Compare and Contrast: Total Shoulder Arthroplasty vs Reverse Shoulder Arthroplasty

1. Compare and Contrast: Total Shoulder Arthroplasty vs Reverse Shoulder Arthroplasty Erin Rencher

2. Objectives • To understand common conditions that lead to Total Shoulder Arthroplasties. • To explain differences between Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty. • Describe different precautions and exercises for Total Shoulder Artrhoplasty and Reverse Total Shoulder Arthroplasty.

3. Common Conditions That Lead to Total Shoulder Replacement • Severe Shoulder Fractures • Osteoarthritis (Degenerative Joint Disease) • Post Traumatic Arthritis • Rotator Cuff Arthropathy (Combination of Severe Arthritis and a massive non-repairable rotator cuff tendon repair) • Avascular Necrosis • Failed Previous Shoulder Replacement Surgery

4. Total Shoulder Arthroplasty • The usual total shoulder replacement involves replacing the arthritic joint surfaces with a polished ball ( humeral head), and socket (glenoid bone).

5. Reverse Total Shoulder Arthroplasty Conditions That Lead to Surgery Procedure In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to scapula and a plastic socket is attached to humerus. This changes the arthrokinematics of the shoulder and allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm. • Reverse total shoulder replacement is often used for people who have shoulder arthritis coupled with an irrepairable rotator cuff tear (a condition called cuff tear arthropathy, or CTA). It is also performed for patients with very complex shoulder problems, including those with failed previous surgical treatments.

7. Precautions For 1st Month After Total Shoulder Arthroplasty • Sling should be worn for 1 week, then for comfort only • Sling should be used for sleeping and when out in public for the first week. The sling should be removed gradually over the course of the week to move the elbow, wrist and hand. • While lying supine a small pillow or towel roll should be placed behind the elbow • to avoid shoulder hyperextension / anterior capsule / subscapularis stretch. • You may do activities like “drinking coffee or reading the paper” immediately following surgery. • No lifting of objects heavier than a coffee cup. • No excessive shoulder motion behind back • No excessive stretching or sudden movements (particularly external rotation) • No supporting of body weight by hand on involved side • Keep incision clean and dry (no soaking for 2 weeks)

8. Exercises That Can Be Performed After Total Shoulder Arthroplasty Day 1 (Post Op) • Passive Forward Flexion in supine to tolerance • ER in scapular plane to available gentle PROM – usually around 30 degrees. (Attention: DO NOT produce undue stress on the anterior joint capsule and subscapularis particularly with shoulder in extension) • Passive internal rotation to chest • Active distal extremity exercise (Elbow, Wrist, Hand) • Pendulums • Frequent cryotherapy for pain, swelling and inflammation management • Patient education regarding proper positioning & joint protection techniques Days 2-10 • Continue above exercises • Assisted flexion and abduction in the scapular plane • Assisted external rotation • Begin sub-maximal, pain-free shoulder isometrics in neutral • Begin scapula musculature isometrics / sets • Begin active assisted Elbow ROM • Pulleys (flexion and abduction) – as long as its no greater than 90 degrees of PROM

9. Precautions For Reverse Total Shoulder Arthroplasty • Joint protection: There is a higher risk of shoulder dislocation following rTSA than a conventional TSA. • Avoidance of shoulder extension past neutral and the combination of shoulder adduction and internal rotation should be avoided for 12 weeks postoperatively. • Patients with rTSA don’t dislocate with the arm in abduction and external rotation. They typically dislocate with the arm in internal rotation and adduction in conjunction with extension. As such, Tucking in a shirt or performing bathroom / personnel hygiene with the operative arm is a particularly dangerous activity particularly in the immediate peri-operative phase. • Deltoid function: Stability and mobility of the shoulder joint is now dependent upon the deltoid and periscapular musculature. This concept becomes the foundation for the postoperative physical therapy management for a patient that has undergone rTSA. • Sling is worn for 3-4 weeks postoperatively. The use of a sling often may be extended for a total of 6 weeks, if the current rTSA procedure is a revision surgery. • While lying supine, the distal humerus / elbow should be supported by a pillow or towel roll to avoid shoulder extension. Patients should be advised to “always be able to visualize their elbow while lying supine.” • No shoulder AROM. • No lifting of objects with operative extremity. • No supporting of body weight with involved extremity. • Keep incision clean and dry (no soaking/wetting for 2 weeks); No whirlpool, Jacuzzi, ocean/lake wading for 4 weeks.

10. Exercises For Reverse Total Shoulder Arthroplasty • Begin PROM in supine after complete resolution of interscalene block. • Forward flexion and elevation in the scapular plane in supine to 90 degrees. • External rotation (ER) in scapular plane to available ROM as indicated by operative findings. Typically around 20-30 degrees. • No Internal Rotation (IR) range of motion (ROM). • Active/Active Assisted ROM (A/AAROM) of cervical spine, elbow, wrist, and hand. • Begin periscapular sub-maximal pain-free isometrics in the scapular plane. • Continuous cryotherapy for first 72 hours postoperatively, then frequent application (4-5 times a day for about 20 minutes). • Insure patient is independent in bed mobility, transfers and ambulation • Insure proper sling fit/alignment/ use. • Instruct patient in proper positioning, posture, initial home exercise program • Provide patient/ family with written home program including exercises and protocol information.

11. References • Nam, MD, D., Kepler, MD, C. K., Neviaser, MD, A. S., Jones, MD, K. J., & Wright, PhD, T. M. (2011). Reverse total shoulder arthroplasty: current concepts, results, and component wear analysis. The Journal of Bone and Joint Srgery, 92(Supplement 2), 23-35. Retrieved from http://www.jbjs.org/article.aspx?articleid=35596 • Shoulder joint replacement . (2007, October). Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00094 • Shoulder replacement surgery (arthroplasty) . (n.d.). Retrieved from http://www.shouldersurgeon.com/shoulder_replacement_surgery/