1. SHOULDER ARTHROPLASTY
Dr.Satyendra Nath Bhattacharyya
Asst. Professor BIMLS, Burdwan

2. HISTORY
 Developments
The first shoulder arthroplasty is thought to have been
carried out in 1894 (Hamblen 1984) but it was in 1951
that the modern story of shoulder replacement began.
In 1951 Charles Neer developed a hemi-arthroplasty,
primarily for the reconstruction of severe proximal
humerus fractures. However, it was also used for people
suffering from osteoarthritis, with surprisingly good
results. In 1973 Neer redesigned the humeral component
and added a glenoid to make the first unconstrained
Total shoulder arthroplasty (TSR) - known as
the Neer II.

3. FACTORS INFLUENCING OUTCOME OF
SHOULDER ARTHROPLASTY(MAINLY IN RA)
 Factors affecting outcome of prosthetic shoulder reconstruction.
 Pathology
Rotator cuff disease
Glenoid erosion bone loss
Humeral bone loss
Bone density
 Surgical technique
Prosthetic placement
Prosthetic-cement-bone interface
Soft-tissue balancing
 Prosthetic design
Size selection
Glenoid
Humeral head
Humeral stem
Material properties
 Rehabilitation programme
Range of motion
Strength
Stability

4. PRIMARY OSTEOARTHRITIS (OA)
 This is the indication for TSR from which the best
results can be expected. Godeneche et al. (2002)
reviewed a series of 267 operations for osteoarthritis and
found that 77% of them had results which were classed
as good or excellent. They found that the result was
dependent on the severity of the degenerative changes
that had taken place prior to surgery. It
seems, therefore, that for patients who have primary
osteoarthritis without gross soft-tissue damage or loss of
bone, we can expect to achieve near-normal range of
movement and strength. Patients who start off with
rotator cuff disease or glenoid erosion should have less
high expectations

5. RHEUMATOID ARTHRITIS (RA)
 People with RA who undergo shoulder arthroplasty are
likely to have a number of the adverse pathological factors .
The expected results will depend on how many and how
severe they are. People with rheumatoid arthritis do not tend
to be referred for replacement arthroplasty until these factors
are fairly advanced, so the results are generally not as good as
in osteoarthritic patients. The surgical approach and basic
postoperative management are the same.
In advanced disease of either the OA or RA type it is not
always possible to insert a glenoid component. If there is
gross bone loss around the glenoid fossa, it is not possible to
attach the implant securely enough.
Also the lack of rotator cuff function causes the humeral head
to 'rock' the glenoid component, causing loosening. The
problem of glenoid fixation is one of the ongoing dilemmas
in shoulder arthroplasty.

6. COMPLEX FRACTURE
 Following a complex fracture it is normally a
hemiarthroplasty that is performed as the glenoid is
intact. The operation can be performed either acutely as
the primary treatment for the fracture or later as a
secondary procedure. The results are better if it is
performed acutely. This is a different operation from the
one performed as an elective procedure as there is
disruption of the tuberosities to which the rotator cuff
muscles are attached. The challenge to the surgeon is to
restore the anatomy to as close to normal as possible

8. PROCEDURE
 The most common surgical approach is known as the
'deltopectoral approach'. The incision passes between
the deltoid and pectoralis major, and access to the
shoulder joint is via the subscapularis muscle and the
anterior part of the capsule. Thus the subscapularis
muscle is the only active structure which will need to be
protected in the early postoperative period.

9. GETTING TO THE JOINT
 The patient is first taken into the operating room and
positioned on a special operating table as though
lounging in a beach chair. The arm is placed on a board
that will allow the surgeon to move it up or down as
necessary during the surgery. Anesthesia is given
and, when it has taken effect, the skin around the
shoulder and upper arm is thoroughly scrubbed and
sterilized with an antiseptic liquid.
 An incision about six inches long is then made over the
shoulder joint. The incision is gradually made deeper
through muscle and other tissue until the bones of the
shoulder joint are exposed.

10. SHOULDER JOINT EXPOSED

11.  Replacing the Socket Portion of the Joint
 The implant that replaces the socket consists of a durable
plastic insert with a very smooth, cupped surface.
 Implant to Replace Socket in Shoulder Blade

12. REMOVING THE SURFACE OF THE SOCKET
 The arm is maneuvered until the humeral head is
dislocated from the socket.
 Special precision instruments are then used to remove
the damaged cartilage and bone surface from the glenoid,
and to shape the socket so it will match the shape of the
implant that will be inserted. Holes are then drilled into
the socket to accommodate the fixation pegs on the
implant. These pegs help stabilize the implant.

13. SOCKET PREPARED FOR IMPLANT

14. INSERTING THE IMPLANT
 The socket implant is attached by using a special kind of
cement for bones. The cement is pressed into the holes.
The implant is then inserted.

15. GLENOID IMPLANT

16. REPLACING THE BALL PORTION OF THE JOINT
 The implant that replaces the ball consists of a long
metal stem that fits down into the humerus. A metal head
in the shape of a partial sphere is mounted on top of this
stem. This head contacts the socket implant in the
shoulder blade.

17. METAL IMPLANT TO REPLACE BALL PORTION OF
SHOULDER JOINT

18. PREPARING THE HUMERAL CANAL
 The upper arm bone has relatively soft, porous
bone tissue in the center. This part of the bone is
called the "canal."
 Special instruments are used to clear some of this
soft bone from the canal.
 Using a precision guide and saw, the damaged
rounded portion (ball) of the humerus is removed.

19. HUMERAL HEAD (BALL) IS REMOVED

20. INSERTING THE IMPLANT
 The metal stem implant may be held in place by either
using the special bone cement, or by making it fit very
tightly in the canal. The surgeon will choose the best
method, depending on the patient's age and expected
activity level.
 If cement is used, it is injected into the canal first, and
then the implant is inserted into the canal. If cement is
not used, the implant is simply inserted into the canal.
 On some implants, the stem and partial sphere are one
piece. On others, they may be two separate pieces. If the
partial sphere is a separate piece, it is usually secured to
the top of the stem after the stem has been inserted.

21. STEM IMPLANT WITH PARTIAL SPHERE (HEAD)

22. SHOULDER IMPLANTS AFTER INSERTION

23. CLOSING THE WOUND
 When all the implants are in place, the surgeon places the
new ball that is now part of the upper arm bone into the
new socket that is part of the shoulder blade. If
necessary, the surgeon may adjust the ligaments that
surround the shoulder to achieve the best possible
shoulder function.
 When the ligaments are properly adjusted, the surgeon
sews the layers of tissue back into their proper position.
A plastic tube may be inserted into the wound to allow
liquids to drain from the site during the first few hours
after surgery. After the tube is inserted, the edges of the
skin are sewn together, and a sterile bandage is applied to
the shoulder. Then, the patient is taken to the recovery
room

25. BIGLIANI/FLATOW® THE COMPLETE SHOULDER
SOLUTION
 The Bigliani/Flatow Shoulder allows for the restoration
of shoulder joint function in cases of shoulder
replacement surgery. Backed by the clinical expertise of
surgeons and decades of experience, the Bigliani/Flatow
Shoulder System is designed to replicate the natural
shoulder's mobility, balance, and stability with a
multitude of component sizes.

27. Anatomical Shoulder™ System
 Traditionally, patients undergoing shoulder reconstruction
faced two postoperative tasks. First, they had to let the
shoulder tissues recover, as would be expected. Then they
had to adapt to anatomical changes imposed by a first- or
second-generation implant that offered nothing more than an
approximate fit.
 But now, with the modular Anatomical Shoulder System, the
shoulder implant can be tailored to each patient’s individual
anatomy.
 This allows a more advanced rehabilitation and an expanded
radius of movement while placing fewer demands on the soft
tissues and on the anchoring of the prosthesis.
 The surgeon enjoys a simple operating technique that places
fewer limiting factors on the success of the surgery. The
design of the Anatomical Shoulder prosthesis truly sets the
new standard for third-generation shoulder arthroplasty.

29. ANATOMICAL SHOULDER™ INVERSE/REVERSE
SYSTEM
FROM ANATOMICAL TO INVERSE/REVERSE
 With the Anatomical Shoulder System and now with the
innovative Anatomical Shoulder Inverse/Reverse system,
Zimmer offers surgeons a complete Shoulder solution
with the possibility to change a done hemi- and total
shoulder arthroplasty with the current implanted
cemented or press-fit stem into an inverse/reverse
shoulder solution.
 This design allows the surgeon the opportunity to revise
a primary anatomical prosthesis to the inverse/reverse
components, without the need for stem removal. Such
revision might be necessary in the setting of irreparable
rotator cuff tear. This greatly simplifies and shortens
revision surgery since the need to remove a well-fixed
stem is eliminated.

31. FEATURES OF ANATOMICAL SHOULDER
INVERSE/REVERSE SYSTEM
 Option to convert to inverse/reverse without stem
removal
 Designed for flexibility and stability by using either
a press-fit or cemented stem
 Infinite variable settings of the humeral head
 Utilizes polyaxial locking screws, variable angulations to
a maximum of 30º in all directions

32. REHABILITATION PROTOCOL
AFTER SHOULDER ARTHROPLASTY
 Phase 1: Weeks 0 - 6
Restriction
Shoulder motion
Week 1
120 degrees of forward flexion
20 degrees of external rotation with the arm at the side
75 degrees of abduction with 0 degrees of rotation
• Week 2
• 140 degrees of forward flexion.
• 40 degrees of external rotation with the arm at the side.
• 75 degrees of abduction with 0 degrees of rotation.
• No active internal rotation.
• No backward extension.

33. Immobilization
• Sling
• After 7-10 days, sling used for comfort only.
Pain Control
• Reduction of pain and discomfort is essential for recovery
• Medications
• Narcotics-for 7-10 days following surgery.
• NSAIDs-for patients with persistent discomfort following
surgery.
• Therapeutic modalities
• Ice, ultrasound, HVGS.
• Moist heat before therapy, ice at end of session.

34.  Motion: Shoulder
• Goals
• 140 degrees of forward flexion.
• 40 degrees of external rotation.
• 75 degrees of abduction.
• Exercises
• Begin with Codman pendulum exercises to
promote early motion.
• Passive ROM exercises (see next slide)

35. Forward flexion External rotation with the arm at the side
External rotation with the arm in 90
degrees of abduction
Cross-body adduction

36. • Capsular stretching for anterior, posterior, and inferior capsule,
by using the opposite arm to assist with motion

37. • Active-assisted motion exercises (see next slide)
• Shoulder flexion.
• Shoulder extension.
• Internal and external rotation.
• Progress to active ROM exercises.

38. Exercises to regain motion. Active-assisted
ROM exercises using a pulley system and
a dowel stick

39. Motion: Elbow
• Passive-progress to active
• 0 to 130 degrees of flexion
• Pronation and supination as tolerated
Muscle Strengthening
• Grip strengthening only

40.  Phase 2: Weeks 6-12
 Criteria for Progression to Phase 2
Minimal pain and tenderness.
Nearly complete motion
Intact subscapularis without evidence of tendon pain
on resisted internal rotation.
 Restrictions
• Increase ROM goals
• 160 degrees of forward flexion
• 60 degrees of external rotation with the arm at the side
• 90 degrees of abduction with 40 degrees of internal and
external rotation

41.  Immobilization
None
 Pain Control
• NSAIDs-for patients with persistent discomfort following
surgery.
• Therapeutic modalities
• Ice, ultrasound, HVGS.
• Moist heat before therapy, ice at end of session.

42. Motion: Shoulder
• Goals
• 160 degrees of forward flexion.
• 60 degrees of external rotation with the arm at the side.
• 90 degrees of abduction with 40 degrees of internal and
external rotation.
• Exercises
• Increase active ROM in all directions.
• Focus on passive stretching at end ranges to maintain
shoulder flexibility (see next slide).
• Utilize joint mobilization techniques for capsular
restrictions,especially the posterior capsule (see 2nd next slide)

43. Forward flexion External rotation with the arm at the side
External rotation with the arm in 90
degrees of abduction
Cross-body adduction

44. Stretching of the posterior capsule

45.  Muscle Strengthening
• Rotator cuff strengthening:
Only three times per week to avoid rotator cuff tendinitis, which will
occur with overtraining
• Begin with closed-chain isometric strengthening (see next slide)
• External rotation.
• Abduction.

46. Closed-chain shoulder exercises.
1. Isometric strengthening of the rotator cuff
in abduction (pushing out against the wall).
2.Isometric strengthening of the rotator cuff
in external rotation.

47. • Exercises performed with the elbow flexed to 90 degrees.
• Starting position is with the shoulder in the neutral
position of 0 degrees of forward
flexion, abduction, abduction,and external rotation.
• Exercises are performed through an arc of 45 degrees in
each of the five planes of motion.
• Six color-coded bands are available; each provides
increasing resistance from 1 to 6 pounds, at increments of
one pound
• Progression to the next band occurs usually in 2to 3-week
intervals. Patients are instructed not to progress to the
next band if there is any discomfort at the present level.
• PROGRESS TO OPEN-CHAIN
STRENGTHENING WITH THERABANDS

48. Open-chain isotonic strengthening of the
rotator cuff (internal rotation) using
Theraband tubing

49. • Theraband exercises permit concentric and eccentric
strengthening of the shoulder muscles and are a form
of isotonic exercises (characterized by variable speed
and fixed resistance)
• External rotation.
• Abduction.
• Forward flexion.
• Progress to light isotonic dumbbell exercises
• External rotation (see next slide).
• Abduction.
• Forward flexion.

50. external rotation strengthening

51. • Scapular stabilizer strengthening
• Closed-chain strengthening exercises (see next three
slides)
• Scapular retraction (rhomboideus, middle trapezius).
• Scapular protraction (serratus anterior).
• Scapular depression (latissimus dorsi,
trapezius,serratus anterior).
• Shoulder shrugs (trapezius, levator scapulae).

52. Closed-chain strengthening exercises of
the scapula stabilizers. A, Scapular
protraction. B and C, Scapular retraction.

53. Additional closed-chain scapular stabilizer
strengthening. A, Start. B, Finish (the right
arm is the focus of rehabilitation).

54. Closed-chain strengthening of the scapular
stabilizers. A, Start. S, Finish.

55.  Phase 3: Months 3 -12
Criteria for Progression to Phase 3
• Full painless ROM.
• Satisfactory physical examination.
 Goals
• Improve shoulder strength, power, and endurance.
• Improve neuromuscular control and shoulder
proprioception.
• Prepare for gradual return to functional activities.

56. • Home maintenance exercise program
• ROM exercises two times a day
• Rotator cuff strengthening three times a week
• Scapular stabilizer strengthening three times a week
 Motion
• Achieve motion equal to contralateral side.
• Utilize both active and passive ROM exercises to
maintain motion.

57.  Muscle Strengthening
• Shoulder
• Begin internal rotation and extension strengthening
• First closed-chain isometric strengthening and
advance to Theraband and light weight isotonic
strengthening.
• Scapular stabilizers
• Progress to open- and closed-chain strengthening
(see next 4 slides).

58. Open-chain strengthening exercises of the
scapula stabilizers without dumbbells

59. Open-chain strengthening exercises of the scapula
stabilizers with lightweight dumbbells.

60. Additional closed-chain scapular stabilizer
strengthening. A, Start. B, Finish (the right
arm is the focus of rehabilitation).

61. Open-chain strengthening of the scapular
stabilizers
using Theraband tubing.

62. • Deltoid strengthening
• Eighr to 12 repetitions for each exercise, for
three sets.
• Strengthening only three times per week to
avoid rotator cuff tendinitis.
Strengthening of the anterior deltoid. A,
Closed-chain isometric. B, Open-chain
isotonic.

63. Isotonic deltoid strengthening with light
dumbbells. A, Start. B, Finish.

64.  Functional Strengthening
• Plyometric exercises (see next slide).
 Maximum improvement by 12-18 month.
 Warning Signs
• Loss of motion.
• Continued pain.
 Treatment of Complications
• These patients may need to move back to earlier
routines.
• May require increased use of pain control modalities
as outlined above.

65. Plyometric shoulder strengthening
exercises using Theraband tubing (A) and
an exercise ball (B).

66. REFERENCES
 Clinical Orthopaedic Rehabilitation 2nd edition
 Zimmer Implants Catalouge

67. THANK YOU