JOINT REPLACMENTS: SHOULDER ARTHROPLASTY Flashcards
SHOUDLER ARTHROLASTY
INDICATIONS:
- Painful shoulder conditions like Arthritis (OA/RA, post traumatic arthritis)
- Severe fractures
- Failure of conservative Mx
- Rotator cuff tear Arthropathy
- Avascular necrosis (Osteonecrosis)
- Failed previous shoulder replacement surgery
SHOULDER ARTHROPLASTY
TYPES
- Total shoulder replacement
- Shoulder hemiarthroplasty
- Reverse TSA
SHOULDER ARTHROPLASTY
TYPES: REVERSE TSA
- Indications: Irreparable rotator cuff damage
- The rotator cuff tendons maintain the humeral head joint stability within the centre of the glenoid during elevation of the extremity.
- In reverse TSA- deltoid tensioned to maintain above
SHOULDER ARTHROPLASTY
COMPLICATIONS
• Infection- Diabetes, RA, Lupus, Previous surgery
• Prosthesis problems – Glenoid/Humeral component loosening
• Dislocation
• Excessive wear
• Nerve Injury – Neuropraxia (Rx conservative)
• Deltoid dysfunction- Delto-pectoreal approach better
• GH instability- Superior (Rot Cuff tear)
- Ant (Disfunction Ant Deltoid, Subscap)
- Post (Retroversion Glenoid)
- Inf ( Humeral length after #)
• Fractures – Peri-operative, Intra or Postoperative. Delay Rehab
SHOULDER ARTHROPLASTY
Total shoulder arthroplasty
• Sling 4/52
• Sleep with sling 4/52
• Deltopectoral approach
• Overall recovery 1-2 yrs
• Passive – active – stretching – strengthening
• Every pt is different. Progress according to pt
functional requirements and presentation
• Avoid combination of ER and Abd above 80°
• Patient education NB
SHOULDER ARTHROPLASTY
Reversed Total shoulder replacement
• Abduction sling 4/52
• Sleep with sling 4/52
• Flexion in scapular plane to 90°
• No abduction – strain ant of shoulder
• No internal rotation 6/52 to prevent dislocation
• Important concepts for rehab:
Joint protection
Deltoid function
Establish appropriate function & ROM expectations
• Risk of dislocation - Avoid Int Rot, Add and Ext for 3/12
SHOULDER ARHTROPLASTY
Management
- 4 phases:
- Phase I – Immediate Post Surgical (0-4 weeks)
- Phase II – Passive and Active Range of Motion (When goals are achieved Phase I or 4-6)
- Phase III – Active Range of Motion & Mild-Moderate strengthening (week 6-12)
- Phase IV – Strengthening and optimal function (12 weeks beyond)
SHOULDER ARTHROPLASTY
Precautions:
- Sling for 4/52. Only removed for bathing, getting dressed and exercises
- While lying/sleeping elbow should be supported by a pillow or towel. Patient should be able to see the elbow. To avoid shoulder extension.
- No lifting, pulling or pushing with the operated shoulder
- No lifting anything heavier than a coffee mug
- No supporting body weight
- Keep incision clean and dry for 2/52
- No AROM shoulder
- No Int Rotation 6/52. No combination of Int Rot, Ext and Add
- No excessive stretching or sudden movements
- No driving until of all narcotic pain medication
SHOULDER ARTHROPLASTY
goals of Phase I – Immediate Post Surgical (0-4 weeks):
Goals:
• Allow healing of soft tissue and maintain integrity of replaced joint
• PROM of shoulder
• AROM of elbow/wrist/hand
• Scapula setting and posture
• Diminish pain and inflammation
• Prevent muscular inhibition
• Independent with ADL (dressing, bathing, etc.) with modifications.
• HEP
• Cryotherapy (continious first 72h, then 5 x per day 20min)
• Patient educations and Precautions
SHOULER ARTHROPLASTY
Patient education
- Sling – Correct position and how long
- Pillow to support elbow after surgery
- Arm might feel ”dead” after surgery due to nerve block
- Circulation drills
- Painful arm always gets dressed first, undressed last
- No AROM. Don’t try to see if Dr did a good job.
- Relax shoulder girdle and maintain good posture and teach scapula setting
- HEP
- Cryotherapy (continious first 72h, then 5 x per day 20min
- No pain, does not mean that the arm is healed. It takes at least 6/52. Stick to exercises received from Physio.
- No driving 4/52
- No lifting, pushing or pulling with operated arm
SHOULDER ARTHROPLASTY
Criteria for progression to the next phase II:
- Tolerates PROM program
- At least 90° PROM flexion
- At least 90° PROM abduction.
- At least 45° PROM ER in plane of scapula
- At least 70° PROM IR in plane of scapula
- Be able to isometrically activate all shoulder, RC, and upper back musculature
SHOULDER ARTHROPLASTY
Goals of Phase II – Passive and Active Range of Motion (Weeks 4-6):
Goals: • Continue PROM progression/ gradually restore full passive ROM • Progress to AAROM and AROM • Gradually restore Active motion • Control Pain and Inflammation • Allow continue healing of soft tissue • Do not overstress healing tissue • Re-establish dynamic shoulder stability
SHOUDLER ARTHROPLASTY
PRECAUTIONS Phase II – Passive and Active Range of Motion (Weeks 4-6):
• As for Phase 1 • Sling should be weaned and used as needed for sleeping. • Begin shoulder AROM against gravity. • No heavy lifting of objects (no heavier than coffee cup) • No supporting of body weight by hands and arms • No sudden jerking motions
SHOULDER ARTHROPLASTY
Criteria for progression to next phase III:
- Tolerates P/AAROM, isometric program
- Has achieved at least 120°-140° PROM flexion
- Has achieved at least 120° PROM abduction.
- Has achieved at least 60°+ PROM ER in plane of Scapula
- Has achieved at least 70° PROM IR in plane of Scapula
- Be able to actively elevate shoulder against gravity with good mechanics to 100°.
SHOULDER ARTHROPLASTY
GOALS & PRECAUTIONS of Phase III – AROM & Mild-Moderate strengthening (week 6-12)
Goals:
• Gradual restoration of shoulder strength, power, and endurance
• Optimize neuromuscular control
• Gradual return to functional activities with involved upper extremity
Precautions:
• No heavy lifting of objects (no heavier than 3kg.)
• No sudden lifting or pushing activities
• No sudden jerking motions
