Reverse Total Shoulder Arthroplasty

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Reverse Total Shoulder Arthroplasty

• Kate Dunn
• DPT 751
• July 12, 2010

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Objectives

• - To understand the surgical procedure of a rTSA
• -To apply current evidence in the development of
  an POC for rTSA
• -To describe the overall physical therapy
  management of a patient who underwent a rTSA
• -To incorporate complex impairments of an
  individual with a rTSA that has PD

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What do we already know?

• -TSA for patients with advanced GH joint
  pathology (OA, RA, RCA)
• -persistent pain and loss of function despite
  conservative management1

• -Hemiarthroplasty for patients with either
  severe cuff pathology or irreparable cuff1
• -replacement of humeral head

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What is a rTSA?

• -Approved by the FDA in 20041
• -Reverses the orientation of the
• shoulder girdle
• -Glenoid fossa gt glenoid base plate glenosphere
• -Humeral head gt humeral shaft concave cup
• - Increases deltoid moment arm to enhance the
  torque
• - Enhanced mechanical advantage of deltoid
  compensates for deficient RC

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Drake GN, OConnor DP, Edwards TB. Indications
for reverse total shoulder arthroplasty in
rotator cuff disease. Clin Orthop Relat Res.
20104681526-1533.
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Why choose a rTSA?

• Indications1,3
• -GH joint arthritis associated with irreparable
  RCT
• -Complex humeral fracture
• -Revision of failed traditional TSA
• -Absent RC
• -Over the age of 70yrs

• Contraindications3
• -Advanced glenoid destruction
• -Severe lesions of deltoid
• -Axillary nerve palsy
• -Patient with expectation of high functional
  return

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Surgical Outcomes

• -Post-op complications3
• -Hardware instability or dislocation (abd with
  ER)
• -Nerve damage
• -Infection
• -Hematoma
• -Intra-operative fracture
• -Complication rates are 2-681

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Review

• -What are some indications for a rTSA?
• -GH joint arthritis with irreparable RC
• -Revision of failed TSA or hemiarthroplasty
• -Over the age of 70 years
• -Who is not appropriate for a rTSA procedure?
• -Glenoid destruction
• -Deltoid that is not intact
• -Patient wanting high functional return
• -What is the most common surgical complication?
• -hardware instability or dislocation

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CASE DESCRIPTION
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Patient Description

• -76y/o female
• -Referred to PT s/p right rTSA (05/14/10)
• -Previous injury fall 07/16/09
• -Previous sx RCR Sept 2009
• -PMHx Parkinsons Disease (1997), CVA (1996),
  PAD, breast cancer (R mastectomy), memory loss
• -Social hx retired, does not drive

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Past Medical History

• -Parkinsons Disease progressive degeneration of
  dopamine cells imbalance of neurotransmitters
  in basal ganglia
• -Body impairments tremors, rigidity, akinesia,
  postural instability
• -FORCE CONTROL (impaired amplitude of movement)
• -Rotator Cuff Repair
• -Sept 2009
• -Repaired supraspinatus infraspinatus
• -Repair sites failed

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Surgical Report

• -Arthritic changes of the humeral head
• -Significant retraction of cuff musculature
• Impression irreparable pathology without
  replacement
• -General anesthesia with an interscalene block
• -Subscapularis released
• -No supraspinatus, biceps tendon, infraspinatus
  attachments found
• -Capsule released, labrum debrided
  circumferentially

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Examination

• -Completed 2.5wks post-op
• -Subjective right shoulder, elbow hand pain
  (5/10), N T into fingers
• -PIPs difficulty washing combing hair,
  difficulty with household chores, shoulder pain
• -Patient goals get back to doing basic household
  chores, be able to move arm without pain
• On 1L of O2 at night

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Examination

• -Observation
• -Rounded shoulders
• -FHP
• -Increased thoracic kyphosis
• -Reverse scapular rhythm
• -Scar mildly adhered
• -Neuro Screen
• -Intact to LT bilaterally
• -Postural instability
• -B UE pill rolling tremor
• -Jaw tremor
• -Decreased facial expressions

• -PROM
• 90 flex
• 60 abd
• 11 ER
• -5 elbow ext
• -Palpation
• -Tender over anterolateral incision mid belly
  of biceps
• -Quick DASH 72
• (0-100, higher score indicates more disability)

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Evaluation

• -Initial Hypothesis Patient presents with
  decreased ability to perform ADLs and functional
  activities secondary to decreased right shoulder
  ROM strength, increased shoulder pain, postural
  instability, and bilateral UE rigidity tone.
• -APTA Guide Patterns
• -4H impaired joint mobility, motor function,
  muscle performance, and ROM associated with joint
  arthroplasty
• -5E impaired motor function sensory integrity
  associated with progressive disorders of the CNS

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Prognosis

• -Good to fair prognosis for return to (I)
  functioning
• -Progress may be limited by
• -Severity of PD (rigidity, tremors, postural
  instability, akinesia)
• -Previous shoulder surgery
• -Age of patient _at_ time of current surgery
• -Cognitive functioning
• -Compliance with POC/ HEP

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Intervention

• -Frequency 3x/wk for 6 weeks to date (3x/wk for
  10wks)
• 1- Pt education precautions, sling use
• 2- Transfer gait training
• 3- Joint/ soft tissue mobilizations
• 4- Ther-ex for ROM
• 5- Ther-ex for strengthening
• 6- Modalities for pain edema management
• -Things to remember
• -Only deltoid teres minor are intact
• -High risk for anterior/inferior subluxation
• -Patient has difficulty with movement initiation
  amplitude of movement
• -Avoid dual tasks (BG controls one, attention on
  the other)

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Joint Kinematics
-TSA convex humeral head moving on concave
glenoid fossa (opposite direction) superior
rotation, inferior glide

• -rTSA concave humeral cup moving on convex
  glenosphere (same direction)
• superior rotation, superior glide

Boudreau S, et al. JOSPT 200737734-743.
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Patient Education

• - Shoulder mechanics function will have some
  limitations when compared to unaffected shoulder
• - Establish appropriate functional ROM
  expectations

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Precautions

• -Sling 4 weeks
• -Potential for instability due to design
• -No active IR or extension for 6 weeks1
• -Pt must be able to visualize elbow while lying
  supine
• (no hyperextension)
• -No resisted IR or extension for 12 weeks
• -No IR, adduction, extension (tucking in shirt)
  for 12 weeks

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Goals

• -STG 5 weeks
• 1-MinA with established HEP
• 2- Decrease in pain by 50

• -LTG 10 weeks
• 1- Able to wash comb hair with R UE
  independently
• 2- R UE AROM within 75 of L UE AROM
• 3- Decreased Quick-DASH by 50

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JOSPT 2007 rTSA Protocol

• -Dislocation precautions for 12 weeks post-op
• -no combined add/IR/ext (tucking in shirt)
• -no GH joint extension beyond neutral
• -Phase 1 Joint Protection (day 1 to week 6)
• -joint protection, PROM, edema/pain management
• -PROM flex 120, ER to tolerance, IR lt50
• -AROM resisted exercises of involved
  elbow/wrist/hand
• -Criteria to move to next phase
• -Pt tolerate PROM of shoulder
• -Pt is able to isometrically activate each
  component of the deltoid scapular muscles

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JOSPT 2007 rTSA Protocol

• -Phase 2 AROM, Early Strength (weeks 6-12)
• -Gradual AROM, control pain inflammation,
  re-establish dynamic stability
• -Begin AROM when gleno-humeral rhythm is
  restored
• -Flex, abd, ER isotonic strengthening
• -Criteria to move to next phase
• -Improving functional ability
• -Pt is able to isotonically activate each
  component of the deltoid scapular muscles

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JOSPT 2007 rTSA Protocol

• -Phase 3 Moderate Strengthening (weeks 12-16)
• -Enhance functional use, increase
  strength/power/ endurance
• -Begin gentle resisted flexion/abduction (5lbs)
  in standing
• -Phase 4 Independent HEP (months 4)
• -3-4x/wk
• -strength gains, return to functional/recreationa
  l activities
• -Criteria for discharge
• -Pt is able to maintain pain-free AROM with
  proper shoulder mechanics
• -ROM 80-120 of flexion, 30 of ER

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Outcomes ROM pain
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Progress at 6 weeks

• -PIPs
• 1- Difficulty washing combing hair
• 2- Difficulty with household chores
• 3- Shoulder pain
• -Non- PIPs
• 1- Swinging arms during gait MET
• 2- Right arm strength
• -STG 5 weeks
• 1-MinA with established HEP MET
• 2- Decrease in pain by 50 MET
• -LTG 10 weeks
• 1- Able to wash comb hair with R UE
  independently ?
• 2- R UE AROM within 75 of L UE AROM ?
• 3- Decreased Quick-DASH by 50 72 gt
  52
• (MCID15pts)5

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Discussion

• -Improvement in passive range of motion, pain
  scores, and functional outcome scores
• -Pt has met all STG, progressing towards LTG
• -Pt is progressing consistently, but may reach
  plateau due to comorbidities
• -Primary focus needs to be on patient education
  and precautions, high functional return is
  unlikely
• -No setbacks in POC, compliance with HEP is
  questionable

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Frankle M, Siegal S, Pupello D, et al. J Bone
Joint Surg. 2005.

• -60 pts (mean age 70yrs) with glenohumeral
  arthritis associated with severe RC deficiency
  treated with rTSA, followed for minimum of 2 yrs
• -2 groups previous RC repair, no previous
  surgery
• -Intervention PROM started day 2, sling worn for
  4 weeks, AAROM began _at_ 4wks, AROM started _at_ 8wks,
  resisted exercises _at_ 12wks
• -All measures improved significantly (plt0.001)
• -ASES increased 33.9pts
• -VAS decreased 4.1pts
• -ROM flexion increased 50, abduction 60, ER
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• -No significant difference between 2 groups in
  terms of demographic data, preoperative scores,
  post-op VAS scores, ROM
• -Device failed in 7 pts, requiring revision _at_
  average of 21.4 months (insuffient bone density,
  glenoid loosening)
• -Results suggest that arthroplasty with rTSA may
  be a viable treatment for pts w/ GH arthritis a
  massive RC tear, future studies need to determine
  the longevity of the implant

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Boileau P, et al. J Shoulder Elbow Surg. 2006

• -45 pts w/ rTSA
• -21 massive irreparable RCT associated with
  arthritis treated
• -5 complex humeral fracture with arthritis
• -19 failure of revision arthroplasty
• -Mean follow-up was 40 months
• -Outcomes ROM , VAS pain scale, Constant
  functional score
• -Intervention sling for 6 weeks, pendulum
  exercises started day 2, physical therapy _at_ wk 3,
  no abd _at_ 90 with ER
• -Results all groups showed significant increase
  in flexion by 66, no significant change in ER or
  IR
• -rTSA can improve function and restore active
  flexion in patients with cuff-deficient shoulders
• -rTSA should not be offered to a young
  individual who wants a normal shoulder or who
  will demand more out of the prosthesis that it
  was designed to do

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Koch et al. J Shoulder Elbow Surg. 1997

• -15 TSA in patients with PD
• -Mean follow-up 5.3yrs
• -Results significant improvement
• -Pain
• -Poor functional results
• -Duration of PD, rigidity, arm swing rapid
  alternating movement scores were not found to be
  significant predictive factors
• -Increased failure rates of TSA in PD- increased
  muscle tone, severity of tremor, increased
  mortality rate of 1.6 to 3x that of general
  population
• -Increase in subluxation rates associated
  complication- result of increased tone of
  shoulder girdle musculature, difficulties w/
  rehab, stretching of RC-capsule arthrotomy site
• -Similar results found by Kryzak, et al in 2009

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How does evidence affect my intervention?

• -Enhance deltoid function in absence of RC
• -Biofeedback to assist pts in learning
  recruitment strategies1
• -PT started _at_ day 2 or 3rd week, no significant
  difference in LT outcome
• -LTG may be limited by severity of PD (tone,
  rigidity, akinesia, dementia)
• -Use rhythmic cues to increase cadence of
  activity
• -Amplitude of movements think BIG concept9
• -HEP compliance issue suggest 5x/wk for 20min1

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Questions?
THANK YOU!
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References

• 1. Boudreau S, Boudreau E, Higgins LD, Wilcox RG.
  Rehabilitation following reverse total shoulder
  arthroplasty. JOSPT 200737734-743.
• 2. Drake GN, OConnor DP, Edwards TB. Indications
  for reverse total shoulder arthroplasty in
  rotator cuff disease. Clin Orthop Relat Res.
  20104681526-1533.
• 3. Volpe S, Craig JA. Postoperative physical
  therapy management of a reverse total shoulder
  arthroplasty (rTSA). Ortho Practice.
  20072111-17.
• 4. Boileau P, Watkinson D, Hatz AM, Hovorka I.
  Neer Award 2005 The Grammont reverse shoulder
  prosthesis Results in cuff tear arthritis,
  fracture sequelae, and revision arthroplasty. J
  Shoulder Elbow Surg. 200615527-540.
• 5. Beaton DE, Katz JN, Fossell AH, et al.
  Measuring the whole or the parts? Validity,
  reliability and responsiveness of the
  Disabilities of the Arm, Shoulder and Hand
  outcome measure in difference regions of the
  upper extremity. J Hand Ther. 200114128-146.
• 6. Frankle M, Siegal S, Pupello D, et al. The
  reverse shoulder prosthesis for glenohumeral
  arthritis associated with severe rotator cuff
  deficiency. J Bone Joint Surg. 2005871697-1704.
• 7. Koch LD, Cofield RH, Ahlskog JE. Total
  shoulder arthroplasty in patients with
  Parkinsons Disease. J Shoulder Elbow Surg.
  1997624-28.
• 8. Kryzak TJ, Sperling JW, Schleck CD, Cofield
  RH. Total shoulder arthroplasty in patients with
  Parkinsons Disease. J Shoulder Elbow Surg.
  20091896-99.
• 9. Farley BG, Koshland GF. Training BIG to move
  faster the application of the speed- amplitude
  relation as a rehabilitation strategy for people
  with Parkinsons Disease. Exp Br Res
  2005167462-467.