2. Reverse Total Shoulder
Arthroplasty
Joint replacement
procedure where the
ball and socket
articulations of the
glenohumeral joint are
reversed
Received FDA approval
for use in the US in 2004
3. Prosthesis design alters the
center of rotation by moving
it medially and inferiorly
This increases the deltoid
moment arm and deltoid
tension
Enhanced mechanical
advantage of deltoid
compensates for the deficient
rotator cuff
Deltoid becomes the primary
elevator of the shoulder joint
4. 1. Achieve functional range of motion while allowing
for adequate soft tissue healing
2. Maximize use of upper extremity for daily activities
at or above shoulder height
3. Educate patient to safely manage their rehabilitation
and use of their arm throughout post-operative
rehabilitation
5. Glenohumeral joints with severe arthropathy and
severe rotator cuff deficiency or a joint in which a
previous TSA has failed (also with cuff deficiency)
Joint must be structurally and anatomically suited to
receive device
Cementless metaglene component
Functional Deltoid
6. Any active infections be it local or systemic
Inadequate bone density to appropriately support the
new prosthesis
Severe deformity
Muscle, nerve, or vascular disease
Obesity, drug abuse, mental incapacity
7. Osteoporsis or poor bone stock for acceptance of
prosthesis
Metabolic disorder or systemic pharmacological
treatments leading to progressive deterioration of
bone support for the implant
e.g. DM, steroid therapies, immunosuppressive
therapies, etc.
Hx of general or local infections
Deformities leading to impaired fixation/positioning
of implant
8. Tumors of the supporting bone structures
Allergic reactions to implant materials
e.g. bone cement, metal, polyethylene
Tissue reactions to implant corrosion or debris due to
wear
Disabilities of other joints
9. Any change in position of prosthesis
Any infection, loosening
Temporary inferior subluxation which will usually
diminish as muscle tone is regained
Cardiovascular disorder
e.g. thrombosis, pulmonary embolism, MI
Hematoma and/or delayed healing
Pneumonia
Subluxation/dislocation of replaced joint
10. Humeral Components:
1. Epiphysis: Upper part of the
prosthetic humeral stem
2. Diaphysis: Lower portion of the
humeral stem
3. Polyethylene Cup: Becomes the
socket of the new ball & socket joint
Glenoid Components:
1. Metaglene: Specially coated metal
plate that is attached to the glenoid
fossa with screws
2. Glenosphere: Half globe metal
piece that is attached to the
metaglene
11. Delto-pectoral
Incision begins inferior to the clavicle & extends 1 cm
lateral to the coracoid tip
Advantages:
a) More traditional & very familiar to most
surgeons
b) Allows clear view of the glenoid & therefore
facilitates accurate implantation of the
glenoid components of the prosthesis
c) Minimizes surgical trauma to the anterior
deltoid
d) Easier identification of the axillary nerve
e) Good for revision surgery
Disadvantages:
a) Subscapularis is incised & repaired (if
possible) following implantation
a) Some have reported higher rates of
dislocation
12. Superior lateral
Incision begins at the level of the
AC joint & extends 4cm inferiorly
Advantages:
a) Subscapularis muscle is not
incised
a) Lower rates of dislocation
Disadvantages:
a) Limited visualization leading to
less ideal component
positioning
b) Decreased external rotation
postoperatively (compared with
the deltopectoral approach)
c) Deltoid muscle is disrupted
13. Anterosuperior
Anterior deltoid is divided from the
anterior edge of the acromioclavicular
arch, allowing exposure to the glenoid
for glenosphere implantation
Advantages:
a) Ease of axial humerus preparation
b) Quality of exposure of the glenoid
c) Increased post-op stability as
compared with the deltopectoral
approach
Disadvantages:
a) Disrupts the deltoid muscle
b) Risk of inaccurate glenoid
positioning
c) Axillary nerve palsy
14. Latissimus Dorsi (LD) Tendon Transfer
For cases where the Teres Minor is
deficient
LD tendon is transferred to the top
& back of the humeral head
LD is well suited for transfer due
to:
a. Large surface area
b. Good strength
c. Good vascularity
LD: Humeral extensor → Humeral
stabilizer with an external rotation
moment
If subscapularis function is
deficient, the procedure is of
questionable benefit & probably
should not be used
15. The Approach Resection of
humeral head
Diaphyseal
Preparation
Preparation of
the Glenoid
Insertion of
Metaglene
Glenosphere
Placement
Insertion of
Humeral Implant
16. “Reverse Total Shoulder Arthroplasty – from the Most to
the Least Common Complication”
The most frequent complication is Scapular Notching
Erosion of the scapular neck related to impingement by
the medial rim of the humeral cup during ADD
Pre-Op findings associated w/ Scapular Notching
RTC Arthropathy
Fatty Infiltration of Infraspinatus
Narrowed Acromiohumeral Distance
Superiorly Oriented Glenoid
19. Precautions
NO extension past neutral x6 weeks
o At 6 weeks progress 10° per week into extension with arm at 15-30° abduction
NO combined humeral IR and extension x12 weeks
o Tucking in shirt or bathroom personal hygiene with operative arm are specifically
dangerous activities
NO horizontal Adduction past neutral x6 weeks
o At 6 weeks progress 10° per week into with AROM. No overpressure
Avoid “cocking position” or “throwing position” of 90° abduction with end
range ER
If subscapular repair then ER will be limited x6 weeks with specifics from
surgeon
Post-operative brace/sling with abduction pillow should be worn at all
times x4 weeks and then progressive weaning from device based on
patient tolerance.
20. Goals of Rehabilitation
Focus should be on:
o Full ROM in scaption progressing then to flexion and
abduction
o Shoulder stability
o AAROM in scaption, flexion, and abduction progressing to
AROM as patient tolerates
o Scapular neuromuscular control and stability
o Realize that ER will be and is expected to be very weak. Do
not overload this tissue as likely the only remaining
external rotator is teres minor.
21. Acute Care Therapy (Days 1-4)
Begin PROM supine and in scapular plane to 90° keeping
elbow bent
ER in available range with arm in 30° abduction and forward
flexion (30-30 position)
o Typically 20-30°
Gripping and hand dexterity
Wrist and Elbow AROM 4-5x daily
3 point pendulums/Codman’s (front-back-horizontal
abduction) PROM and AROM
Neck ROM and stretching to trapezius and levator scapulae
Brace/sling education and management
OT evaluation for dressing may be indicated at this time
22. Outpatient Therapy Phase I (Day 10-21)
PROM in scaption, flexion and abd to 120°. No overpressure at end range.
o Limit ER to 45° and perform at 30-30 position
AAROM pulleys with focus on scapular plane but also flexion and
abduction
o AAROM using non operative hand
Deltoid and shoulder isometrics – submaximal
o Recommend use of theraband with patient positioned in desired plane and moving
away from anchor point of theraband.
Gentle resisted exercise of elbow, wrist and hand
AROM in scapular plane working from gravity reduced position to full
gravity/AROM
o Continue AROM 3 point pendulums
o Consider ball on mat table pendulums
Scapular AROM – scapular clocks
UE weight bearing stability exercises (limit weight bearing to 25%)
o Examples include mat UE walking in flexion/scaption, “window washing”, etc.
23. Phase II (3 – 6 weeks)
Continue above where deficits persist
PROM working to 150° scaption, flexion and abduction
o Continue to limit ER to 45° and perform at 30-30 position
AROM working to decrease substitution patterns
UBE/Arm bike – ensuring no extension past neutral and providing pt
has motion to allow. Keep rotation neutral
Isometric push downs progressing to light resistance
o Goal is to initiate scapular depression and scapular stability
Shoulder stability exercises progressed to include
o Alternating isometrics (sub max)
o Ball on wall cross and circles
o Ball on wall stability with therapist perturbations
Progress scapular stability to include rows (NO humeral extension)
Y-T scapular exercises on Swiss ball. NO “W” (YTW). NO resistance
24. Criteria for progression to phase III
AROM above 90° in scaption, flexion and abduction
Activation of all components of the deltoid as well as
scapular musculature with stability exercises (with
arm in scapular plane)
No increased pain with PROM, AAROM, or
shoulder/scapular stability exercises
25. Phase III (6-12 weeks)
Full PROM in scaption, 160-170° Flexion, 150° abduction
Begin ER with arm in slight flexion and 60° abduction
Begin ER with arm in slight flexion and 90° abduction (limit 45° ER)
AROM in scaption, flexion and abduction progressing as tolerated by patient
Continue with shoulder and scapular stability progressing as tolerated
Shoulder strengthening to include:
o Push downs
o Theraband scaption (full can) , flexion, abduction, IR
o Extension to allowable ROM (see precautions)
o ER strengthening with care not to overload teres minor
Scapular strengthening to include:
o Gradual addition of light weight with rows into allowable extension
o Y-T-W on Swiss ball using care in “W” position to avoid excessive ER
UBE/Arm bike with resistance increasing as patient tolerates
Serratus, latissimus dorsi, and gentle pectoral strengthening
o Press up with a plus
o Serratus punch
o Pull downs (begin with theraband and progress to cable column)
26. 66 y.o. male, R rTSA on 10/3/14
Post-op days 1-3, seen as inpatient
PROM shoulder flexion & scaption to 90°
PROM shoulder ER to 15° at 0° ADD & 30/30
Shoulder IR full to stomach
Closed reduction on 10/15/14
Dislocation likely occurred while sleeping
Return to outpatient clinic on 10/29/14
PROM shoulder flexion 136°
PROM shoulder ER to neutral
PROM shoulder ABD 102°
Shoulder IR to stomach w/ slight forward flexion
27. 7 Weeks Post-op
AROM shoulder flexion (sitting) 137°
PROM shoulder flexion (supine) 155°
PROM shoulder ER (supine) 42°
PROM shoulder ABD (supine) 115°
Weak Shoulder ER
Only Teres Minor for ER
Scapular control is improving, but still has difficulty
w/ scapular depression.
Use of substitution is decreasing.
Shoulder musculature fatigues quickly
No c/o pain
28. 1. Edwards TB, Williams MD, Labriola JE, Elkousy HA, Gartsman GM, O’Connor DP. Subscapularis insufficiency and the risk of shoulder
dislocation after reverse shoulder arthroplasty. J Shoulder Elbow Surg.2009;18:892–896. doi: 10.1016/j.jse.2008.12.013.
2. Farshad, Mazda, and Christian Gerber. "Reverse Total Shoulder Arthroplasty-from the Most to the Least Common Complication - Springer."
Reverse Total Shoulder Arthroplasty-from the Most to the Least Common Complication - Springer. Department of Orthopaedics, Balgrist
University Hospital, University of Zürich, Forchstrasse 340, 8008 Zürich, Switzerland, 01 Dec. 2010. Web. 23 Nov. 2014.
<http://dx.doi.org/10.1007%2Fs00264-010-1125-2>.
3. Frankle, Mark A. Rotator Cuff Deficiency of the Shoulder. 1st ed. New York: Thieme, 2008. Web. 21 Nov. 2014.
4. Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg
Am. 2006;88:113–120. doi: 10.2106/JBJS.E.00282.
5. Molé D, Wein F, Dézaly C, Valenti P, Sirveaux F. Surgical Technique: The Anterosuperior Approach for Reverse Shoulder Arthroplasty. Clinical
Orthopaedics and Related Research 2011;469(9):2461-2468. doi:10.1007/s11999-011-1861-7.
6. Nam D, Kepler CK, Neviaser AS, Jones KJ, Wright TM, Craig EV, et al. Reverse total shoulder arthroplasty : c0 urrent concepts, results, and
component wear analysis. J Bone Joint Surg Am 2010;92 Suppl 2:23-35.
7. "Reverse Shoulder Arthroplasty." Houston Methodist Orthopedics & Sports Medicine. Houston Methodist Orthopedics & Sports Medicine, n.d.
Web. 23 Nov. 2014. <http://www.methodistorthopedics.com/reverse-shoulder-arthroplasty>.
8. Walch G, Wall B, Mottier F. Complications and revision of the reverse prothesis: a multicenter study of 457 cases. In: Boileau P, editor. Reverse
shoulder arthroplasty. Nice: Sauramps; 2006. p. 335-52
9. Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a
systematic review. J Shoulder Elbow Surg. 2011;20:146–157
Notas do Editor
Humeral Components:
1. Epiphysis: Upper part of the prosthetic humeral stem. It is a metal component that lies even with the proximal humerus
2. Diaphysis: Lower portion of the humeral stem. It is inserted down into the shaft of the humerus
3. Polyethylene Cup: This becomes the socket of the new ball and socket joint. It is made of polyethylene and is attached to the epiphysis proximally.
Glenoid Components:
1. Metaglene: Specially coated metal plate that is attached to the glenoid fossa with screws.
2. Glenosphere: A half globe metal piece that is attached to the metaglene. The glenosphere becomes the ball part of the new glenohumeral joint.
Advantages:
e) Extensile approach which allows easy access to the anterior humerus which is especially useful in revision arthroplasty where humeral osteotomy may be necessary for component extraction.
Disadvantages:
a) The complete release of the subscapularis, may predispose to weakened anterior restraints in deltopectoral approaches. Therefore, the subscapularis seems to be of tremendous importance and should be repaired and protected whenever possible. (Zumstein)
Disadvantages:
b) Decreased ER: Had a hard time finding the original source of this information. I did read in one article that the subscapularis was circumferentially released to increase post-operative external rotation and facilitate repair. So the only concept that makes sense to me is that in a stiff shoulder, not releasing and repairing the subscapularis (if reparable) would likely decrease postoperative external rotation.
Advantages:
b) Specifically, it enhances the reaming precision and accuracy of component fixation.
c) Since the subscapularis is not messed with. In the research I did find one study where out of 527 reverse arthroplasties with a minimum 2-year follow-up, postoperative instability rate was greater with the deltopectoral (5.1%) than with the anterosuperior (0.8%) approach. Other published studies confirm this finding.
Disadvantages:
b:) specifically, height and inferior tilt.
-With a deficient subscapularis, this would mess up the balance of the force couples and the transferred muscle would have nothing to work against and would fail to function. An intact teres minor tendon leads to better results than if it is also ruptured.
The Approach: Delto-pectoral vs. superior lateral vs. anterosuperior. Etc. – They will go in, make the incision.
Resection of Humeral Head: This step includes removal of osteophytes and performing a humeral osteotomy at the appropriate angle for the prosthesis
Diaphyseal Preparation: Includes humeral reaming which is where they use a coarse metal tool to shape the intramedullary canal before inserting the prosthesis.
Preparation of the glenoid: This step involves glenoid reaming either with a power or hand tool until a smooth platform devoid of cartilage is created for the metaglene and glenosphere with sufficient depth.
Insertion of the metaglene: Involves correctly lining up, inserting, and securing the metaglene into the prepared glenoid.
Glenosphere Placement: First the attach a trial glenosphere and insert a trial cup and then assess for full ROM. Once the surgeon is happy with the sizing, he will align and insert the real glenosphere to the metaglene using a cannulated screwdriver
Insertion of the Humeral Implant: Involves attaching the diaphyseal and epiphyseal components and inserting a humeral spacer. Bone cement is then introduced to the implant assembly while in line with the long axis of the humerus. Lastly, the surgeon will impact the humeral cup to ensure it is fully secure before reducing the joint and making the final assessment.
Farshad, Mazda, and Christian Gerber. "Reverse Total Shoulder Arthroplasty-from the Most to the Least Common Complication - Springer." Reverse Total Shoulder Arthroplasty-from the Most to the Least Common Complication - Springer. Department of Orthopaedics, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008 Zürich, Switzerland, 01 Dec. 2010. Web. 23 Nov. 2014. <http://dx.doi.org/10.1007%2Fs00264-010-1125-2>.
This study looked at 111 cases involving Delta III (DePuy) and 230 cases involving the Anatomical Reverse (Zimmer).
Reverse total shoulder arthroplasty has been reported to be associated with a complication rate that is 4 times that of conventional total shoulder arthroplasty.
According to this article, the safest methods to prevent scapular notching are inferior positioning of the glenoid base plate, larger size implants with shallow concave components, and, possibly, use of a prosthetic system with less medialisation of the center of rotation.
"Reverse Shoulder Arthroplasty." Houston Methodist Orthopedics & Sports Medicine. Houston Methodist Orthopedics & Sports Medicine, n.d. Web. 23 Nov. 2014. <http://www.methodistorthopedics.com/reverse-shoulder-arthroplasty>.
fxrxinc.com
Infection
The chance of infection is around 5%, higher that convention TSA, but around the same for TKA or THA. Sometimes infections show up very early, before you leave the hospital. Other times infections may not show up for months, or even years, after the operation. Infection can also spread into the artificial joint from other infected areas. Once an infection lodges in your joint, it is almost impossible for your immune system to clear it. You may need to take antibiotics when you have dental work or surgical procedures on your bladder and colon.
Fracture
In patients with weak bone, a fracture can occur when reaming the canal to allow for insertion of the humeral stem or when the glenoid reamed to create a bone tunnel or flattened to seat the glenoid base plate. An acromion fracture can also occur due to the arm being an average of 2.5cm longer following the surgery, which increases the tension of the deltoid. The deltoid’s lever arm is also increased due to the center of rotation being moved medially, which increases the load on the acromion. The incidence of acromion fracture is 3%.
Dislocation
There is a greater risk of dislocation right after surgery, before the tissues have healed around the new joint. The incidence of dislocation ranges from 0% to 14%. Biomechanically, a lack of compressive forces followed by a shallow socket depth are the main parameters associated with instability
Loosening
The major reason that artificial joints eventually fail is that they loosen where the metal or cement meets the bone. Risk factors for the glenoid component loosening are female, younger than 70, and superiolateral approach.