FIGUREEffect of rotator cuff deficiency Centring forces lost. Superior humeral migration. GH joint cartilage destruction. Superior glenoid erosion. Synovial fluid leak. Osteoporosis. Humeral head destruction. F Articulation with acromion, Coraco -acromio ligt erosion. Acromio clavicular joint destruction.
Problems with Rotator cuff tear andtraditional TSR Joint mechanics altered. Centre of rotation superiorly shifted during elevation. Increased shear forces. Glenoid loosening. Humeral head migrates superiorly. 90° Flexion typical. High functional return unrealistic. Pain relief? Overhead motion unlikely.
Reversed Prosthesis (rTSR) Grammont et al (1993) Salvage procedure. (Boileau et al) 2005
Indications for rTSR Pain associated with rotator cuff tear arthropathy (most common). Failed hemiarthroplasty with irreparable rotator cuff tears. Pseudoparalysis .(i.e. inability to lift the arm above the horizontal) Reconstructions after tumour resection. Fractures of the shoulder .(Neer three-part or four-part #) Non-union #. Severe rheumatoid arthritis.
Biomechanical effects of reversed prosthesis -The lever arm distance (L) is increased and deltoid force (F)is increased by lowering and medializing the centre of rotation which is now also fixed. -Torque (F x L) in abducting the arm is increased. -Deltoid tension increased on lifting and lowering arm. -↑ Joint compression. -105° elevation +.
Medialising the centre of rotation recruits more of the deltoid fibres for elevation or abduction but…
Effects of reversed prosthesis onmuscle lengths and tensions. Fewer posterior deltoid fibres are available for external rotation. Remaining Cuff length tension is decreased. Teres minor dysfunction→ No rotation (Boudreau et al 2007). 30° External rotation= optimum required for function. Teres minor/posterior cuff and deltoid therefore vital for function. However 35°+ External rotation→ posterior notching. Care with passive external rotation for stability.
Immediate post op. Cryotherapy Ensure Interscalene block has worn off. Early phase of rehabilitation. Analgesic effect (15-16° tissue temperature) Post rTSR (Speer et al 1996) No =50. 24 hours hourly Rx. 4-6x daily until 10/7. - Easier pain -Easier movement (10 days) -Better sleep.
Immobilisation1st approach Sling for comfort only 2-3/52. (Static joint control more important) Remove as pain starts to settle.(Blacknall et al 2011)2nd approach ?Abduction sling in 30°elevation and Abduction recommended by (Boudreau 2007). Patient “to see the elbow”. 4-6 weeks immobilisation if the shoulder is a revision. 15° External rotation of sling if posterior cuff repaired. Less muscle stiffness.
Precautions Avoid adduction + Internal Rotation (Anterior-inferior dislocation). Other sources advocate no ABER. Consensus is to avoid extension beyond neutral. Avoid hand behind back in early stages of rehabilitation. No Lifting. (Limited to cup/eating utensils). No weight bearing through limb.
Early Rehabilitation (1-6weeks)Rehabilitation is different compared with a conventional TSR Check post-op notes. Implant fixation. ?Subscapularis repair (osteotomy of tuberosity)/ Latissimus dorsi repair. Mackensie incision. Deltoid split. No deltoid or active ROM 6/52. Isotonic deltoid exercises at 12/52. Acromial stress #?. Stop AROM or deltoid isometrics for 4-6/52 or until pain subsides. Nerve Block resolution.(Deltoid and sensory function affected)
Early rehabilitation (1-6weeks) Hand, wrist, elbow exercises. Scapular setting and postural control. Restore PROM. -Flexion -90° in scapula plane, -Abduction -Nil-20°, -External Rotation in scapula plane 0-30°. ½ lever exercises/pulley. Sub maximal (less than 30%) isometric periscapula exercises at 2/52 & deltoid exercises at 4/52. Active assisted exercises within a “safe zone” at 4/52. No active IR ROM or hand behind the back for 6/52.
Phase 1 Rehabilitation for rTSR(after Blacknall 2011)Protected mobilisation phase-Sling as comfortable.-Assisted flexion /Pulley to 90° because the Delta 3 implant impinges at 90°.-Focus on scapula dissociation with movements.-Supine 30° passive external rotation.-Static joint holds at 90°.-Functional Base Test .-Movement up to 90° active assisted flexion in supine with a stick at 4/52.-Constrained active assisted exercises and static joint control.
Phase 2 Rehabilitation. Movement controlphase.• Progress to AROM and joint control exercises through previously active assisted ranges in a logical manner.• No elevation restriction.• Address previously learned abnormal movement patterns.• Address any scapula dyskinesis. N.B. Increased scapular upward rotation in rTSR.• Focus on Neuromuscular control. Progression criteria:-Pain free-No instability-Completed functional base test.• Little and often rule. Avoid fatigue .Full control of movement.
Rehabilitation exercises and strategies (Phase 2)• Short lever flexion to long lever.• Incline glenohumeral dissociation.• Increase ER control in different positions.• Scapula dynamic control exercises/rehabilitation.• Use biofeedback++Mirrors, Video, therapist verbal and tactile input, US, Surface electromyography.• Incorporate exercises into function.• Posterior Cuff/Lat Dorsi rehab (as appropriate)• Hand behind back and extension control. Anterior deltoid control essential for this.• Wrist & elbow strengthening.
Functional Rehabilitation 4months +. (Phase3) Progress deltoid rehabilitation. 20-30 reps no fatigue. Resisted shoulder external rotation and belly press exercises. Functional specific training in standing. Progress strength and endurance through functional activity. Limit 4.5-6.8 kg maximum. (Boudreau et al 2007, Blacknall et al 2011)
Function guide Dextrous activities at low level (Crafts), feeding, personal care and dressing. Functional loaded movement. Gardening without overhead or loaded activity e.g. pruning or digging. Walking, ballroom dancing, stationary bicycling allowed. Swimming, bowls and golf only allowable with movement control. Technique change. No sporting activity that could lead to a fall e.g. Skiing, Tennis, Step aerobics etc...(Magnussen et al 2010)
Summary rTSR rehabilitation is different from traditional shoulder replacement. Pre-op assessment, includes discussion of expectations and post op social circumstances to prevent possible complications. Therapists must have good communication with the surgeon. Each case should be dealt with on an individual basis. Papers report differing positions for instability of the rTSR.• The consensus is that rehabilitation in the initial stages focuses on stability and protection of the prosthesis. Later rehabilitation focuses on rehabilitation of the Deltoid with static and dynamic shoulder control through progressive AAROM ,then AROM. Must address any abnormal previously learned movement patterns and any scapula dyskinesis.
Summary Continued. Expected elevation is increased with a functioning Teres Minor or the posterior cuff. Increased external rotation movement to 30° and control has been linked with improved stability and function of the rTSR. Latissimus transfer /cuff repair can be additional procedures to deal with. They will expand the timeframe of recovery. Some patients will still have a poor outcome. Having strategies to deal with this are necessary. Research studies have still shown this procedure to have great benefits in terms of pain control, movement and function. Strategies for rehabilitation of the rTSR are changing and evolving. There are differences in rehabilitation regimens which need evaluation. Longer term studies for the rTSR are required.