Shoulder: Total Shoulder Replacement

what are common conditions that may lead to total shoulder replacements?

• OA

• RA

• Avascular necrosis

• proximal humeral fractures

• post-traumatic arthritis

which gender tends to show higher prevelance of TSR?

women

what are the surgical indications for TSR?

• severe pain and loss of shoulder function

• advanced joint degeneration

• complex proximal humeral fractures

• irreparable rotator cuff pathology

• failed conservative treatment or failed prior fixation or prior shoulder surgery

what are the risk factors for TSR?

• advanced age (over 65)

• poor bone quality/osteoporosis

• prior fracture or shoulder trauma

• rotator cuff dysfunction

• RA

• previous shoulder surgery

what are the general contraindications for TSR?

• active local or systemic infection

• severe glenoid bone loss/deformity

  • medical conditions that make surgery/anesthesia unsafe

what are the contraindications for aTSR?

• irreparable/full thickness rotator cuff tear

• rotator cuff arthropathy

• poor or insufficient humeral bone density

• severe instability or posterior subluxation that cannot be corrected

what are contraindications for a rTSR?

• axillary nerve palsy

• severe deltoid dysfunction/insufficiency

what is the general timeframe for the protection phase?

• for aTSR about 0-4 weeks

• for rTSR about 0-6 weeks

reverse total shoulder replacements tend to have longer healing/immobilizations and tend to have larger functional deficits

what is the general timeframe for the controlled motion phase?

• for aTSR: 4-12 weeks

• for rTSR: 6-12 to 16 weeks

what is the general timeframe for the return to function phase?

• for aTSR: 12+

• for rTSR: 12 to 16+

how long is immobilization generally prescribed for?

• for sTSR: sling for about 4 weeks and can be removed for exercise as cleared by surgeon

• for rTSR: up to 6 weeks and can be removed for exercises/hygiene, may requires abduction splint

what are the ROM restrictions for aTSR?

• 0-4 weeks: elevation of arm up to 120, ER up to 30

• 4-6 weeks: no GH extension past neutral

• 6-12 weeks: combined adduction, IR, extension permitted

what are the ROM restrictions for rTSR?

12 weeks or more: no GH extension or IR past neutral, no combined GH extension, adduction, IR. 0-20 ER and up to 90-120 elevation in scapular plane

what should interventions look like for aTSR during phase I?

• grade I/II joint oscillations

• AROM at scapula and distal extremity joints only

• pendulum exercises

• PROM to AAROM GH joint in supine initially then progress to sitting and standing after 3 weeks

• AROM of GH joint by 4-6 weeks

• no active IR for at least 6 weeks

• only light NWB isos

what should interventions look like for aTSR during phase II?

• continue AROM

• gradually increase GH rotation

• gentle stretching after 6-8 weeks if needed

• submax isometrics of GH muscles with light weight bearing

• can progress to low resistance dynamic strengthening of elbow and writst, ST and GH joints if mechanics during AROM allow

what should interventions look like for aTSR during phase III?

• progress end range self-stretching

• progress PRE in functional patterns

• progress closed chain stabilization exercises

what is the criteria to progress from the protective phase?

• PROM: 90 degrees of abduction, 45 degrees of ER, 70 degrees internal rotation with minimal pain

• no pain during resisted, isometric IR of the subscapularis

• ability to perform most waist level ADLs without pain

• (rTSA) tolerance of AAROM and able to isometrically activate the deltoid and periscapular muscles in scapular plain

precautions of the protective phase?

• only passive or assisted shoulder ROM exercises within “safe” limit as noted during surgery and no end-range stretching

• ROM restrictions up to 4 weeks, shoulder abduction up to 120 degrees and ER up to 30 degrees (arms at side)

• no reaching behind the back

• no lifting object heavier than a coffee cup

• no supporting of bodyweight with hand on involved side

• no driving for 4-6 weeks

• place a small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextension

• light ADLs with elbow at waist level

what are the precautions of the controlled motion/intermediate phase?

• avoid heavy lifting/UE weight bearing

• aTSR: protect healing subscapularis, gradually progress ER/IR

• rTSA: avoid shoulder hyperextension/behind back IR

• progress based on healing + surgeon precautions

what is the criteria for progression from the controlled motion phase?

• minimal pain/inflammation

• improving functional AROM

• good scapulohumeral mechanics

• no postoperative complication

what are the precautions for the return to function phase?

modify high demand, high impact work or recreational activities

what is the criteria to progress from the return to function phase?

• MD clearance

• maintenance of pain-free full ROM

• symmetric scapulohumeral mechanics