Total Shoulder Arthroplasty

Definition/Description

The shoulder complex, composed of the clavicle and scapula, sacrifices stability for mobility, making it vulnerable to injury, dysfunction, and instability [1]. The most common indication for arthroplasty is pain that does not respond well to conservative treatment or joint replacement. Severe fractures [2]. Depending on the mechanism of dysfunction or injury, shoulder replacement can be a partial or total replacement. [2][3]

Epidemiology /Etiology

In 1894, French surgeon Jean Pean performed the first documented shoulder replacement. [3] Initial implants included platinum and rubber implants for the glenohumeral joint. Charles Neer credited for development of modern total shoulder arthroplasty (TSA) Modern prosthetics used in surgery since the 1950s. [3][4][2]

Approximately 23,000 shoulder replacements are performed each year, compared to 400,000 knee replacements and 343,000 hip replacements. [5] This is mainly due to the relatively complex anatomy and biomechanics of the shoulder joint. Due to the complexity of the region There are many variations of prostheses and surgical procedures performed depending on the tissues involved. Since Neer’s initial design in 1951, more than 70 different shoulder systems have been designed for shoulder reconstructive arthroplasty. [6] Earliest shoulders Replacement surgery is limited to the treatment of proximal humerus fractures, but current implications for shoulder arthroplasty include: And a previous failed shoulder replacement. Understanding the different prosthetic options and indications for each injury is important to all practitioners across the healthcare continuum. Algorithms have been developed to ensure each patient is matched to the correct program and equipped Correct Prosthetic Selection. The following is an example from Wiater and Fabing detailing the method for choosing the correct program [6].

Medical Management

There are 3 main types of shoulder reconstructive surgery: femoral head replacement total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) [6].

Hemiarthroplasty

Femoral head replacement involves the replacement of the articular surface of the humerus with a stemmed humeral component and a prosthetic humeral head component. [4][6] Femoral head replacement is indicated when only the humerus is involved or when the glenoid is not suitable for supporting the prosthesis. Indications These include: arthritic conditions involving the humeral head and osteonecrosis not involving the glenoid However, the most common indication for this procedure is a severe fracture of the proximal humerus. An optional technique is resurfacing hemiarthroplasty, which does not require a stemmed Inserting the component into the long axis of the humerus rather than the humeral head simply resurfaces with the prosthetic component. The procedure has been shown to be effective in the treatment of arthritis in the shoulder and is beneficial for young athletic patients concerned about prosthetic loosening component.

Total Shoulder Arthroplasty

Total shoulder replacement, or TSA, is a surgery to replace a diseased or damaged ball and socket joint of the shoulder with a prosthesis made of polyethylene and metal components. In TSA, the current component of the glenoid is a spike or keel of high molecular weight polyethylene Glue parts. [3] By allowing bony ingrowth through the flow ends of the components, they become fixed. For some shoulders with poor bone quality, a metal backing is used to increase the durability and fixation of the polyethylene component. [3][4] Pressure remains controversial Metal backings may interfere with joints.

The humeral component consists of an artificial metal humeral head attached to a metaphyseal stem that is fully cemented or pressed into the humeral shaft at the proximal end. [3][4] Harris et al. found no difference in fretting between complete and proximal cement technology. [7]

Indications for TSA include: osteoarthritis, inflammatory arthritis, osteonecrosis involving the glenoid, and posttraumatic degenerative joint disease. Patients must also have an intact rotator cuff complex or other repair techniques will be involved. A prospective study by Barrett et al. Al. found that 47 or 50 of the patients treated with TSA had significantly less pain and increased range of motion compared with preoperative measurements. [8] A study by Collins et al. in 2004. Comparing traditional TSA to femoral head replacement, although both groups showed significantly less pain As measured before treatment, ROM increased more in the TSA group. [9]

There are many variations of the TSA program. Resurfacing Total shoulder arthroplasty involves replacing the degenerated bony surface of the humeral head and does not require insertion of a stemmed component into the long axis of the humerus. because there is no humeral component with a stem Technology is becoming a popular choice. Levy and Copeland compared cementless resurfacing TSA with standard stem prostheses and found comparable results. [10] An alternative for active individuals is TSA with biological glenoid resurfacing. The procedure involves the TSA humerus Partially combined with glenoid resurfacing using a biological tissue form (fascia lata anterior achilles tendon meniscus), the study showed comparable results to conventional TSA.

A comparison of published studies has shown some disagreement on whether TSA is superior to femoral head replacement as a treatment option in patients with primary osteoarthritis. The meta-analysis by Radnay et al. A forward elevation gain in external rotation was found to significantly reduce pain and In a total of 1952 patients, TSA patient satisfaction compared with femoral head arthroplasty [11]

Reverse Total Shoulder Arthroplasty (rTSA)

Reverse total shoulder arthroplasty, or rTSA, refers to a similar procedure in which the prosthetic ball and socket that make up the joint are reversed to treat certain complex shoulder problems. [12][13][4] rTSA involves a stemmed humeral component containing a polyethylene humeral socket replacement The humeral head and a highly polished metal ball called the glenoid replace the glenoid socket or glenoid. [3][14] One can think of this as a “ball and socket” component being switched. This allows better fixation of prosthetic components and increases the stability of the joint. One rTSA is currently indicated for patients with osteoarthritis or compound humeral fractures with rotator cuff complex defects. [13][15] Masson et al. Also stated that rTSA should be considered in patients with shoulder problems that cannot be resolved using Traditional TSA. [12] Several features make rTSA more suitable for certain patient populations. The deep concavity of the humeral articular components and the simplicity of the glenoid components allow for better fixation of the prosthesis and reduce problems with component loosening. Compensation for rotator cuff dysfunction is performed with rTSA, which is not usually managed in conventional TSA. Several long-term studies have been conducted on this procedure with positive results. [14] Early studies found complication and revision rates of 50% and 60%, respectively, but A 2007 retrospective study by Wall et al. The complication rate was found to be only 19%. [12] The authors of this study also suggested that rTSA could be used in more patients undergoing shoulder arthroplasty than just those with rotator cuff disease. Early evidence suggests that RTSA is a A viable option in certain patient populations requiring more research than TSA and femoral head replacement [12].

Complications

Total shoulder arthroplasty may involve many complications, including [16]:

• Component Loosening – Symptomatic loosening of the glenoid and humeral components accounts for one-third of TSA complications.
• Glenoid loosening – most loosening is thought to be the result of aseptic loosening of bone cement, and innovations in implants such as press-fit plasma sprayed and tissue ingrowth implants are promising alternatives that may prove superior to conventional bone cement Cement implants are more stable.
• Humeral Looseness – Although glenoid looseness is a major cause of loosening complications, radiolucent threads of 2 mm or more have been found in the humeral component, and most often in cementless implants.
• Glenohumeral instability – the second leading cause of TSA complications
• Anterior instability – usually associated with dysfunction of the humeral component of the anterior deltoid or malrotation of a sutured subscapularis tendon rupture. The most common causes are poor surgical technique, poor tissue quality, improper physical therapy, or use of Oversized components.
• High-grade instability – progressive high-grade migration may be due to failed rotator cuff repair or complete tearing of the rotator cuff insertion, but in a study of 29 proximal humeral displacements with TSA, only 7 developed rotator cuff torn. This indicates The cause is more likely a muscular imbalance, strong deltoids, weak rotator cuff and poor recovery. This finding helps to emphasize the importance of strengthening the rotator cuff of patients after TSA.
• Posterior instability – Excessive retroversion of the glenoid or humeral components can cause posterior instability. Asymmetric wear of the posterior glenoid indicates long-standing OA and may lead to excessive retroversion of the glenoid components.
• Inferior Instability – Inferior instability in proximal humeral fractures commonly associated with TSA can also be seen in patients with chronic fractures treated with TSA for prosthetic revision prior to osteosynthesis or in patients with uncomplicated RA or OA. Restore humerus length and proper tension The delts will correct instability.
• Rotator cuff tear – the third most common complication of TSA. Both surgical and nonsurgical treatments have been used, but the benefit of surgical treatment is unclear.
• Fractures – Periprosthetic intraoperative and postoperative fractures can delay postoperative recovery.
• Infection – A rare but potentially devastating complication, most cases are associated with risk factors such as diabetes RA systemic lupus erythematosus and previous shoulder surgery.
• Nerve damage – Neuropraxia is the most common and can be treated with non-surgical treatments, usually with good results.
• Prosthetic Complications – Implant complications such as separation of the polyethylene glenoid insert from the metal backing or fracture of the keel insert can occasionally occur.
• Deltoid Dysfunction – An earlier procedure that removes the deltoid from its origin. The more common deltoid approach today does not disrupt the attachment of the deltoid, thereby reducing atrophy and denervation complications.

Post Surgical Presentation/Precautions

Conventional Total Shoulder Arthroplasty

During the daytime for the first week and nighttime for the first month after the intermittent deltoid approach, the patient will use a shoulder immobilizer. [17][2] Four weeks after surgery, the patient will wear the shoulder straps. In some cases where the deltoid muscle is removed Its attachment precautions will vary depending on which part of the deltoid muscle is cut and the general quality of the soft tissue.

Reverse Total Shoulder Arthroplasty

In the first few days after rTSA, flexion/elevation of the scapular plane up to 900 can be done passively, but pure abduction is contraindicated because it stresses the anterior structures of the shoulder. [13] Internal rotation is also not recommended for the first 6 weeks postoperatively Prevent misalignment. Much like traditional TSA, patients with rTSA will be placed in an abduction sling/retainer for 3-4 weeks after surgery. [14] In traditional and reverse TSA, postoperative preventive measures and treatment progression will be decided by the surgeon based on the quality of the procedure Bone and soft tissue and any considerations arising from surgical complications.

Physical Therapy Management

Overall recovery from total shoulder arthroplasty can take up to 1 to 2 years. To date, there is limited evidence detailing any postoperative rehabilitation program. Those that are available usually include a progression from passive to active range of motion, then combined with progressive Stretches and strengthens. [17]

The patient’s progress through the rehabilitation phase must be continually modified according to the patient’s underlying pathology and clinical presentation. [2] Many protocols will provide time frames between phases, which should be used as a guideline for patients only. physical therapists should Continue working with the referring surgeon to develop a specific rehabilitation plan for each patient, focusing on meeting certain impairment and functional criteria before moving on to the next phase. Patient education before and after surgery is critical for patients It must be known that different levels of postoperative function are expected depending on a number of factors such as the type of surgical implantation status of the remaining rotator cuff and the bone mass of the glenoid and humeral head. [13]

Throughout the rehabilitation process, a number of outcome measures can be used to assess patients. [13][17][2] Some of the more commonly used measures are the Constant Score simple shoulder test and range of motion. These can be used to assess patient status and progress them in different ways recovery stage. The following is an overview by Wilcox et al. A 4-stage plan for rehabilitation after total shoulder arthroplasty is detailed. [2]

Click a thumbnail to view the Wilcox protocol.

Reverse shoulder arthroplasty is an increasingly popular technique that requires a somewhat different post-operative rehabilitation protocol and its own precautions. Boudreau et al. Emphasizes 3 key concepts to keep in mind when developing a post-operative recovery plan: Joint protection Deltoid function and establish proper functional and ROM expectations. [13] With rTSA, there is a higher potential for instability, so patients must avoid placing the surgical arm in internal rotation and adduction-extension for at least the first 12 weeks. deltoid club Be the primary enabler of shoulder elevation, the strength and recruitment of which is critical to the ultimate function of the associated limb. In the end, functional recovery and ROM will vary from case to case, depending on the many variables and expectations for the level of function before and after surgery Returns must be discussed with each patient. Boudreau et al. An extensive protocol is provided along with their articles, which can be accessed through the Journal of Orthopedics and Sports Physiotherapy.

Expected Outcomes

Many factors affect postoperative patient outcomes; they include preoperative health status preoperative shoulder function age sex and social environment [2][17] prosthesis strength ROM patient report survey longevity compared to patient pain reports When conducting research, preoperative measurements are often used as outcome measures. Some studies have used the simple shoulder test (SST) to track patients’ progress. Since there is no generally accepted measure of functional outcome for TSA, it is difficult to compare outcomes between studies. This The etiology of TSA appears to be the greatest predictor of postoperative success.

• Osteoarthritis: For patients with OA who have failed conservative treatment, TSA is the most successful option for pain relief and restoration of function. [2] It also has the greatest success rate, with most series reporting 90%-95% of patients who are ultimately pain-free after the procedure. most of them Patients should expect to achieve acceptable functional ROM, defined as 140° of forward flexion.
• Rheumatoid Arthritis: Although RA patients may require more complex surgical procedures, patients with advanced RA can benefit greatly from TSA. [2] A study by Stewart and Kelly concluded that TSA provided reliable long-term pain relief through ROM and functional improvement, although the results The primary focus is on surgical outcomes such as loosening of components. [18] Patients with RA are not expected to experience comparable increases in ROM compared with OA, and rehabilitation should focus on performing functional activities below 90°, as they may not be able to achieve full overhead motion.
• Rotator Cuff Arthropathy: Patients with rotator cuff tear arthrosis after TSA also generally had lower ROM and functional outcomes than those who received TSA for osteoarthritis. Most of these patients are unable to achieve more than 90° of forward flexion. [2] Often still relieves pain But there is a high rate of loose parts. Several studies have suggested that these patients are better candidates for reverse total shoulder arthroplasty with loss of rotator cuff function. [4][13][14]
• Proximal humeral fractures: Due to the variability in humeral fractures, it is difficult to establish baseline functional outcome measures for this subset of patients. Multiple studies have found that postoperative forward flexion between 92° and 102° is associated with significantly less pain. [2] It is also important to consider the type of underlying fracture, as this may determine the rest of the rehabilitation process.

Key Research

Cochrane Review: Surgery for shoulder osteoarthritis (2010)

Cochrane Review: Surgical interventions for rheumatoid shoulder (2010)

Resources

American Academy of Orthopedic Surgeons

Medline Plus- Shoulder Replacement

Clinical Bottom Line

Due to a variety of etiologies, total shoulder arthroplasty has become a viable option for patients with advanced shoulder dysfunction. This procedure, along with the newer reverse total shoulder replacement, can help reduce pain and enhance a patient’s function when needed. Postoperative rehabilitation of these patients is key to a successful outcome. Current evidence and guidelines on postoperative recovery are limited, so each patient should be assessed on a case-by-case basis, in close collaboration with the patient’s other patients healthcare facility.