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SHOULDER ARTHROPLASTY
Dr.Satyendra Nath Bhattacharyya
Asst. Professor BIMLS, Burdwan
HISTORY
Developments
The first shoulder arthroplasty is thought to have been
carried out in 1894 (Hamblen 1984) but it was in 1951
that the modern story of shoulder replacement began.
In 1951 Charles Neer developed a hemi-arthroplasty,
primarily for the reconstruction of severe proximal
humerus fractures. However, it was also used for people
suffering from osteoarthritis, with surprisingly good
results. In 1973 Neer redesigned the humeral component
and added a glenoid to make the first unconstrained
Total shoulder arthroplasty (TSR) - known as
the Neer II.
FACTORS INFLUENCING OUTCOME OF SHOULDER ARTHROPLASTY(MAINLY IN RA)
Factors affecting outcome of prosthetic shoulder reconstruction. Pathology
Rotator cuff disease
Glenoid erosion bone loss
Humeral bone loss
Bone density Surgical technique
Prosthetic placement
Prosthetic-cement-bone interface
Soft-tissue balancing Prosthetic design
Size selection
Glenoid
Humeral head
Humeral stem
Material properties Rehabilitation programme
Range of motion
Strength
Stability
PRIMARY OSTEOARTHRITIS (OA)
This is the indication for TSR from which the best results can be expected. Godeneche et al. (2002) reviewed a series of 267 operations for osteoarthritis and found that 77% of them had results which were classed as good or excellent. They found that the result was dependent on the severity of the degenerative changes that had taken place prior to surgery. It seems, therefore, that for patients who have primary osteoarthritis without gross soft-tissue damage or loss of bone, we can expect to achieve near-normal range of movement and strength. Patients who start off with rotator cuff disease or glenoid erosion should have less high expectations
RHEUMATOID ARTHRITIS (RA)
People with RA who undergo shoulder arthroplasty are
likely to have a number of the adverse pathological factors . The expected results will depend on how many and how severe they are. People with rheumatoid arthritis do not tend to be referred for replacement arthroplasty until these factors are fairly advanced, so the results are generally not as good as in osteoarthritic patients. The surgical approach and basic postoperative management are the same.
In advanced disease of either the OA or RA type it is not always possible to insert a glenoid component. If there is gross bone loss around the glenoid fossa, it is not possible to attach the implant securely enough.
Also the lack of rotator cuff function causes the humeral head to 'rock' the glenoid component, causing loosening. The problem of glenoid fixation is one of the ongoing dilemmas in shoulder arthroplasty.
COMPLEX FRACTURE
Following a complex fracture it is normally a hemiarthroplasty that is performed as the glenoid is intact. The operation can be performed either acutely as the primary treatment for the fracture or later as a secondary procedure. The results are better if it is performed acutely. This is a different operation from the
one performed as an elective procedure as there is disruption of the tuberosities to which the rotator cuff
muscles are attached. The challenge to the surgeon is to
restore the anatomy to as close to normal as possible
PROCEDURE
The most common surgical approach is known as the
'deltopectoral approach'. The incision passes between
the deltoid and pectoralis major, and access to the
shoulder joint is via the subscapularis muscle and the
anterior part of the capsule. Thus the subscapularis
muscle is the only active structure which will need to be
protected in the early postoperative period.
GETTING TO THE JOINT
The patient is first taken into the operating room and positioned on a special operating table as though lounging in a beach chair. The arm is placed on a board that will allow the surgeon to move it up or down as necessary during the surgery. Anesthesia is given and, when it has taken effect, the skin around the shoulder and upper arm is thoroughly scrubbed and sterilized with an antiseptic liquid.
An incision about six inches long is then made over the shoulder joint. The incision is gradually made deeper through muscle and other tissue until the bones of the shoulder joint are exposed.
SHOULDER JOINT EXPOSED
Replacing the Socket Portion of the Joint The implant that replaces the socket consists of a durable
plastic insert with a very smooth, cupped surface. Implant to Replace Socket in Shoulder Blade
REMOVING THE SURFACE OF THE SOCKET
The arm is maneuvered until the humeral head is dislocated from the socket.
Special precision instruments are then used to remove the damaged cartilage and bone surface from the glenoid, and to shape the socket so it will match the shape of the implant that will be inserted. Holes are then drilled into the socket to accommodate the fixation pegs on the implant. These pegs help stabilize the implant.
SOCKET PREPARED FOR IMPLANT
INSERTING THE IMPLANT
The socket implant is attached by using a special kind of cement for bones. The cement is pressed into the holes. The implant is then inserted.
GLENOID IMPLANT
REPLACING THE BALL PORTION OF THE JOINT
The implant that replaces the ball consists of a long metal stem that fits down into the humerus. A metal head in the shape of a partial sphere is mounted on top of this stem. This head contacts the socket implant in the shoulder blade.
METAL IMPLANT TO REPLACE BALL PORTION OF SHOULDER JOINT
PREPARING THE HUMERAL CANAL
The upper arm bone has relatively soft, porous bone tissue in the center. This part of the bone is called the "canal."
Special instruments are used to clear some of this soft bone from the canal.
Using a precision guide and saw, the damaged rounded portion (ball) of the humerus is removed.
HUMERAL HEAD (BALL) IS REMOVED
INSERTING THE IMPLANT
The metal stem implant may be held in place by either using the special bone cement, or by making it fit very tightly in the canal. The surgeon will choose the best method, depending on the patient's age and expected activity level.
If cement is used, it is injected into the canal first, and then the implant is inserted into the canal. If cement is not used, the implant is simply inserted into the canal.
On some implants, the stem and partial sphere are one piece. On others, they may be two separate pieces. If the partial sphere is a separate piece, it is usually secured to the top of the stem after the stem has been inserted.
STEM IMPLANT WITH PARTIAL SPHERE (HEAD)
SHOULDER IMPLANTS AFTER INSERTION
CLOSING THE WOUND
When all the implants are in place, the surgeon places the new ball that is now part of the upper arm bone into the new socket that is part of the shoulder blade. If necessary, the surgeon may adjust the ligaments that surround the shoulder to achieve the best possible shoulder function.
When the ligaments are properly adjusted, the surgeon sews the layers of tissue back into their proper position. A plastic tube may be inserted into the wound to allow liquids to drain from the site during the first few hours after surgery. After the tube is inserted, the edges of the skin are sewn together, and a sterile bandage is applied to the shoulder. Then, the patient is taken to the recovery room
BIGLIANI/FLATOW® THE COMPLETE SHOULDER SOLUTION
The Bigliani/Flatow Shoulder allows for the restoration of shoulder joint function in cases of shoulder replacement surgery. Backed by the clinical expertise of surgeons and decades of experience, the Bigliani/Flatow Shoulder System is designed to replicate the natural shoulder's mobility, balance, and stability with a multitude of component sizes.
Anatomical Shoulder™ System Traditionally, patients undergoing shoulder reconstruction
faced two postoperative tasks. First, they had to let the shoulder tissues recover, as would be expected. Then they had to adapt to anatomical changes imposed by a first- or second-generation implant that offered nothing more than an approximate fit.
But now, with the modular Anatomical Shoulder System, the shoulder implant can be tailored to each patient’s individual anatomy.
This allows a more advanced rehabilitation and an expanded radius of movement while placing fewer demands on the soft tissues and on the anchoring of the prosthesis.
The surgeon enjoys a simple operating technique that places fewer limiting factors on the success of the surgery. The design of the Anatomical Shoulder prosthesis truly sets the new standard for third-generation shoulder arthroplasty.
ANATOMICAL SHOULDER™ INVERSE/REVERSE SYSTEM FROM ANATOMICAL TO INVERSE/REVERSE
With the Anatomical Shoulder System and now with the innovative Anatomical Shoulder Inverse/Reverse system, Zimmer offers surgeons a complete Shoulder solution with the possibility to change a done hemi- and total shoulder arthroplasty with the current implanted cemented or press-fit stem into an inverse/reverse shoulder solution.
This design allows the surgeon the opportunity to revise a primary anatomical prosthesis to the inverse/reverse components, without the need for stem removal. Such revision might be necessary in the setting of irreparable rotator cuff tear. This greatly simplifies and shortens revision surgery since the need to remove a well-fixed stem is eliminated.
FEATURES OF ANATOMICAL SHOULDER INVERSE/REVERSE SYSTEM
Option to convert to inverse/reverse without stem removal
Designed for flexibility and stability by using either a press-fit or cemented stem
Infinite variable settings of the humeral head Utilizes polyaxial locking screws, variable angulations to
a maximum of 30º in all directions
REHABILITATION PROTOCOLAFTER SHOULDER ARTHROPLASTY
Phase 1: Weeks 0 - 6 RestrictionShoulder motion Week 1 120 degrees of forward flexion 20 degrees of external rotation with the arm at the side 75 degrees of abduction with 0 degrees of rotation • Week 2 • 140 degrees of forward flexion. • 40 degrees of external rotation with the arm at the
side. • 75 degrees of abduction with 0 degrees of rotation. • No active internal rotation. • No backward extension.
Immobilization • Sling • After 7-10 days, sling used for comfort only. Pain Control • Reduction of pain and discomfort is essential for
recovery • Medications • Narcotics-for 7-10 days following surgery. • NSAIDs-for patients with persistent discomfort
following surgery. • Therapeutic modalities • Ice, ultrasound, HVGS. • Moist heat before therapy, ice at end of session.
Motion: Shoulder • Goals • 140 degrees of forward flexion. • 40 degrees of external rotation. • 75 degrees of abduction. • Exercises • Begin with Codman pendulum
exercises to promote early motion. • Passive ROM exercises (see next slide)
Forward flexion External rotation with the arm at the side
External rotation with the arm in 90 degrees of abduction Cross-body adduction
• Capsular stretching for anterior, posterior, and inferior capsule, by using the opposite arm to assist with motion
• Active-assisted motion exercises (see next slide)
• Shoulder flexion. • Shoulder extension. • Internal and external rotation. • Progress to active ROM exercises.
Exercises to regain motion. Active-assisted ROM exercises using a pulley system and a dowel stick
Motion: Elbow • Passive-progress to active • 0 to 130 degrees of flexion • Pronation and supination as
toleratedMuscle Strengthening • Grip strengthening only
Phase 2: Weeks 6-12 Criteria for Progression to Phase 2 Minimal pain and tenderness. Nearly complete motion
Intact subscapularis without evidence of tendon pain
on resisted internal rotation. Restrictions • Increase ROM goals • 160 degrees of forward flexion • 60 degrees of external rotation with the arm at the
side • 90 degrees of abduction with 40 degrees of
internal and external rotation
Immobilization None Pain Control• NSAIDs-for patients with persistent
discomfort following surgery.• Therapeutic modalities • Ice, ultrasound, HVGS. • Moist heat before therapy, ice at end of
session.
Motion: Shoulder• Goals • 160 degrees of forward flexion. • 60 degrees of external rotation with the arm at
the side. • 90 degrees of abduction with 40 degrees of
internal and external rotation.• Exercises • Increase active ROM in all directions. • Focus on passive stretching at end ranges to
maintain shoulder flexibility (see next slide). • Utilize joint mobilization techniques for capsular
restrictions,especially the posterior capsule (see 2nd next slide)
Forward flexion External rotation with the arm at the side
External rotation with the arm in 90 degrees of abduction Cross-body adduction
Stretching of the posterior capsule
Muscle Strengthening• Rotator cuff strengthening:
Only three times per week to avoid rotator cuff tendinitis, which will occur with overtraining
• Begin with closed-chain isometric strengthening (see
next slide) • External rotation. • Abduction.
Closed-chain shoulder exercises. 1. Isometric strengthening of the rotator cuff in abduction (pushing out against the wall). 2.Isometric strengthening of the rotator cuff in external rotation.
• Exercises performed with the elbow flexed to 90 degrees.
• Starting position is with the shoulder in the neutral position of 0 degrees of forward flexion, abduction, abduction,and external rotation.
• Exercises are performed through an arc of 45 degrees in each of the five planes of motion.
• Six color-coded bands are available; each provides increasing resistance from 1 to 6 pounds, at increments of one pound
• Progression to the next band occurs usually in 2to 3-week intervals. Patients are instructed not to progress to the next band if there is any discomfort at the present level.
• PROGRESS TO OPEN-CHAIN STRENGTHENING WITH THERABANDS
Open-chain isotonic strengthening of the rotator cuff (internal rotation) using Theraband tubing
• Theraband exercises permit concentric and eccentric strengthening of the shoulder muscles and are a form of isotonic exercises (characterized by variable speed and fixed resistance)
• External rotation. • Abduction. • Forward flexion.• Progress to light isotonic dumbbell exercises • External rotation (see next slide). • Abduction. • Forward flexion.
external rotation strengthening
• Scapular stabilizer strengthening • Closed-chain strengthening exercises (see
next three slides) • Scapular retraction (rhomboideus,
middle trapezius). • Scapular protraction (serratus anterior). • Scapular depression (latissimus dorsi,
trapezius,serratus anterior). • Shoulder shrugs (trapezius, levator
scapulae).
Closed-chain strengthening exercises of the scapula stabilizers. A, Scapular protraction. B and C, Scapular retraction.
Additional closed-chain scapular stabilizer strengthening. A, Start. B, Finish (the right arm is the focus of rehabilitation).
Closed-chain strengthening of the scapular stabilizers. A, Start. S, Finish.
Phase 3: Months 3 -12Criteria for Progression to Phase 3 • Full painless ROM. • Satisfactory physical examination. Goals • Improve shoulder strength, power, and
endurance. • Improve neuromuscular control and
shoulder proprioception. • Prepare for gradual return to functional
activities.
• Home maintenance exercise program
• ROM exercises two times a day
• Rotator cuff strengthening three times a week
• Scapular stabilizer strengthening three times a week
Motion • Achieve motion equal to contralateral side. • Utilize both active and passive ROM
exercises to maintain motion.
Muscle Strengthening
• Shoulder
• Begin internal rotation and extension strengthening
• First closed-chain isometric strengthening and advance to Theraband and light weight isotonic strengthening.
• Scapular stabilizers
• Progress to open- and closed-chain strengthening
(see next 4 slides).
Open-chain strengthening exercises of the scapula stabilizers without dumbbells
Open-chain strengthening exercises of the scapula stabilizers with lightweight dumbbells.
Additional closed-chain scapular stabilizer strengthening. A, Start. B, Finish (the right arm is the focus of rehabilitation).
Open-chain strengthening of the scapular stabilizersusing Theraband tubing.
• Deltoid strengthening • Eighr to 12 repetitions for each exercise, for three sets. • Strengthening only three times per week to avoid rotator cuff tendinitis.
Strengthening of the anterior deltoid. A, Closed-chain isometric. B, Open-chainisotonic.
Isotonic deltoid strengthening with light dumbbells. A, Start. B, Finish.
Functional Strengthening • Plyometric exercises (see next slide). Maximum improvement by 12-18 month. Warning Signs • Loss of motion. • Continued pain. Treatment of Complications • These patients may need to move back
to earlier routines. • May require increased use of pain
control modalities as outlined above.
Plyometric shoulder strengthening exercises using Theraband tubing (A) and an exercise ball (B).
REFERENCES
Clinical Orthopaedic Rehabilitation 2nd edition Zimmer Implants Catalouge
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