Chapter 12: Total Shoulder Arthroscopy and Reverse Total Arthroscopy What Physical Therapists Need to Know 2 CCHs
By: Lisa Augustyn, PT, DPT Learning objectives
Describe the path toward having a total shoulder replacement/arthroplasty or a reverse total shoulder replacement/arthroplasty. Be able to describe the signs and symptoms associated with shoulder osteoarthritis and treatment strategies for shoulder osteoarthritis. Describe an overview of surgical procedure of both the total shoulder replacement and reverse total shoulder replacement. Since the development of the Neer prosthesis in the 1950s, shoulder arthroplasty has advanced considerably. The total shoulder arthroplasty (TSA) can significantly improve function in patients with shoulder osteoarthritis (OA). But a patient may still have difficulty performing activities of daily living (ADLs). More patients are becoming candidates for TSA. There has been an increase in the number of these procedures similar to the
State the components of a typical physical therapy rehabilitation plan following a total shoulder replacement and reverse total shoulder replacement. Describe complications related to total shoulder replacement and reverse total shoulder replacement surgeries. Describe surgical outcomes of total shoulder replacement and reverse total shoulder replacement.
INTRODUCTION
increase in other total joint arthroplasties. The reverse TSA (rTSA) is also used in cases where the traditional TSA cannot be utilized. It is important to understand the surgical procedures for the TSA and rTSA as well as understand the rehabilitation protocols. It is also important for physical therapists to understand complications that may occur following these types of surgical procedures.
PATH TO TSA AND REVERSE TSA: HOW A PATIENT GETS TO THIS POINT?
Shoulder OA is characterized by a narrowing of the glenohumeral joint. Patients with this condition typically present with shoulder pain, limitations of shoulder function, and upper extremity disability. Patients with shoulder OA typically complain of chronic shoulder pain with an insidious onset. Other complaints include shoulder stiffness, pain in the morning, and increased symptoms with weather changes. Pain also generally increases with activity, and patients may complain of a specific injury that exacerbated the pain and stiffness. When nonoperative treatment of shoulder arthritis fails to decrease pain or improve function, or when there is severe wear and tear of the joint causing parts to loosen and move out of place, shoulder arthroplasty becomes the ultimate treatment that may provide the best results. Shoulder arthroplasty has become an acceptable treatment option for many painful and degenerative conditions of the shoulder. Over the past 5 to 10 years, reverse total shoulder arthroplasty has gained in popularity for managing complex proximal humerus fractures. Proximal humerus fractures account for about 5% of all humeral fractures (Ryan et al.) Females are affected twice as frequently as males are, and with advancing age, the severity of the fracture is increased. Simple, minimally, or nondisplaced fractures can be managed successfully without surgery, but the more complex three-part and four-part displaced fractures are more likely to require surgical intervention. Management of a proximal humeral fracture depends on multiple patient factors, including advanced aging, increased number and severity of comorbidities, pre-existing rotator cuff abnormalities, osteoporosis, and the ability to engage in postoperative rehabilitation. There is debate and conflicting Shoulder OA epidemiology Shoulder osteoarthritis—also known as degenerative joint disease of the shoulder—is a gradual, progressive, mechanical, biochemical breakdown of articular cartilage and other joint tissues, including bone and joint capsule (Millett, Gobezie, & Boykin, 2008). As the articular surface of the shoulder joint wears, friction within the joint increases, which can cause progressive loss of the normal load-bearing surfaces with pain
literature regarding the optimal management of this difficult group, including whether it should be operative or nonoperative management and, if operative management, which type of surgery should be performed. There is a lower surgical rate in older patients because of the perceived poor outcomes of TSA, the lack of emphasis by patients and providers about the importance of having a functional shoulder, and the cost of surgery. For active patients, urgent lifting requirements can cause more stress on the shoulder arthroplasty, and the implant can fail. Patients may need a TSA or rTSA because of such conditions as shoulder OA, rheumatoid arthritis, rotator cuff deficiency, cuff tear arthropathy, osteonecrosis, and proximal humerus fracture pathology. TSA has been found to be the most successful intervention for pain relief and restoration of function in patients with severe shoulder OA (Wilcox III, Arslanian, & Millett, 2005). Patients with severe rheumatoid arthritis also benefit greatly from TSA. But confounding factors, which include poor bone stock and soft tissue deficiencies, could complicate the surgical procedure. Patients with a rotator cuff deficiency or cuff tear arthropathy may also benefit from TSA but may require the reverse TSA procedure to maximize outcomes. Osteonecrosis can lead to painful degenerative changes that include the collapse of the articular surface of the humeral head. These patients could also benefit from TSA surgery; however, functional outcomes vary because of etiology of the osteonecrosis. As previously discussed, TSA is also a reasonable treatment option for patients who have a nonunion or malunion of the proximal humerus because of fracture. and disability. Risk factors for shoulder OA include age, genetics, sex, weight, joint infection, history of shoulder dislocation, and previous injury. Certain occupations, including those in heavy construction, and a history of participation in overhead sports are also risk factors for shoulder OA. As the population ages, the prevalence of shoulder OA increases.
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