and concave cup. The prosthesis design in rTSA alters the center of rotation of the shoulder joint by moving it medially and inferiorly. This design increases the deltoid movement arm and deltoid ten- sion, which enhances both the torque produced by the deltoid and the line of pull or action of the deltoid. The enhanced mechanical advantage of the deltoid compensates for the deficient rotator cuff, as the deltoid becomes the primary elevator of the shoulder joint. Operative technique is crucial for a good outcome following rTSA. The complication rate of this procedure varies, depending upon the indication for prosthesis insertion. Common complications include component instability or dislocation, nerve damage, in- traoperative fracture, infection, hematoma, and hardware failure. Patient improvement varies and can be affected by the status of the posterior rotator cuff, component placement, previous surgi- cal history, and the integrity of surrounding bone and soft tissue. exercises to increase flexibility of the joint. It is not until the flex- ibility and ROM goals are achieved that strengthening can begin, which usually occurs about six to eight weeks postsurgery. At six weeks postsurgery, normal ADLs can be resumed. Patients usually return to athletic activities within four months. Patients can expect alleviation of pain and significant improvement in ROM following surgery. Improvement in function can even continue for up to two years following surgery. of recovery and uses timelines for progression to the next phase. These phases are passive ROM, active ROM, and strengthening phases; however, patients may not always progress clinically at the same rate as delineated by the phases of the protocol. Early scapu- lar muscular stabilization is crucial to the rehabilitation of a patient who has undergone TSA. But the protocols found in the literature seldom include this information. The first major goal of therapy is to maximize PROM, followed by regaining strength because restoring strength depends directly on the available PROM. Total shoulder arthroplasty/hemiarthroplasty protocol (Wilcox et al., 2005) This protocol should serve as a guideline for the postoperative re- habilitation course of a patient who has undergone TSA or hemi- arthroplasty. It is not intended to be a substitute for appropriate clinical decision making regarding the progression of a patient’s postoperative rehabilitation. The actual postsurgical physical ther- apy management must be based on the surgical approach, physi- cal exam and findings, individual progress, and the presence of postoperative complications if there are any. The clinician should consult with the referring surgeon if there are any questions or concerns regarding the patient’s progress or ability to progress to the next phase of the protocol. Patients with concomitant repair of a rotator cuff tear and a TSA or hemiarthroplasty that is secondary to fracture or cuff arthropathy should be progressed to the next phase based on meeting clinical criteria and not based on postoperative timelines. Upon the start of postoperative care, the patient should complete a joint specific outcome measure to determine functional status that can be used throughout care to help determine progression. PHASE I: IMMEDIATE POSTSURGICAL PHASE Goals ● Allow healing of soft tissue. ● Maintain integrity of replaced joint. ● Gradually increase PROM of the shoulder; restore AROM of elbow, wrist, and hand. ● Reduce pain and inflammation. ● Reduce muscular inhibition. ● Independence with ADLs with modifications while maintaining the integrity of the replaced joint.
A hemiarthroplasty had become the standard for the replacement of the humeral head in the presence of either severe cuff pathol - ogy or an irreparable cuff. But outcomes have been limited in terms of pain relief and ROM. The expectation for high functional return following a hemiarthroplasty in the presence of rotator cuff arthropathy is not realistic because when there is no rotator cuff, functional outcomes are unpredictable, and overhead motion is not likely to be achieved. The reverse, or inverse, total shoulder arthroplasty is a treatment option for patients requiring a shoulder replacement because of glenohumeral joint arthritis when it is associated with irreparable rotator cuff damage, complex fractures, or for the revision of a pre- viously failed conventional TSA in which the rotator cuff tendons are deficient or absent. The reverse TSA reverses the orientation of the shoulder joint by replacing the glenoid fossa with a glenoid base plate and glenosphere, and the humeral head with a shaft
PHYSICAL THERAPY REHABILITATION FOLLOWING SHOULDER REPLACEMENT SURGERY Patients typically wear a sling for three to six weeks to protect the repair; again, this will depend on the surgeon’s postoperative protocol. Patients will also need assistance to perform their nor - mal daily activities for approximately four to six weeks following surgery because of restrictions of mobility and limitations in ROM and strength.
Postoperative rehabilitation begins immediately following surgery, with joint motion, in-home exercises, and a therapist-supervised program. The initial six weeks of rehabilitation focus on stretching Specifics of physical therapy rehabilitation following TSA TSA surgery primarily involves soft tissue reconstruction. A major factor for success following the surgery is the postoperative re- habilitation. Postoperative rehabilitation is crucial to the overall functional outcome of individuals who have undergone TSA. Re- covery may take up to two years following surgery, and outcomes are primarily based on the status of the involved soft tissue. Most programs presented in the literature following TSA are strict- ly structured with regular supervision by the therapist and primary surgeon. But one study challenged this traditional treatment pro- tocol by looking at the effectiveness of a home-based therapeutic exercise program following TSA. The favorable results reported that 70% to 90% of patients maintained ROM in forward flexion and external rotation over a two-year follow-up period. Average forward flexion was found to be 148 degrees in the group with OA and 113 degrees in the group with osteonecrosis (Wilcox III et al., 2005). The results of this protocol were not published, and it appears that the focus was on ROM. But ROM is not the only component to determine successful outcomes. Typical protocols involve physical therapy supervision with eventual transition to an independent home program. It is standard practice for patients to begin early PROM follow- ing a TSA, which can begin as early as a few hours following the procedure. Typical protocols are not written to address underly - ing pathology, but these patients may need a modified protocol and may progress at a different pace. For example, patients with rotator cuff pathology may need a modified approach. Patients with severe RA or who had a delayed or primary humerus fracture may have needed to have a TSA for pain control with low expec- tations for ROM and improved function. The protocol that these individuals will need to follow will differ from that of the young pa- tient with osteonecrosis who has a healthy rotator cuff and a high expectation to return to a high functional level. Patients with an underlying condition or pathology should be progressed to the next phase of rehabilitation based upon specified clinical criteria and not on typical postoperative time frames. The physical therapist and surgeon need to collaborate to prog- ress the patient appropriately through rehabilitation. Time frames on protocols should be used as an approximation and as a guide for progression and not the progression criteria itself. The protocol following TSA is typically broken down into three or four phases
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