The document discusses reverse total shoulder arthroplasty (rTSA), including: - The procedure reverses the ball and socket of the shoulder joint. - It was approved for use in the US in 2004. - The new design moves the center of rotation medially and inferiorly, increasing deltoid tension and function as the primary shoulder elevator. - Indications include severe rotator cuff deficiency or previous TSA failure. Contraindications include infection or inadequate bone stock. Potential complications range from minor issues like stiffness or hematoma to more serious problems like prosthesis loosening or nerve damage.

1. Scott Davenport
Daniel Woodward
Amy Monroe

2. Reverse Total Shoulder
Arthroplasty
 Joint replacement
procedure where the
ball and socket
articulations of the
glenohumeral joint are
reversed
 Received FDA approval
for use in the US in 2004

3.  Prosthesis design alters the
center of rotation by moving
it medially and inferiorly
 This increases the deltoid
moment arm and deltoid
tension
 Enhanced mechanical
advantage of deltoid
compensates for the deficient
rotator cuff
 Deltoid becomes the primary
elevator of the shoulder joint

4. 1. Achieve functional range of motion while allowing
for adequate soft tissue healing
2. Maximize use of upper extremity for daily activities
at or above shoulder height
3. Educate patient to safely manage their rehabilitation
and use of their arm throughout post-operative
rehabilitation

5.  Glenohumeral joints with severe arthropathy and
severe rotator cuff deficiency or a joint in which a
previous TSA has failed (also with cuff deficiency)
 Joint must be structurally and anatomically suited to
receive device
 Cementless metaglene component
 Functional Deltoid

6.  Any active infections be it local or systemic
 Inadequate bone density to appropriately support the
new prosthesis
 Severe deformity
 Muscle, nerve, or vascular disease
 Obesity, drug abuse, mental incapacity

7.  Osteoporsis or poor bone stock for acceptance of
prosthesis
 Metabolic disorder or systemic pharmacological
treatments leading to progressive deterioration of
bone support for the implant
 e.g. DM, steroid therapies, immunosuppressive
therapies, etc.
 Hx of general or local infections
 Deformities leading to impaired fixation/positioning
of implant

8.  Tumors of the supporting bone structures
 Allergic reactions to implant materials
 e.g. bone cement, metal, polyethylene
 Tissue reactions to implant corrosion or debris due to
wear
 Disabilities of other joints

9.  Any change in position of prosthesis
 Any infection, loosening
 Temporary inferior subluxation which will usually
diminish as muscle tone is regained
 Cardiovascular disorder
 e.g. thrombosis, pulmonary embolism, MI
 Hematoma and/or delayed healing
 Pneumonia
 Subluxation/dislocation of replaced joint

10. Humeral Components:
1. Epiphysis: Upper part of the
prosthetic humeral stem
2. Diaphysis: Lower portion of the
humeral stem
3. Polyethylene Cup: Becomes the
socket of the new ball & socket joint
Glenoid Components:
1. Metaglene: Specially coated metal
plate that is attached to the glenoid
fossa with screws
2. Glenosphere: Half globe metal
piece that is attached to the
metaglene

11. Delto-pectoral
Incision begins inferior to the clavicle & extends 1 cm
lateral to the coracoid tip
Advantages:
a) More traditional & very familiar to most
surgeons
b) Allows clear view of the glenoid & therefore
facilitates accurate implantation of the
glenoid components of the prosthesis
c) Minimizes surgical trauma to the anterior
deltoid
d) Easier identification of the axillary nerve
e) Good for revision surgery
Disadvantages:
a) Subscapularis is incised & repaired (if
possible) following implantation
a) Some have reported higher rates of
dislocation

12. Superior lateral
 Incision begins at the level of the
AC joint & extends 4cm inferiorly
Advantages:
a) Subscapularis muscle is not
incised
a) Lower rates of dislocation
Disadvantages:
a) Limited visualization leading to
less ideal component
positioning
b) Decreased external rotation
postoperatively (compared with
the deltopectoral approach)
c) Deltoid muscle is disrupted

13. Anterosuperior
 Anterior deltoid is divided from the
anterior edge of the acromioclavicular
arch, allowing exposure to the glenoid
for glenosphere implantation
Advantages:
a) Ease of axial humerus preparation
b) Quality of exposure of the glenoid
c) Increased post-op stability as
compared with the deltopectoral
approach
Disadvantages:
a) Disrupts the deltoid muscle
b) Risk of inaccurate glenoid
positioning
c) Axillary nerve palsy

14. Latissimus Dorsi (LD) Tendon Transfer
 For cases where the Teres Minor is
deficient
 LD tendon is transferred to the top
& back of the humeral head
 LD is well suited for transfer due
to:
a. Large surface area
b. Good strength
c. Good vascularity
 LD: Humeral extensor → Humeral
stabilizer with an external rotation
moment
 If subscapularis function is
deficient, the procedure is of
questionable benefit & probably
should not be used

15. The Approach Resection of
humeral head
Diaphyseal
Preparation
Preparation of
the Glenoid
Insertion of
Metaglene
Glenosphere
Placement
Insertion of
Humeral Implant

16. “Reverse Total Shoulder Arthroplasty – from the Most to
the Least Common Complication”
 The most frequent complication is Scapular Notching
 Erosion of the scapular neck related to impingement by
the medial rim of the humeral cup during ADD
 Pre-Op findings associated w/ Scapular Notching
 RTC Arthropathy
 Fatty Infiltration of Infraspinatus
 Narrowed Acromiohumeral Distance
 Superiorly Oriented Glenoid

18.  Anesthesia
 Infection
 Fracture
 Dislocation/Instability
 Loosening
 Nerve or Blood Vessel
Injury
 Hematoma
 Poor Screw Placement

19. Precautions
 NO extension past neutral x6 weeks
o At 6 weeks progress 10° per week into extension with arm at 15-30° abduction
 NO combined humeral IR and extension x12 weeks
o Tucking in shirt or bathroom personal hygiene with operative arm are specifically
dangerous activities
 NO horizontal Adduction past neutral x6 weeks
o At 6 weeks progress 10° per week into with AROM. No overpressure
 Avoid “cocking position” or “throwing position” of 90° abduction with end
range ER
 If subscapular repair then ER will be limited x6 weeks with specifics from
surgeon
 Post-operative brace/sling with abduction pillow should be worn at all
times x4 weeks and then progressive weaning from device based on
patient tolerance.

20. Goals of Rehabilitation
 Focus should be on:
o Full ROM in scaption progressing then to flexion and
abduction
o Shoulder stability
o AAROM in scaption, flexion, and abduction progressing to
AROM as patient tolerates
o Scapular neuromuscular control and stability
o Realize that ER will be and is expected to be very weak. Do
not overload this tissue as likely the only remaining
external rotator is teres minor.

21. Acute Care Therapy (Days 1-4)
 Begin PROM supine and in scapular plane to 90° keeping
elbow bent
 ER in available range with arm in 30° abduction and forward
flexion (30-30 position)
o Typically 20-30°
 Gripping and hand dexterity
 Wrist and Elbow AROM 4-5x daily
 3 point pendulums/Codman’s (front-back-horizontal
abduction) PROM and AROM
 Neck ROM and stretching to trapezius and levator scapulae
 Brace/sling education and management
 OT evaluation for dressing may be indicated at this time

22. Outpatient Therapy Phase I (Day 10-21)
 PROM in scaption, flexion and abd to 120°. No overpressure at end range.
o Limit ER to 45° and perform at 30-30 position
 AAROM pulleys with focus on scapular plane but also flexion and
abduction
o AAROM using non operative hand
 Deltoid and shoulder isometrics – submaximal
o Recommend use of theraband with patient positioned in desired plane and moving
away from anchor point of theraband.
 Gentle resisted exercise of elbow, wrist and hand
 AROM in scapular plane working from gravity reduced position to full
gravity/AROM
o Continue AROM 3 point pendulums
o Consider ball on mat table pendulums
 Scapular AROM – scapular clocks
 UE weight bearing stability exercises (limit weight bearing to 25%)
o Examples include mat UE walking in flexion/scaption, “window washing”, etc.

23. Phase II (3 – 6 weeks)
 Continue above where deficits persist
 PROM working to 150° scaption, flexion and abduction
o Continue to limit ER to 45° and perform at 30-30 position
 AROM working to decrease substitution patterns
 UBE/Arm bike – ensuring no extension past neutral and providing pt
has motion to allow. Keep rotation neutral
 Isometric push downs progressing to light resistance
o Goal is to initiate scapular depression and scapular stability
 Shoulder stability exercises progressed to include
o Alternating isometrics (sub max)
o Ball on wall cross and circles
o Ball on wall stability with therapist perturbations
 Progress scapular stability to include rows (NO humeral extension)
 Y-T scapular exercises on Swiss ball. NO “W” (YTW). NO resistance

24. Criteria for progression to phase III
 AROM above 90° in scaption, flexion and abduction
 Activation of all components of the deltoid as well as
scapular musculature with stability exercises (with
arm in scapular plane)
 No increased pain with PROM, AAROM, or
shoulder/scapular stability exercises

25. Phase III (6-12 weeks)
 Full PROM in scaption, 160-170° Flexion, 150° abduction
 Begin ER with arm in slight flexion and 60° abduction
 Begin ER with arm in slight flexion and 90° abduction (limit 45° ER)
 AROM in scaption, flexion and abduction progressing as tolerated by patient
 Continue with shoulder and scapular stability progressing as tolerated
 Shoulder strengthening to include:
o Push downs
o Theraband scaption (full can) , flexion, abduction, IR
o Extension to allowable ROM (see precautions)
o ER strengthening with care not to overload teres minor
 Scapular strengthening to include:
o Gradual addition of light weight with rows into allowable extension
o Y-T-W on Swiss ball using care in “W” position to avoid excessive ER
 UBE/Arm bike with resistance increasing as patient tolerates
 Serratus, latissimus dorsi, and gentle pectoral strengthening
o Press up with a plus
o Serratus punch
o Pull downs (begin with theraband and progress to cable column)

26.  66 y.o. male, R rTSA on 10/3/14
 Post-op days 1-3, seen as inpatient
 PROM shoulder flexion & scaption to 90°
 PROM shoulder ER to 15° at 0° ADD & 30/30
 Shoulder IR full to stomach
 Closed reduction on 10/15/14
 Dislocation likely occurred while sleeping
 Return to outpatient clinic on 10/29/14
 PROM shoulder flexion 136°
 PROM shoulder ER to neutral
 PROM shoulder ABD 102°
 Shoulder IR to stomach w/ slight forward flexion

27.  7 Weeks Post-op
 AROM shoulder flexion (sitting) 137°
 PROM shoulder flexion (supine) 155°
 PROM shoulder ER (supine) 42°
 PROM shoulder ABD (supine) 115°
 Weak Shoulder ER
 Only Teres Minor for ER
 Scapular control is improving, but still has difficulty
w/ scapular depression.
 Use of substitution is decreasing.
 Shoulder musculature fatigues quickly
 No c/o pain

28. 1. Edwards TB, Williams MD, Labriola JE, Elkousy HA, Gartsman GM, O’Connor DP. Subscapularis insufficiency and the risk of shoulder
dislocation after reverse shoulder arthroplasty. J Shoulder Elbow Surg.2009;18:892–896. doi: 10.1016/j.jse.2008.12.013.
2. Farshad, Mazda, and Christian Gerber. "Reverse Total Shoulder Arthroplasty-from the Most to the Least Common Complication - Springer."
Reverse Total Shoulder Arthroplasty-from the Most to the Least Common Complication - Springer. Department of Orthopaedics, Balgrist
University Hospital, University of Zürich, Forchstrasse 340, 8008 Zürich, Switzerland, 01 Dec. 2010. Web. 23 Nov. 2014.
<http://dx.doi.org/10.1007%2Fs00264-010-1125-2>.
3. Frankle, Mark A. Rotator Cuff Deficiency of the Shoulder. 1st ed. New York: Thieme, 2008. Web. 21 Nov. 2014.
4. Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg
Am. 2006;88:113–120. doi: 10.2106/JBJS.E.00282.
5. Molé D, Wein F, Dézaly C, Valenti P, Sirveaux F. Surgical Technique: The Anterosuperior Approach for Reverse Shoulder Arthroplasty. Clinical
Orthopaedics and Related Research 2011;469(9):2461-2468. doi:10.1007/s11999-011-1861-7.
6. Nam D, Kepler CK, Neviaser AS, Jones KJ, Wright TM, Craig EV, et al. Reverse total shoulder arthroplasty : c0 urrent concepts, results, and
component wear analysis. J Bone Joint Surg Am 2010;92 Suppl 2:23-35.
7. "Reverse Shoulder Arthroplasty." Houston Methodist Orthopedics & Sports Medicine. Houston Methodist Orthopedics & Sports Medicine, n.d.
Web. 23 Nov. 2014. <http://www.methodistorthopedics.com/reverse-shoulder-arthroplasty>.
8. Walch G, Wall B, Mottier F. Complications and revision of the reverse prothesis: a multicenter study of 457 cases. In: Boileau P, editor. Reverse
shoulder arthroplasty. Nice: Sauramps; 2006. p. 335-52
9. Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a
systematic review. J Shoulder Elbow Surg. 2011;20:146–157