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Total Shoulder Replacement

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on 19 May 2017

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Transcript of Total Shoulder Replacement


19 - year - old
College Basketball Player

Car Accident - ORIF rehab
Total Shoulder Replacement
Reverse Total Shoulder Arthroplasty (rTSA)

Total Shoulder Arthroplasty (TSA)
Proximal Humerus Fractures
Surgically repaired with:
Open Reduction Internal Fixation (ORIF)
Surgical Procedure:
Pt description
Goals of Rehabilitation:

Precautions & Contraindications:
Pre-surgical Phase:
Phase I
Phase II
Phase III
Phase IV
Neer's Classification:
Pt description
Surgical Procedure:
Goals of Rehabilitation:

Precautions & Contraindications:
Pre-surgical Phase:
Phase I
Phase II
Phase III
Phase IV
Primary common goal of TSA or rTSA: pain relief with a secondary benefit of restoring motion, strength and return to a functional level as near to normal as possible.

= TSA except arthrokinematics are reversed; concave humeral head component fixed with convex glenoid component
= both components of GH joint replaced by prostheses
Reasons for Replacement:
Rheumatoid Arthritis
Acute Proximal Humerus Fractures
(3+ parts)
Rotator Cuff Arthropathy
Head Splitting Fractures --> AVN

Decision between ORIF and TSA:
Patient's Age
The older they are the more likely TSA/rTSA is indicated.

They try to fixate younger individuals with good bone stock.
Severity of Fracture
Fractures categorized by Neer's Classification. Any dislocations of fragments are more severe

Condition of the calcar is key
Functional Status
Patient's ability to tolerate postoperative rehabilitation.

ORIF and TSA both require PT

ORIF > TSA in postop rehab demands
Vascular Supply
Vascular supply to the bone fragments determines if ORIF will be successful.

The presence of AVN = TSA/rTSA
Deltoid & RTC
Loss of RTC function indicates use of rTSA over TSA

Deltoid function is absolutely pertinent in the use of rTSA
Other Factors
Ability to tolerate anesthesia (TSA longer surgery)
Average Patient:
Age: 77.5 years old
Poor bone quality
9/10 times rTSA
10% women 50+ y.o.
have osteoporosis

The structures at greatest risk during procedure:

Brachial Plexus
Brachial Vasculature to the entire arm and scapula
Pectoralis Major
Long Head of the Biceps
Significant Osteopenia or Osteoporiss
Previous/concurrent rotator cuff tear or deficiency
Inability to follow immobilization and rehabilitation techniques
Previously failed shoulder joint replacement

when patients exhibit one or more of the above comorbidities
Advanced Age

>75 years old
The deltoid ABSOLUTELY HAS TO BE FUNCTIONAL in order for an rTSA to be successful!!
The functional capacity of the musculature surrounding the shoulder girdle preoperatively is the primary factor in choosing which procedure is best:

Humeral Head Prosthesis
Head is cut and reamed

Stem inserted into long length of bone

> Fitted with 20 degrees of retroversion

Glenoid Prosthesis
Labrum and biceps anchor removed to be replaced later

Inferior Capsule release performed

Usually metal humeral component and plastic glenoid component

Biceps is replaced into the bicipital groove
Specifically the rTSA
Round glenosphere is impacted into baseplate on scapula first

Humeral head now has the concave component and is reamed after glenoid

Increased deltoid lever arm and decreases shear on baseplate

Increases medial center of rotation compared to TSA
Patient placed in Beach-Chair position with arm draped free

Deltopectoral approach is becoming more common
Allows for improved exposure of humerus and glenoid

Improved implant positioning and tilt --> less loosening

The subscapularis muscle is removed from its insertion on the lesser tuberosity
> Will be repaired and reattached to humerus at end of procedure (try their best to preserve length)

Capsule is opened to expose glenoid and humeral head

Dislocate humeral head via ADDuction, ER, and superior pressure from elbow

Incision made from coracoid process and distally 10 cm
72-year old female

Dx: Osteoarthritis (4 years), full thickness rotator cuff tear

PMH: Osteoporosis

Surgery: Reverse Total Shoulder Arthroplasty
Postural Examination:
Upper Quarter Screen:
Selective Tissue Tension Testing
Neurological Testing
Joint Mobility Testing:
Functional Outcomes Tests:
19 year-old male

College basketball player

MOI: Pedestrian-car accident

Dx: 4-part proximal humerus fx with anterior dislocation
Postural Examination
Upper Quarter Screen
Selective Tissue Tension Testing
Neurological Testing
Joint Mobility Testing
Special Tests
* Inspect the skin of the shoulder, arm and neck (infection?)
* Note if patient has a pain pump in their neck still
* Notice amount of discomfort they are in
* Notice if the patient has their arm in the immobilizing sling properly

Immobilizing sling is used throughout
Phase I and II
Glenohumeral resting position:
50 degrees ABD
Slight horizontal ADD
Slight ER
* Observe patient in sitting and standing
* Note any guarding postures

Things to look for:
Tight Upper Trapezius
Ipsilateral lateral trunk flexion
Overactive ipsilateral SCM -- tilted head
A full UQS is not appropriate for a patient who presents to your facility post-op.


Assessing cervical ROM would be beneficial in ruling out any potential complications from the surgery and/or satellite injuries that could hinder progression and prognosis for the patient
Expected preoperative values:
Testing the general sensation of entire involved arm

Brachial plexus (C5-T1) is at risk with the deltopectoral surgical approach
No joint mobilization should ever be performed on the prosthesis; the mechanism of replacement is self-limiting
* Simple Shoulder Test

* American Shoulder and Elbow Surgeon's Shoulder Evaluation Short Form

* Scapular lift-off test/Napoleon Sign or Ultrasound to monitor subscapularis repair throughout rehab (6+ months)
The shoulder girdle and arm should be palpated gently for warmth and abnormal deformity

Also palpate peri-scapular muscles looking for guarding
Anterior-posterior view of OA
> Check for various fractures along long axis of humerus or in the scapula
> Ensure bone is healing around the implant (especially press-fit models)
> Assess the integrity and placement of the prosthesis
Axillary View of OA
Normal Joint Space
Loss of Joint Space
A-P View
Axillary View
A-P View of Anterior Dislocation in 78-y.o. woman
A-P View of dissociation
A-P View of Intraarticular migration of humeral head component within the bone
Risk Factors:
Abnormal Bony Pathology (Cancer, rickets)
Nutritional Deficits
Typical MOI:
Acute Trauma to superior aspect of the arm

Ex: MVA or Fall from a height

Other less common include microtrauma such as repetitive stress to the area or FOOSH
Patient Demographics
Younger Patients
Thrill-seeking behaviors increase incidence of proximal humerus fractures from the ages 15-45

The younger (better bone quality), the more acute the trauma has to be, the more likely they will have concomitant injuries
Older Patients
They have an increased incidence of falls

Decreased reaction time

Decreased bone health prior to MVA or acute trauma
Other things to consider....
Patient's age
Functional status
Psychosocial factors
Ability to tolerate postoperative rehab
Fracture pattern
Associated injuries
Pt's Post-Op Goals
Patient's need to regain full motion for a job or sport

Pt's willingness to cooperate with differing rehab programs

Necessary functional demands for ADLs

** Younger, healthier patients who want to return to full function are more likely to undergo a surgical procedure - and it's indicated because their bodies can tolerate it better.

** 69-79% of such cases are treated without surgery and let the bone heal on its own.
Bony Anatomy:
Greater tuberosity**
Lesser tuberosity**
Humeral head
Surgical Neck
Anatomical Neck
Bicipital groove
Pectoralis major
Teres Major
Teres Minor
Latissimus Dorsi
Other Important Features:
Brachial Plexus
Arteries branchian from the Subclavian A.
Four categories depending on how many parts become displaced, and the fracture is named by the structure that is displaced.
1-Part Fx:
2-Part Fx:
3-Part Fx:
4-Part Fx:
Any number of fracture lines but no bony segment is displaced more than 1cm
Involves single displacement > 1cm
Humeral displacement at surgical neck and a tuberosity
Typically displacement of surgical neck and both tuberosities
High risk for rupturing posterior humeral circumflex artery --> AVN
* Pt will present with pain in superior/lateral aspect of arm

* Hx of trauma to area

* Complain they have difficulty moving arm and may be holding it

* Proximal arm would have swelling, as well a severe bruising and ecchymosis.

* Humeral head could also be dislocated and visible anterior or posterior
* Shoulder would appear internally rotated in an attempt to relocate anteriorly displace humeral head

* Patient will be guarding due to pain and unwilling to move it

No formal UQS should be necessary

MOI as well as type/location of pain should be consistent with fx

Cervical clearing should be conducted to rule out spinal involvement
You would not conduct STTT on an acute fracture.

If this young patient fell and could not move arm, before continuing your exam you would REFER OUT for x-rays
* General sensory screen of dermatomes and peripheral nerves

* C5-C7 DTRs would be expected to be intact as long as there is no brachial plexus involvement
You would not test the joint mobility of this patient due to the MOI and pain descriptors.

Drop Arm Test
Evaluating the rotator cuff and any potential involvement

Patient may not be able to hold arm up to due pain, severity of fracture, dislocated fragments - false positive??
Empty/Full Can
Rotator cuff involvement, seeing if the patient has muscular control over their glenohumeral joint and how limiting the pain is
Tuning Fork
128 Hz

Vibrating bone and eliciting pain if fracture is present
Severe point tenderness over fracture site.

With this particular patient, pain over the anterior portion of the shoulder due to dislocation of tuberosity
A-P View:
Trans-Scap View
Axillary View:
Gold Standard for diagnosing and classifying proximal humerus fractures
Conservative Management: (~65%)
Frail, older patients, osteoporosis, smoking. alcohol abuse, DM, RA, compromised immune system, etc.
--> Immobilized for 10-14 days in broad arm sling
--> after 14 days, patient does not need to wear sling full-time
Surgical Management:
Goal: reduce all fracture fragments, reestablish neck shaft angle, restore calcar, achieve overall stable fixation

Phase I
> Deltoid is retracted and arm abducted to gain access to humeral head

> Plate placed on lateral side of humerus to counteract pec major pull

** Important that deltoid stays attached and plate is far enough away from bicipital groove to avoid impingement
>> Surgeon might perform biceps tenodesis to help with this
Phase II
> If the tuberosities and head are displaced (3-4 part fractures), they are manually fitted into place (screws)

> Humeral head locked into place by 5 fixed angle screws
Phase III
> Radiograph taken

Swelling and ecchymosis
Joints above and below need to be ruled out for any other complications
Cervical clearing
Neurological screening done on both (but for different reasons!)
No mobility testing
Radiograph = gold standard
Both procedures require bony healing before excessive strengthening can occur
Both have surgical incision site that needs to be monitored for infection, and massaged/mobilized once healed
Both should be progressed from OKC--> CKC
Both are immobilized and need to be monitored for contractures at the elbow and neck
Posture assessed for both
1. Return to prior level of function with full range of motion and strength while protecting injured and repaired structures and preventing joint stiffness.

2. Neuromuscular education to restore scapulothoracic and scapulohumeral rhythm.

3. Restore strength of rotator cuff musculature after surgical re-attachment.

4. Pain-free movement in all planes.

1. Tuberosities are repaired and bony healing must occur before stress is applied to the rotator cuff tendons (approximately phase II).

2. Any abnormal hard end-feel felt could potentially be a misplaced screw or a migrated locking-plate blocking motion. This needs to be managed with surgical intervention. Have patient report to physician, document your findings, and communicate with MD prior to patient’s appointment.

3. Rotator cuff muscles are re-attached and should not be strengthened/activated until after 6-8 weeks to allow appropriate healing.

4. Patient is a high level athlete and is at risk for overexertion too early (“overdo complex”).

Not applicable due to traumatic nature of the injury
1. Achieve functional range of motion and maximize use of upper extremity for ADLs at or above shoulder height, while allowing adequate tissue healing.1

2. Neuromuscular re-education of deltoid to become primary mover of shoulder.

3. Significant strengthening of scapular, arm and peri-scapular muscles to achieve muscular stability for prosthesis.

4. Lifting education and strengthening to safely handle grandchildren, shopping, cleaning, etc.

1. Surgical Approach: deltopectoral or superior?
2. Dislocation biomechanics have changed!! IR + ADD + Ext (past neutral)
3. Deltoid
4. Glenoid loading
5. Subscapularis tears highly common
- Achieve as much strength and range as possible before surgery and immobilization causes atrophy
- Correct postural deficits
- Fracture
- Treatment increases pain or swelling
- Deltoid isometrics
- Supine punches
- Static stretching in all planes
- Wall push-ups

ADL precautions:
> Can't reach behind back until 12 weeks post-op
- Bathroom hygiene
- Grabbing wallet out of back pocket
- Resting BW on arm when sitting on the ground and leaning back

> Immobilizing sling education

> Postural training
P/C: Limited to less than 120° elevation, 30° external rotation, 45° abduction, no internal rotation.
Cervical Neck Stretching

Ball Squeezes

Head presses


Pronate/Supinate with hammer

Scapular clocks
Minimal strengthening, no forceful stretching, sub-maximal deltoid recruitment
*note capsular pattern
No precautions at this point - return to ADLs and continue pool program introduced in Phase III as HEP
No weight lifting above shoulder height that exceeds 6-10lbs
Table slides with towel

Rows kneeling


Wall slides

Thera-band rows

Loading and unloading a dishwasher
Horizontal ABD/ADD with buoy weights

Concentric/eccentric ADD

ABD with board

Press down

Pushing/pulling vacuum

Digging holes in garden
Extension past neutral

IR/ER under water (with and without buoy weight)

UE Figure 8

Flexion/Extension board push down

Cans to cupboard

Setting the table

Cervical Neck Stretches

Shoulder Shrugs


AAROM Abduction

Scapular Clocks

Weighted Pronation/Supination
Door Frame Stretches

Theraband Abduction


Cat/Camel Stretch

Theraband ER

Supine Toss & Catch

Prone Superman

Military Press

Squat + MB Toss

Advanced Superman

Bench Press

Turkish Get-up
Foam Roll Snow Angels

Full Plank + Rotation


Foam Roll Lats

Modified Handstand Shoulder Taps

Shot Put
Traumatic onset
Younger patient population
Earlier and more dramatic progressions
Restricted external rotation
Candidate for more aggressive rehabilitation
More potential for return to maximal use of UE
: This study followed 39 patients under the age of 40 who underwent surgical treatment for a four-part proximal humerus fracture. Surgery was performed within 1 week of the fracture and the patient was treated with open reduction and internal fixation. Physical therapy was initated around 5 days after surgery. Union was achieved in 36 subjects and 26 patients were pain-free after 26 months. The average active flexion was 145°. Subjects were separated into 2 groups: anatomical neck fracture and surgical neck fracture. The surgical neck fracture group had significantly better pain scores as well as greater flexion range of motion. There were significantly less complications involving surgical neck fractures as well.

Critical Review:
This research study sufficiently supported the research question. It allowed the reader to gain a better understanding of developing a prognosis for a patient with a proximal humerus fracture. The subject selection allowed for a very specific population to be analyzed. With this type of traumatic injury, there are numerous options but open reduction internal fixation is usually performed on younger patients to give them the greatest benefit. The follow-up period seemed a little short for this study. The long term effects of a proximal humerus fracture could potentially have a significant impact on arm function and would be interesting to see. As an observational study, this was very effective in stating the outcomes of an open reduction internal fixation of a humerus fracture in a younger patient.

Four-part fracture dislocations of the proximal humerus in young adults: Results of fixation
Omar A. Soliman, Wael M.T. Koptan
Requires more soft tissue healing than ORIF
More precautions early on
IR + Extension (past neutral) + ADD restricted
MOI can be traumatic but usually degenerative
Traumatic usually older patients with poor bone quality and thus not ORIF candidates
Less potential for return to full function
Goal is primarily pain relief - not function
Maintains functional use of the uninvolved limb
Strengthens scapular stabilizers ensuring proper arm movement in later phases
creates dynamic stability at the shoulder
return some upper extremity power
simulates arm impact during running
develops core/shoulder strength and range of motion
teaches patient how to safely fall during sport activities
Minimal contraction of the shoulder, with maximum assistance with the cane - PUSH THEM
Gaining proximal stability is key in re-educating her on how to accommodate for loss of range
Really focus on elevation/flexion because it will have the biggest impact on ADLs and there are little to no precautions
Teach her how to use non-dominant hand efficiently
This is where we need to teach the patient how to push herself to gain more range
Pushing up from a chair with both arms and one arm
Reaching overhead as much as possible along with moving objects at that height - necessary to live independently
Really focus on scapular stability
Door frame stretches are a great way for her to maintain range at home
No ER past 40 degrees, no cross body ADD, prevent muscle atrophy, regain full ROM
No IR behind back
Review and Revise HEP with patient; ensure quality of technique
Progressive return to full motion in all planes - return to practice followed by return to competition
Axial CT image of a 79-year-old man

72-year old

rTSA of dominant arm

Posture: slight forward head, rounded shoulders, excess kyphosis of T-spine

Retired, lives independently, gardens, shops, cleans, grandkids
Pulleys for shoulder flexion:
3-part impact fracture
4-part impacted fracture
3-part dislocated fracture
Full transcript