohumeral motion.
J Shoulder Elbow Surg. 2013 Feb;22(2):179-87.
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RTSA PROM
PASSIVE MOTION IS LIMITED BY BONY BLOCK. POTENTIAL OF 120-145 DEGREES OF GLENOHUMERAL ELEVATION MAXIMUM.
RTSA PRECAUTIONS
RTSA Stability Precautions
For 12 weeks, or as instructed by surgeon:
1. NO Internal Rotation Behind the Back (IRBB)
2. NO Horizontal Adduction (HADD)
3. NO traction/weight bearing on the post operative arm
4. Lifting limitation of 5 #
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Limit external rotation to 20⁰, 4 weeksNo combined abduction and external rotation, 6 weeks
No internal rotation (IR) resistance, 12 weeks
Subscapularis Precautions If Repaired
Gaunt & McCluskey 2012
Teres Minor May Be Intact
If present, active external rotation is presentIf absent, only passive external rotation is possible
Beware: Teres minor can also be repaired by
latissimus dorsi transfer
Gaunt & McCluskey 2012
RTSA PRECAUTIONS
PROTECT REPAIRED MUSCLES/TENDONS
FROM TENSION FOR 6 WEEKS
FROM RESISTANCE FOR 12 WEEKS.
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Elevation By The Deltoid Muscle
flickr.com
Elevation By The Deltoid Muscle
Prosthetic shape and surgical procedure increase the effectiveness of the deltoid for elevation.
• Medialized joint axis
• Distalized deltoid insertion
Elevation By The Deltoid Muscle
“Medialized joint axis”
Increases deltoid force by lengthening the deltoid’s lever arm.
Yellow arrow is a little longer than the orange
arrow.
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Elevation By The Deltoid Muscle
“Distalized deltoid insertion”
Stretches the deltoid by making the proximal
humerus a little longer.
Yellow arrow is a little longer than the orange
arrow.
Elevation By The Deltoid Muscle
http://www.jointforlife.com/services-shoulder-arthroplasty.html
F1 x L1 < F2 x L2
ELEVATION BY THE DELTOID
RTSA PROVIDES A MECHANICAL ADVANTAGE TO THE DELTOID…BECAUSE THERE IS NO ROTATOR CUFF.
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Rehabilitation Program
1-2 Weeks After RSA
Conceptual Model
Precautions with ADLs
Pain control
Sling and supportPendulums
Table slides
Bony and Soft Tissue Healing
1-2 Weeks After RSA
Patient EducationSling and support reduce pain!
Sling must fit properly with hand slightly above the elbow to reduce swelling; elbow seated in the corner of the sling to prevent wrist
hanging on the edge of the sling.
ncmedical.com
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nationalbraceandsplint.com
1-2 Weeks After RSA
Patient EducationSling and support reduce pain!
Sitting: forearm rests on table or pillow to support weight of the arm and promote capillary flow through the healing tissue
1-2 Weeks After RSA
Patient EducationSleeping Position is Key
Reclined (vs supine) is more comfortable for the first 12 weeks: support behind upper arm (humerus) and under forearm
Scrapetv.com
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1-2 Weeks After RTSA
Patient EducationMobility Training
~Must avoid pushing IRBB and HADD for stability~
NO pushing up from sitting from the arm of a chair
NO pushing across the body or behind the back
Hygeine!?
1-2 Weeks After RTSA
Home Exercise Program
Pendulum Instructions•Approximately 2 minutes
•Pain relief
•Small diameter
•Relaxed
•Arm dangles like a necklace/ necktie
•OK if not perfectly passive (vs. RCR)
•Combine with dressing
1-2 Weeks After RTSA
Table Slide Instructions
• Weight of arm is supported
• Can use the opposite hand to propel the arm
• Slide the affected arm forward to “tension”
• Hold 10 seconds
• Repeat 10 times
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Rehab Program
Gentle passive motion
Motor relearning
Wean out of slingProgressive
AROM
4-12 Weeks After RTSA
Rehab Program
Wean out of sling
4-12 Weeks After RTSA
Weaning Out of The Sling
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Rehab Program
Gentle passive motion
4-12 Weeks After RTSA
4-12 Weeks After RTSAGentle Passive Range of Motion
• Therapist assisted
• Performed with the patient in supine to support the trunk, allows easy control of the scapula
• Support behind the humerus to prevent pre-loading the anterior shoulder tissue
4-12 Weeks After RTSAGentle Passive Range of Motion
Pearl
Abduction with external rotation begins after 6 weeks to protect the inferior fibers of the
subscapularis.
Come to abduction from a flexed position, instead of from abduction.
~Reduces scapular shrugging allows manual control of glenohumeral rotation.~
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4-12 Weeks After RTSAGentle Passive Range of Motion
Pearl Video
PROM : Clinical Observation
Conclusions:
• PROM gained by 8-10 weeks post-operatively
• AROM is much slower, continues to improve for the next year or more…TBA
Rehab Program
Motor relearning
4-12 Weeks After RTSA
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4-12 Weeks After RTSA
MOTOR RELEARNING
Practice meaningful tasks to learn using deltoid elevation.
Fun, light activity 2 sessions 30 minutes per day.
Ideas: checkers, cards, dusting, watering with a hose, grooming
http://www.freeimageslive.co.uk/free_stock_image/checkersjpg
4-12 Weeks After RTSA
Activity Journal
Charts progress for outcomes and motivation
Allows you to correlate pain and activity
Handy for documantation
http://lauraberry.wordpress.com/2008/07/02/journal-vs-diary/
Rehab Program
Progressive AROM
4-12 Weeks After RTSA
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Shoulder AROM ExercisesThoughtful Use of Gravity
The shoulder is a 3rd class lever.
Use supine, side lying, friction-free, reclined, & active assisted exercises to reduce the load on the deltoid.
Shoulder AROM
~Elevation progression~1. Supine active assisted flexion
2. Supine with elbow flexed, progressing to elbow extended
3. Supine “X”s and “O”s4. All the above with 1# can of vegetables
5. Prone TYI6. Wall slide and wall slide/lift off
(Wall slide liftoff combines high deltoid excursion and scapular depression, very challenging.)
4-12 Weeks After RTSAEXERCISES 4x / Day
True flexion10x 10 seconds
Posterior tissue stretch
Instructions
• 10x 10 seconds
• Elbows extended
• Close to ears
• Targeting posterior tissue
• Gravity assisted after 90 degrees
• Scapular depression
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4-12 Weeks After RTSAEXERCISE 4x / Day
Hammock stretch5 minutes
Supported elevation progression
Instructions
• Short lever arm improves control
• Stretches anterior/inferior capsule and subscapularis
• Anterior to posterior motion causes scapular retraction instead of elevation (shrugging)
4-12 Weeks After RTSAEXERCISE 4x / DayElevation
progression Instructions• 5 minutes
• Supine position prevents trunk compensation
• Play with lever arm:
– Elbow flexed “punches”
– Elbow extended to maximum flexion (becomes gravity assisted after 90⁰)
– Diagonals, circles to challenge control
– Add 1# canned vegetables/ water bottle for resistance
4-12 Weeks After RTSAEXERCISE 2x / Day
TYI prone Instructions
• 10 repetitions each, 1-2 times per day
• Progress to 30 repetitions then add water bottle resistance
• Scapular stability
• High-excursion exercise for the deltoid
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AROM Expectations By Diagnosis
CTA Massive RCT RAFixed
Dislocation
OAPost-
TraumaticFracture
132 161 60 115 115142
CTA: Cuff Tear Arthropathy, n=63Massive RCT: Massive Irreparable Rotator Cuff Tear, n=10RA: Rheumatoid Arthritis, n=6Fixed Dislocation: n=8OA: Post-Traumatic Arthritis: n=20Acute Fracture: n=13
Gartsman & Edwards 2008
Elevation AROM : Clinical Observation
DATA, Cohort Summer 2013
0
20
40
60
80
100
120
140
7 8 9 10 11 12
GK
RM
RH
JF
SA
JK
AROM : Clinical Observation
Conclusions:
• AROM is more variable than PROM
7-12 weeks after RTSA.
• AROM is much slower than PROM, continues to improve for the next year or
more…TBA
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Elevation Active Range Of Motion (AROM) Outcomes
After four years,Flexion: 128 : (40:-180:)
ER: 30: (-55:-90:) IR: 39 : (0 : -105 :)
Cuff D, Clark R, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of rotator cuff
deficiency:a concise follow-up, at a minimum of five years, of a previous report.
J Bone Joint Surg Am. 2012 Nov 7;94(21):1996-2000.
AROM Expectations
http://thewondersofchordata.wikispaces.com/Okapi
Rehab Program
Discuss
restrictions
Modify / adapt activities
Emphasize continued exercise program
Light resistive exercises
12 + Weeks After RTSA
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12+ Weeks After RTSA
Activity Restrictions
Communication with surgeon about lifelong precautions; otherwise, 5# lifting restriction, no sports or heavy activities
Emphasize continued home program
Anticipate continued improvement 2-5 years!
Last 2-3 VisitsExercise 1- 2x / Day
Wall slide lift-off Instructions
• 10 x 10 seconds
• ***Practice without shrugging*** using as much wall assist as needed
• Combines pattern of glenohumeral elevation with scapular depression
Last 2-3 visitsExercise 1-2x / Day
Lightest resistance Instructions
• 10-20 repetitions 1-2 times per day, progressing to 30 repetitions
• Lightest tubing or band
• Glenohumeral motions: flexion, extension, abduction, IR,
• ER if available
• Scapulothoracic motions: lawnmower row, dynamic hug
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THERAPY VISITS: TARGET PER PHASE
1-2 Visits: Instruct in precautions use of sling, pendulums and table slides1-2 Visits per week: Passive range of motion, evaluation/progression of home exercise program1-2 Visits per week: Progress through active range of motion gravity reduced to elevation against gravity1-2 Visits: Theratubing or gym program instruction
Outcomes
OutcomesExcellent / Good Subjective Results By
Diagnosis
CTA Massive RCT RAFixed
Dislocation
OAPost-
TraumaticFracture
75% 80% 50% 100% 66% 50%
CTA: Cuff Tear Arthropathy, n=63Massive RCT: Massive Irreparable Rotator Cuff Tear, n=10RA: Rheumatoid Arthritis, n=6Fixed Dislocation: n=8OA: Post-Traumatic Arthritis: n=20Acute Fracture: n=13
Gartsman & Edwards 2008
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Outcomes
After two years,
DASH scores average approximately 35.
Gallinet D, Adam A, Gasse N, Rochet S, Obert L.
Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty.
J Shoulder Elbow Surg. 2013 Jan;22(1):38-44.
Outcomes
Return to golf with surgeon approval.
Flickr.com
Complications
where.ca.com
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Complications
• Infection- P. Acnes
• Fixation failure
• Dislocation
• Acromial fracture
• Scapular spine fracture
Complications
Infection
The customary signs….
Opening (dehiscence) or pimple on the incision.
Solution: Keflex, Bactrim
Complications
Fixation failure
Sign: Painful gentle PROM, unusual joint noises, sudden loss of ROM
Solution: Surgical
Depts.washington.edu
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Complication
Dislocation
Signs: Clunk with passive motion, pain, inability to perform active motion.
Solution: Surgical
Complication
Acromial fracture
Deltoid pull off
Sign: Tenderness at acromion
Solution: Rest, return to sling
radiologycasereprots.net
Complication
Scapular spine fracture
Sign: tenderness
posterior AC joint
Solution: rest
shoulderarthritis.blogspot.com
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Thank Youkimkraftpt@gmail.com