Upper Extremity Arthroplasty

Upper Extremity Arthroplasty Overview

  • Types of Arthroplasty

    • Shoulder Arthroplasty

    • Elbow Arthroplasty

  • Prosthetic Fixation

  • Indications for Arthroplasty

  • Rehabilitation

    • Refer to LE Arthroplasty ppt for general guidelines and considerations immediately post-operative.

Shoulder Arthroplasty

Anatomy of the Shoulder

  • Key Structures:

    • Acromioclavicular (AC) joint

    • Coracoid process

    • Acromion (top of the shoulder)

    • Collarbone (clavicle)

    • Head of the humerus (shoulder joint)

    • Shoulder socket (glenoid)

    • Upper arm bone (humerus)

    • Shoulder blade (scapula)

    • Ribs

    • Sternoclavicular (SC) joint

    • Thoracic spine

    • Breastbone (sternum)

Detailed Shoulder Anatomy

  • Additional Structures:

    • Bursa

    • Supraspinatus tendon

    • Long biceps tendon

    • Supraspinatus muscle

    • Joint capsule (internal view)

    • Shoulder labrum

    • Subscapularis muscle

Prosthetic Components in Shoulder Arthroplasty

  • Types of Prosthetics:

    • Resurfacing Hemiarthroplasty (Stemless Hemiarthroplasty)

    • Stemmed Hemiarthroplasty

    • Total Shoulder Arthroplasty (TSA)

    • Reverse Total Shoulder Arthroplasty (rTSA) or Reverse Shoulder Arthroplasty (RSA)

    • Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer (rTSA with LDTT)

Surgical Approaches for Shoulder Arthroplasty

  • Common Approaches:

    • Deltopectoral Approach:

    • Access between anterior deltoid and pectoralis major

    • Subscapularis tendon is cut

    • Superior Approach:

    • Anterior deltoid is released from the clavicle

    • Subscapularis tendon is cut approximately 1 cm proximal to its insertion, or there is a lesser tuberosity osteotomy

    • Anterosuperior Transdeltoid Approach:

    • Anterior deltoid bundle is released from the anterior edge of the acromion

    • Subscapularis tendon is spared, but long head of biceps tendon tenodesis is performed

    • Variations of these approaches may also be employed

Nerves at Risk During Shoulder Arthroplasty

  • Axillary nerve

  • Suprascapular nerve

  • Musculocutaneous nerve

Rehabilitation Post-Total Shoulder Arthroplasty (TSA)

Post-operative Days 1-4 (In Hospital)

  • Contraindications:

    • Movement:

    • No external rotation past neutral

    • No end-range for horizontal abduction, abduction/external rotation (abd/ER)

    • No active range of motion (AROM) for internal rotation (IR) and flexion (with superior approach)

    • Resistance Training:

    • No resistance training (RT)

    • No weight bearing (WB) on upper extremity

    • No heavy pushing or pulling

    • No lifting objects greater than 3 lbs

  • Physical Therapy (PT) Prescription:

    • Education on contraindications and positioning

    • AROM for elbow, wrist & hand, cervical spine

    • Pendulum exercises to tolerance

    • Passive range of motion (PROM) for flexion, abduction, IR, ER in scapular plane

    • Application of cryotherapy

Up to 6 Weeks Post-Op

  • Contraindications: (Same as above)

  • Movement:

    • No extension beyond neutral

    • No end-range for HBB, abd/ER, ER

    • No AROM for IR and flexion (with superior approach)

  • Physical Therapy:

    • Continue PROM for flexion, abduction, IR, ER in scapular plane

    • Active Assistive Range of Motion (AAROM) with therapist or pulleys: flexion (unless superior approach) and elevation in scapular plane

  • Goals by ~ Week 6:

    • 140° flexion

    • 120° abduction with no rotation

    • 30° external rotation in neutral

6 to 12 Weeks Post-Op

  • Physical Therapy:

    • Continue PROM and AAROM

    • Add AAROM horizontal adduction

    • Begin AROM: flexion, internal rotation, external rotation, pain-free elevation in scapular plane

  • Muscle Activation:

    • Sub-maximal isometric exercises in neutral, pain-free positions

    • Scapular exercises involving trapezius, serratus anterior, rhomboids, latissimus dorsi

    • Late phase: minimal resistance shoulder flexion, elevation, IR, ER

  • Contraindications:

    • No lifting objects greater than 3 lbs

    • No internal rotation resistance training (to be initiated between 9 and 12 weeks)

Ideal TSA Rehabilitation Outcome

  • Shoulder ROM Goals:

    • Flexion: 160° (target range: 140-160°)

    • Abduction: 150-160°

    • External Rotation: 40-60° in neutral

    • Internal Rotation: 70° in scapular plane and at 90° abduction

    • Full extension

    • HBB: thumb to level of L2

  • Typical Rehabilitation Length: Approximately 4 months

  • Return to Functional/Recreational Activities: Approximately 4-6 months

Reverse Total Shoulder Arthroplasty (rTSA)/Reverse Shoulder Arthroplasty (RSA) - PT Management

  • Differences from TSA:

    • No extension beyond neutral for 12 weeks (vs. 6-8 weeks)

    • No end-range horizontal abduction for 12 weeks (vs. 6 weeks)

    • No end-range internal rotation for 6 weeks

rTSA with Latissimus Dorsi Tendon Transfer (PT Management)

  • Differences from rTSA:

    • No range of motion (ROM) at all for 4-6 weeks

    • No lifting objects greater than 6 lbs for 16 weeks

    • No resistance training up to 9 weeks (vs. 6 weeks)

    • Up to 12 weeks post-superior approach

Criteria for PT Discharge (TSA, Hemiarthroplasty, rTSA)

  • Patient is able to maintain non-painful Active Range of Motion (AROM)

  • Maximized functional use of the upper extremity

  • Maximized muscular strength, power, and endurance

  • Patient has returned to functional activities

Lifelong Recommendations Post TSA and rTSA

  • ROM Exercises

  • Lifelong Restrictions:

    • For TSA:

    • Lifting objects more than 11.3 kg on operated side is restricted

    • External Rotation ROM restricted to 55° on operated side

    • For rTSA:

    • Lifting objects more than 6.8 kg on operated side is restricted

Activities Recommended Post-TSA (Healy et al., 2001)

  • Recommended/Allowed:

    • Cross-country skiing

    • Nordic track

    • Speed walking and jogging

    • Swimming

    • Double tennis

    • Low impact aerobics

    • Cycling (stationary and road)

    • Bowling

    • Canoeing

    • Croquet

    • Shuffleboard

    • Horseshoes

    • Dancing (jazz, ballroom, square)

    • Golf

    • Ice skating

  • Allowed with Experience:

    • Shooting

    • Downhill skiing

    • Football

    • Gymnastics

    • Hockey

    • Rock climbing

    • High impact aerobics

    • Baseball/softball

    • Fencing

    • Handball

    • Horseback riding

    • Lacrosse

    • Racquetball/squash

    • Skating (roller, inline)

    • Rowing

    • Soccer

    • Tennis (single)

    • Volleyball

    • Weight training

Elbow Arthroplasty

Overview

  • Prosthetic Components:

    • Semi-constrained (linked) prostheses

    • Non-constrained (unlinked) prostheses

Surgical Approaches for Elbow Arthroplasty

  • Common Approaches:

    • Posterior Approach:

    • Involves the triceps mechanism

    • Surgical Techniques:

    • Campbell

    • Van Gorder

    • Mayo Modification

    • Köcher Splitting

    • Alonso Liames Sparing

    • Mayo Reflecting

Nerves at Risk During Elbow Arthroplasty

  • Ulnar nerve (most common)

  • Radial nerve and median nerve (less likely)

Total Elbow Arthroplasty (TEA) - Post-Operative Contraindications

  • ROM Restrictions:

    • No AROM elbow extension against gravity for 6 weeks

    • AAROM/AROM in gravity-free plane generally permitted (verify with surgeon)

    • Non-constraint procedures only

    • No elbow extension combined with supination for 6 weeks

  • Resistance Training Restrictions:

    • No elbow extension exercises for 12 weeks

    • No elbow flexion exercises for 6-8 weeks

    • No wrist exercises for 6-8 weeks

Activity Restrictions Post-TEA

  • No driving for 2-3 weeks

  • No weight bearing on upper extremity for 12 weeks

  • No pushing or pulling for 12 weeks

  • No lifting objects greater than 10-15 lbs for life

  • No hobbies involving repetitive throwing for life

TEA - Post-Op Management

  • Immobilization:

    • Elbow extension splint for approximately 4-8 weeks

  • Rehabilitation Phases:

    • POD1 to Week 6:

    • AAROM to AROM for elbow, forearm & wrist

    • Elbow extension in gravity-free plane only if allowed

    • AROM cervical spine, shoulder, fingers

    • Apply cryotherapy during the rehabilitation process

    • Education regarding contraindications and positioning

    • Week 6 to 12:

    • Begin AROM elbow extension against gravity

    • Begin strength training for elbow flexion and wrist – isometric to isotonic (caution in positioning)

    • Elbow supported

    • Week 12 and Beyond:

    • Begin isotonic elbow strengthening exercises and progress to functional use

  • End of Rehabilitation Goals for Elbow ROM: Approximately 30°-130°

  • Patients unlikely to regain full extension or flexion

Reflections for Physical Therapy with Patients

  1. How much ROM/strength can I realistically aim to increase/change for in X (time)?

  2. What range does the patient need to be functional? (in the event that full ROM is not possible)

  3. Is this the most that can be achieved (based on age, type of injury, co-morbidities, etc)? (i.e., have we reached a plateau?)

  4. Am I the right professional for the needs of my patient?

References

  • Bennett JB and Mehlhoff TL (2009). Total Elbow Arthroplasty: Surgical Technique. J Hand Surg, 34A:933–939.

  • Brotzman, SB, Wilk, KE. Handbook of Orthopaedic Rehabilitation 2nd Edition, Mosby Elsevier, 2007.

  • Brukner, P., Khan, K. Clinical Sports Medicine, 3rd Edition McGraw Hill, 2006.

  • Bullock GS, Garrigues GE, Ledbetter L, Kennedy J (2018). A Systematic Review of Proposed Rehabilitation Guidelines Following Anatomic and Reverse Shoulder Arthroplasty. Journal of Orthopedic and Sports Physical Therapy, 49 (5), 337-346.

  • Cioppa-Mosca, J, Cahill, JB, Tucker, CY. Postsurgical Rehabilitation Guidelines for the Orthopedic Clinician, Mosby Elsevier, 2006.

  • Donatelli, RA. Physical Therapy of the Shoulder, Churchill Livingstone, 2004.

  • Healy, WL, Iorio, L, Lemos, MJ, (2001). Athletic activities after joint replacement. American Journal of Sports Medicine, 29, 377-388.

  • Hatzidakis AM, Norris TR, Boileau P (2005). Reverse Shoulder Arthroplasty Indications, Technique, and Results. Techniques in Shoulder and Elbow Surgery 6(3):135–149.

  • Koval, KJ, Zuckerman, JD. Handbook of Fractures, 3rd ed, Lippincott Williams & Wilkins, 2006.

  • Magee, DJ, Zachazewski, JE, Quillen, WS. Pathology and Intervention in Musculoskeletal Rehabilitation 1st Edition, Saunders Elsevier, 2009.

  • Morrey BF and Sanchez-Sotelo J (2011). Approaches for elbow arthroplasty: how to handle the triceps. J Shoulder Elbow Surg, 20, S90-S96.

  • Netter, F. (2006) Atlas of Human Anatomy, 4th Edition. W.B. Saunders.

  • Rockwood, CA, Green, DP. Fractures in adults 6th ed vol 1 & 2, Lippincott Williams & Wilkins, 2006.

  • Nove-Josserand L, Clavert P (2018). Glenoid exposure in total shoulder arthroplasty. Orthopaedics & Traumatology: Surgery & Research 104, S129–S135.

  • Sanchez-Sotelo, J., (2011). Total elbow arthroplasty. Open.Orthop J 5, 115-123.

  • Total shoulder arthroplasty. Physiopedia. Retrieved online October 17, 2018, available at: https://www.physio-pedia.com/TotalShoulderArthroplasty.

  • TEA protocols (retrieved online in 2009):

    • www.brighamandwomens.org/RehabilitationServices/Physical%20Therapy%20Standards%20of%20Care%20and%20Protocols/Shoulder%20-%20Total%20Shoulder%20Arthroplasty%20protocol.pdf

  • TSA protocols (online link retrieved in 2009): https://www.brighamandwomens.org/RehabilitationServices/Physical%20Therapy%20Standards%20of%20Care%20and%20Protocols/Shoulder%20- %20Total%20Shoulder%20Arthroplasty%20protocol.pdf.