Introduction 7/14/2014. Reverse Total Shoulder Arthroplasty Optimizing Outcomes. Reverse Total Shoulder Arthroplasty. Kim Kraft, PT, DPT, CHT

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1 Reverse Total Shoulder Arthroplasty Optimizing 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 1

2 Shoulder Arthroplasty History Total 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 RTSA Traditional 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 2

3 Reverse Total Shoulder Arthroplasty Indication Massive Irreparable RC Tear Cuff 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 A Systematic Approach to Shoulder Rehabilitation. Human Performance and Rehabilitation Centers, Inc. Columbus GA. 3

4 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 4

5 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 5

6 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 6

7 DeltoPectoral Incision humerus to prevent shoulder extension reducing anterior shoulder tension and support under forearm to support the weight 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

8 Prep and Ream Humeral Canal Gartsman & Edwards 2008 A Little BLUE Glue Cementing prevents subsidence Gartsman & Edwards 2008 Humeral Component Insertion Gartsman & Edwards

9 Glenoid Reaming and Glenosphere Prep Gartsman & Edwards 2008 Glenosphere Insertion Gartsman & Edwards 2008 Humeral Spacer Trial / Stability Test Gartsman & Edwards

10 Subscapularis Muscle Repaired If 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 IMPLANTATION HAS PRECAUTIONS ASSOCIATED WITH BONE FIXATION, INFECTION, AND SOFT TISSUE HEALING RSA PRECAUTIONS Arthrokinematics PROM Notching 10

11 Arthrokinematics The Story of the Golf Ball and the Tee 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 The Story of the Golf Ball and the Tee Roll and glide in the same direction Increased translation Reduces PROM available Humeral component can abut scapula inferiorly (notching) or superiorly (scapular spine fracture) Edge of the humeral component abuts the scapular neck Limits PROM Cause: Translation Notching J Bone Joint Surg Br 2004;86[3]:

12 Notching 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 Feb;22(2):

13 PASSIVE MOTION IS LIMITED BY BONY BLOCK. POTENTIAL OF DEGREES OF GLENOHUMERAL ELEVATION MAXIMUM. RTSA PROM 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 # 13

14 Subscapularis Precautions If Repaired Gaunt & McCluskey 2012 Limit external rotation to 20⁰, 4 weeks No combined abduction and external rotation, 6 weeks No internal rotation (IR) resistance, 12 weeks Teres Minor May Be Intact Gaunt & McCluskey 2012 If present, active external rotation is present If absent, only passive external rotation is possible Beware: Teres minor can also be repaired by latissimus dorsi transfer PROTECT REPAIRED MUSCLES/TENDONS FROM TENSION FOR 6 WEEKS FROM RESISTANCE FOR 12 WEEKS. RTSA PRECAUTIONS 14

15 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. 15

16 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 F1 x L1 < F2 x L2 RTSA PROVIDES A MECHANICAL ADVANTAGE TO THE DELTOID BECAUSE THERE IS NO ROTATOR CUFF. ELEVATION BY THE DELTOID 16

17 Rehabilitation Program 1-2 Weeks After RSA Conceptual Model Precautions with ADLs Pain control Bony and Soft Tissue Healing Sling and support Pendulums Table slides 1-2 Weeks After RSA Sling and support reduce pain! Patient Education 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 17

18 nationalbraceandsplint.com 1-2 Weeks After RSA Sling Patient and support Education 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 Sleeping Position Education is Key Reclined (vs supine) is more comfortable for the first 12 weeks: support behind upper arm (humerus) and under forearm Scrapetv.com 18

19 1-2 Weeks After RTSA Patient Mobility Education 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 19

20 Rehab Program Gentle passive motion Motor relearning 4-12 Weeks After RTSA Wean out of sling Progressive AROM Rehab Program 4-12 Weeks After RTSA Wean out of sling Weaning Out of The Sling 20

21 Rehab Program Gentle passive motion 4-12 Weeks After RTSA 4-12 Weeks After RTSA Gentle 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 RTSA Gentle 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.~ 21

22 4-12 Weeks After RTSA Gentle Passive Range of Motion Pearl Video PROM : Clinical Observation Conclusions: PROM gained by 8-10 weeks postoperatively AROM is much slower, continues to improve for the next year or more TBA Rehab Program Motor relearning 4-12 Weeks After RTSA 22

23 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 ee_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 /07/02/journal-vs-diary/ Rehab Program 4-12 Weeks After RTSA Progressive AROM 23

24 Shoulder AROM Exercises Thoughtful Use of Gravity The shoulder is a 3 rd 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 s 4. All the above with 1# can of vegetables 5. Prone TYI 6. Wall slide and wall slide/lift off (Wall slide liftoff combines high deltoid excursion and scapular depression, very challenging.) 4-12 Weeks After RTSA EXERCISES 4x / Day True flexion 10x 10 seconds Posterior tissue stretch Instructions 10x 10 seconds Elbows extended Close to ears Targeting posterior tissue Gravity assisted after 90 degrees Scapular depression 24

25 4-12 Weeks After RTSA EXERCISE 4x / Day Hammock stretch 5 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 RTSA EXERCISE 4x / Day Elevation 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 RTSA EXERCISE 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 25

26 AROM Expectations By Diagnosis CTA Massive RCT RA Fixed Dislocation OA Post- Traumatic Fracture 142 CTA: Cuff Tear Arthropathy, n=63 Massive RCT: Massive Irreparable Rotator Cuff Tear, n=10 RA: Rheumatoid Arthritis, n=6 Fixed Dislocation: n=8 OA: Post-Traumatic Arthritis: n=20 Acute Fracture: n=13 Gartsman & Edwards Elevation AROM : Clinical Observation DATA, Cohort Summer 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 26

27 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 Nov 7;94(21): AROM Expectations Rehab Program Discuss restrictions Modify / adapt activities 12 + Weeks After RTSA Emphasize continued exercise program Light resistive exercises 27

28 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 Visits Exercise 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 visits Exercise 1-2x / Day Lightest resistance Instructions 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 28

29 1-2 Visits: Instruct in precautions use of sling, pendulums and table slides 1-2 Visits per week: Passive range of motion, evaluation/progression of home exercise program 1-2 Visits per week: Progress through active range of motion gravity reduced to elevation against gravity 1-2 Visits: Theratubing or gym program instruction THERAPY VISITS: TARGET PER PHASE Outcomes Outcomes Excellent / Good Subjective Results By Diagnosis CTA Massive RCT RA Fixed Dislocation OA Post- Traumatic Fracture 75% 80% 50% 100% 66% 50% CTA: Cuff Tear Arthropathy, n=63 Massive RCT: Massive Irreparable Rotator Cuff Tear, n=10 RA: Rheumatoid Arthritis, n=6 Fixed Dislocation: n=8 OA: Post-Traumatic Arthritis: n=20 Acute Fracture: n=13 Gartsman & Edwards

30 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 Jan;22(1): Outcomes Flickr.com Return to golf with surgeon approval. Complications where.ca.com 30

31 Complications Infection- P. Acnes Fixation failure Dislocation Acromial fracture Scapular spine fracture Infection Complications The customary signs. Opening (dehiscence) or pimple on the incision. Solution: Keflex, Bactrim Fixation failure Complications Sign: Painful gentle PROM, unusual joint noises, sudden loss of ROM Solution: Surgical Depts.washington.edu 31

32 Complication Dislocation Signs: Clunk with passive motion, pain, inability to perform active motion. Solution: Surgical Acromial fracture Deltoid pull off Complication Sign: Tenderness at acromion Solution: Rest, return to sling radiologycasereprots.net Scapular spine fracture Complication Sign: tenderness posterior AC joint Solution: rest shoulderarthritis.blogspot.com 32

33 Thank You 33