Shoulder Unit- Total Shoulder

Question 1

Etiology

Answer 1

• Severe glenohumeral arthritis (OA, RA)
• Avascular necrosis
• Trauma
• Tumor

Question 2

TSA indicated when?

Answer 2

conservative treatment has failed and pain, instability, or limitations in ROM interfere with a patient’s ability to perform functional tasks

-not for those with longstanding rotator tears due to lack of stability for glenoid component of arthroplasty

Question 3

What do they do in surgery?

Answer 3

• Subscapularis tendon and anterior capsule are divided, other rotator cuff insertions on the greater tuberosity are preserved
• The subscapularis and capsule are repaired once components are in place

Question 4

Concomitant (associated) surgical procedures performed

Answer 4

• Repair of deficient rotator cuff
• Anterior acromioplasty for history of impingement
• Subscapularis lengthening for significant history of internal rotation contracture
• Bone graft to glenoid if bone stock insufficient for fixation of glenoid implant

Question 5

Important Rehab Considerations

Answer 5

NO active IR, and NO active and passive ER

-Patients must wear their immobilizer to avoid external rotation
> can be challenging to regain ER

Question 6

TSA Prognosis:

Answer 6

• Good to excellent results occur in 90% of TSA’s

- Post operative care will vary patient to patient and depend on a variety of factors

Question 7

What is the average increase in active forward elevation?

Answer 7

average of 140 degrees

Question 8

What is the average increase in active external rotation?

Answer 8

average of 47 degrees

Question 9

How many MMT grades will strength increase?

Answer 9

Strength increases by one full grade on a manual muscle test to 4/5

Question 10

Difference in TSA with OA vs RA?

Answer 10

Patients with RA do not show as great a functional gain compared to patients with OA

OA progresses faster

Question 11

what complications can occur with TSA?

Answer 11

• Instability
• Rotator cuff tear
• Intraoperative fracture
• Axillary nerve injury
• Loosening of components

Question 12

Management Maximum Protection Phase

Answer 12

1. Maintain mobility in adjacent joint
2. Regain shoulder mobility
3. Minimize muscle atrophy

Question 13

Management Maximum Protection Phase: Regain shoulder mobility

Answer 13

-PROM in plane of scapula
>Abduction, limited internal and external rotation with elbow flexed
&raquo_space;Position patient lying supine with humerus slightly anterior to the midline of the body to avoid excessive stress to the anterior capsule and suture line

Question 14

Goals Controlled Mobility Phase

Answer 14

1. Re-establish mobility and control of shoulder motions

2. Improve strength, endurance and stability of the shoulder girdle

Question 15

Goals Controlled Mobility Phase: Re-establish mobility and control of shoulder motions

Answer 15

If rotator cuff is intact can begin 2-3 weeks postop; if cuff repair is tenuous may not be initiated until 6 weeks or longer postop

> Transition from assisted to active ROM in all planes and diagonal planes of motion

> Avoid combined external rotation and abduction because they are stressful to the repair – keep arm at side for ER

>

• Begin combining external rotation to neutral with forward flexion and scaption

Question 16

Return to Functional Activity Phase: To advance need to have:

Answer 16

• Pain free active shoulder ROM through functional range
• Greater than 3/5 strength

-Begins no earlier than 6 weeks postop for intact rotator cuff
>Considerably longer for deficient rotator cuff mechanism

Question 17

Goals for Return to Functional Activity Phase

Answer 17

1. Continue to improve mobility
2. Continue to improve strength, stability and endurance of the shoulder
3. Instruct in home exercise program

Question 18

Goals for Return to Functional Activity Phase: Home Program

Answer 18

Most patients are usually discharged from formal therapy after 3 months, need to continue with home program for up to 2 years for optimal results