Reverse Total Shoulder Arthroplasty

2. Reverse Total Shoulder Arthroplasty Kate Dunn DPT 751 July 12, 2010

3. 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

4. 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 pathologyor irreparable cuff1 -replacement of humeral head

5. What is a rTSA? -Approved by the FDA in 20041 -Reverses the orientation of the shoulder girdle -Glenoid fossa > glenoid base plate & glenosphere -Humeral head > humeral shaft & concave cup - Increases deltoid moment arm to enhance the torque - Enhanced mechanical advantage of deltoid compensates for deficient RC

6. Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. ClinOrthopRelat Res. 2010;468:1526-1533.

7. 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

8. Surgical Outcomes -Post-op complications3 -Hardware instability or dislocation (abd with ER) -Nerve damage -Infection -Hematoma -Intra-operative fracture -Complication rates are 2-68%1

9. 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

10. CASE DESCRIPTION

11. 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: Parkinson’s Disease (1997), CVA (1996), PAD, breast cancer (R mastectomy), memory loss -Social hx: retired, does not drive

12. Past Medical History -Parkinson’s 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

13. 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

14. Examination -Completed 2.5wks post-op -Subjective: right shoulder, elbow & hand pain (5/10), N & T into fingers -PIP’s: 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

15. 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)

17. Evaluation -Initial Hypothesis: Patient presents with decreased ability to perform ADL’s 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

18. 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 @ time of current surgery -Cognitive functioning -Compliance with POC/ HEP

19. 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)

20. 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 2007;37:734-743.

21. Patient Education - Shoulder mechanics & function will have some limitations when compared to unaffected shoulder - Establish appropriate functional & ROM expectations

22. 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

23. 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%

24. 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 <50° -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

25. 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

26. JOSPT 2007: rTSA Protocol -Phase 3: Moderate Strengthening (weeks 12-16) -Enhance functional use, increase strength/power/ endurance -Begin gentle resisted flexion/abduction (5+lbs) in standing -Phase 4: Independent HEP (months 4+) -3-4x/wk -strength gains, return to functional/recreational activities -Criteria for discharge: -Pt is able to maintain pain-free AROM with proper shoulder mechanics -ROM: 80-120° of flexion, 30° of ER

27. Outcomes: ROM & pain

28. Progress at 6 weeks -PIP’s 1- Difficulty washing & combing hair 2- Difficulty with household chores 3- Shoulder pain -Non- PIP’s 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% > 52% (MCID=15pts)5

30. 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

31. 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 @ 4wks, AROM started @ 8wks, resisted exercises @ 12wks -All measures improved significantly (p<0.001) -ASES increased 33.9pts -VAS decreased 4.1pts -ROM: flexion increased 50°, abduction 60°, ER 29° -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 @ 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

32. 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 @ wk 3, no abd @ 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

33. Koch et al. J Shoulder Elbow Surg. 1997 -15 TSA in patient’s 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

34. How does evidence affect my intervention? -Enhance deltoid function in absence of RC -Biofeedback: to assist pts in learning recruitment strategies1 -PT started @ 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

35. Questions? THANK YOU!

36. References 1. Boudreau S, Boudreau E, Higgins LD, Wilcox RG. Rehabilitation following reverse total shoulder arthroplasty. JOSPT 2007;37:734-743. 2. Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. ClinOrthopRelat Res. 2010;468:1526-1533. 3. Volpe S, Craig JA. Postoperative physical therapy management of a reverse total shoulder arthroplasty (rTSA). Ortho Practice. 2007;21:11-17. 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. 2006;15:527-540. 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. 2001;14:128-146. 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. 2005;87:1697-1704. 7. Koch LD, Cofield RH, Ahlskog JE. Total shoulder arthroplasty in patients with Parkinson’s Disease. J Shoulder Elbow Surg. 1997;6:24-28. 8. Kryzak TJ, Sperling JW, Schleck CD, Cofield RH. Total shoulder arthroplasty in patients with Parkinson’s Disease. J Shoulder Elbow Surg. 2009;18:96-99. 9. Farley BG, Koshland GF. Training BIG to move faster: the application of the speed- amplitude relation as a rehabilitation strategy for people with Parkinson’s Disease. Exp Br Res 2005;167:462-467.