Total Shoulder Arthroplasty

occurence of reverse vs anatomical shoulder arthroplasty

over 70 y.o. is more likely to be reverse because it provides more stability

most common indications for arthroplasties

OA, RTC tear, fracture

most common comorbidities for arthroplasties

HTN, obesity, DM

indications for anatomical TSA

severe OA, significant ROM loss, high levels of pain, reduced ADL performance, intact RTC, unsuccessful conservative management

complications of TSA

shoulder stiffness, RTC failure, prosthetic loosening

surgical procedure for anatomical TSA

deltopectoral, biceps tendon attached to pec, subscap peel, osteophyte removal, labrum excised, glenoid fitted

why is post-op subscap protection important

TSAs are primarily a soft tissue surgery which is where the joint stability comes from

how is post op protocol determined during surgery

ER during operation to measure the strain

best to worst repair strengths surgical techniques

bone-to-bone, tendon-to-tendon, tendon-to-bone

characteristics of post-op immobilization

sling with abduction pillow for 6 weeks, no ER at 90, abduction, extension

priorities of protection phase of anatomical TSA rehab (0-6 weeks)

healing tissues, PROM in appropriate ranges, ADL modification, pain management

ROM restrictions during protection phase of anatomical TSA rehab

no more than 30 deg ER and 120 deg flexion, no WB through UE

interventions during protection phase of anatomical TSA rehab

active elbow and wrist, promote circulation to avoid swelling, scapular retraction

exercises during the protection phase of anatomical TSA rehab

pulleys, manual ROM, assisted stretching, table slides

priorities of progressive mobility phase of anatomical TSA rehab (6-12 weeks)

restore ROM, progress AROM, manage stress on prosthesis

when is it anticipated to reach max ROM for anatomical TSA

12 weeks

precautions of progressive mobility phase of anatomical TSA rehab

ER at 90 and abduction past 60 degrees, “coffee cup” loads

long term restrictions in ROM after anatomical TSA

140-150 flexion, 50-60 ER, IR to lumbar spine

exercises during progressive mobility phase of anatomical TSA rehab

seated AROM, serratus punches, ROM with cane, rhythmic stabilization

priorities during strengthening/functional optimization phase of anatomical TSA rehab (12+ weeks)

maximize ROM, progressive strengthening, return to ADL and recreation, initiate WB activities

lifetime lifting limit of anatomical TSA

15-25 lbs

exercises during the strengthening/functional optimization phase of anatomical TSA rehab

push ups, I/Y/T, bicep curls, rotation with band, PNF with resistance

characteristics of reverse TSA

convex/concave relationship switches, provides stability for weak RTC, provides mechanical advantage to deltoid

indications for reverse TSA

RTC insufficiency, proximal humerus fracture, tumor, failed TSA, chronic instability

complications of reverse TSA

scapular notching, glenoid loosening

pros and cons of deltopectoral approach to reverse TSA

pros: preserves deltoid and less risk to axillary nerve; cons: subscap release, extensive capsule injury (instability)

pros and cons of anteriorsuperior approach to reverse TSA

pros: subscap preserved, decreased post-op instability; cons: risk of axillary nerve injury and anterior delt injury

tendon transfer of reverse TSA

lats and teres major wrapped around humerus to generate more ER

risk of dislocation in reverse vs anatomic TSA

higher in reverse especially during combined extension/IR

priorities during protection/immobilization phase of reverse TSA rehab (0-6 weeks)

ADL modification, protect subscap, ROM in allowable range, pain management

initial precautions of reverse TSA rehab

sling for 6 weeks, avoid excessive IR, no more than 120 deg elevation and 45 deg ER, no AROM, no lifting

priorities during progressive mobility phase of reverse TSA rehab (6-12 weeks)

progress ROM, initiate AROM, control stress on prosthesis

what to avoid while initiating AROM after reverse TSA

excessive deltoid activation, shrugging compensation during elevation

interventions during progressive mobility phase of reverse TSA rehab

beach chair progression, periscapular activation, initial deltoid activation

priorities during strengthening/functional optimization phase of reverse TSA rehab (12+ weeks)

progressive deltoid strengthening, maximize AROM, return to ADLs

lifetime lifting restrictions after reverse TSA

10-15 lbs

lifetime ROM restrictions after reverse TSA

flexion: AROM-105, PROM-140; ER: 30-40