rsa - amazon web servicesrtsa.s3.amazonaws.com/rtsa ppt slides.pdf · shoulder tissue 4-12 weeks...

7/14/2014

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Reverse Total Shoulder ArthroplastyOptimizing 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

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Shoulder Arthroplasty HistoryTotal

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 RTSATraditional Total Shoulder

Arthroplasty(Total, TSA)


(Reverse, RSA or RTSA)


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

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Reverse Total Shoulder Arthroplasty Indication

Massive Irreparable RC TearCuff 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 2012. A Systematic Approach to Shoulder Rehabilitation. Human Performance and Rehabilitation Centers, Inc. Columbus GA.

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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

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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

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=vuTjv028kSSAwM&tbnid=3YpCrDTg2slwDM:&ved=0CAUQjRw&url=http://www.orthopaedictreatment.co.uk/shoulder/sub17.asp&ei=crsbU9qWNoONygGnloH4Dg&bvm=bv.62578216,d.aWc&psig=AFQjCNFy5-_HqSSumrB7UzEwjmjHmwrYWQ&ust=1394412228427398

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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

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DeltoPectoral Incision

humerus to prevent shoulder extension reducing anterior shoulder tension and

support under forearm to support the weight

http://strumentistaso.altervista.org/Ortopedia/frattura-testa-omerale.html

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


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Prep and Ream Humeral Canal


A Little BLUE Glue

Cementing prevents subsidence


Humeral Component Insertion


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Glenoid Reaming and Glenosphere Prep


Glenosphere Insertion


Humeral Spacer Trial / Stability Test


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Subscapularis Muscle RepairedIf 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


RSA PRECAUTIONS

RSA IMPLANTATION HAS PRECAUTIONS ASSOCIATED WITH BONE FIXATION, INFECTION, AND SOFT TISSUE HEALING

Arthrokinematics ● PROM ● Notching

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ArthrokinematicsThe Story of the Golf Ball and the Tee

http://bleacherreport.com/articles1499870-dwight-howards-shoulder-injury-why-his-torn-labrum-may-linger-until-

offseason

• 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

• Roll and glide in the same direction

• Increased translation

• Reduces PROM available

• Humeral component can abut scapula inferiorly (notching) or superiorly (scapular spine fracture)

The Story of the Golf Ball and the Tee

Notching

• Edge of the humeral component abuts the scapular neck

• Limits PROM

• Cause: Translation

J Bone Joint Surg Br 2004;86[3]: 388-395.

http://bleacherreport.com/articles1499870

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Notching

http://shoulderarthritis.blogspot.com/2012/04/radiographic-analysis-of-effects-of.html

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. 2013 Feb;22(2):179-87.

http://shoulderarthritis.blogspot.com/2012/04/

http://shoulderarthritis.blogspot.com/2012/04/

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RTSA PROM

PASSIVE MOTION IS LIMITED BY BONY BLOCK. POTENTIAL OF 120-145 DEGREES OF GLENOHUMERAL ELEVATION MAXIMUM.

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 #

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Limit external rotation to 20⁰, 4 weeksNo combined abduction and external rotation, 6 weeks

No internal rotation (IR) resistance, 12 weeks

Subscapularis Precautions If Repaired

Gaunt & McCluskey 2012

Teres Minor May Be Intact

If present, active external rotation is presentIf absent, only passive external rotation is possible

Beware: Teres minor can also be repaired by

latissimus dorsi transfer

Gaunt & McCluskey 2012

RTSA PRECAUTIONS

PROTECT REPAIRED MUSCLES/TENDONS

FROM TENSION FOR 6 WEEKS

FROM RESISTANCE FOR 12 WEEKS.

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Elevation By The Deltoid Muscle

flickr.com


Prosthetic shape and surgical procedure increase the effectiveness of the deltoid for elevation.

• Medialized joint axis

• Distalized deltoid insertion


“Medialized joint axis”

Increases deltoid force by lengthening the deltoid’s lever arm.

Yellow arrow is a little longer than the orange

arrow.

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“Distalized deltoid insertion”

Stretches the deltoid by making the proximal

humerus a little longer.

Yellow arrow is a little longer than the orange

arrow.


http://www.jointforlife.com/services-shoulder-arthroplasty.html

F1 x L1 < F2 x L2

ELEVATION BY THE DELTOID

RTSA PROVIDES A MECHANICAL ADVANTAGE TO THE DELTOID…BECAUSE THERE IS NO ROTATOR CUFF.

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Rehabilitation Program

1-2 Weeks After RSA

Conceptual Model

Precautions with ADLs

Pain control

Sling and supportPendulums

Table slides

Bony and Soft Tissue Healing

1-2 Weeks After RSA

Patient EducationSling and support reduce pain!

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

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nationalbraceandsplint.com

1-2 Weeks After RSA

Patient EducationSling and support 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 EducationSleeping Position is Key

Reclined (vs supine) is more comfortable for the first 12 weeks: support behind upper arm (humerus) and under forearm

Scrapetv.com

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1-2 Weeks After RTSA

Patient EducationMobility 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!?


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


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

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Rehab Program

Gentle passive motion

Motor relearning

Wean out of slingProgressive

AROM


Rehab Program

Wean out of sling


Weaning Out of The Sling

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Rehab Program

Gentle passive motion


4-12 Weeks After RTSAGentle 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


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.~

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Pearl Video

PROM : Clinical Observation

Conclusions:

• PROM gained by 8-10 weeks post-operatively

• AROM is much slower, continues to improve for the next year or more…TBA

Rehab Program

Motor relearning


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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

http://www.freeimageslive.co.uk/free_stock_image/checkersjpg


Activity Journal

Charts progress for outcomes and motivation

Allows you to correlate pain and activity

Handy for documantation

http://lauraberry.wordpress.com/2008/07/02/journal-vs-diary/

Rehab Program

Progressive AROM


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Shoulder AROM ExercisesThoughtful Use of Gravity

The shoulder is a 3rd 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”s4. All the above with 1# can of vegetables

5. Prone TYI6. Wall slide and wall slide/lift off

(Wall slide liftoff combines high deltoid excursion and scapular depression, very challenging.)

4-12 Weeks After RTSAEXERCISES 4x / Day

True flexion10x 10 seconds

Posterior tissue stretch

Instructions

• 10x 10 seconds

• Elbows extended

• Close to ears

• Targeting posterior tissue

• Gravity assisted after 90 degrees

• Scapular depression

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4-12 Weeks After RTSAEXERCISE 4x / Day

Hammock stretch5 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 RTSAEXERCISE 4x / DayElevation

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 RTSAEXERCISE 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

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AROM Expectations By Diagnosis

CTA Massive RCT RAFixed

Dislocation

OAPost-

TraumaticFracture

132 161 60 115 115142

CTA: Cuff Tear Arthropathy, n=63Massive RCT: Massive Irreparable Rotator Cuff Tear, n=10RA: Rheumatoid Arthritis, n=6Fixed Dislocation: n=8OA: Post-Traumatic Arthritis: n=20Acute Fracture: n=13


Elevation AROM : Clinical Observation

DATA, Cohort Summer 2013

0

20

40

60

80

100

120

140

7 8 9 10 11 12

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

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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. 2012 Nov 7;94(21):1996-2000.

AROM Expectations

http://thewondersofchordata.wikispaces.com/Okapi

Rehab Program

Discuss

restrictions

Modify / adapt activities

Emphasize continued exercise program

Light resistive exercises

12 + Weeks After RTSA

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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 VisitsExercise 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 visitsExercise 1-2x / Day

Lightest resistance Instructions

• 10-20 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

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THERAPY VISITS: TARGET PER PHASE

1-2 Visits: Instruct in precautions use of sling, pendulums and table slides1-2 Visits per week: Passive range of motion, evaluation/progression of home exercise program1-2 Visits per week: Progress through active range of motion gravity reduced to elevation against gravity1-2 Visits: Theratubing or gym program instruction

Outcomes

OutcomesExcellent / Good Subjective Results By

Diagnosis

CTA Massive RCT RAFixed

Dislocation

OAPost-

TraumaticFracture

75% 80% 50% 100% 66% 50%

CTA: Cuff Tear Arthropathy, n=63Massive RCT: Massive Irreparable Rotator Cuff Tear, n=10RA: Rheumatoid Arthritis, n=6Fixed Dislocation: n=8OA: Post-Traumatic Arthritis: n=20Acute Fracture: n=13


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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. 2013 Jan;22(1):38-44.

Outcomes

Return to golf with surgeon approval.

Flickr.com

Complications

where.ca.com

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Complications

• Infection- P. Acnes

• Fixation failure

• Dislocation

• Acromial fracture

• Scapular spine fracture

Complications

Infection

The customary signs….

Opening (dehiscence) or pimple on the incision.

Solution: Keflex, Bactrim

Complications

Fixation failure

Sign: Painful gentle PROM, unusual joint noises, sudden loss of ROM

Solution: Surgical

Depts.washington.edu

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Complication

Dislocation

Signs: Clunk with passive motion, pain, inability to perform active motion.

Solution: Surgical

Complication

Acromial fracture

Deltoid pull off

Sign: Tenderness at acromion

Solution: Rest, return to sling

radiologycasereprots.net

Complication

Scapular spine fracture

Sign: tenderness

posterior AC joint

Solution: rest

shoulderarthritis.blogspot.com

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Thank [email protected]

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