TSA Case Study

8/10/2019 TSA Case Study

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Kate DunnDPT 751

July 12, 2010


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- To understand the surgical procedure of a

rTSA

-To apply current evidence in the development

of an POC for rTSA

-To describe the overall physical therapy

management of a patient who underwent a

rTSA-To incorporate complex impairments of an

individual with a rTSA that has PD


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-TSA: for patients withadvanced GH jointpathology (OA, RA, RCA)

-persistent pain and loss offunction despite

conservativemanagement1

-Hemiarthroplasty: for

patients with either

severe cuff pathologyor

irreparable cuff

1

-replacement of humeral

head


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-Approved by the FDA in 20041

-Reverses the orientation of the

shoulder girdle

-Glenoid fossa > glenoid base plate & glenosphere

-Humeral head > humeral shaft & concave cup

- Increases deltoid moment arm to enhance the torque- Enhanced mechanical advantage of deltoid compensates

for deficient RC


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Drake GN, OConnor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease.

Clin Orthop Relat Res. 2010;468:1526-1533.


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Indications1,3

-GH joint arthritis

associated withirreparable RCT

-Complex humeral

fracture

-Revision of failedtraditional TSA

-Absent RC

-Over the age of 70yrs

Contraindications3

-Advanced glenoid

destruction-Severe lesions of deltoid

-Axillary nerve palsy

-Patient with expectation

of high functional return


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-Post-op complications3

-Hardware instability or dislocation (abd with ER)

-Nerve damage

-Infection

-Hematoma-Intra-operative fracture

-Complication rates are 2-68%1


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-What are some indications for a rTSA?-GH joint arthritis with irreparable RC

-Revision of failed TSA or hemiarthroplasty

-Over the age of 70 years

-Who is not appropriate for a rTSA procedure?

-Glenoid destruction

-Deltoid that is not intact

-Patient wanting high functional return

-What is the most common surgical complication?-hardware instability or dislocation


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-76y/o female-Referred to PT s/p right rTSA (05/14/10)

-Previous injury: fall 07/16/09

-Previous sx: RCR Sept 2009

-PMHx: Parkinsons Disease (1997), CVA (1996), PAD,

breast cancer (R mastectomy), memory loss-Social hx: retired, does not drive


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-Parkinsons Disease: progressive degeneration ofdopamine cells & imbalance of neurotransmitters in

basal ganglia-Body impairments: tremors, rigidity, akinesia, postural instability

-FORCE CONTROL (impaired amplitude of movement)

-Rotator Cuff Repair

-Sept 2009-Repaired supraspinatus & infraspinatus

-Repair sites failed


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-Arthritic changes of the humeral head-Significant retraction of cuff musculature

Impression: irreparable pathology without replacement

-General anesthesia with an interscalene block-Subscapularis released

-No supraspinatus, biceps tendon, infraspinatus

attachments found-Capsule released, labrum debrided circumferentially


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-Completed 2.5wks post-op

-Subjective: right shoulder, elbow & hand pain (5/10),

N & T into fingers

-PIPs: difficulty washing & combing hair, difficulty with

household chores, shoulder pain

-Patient goals: get back to doing basic household

chores, be able to move arm without pain

*On 1L of O2 at night


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-Observation

-Rounded shoulders

-FHP

-Increased thoracic kyphosis

-Reverse scapular rhythm

-Scar mildly adhered

-Neuro Screen

-Intact to LT bilaterally

-Postural instability-B UE pill rolling tremor

-Jaw tremor

-Decreased facial expressions

-PROM

90 flex

60 abd

11 ER

-5 elbow ext-Palpation

-Tender over anterolateral

incision & mid belly of biceps

-Quick DASH: 72%

(0-100%, higher scoreindicates more disability)


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-Initial Hypothesis: Patient presents with decreased ability

to perform ADLs and functional activities secondary to

decreased right shoulder ROM & strength, increased

shoulder pain, postural instability, and bilateral UE

rigidity & tone.

-APTA Guide Patterns

-4H: impaired joint mobility, motor function, muscle

performance, and ROM associated with joint

arthroplasty

-5E: impaired motor function & sensory integrity

associated with progressive disorders of the CNS


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-Good to fair prognosis for return to (I)

functioning

-Progress may be limited by:

-Severity of PD (rigidity, tremors, postural instability,

akinesia)

-Previous shoulder surgery-Age of patient @ time of current surgery

-Cognitive functioning

-Compliance with POC/ HEP


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-Frequency: 3x/wk for 6 weeks to date (3x/wk for 10wks)1- Pt education: precautions, sling use

2- Transfer & gait training

3- Joint/ soft tissue mobilizations

4- Ther-ex for ROM

5- Ther-ex for strengthening

6- Modalities for pain & edema management

-Things to remember:

-Only deltoid & teres minor are intact-High risk for anterior/inferior subluxation

-Patient has difficulty with movement initiation & amplitude

of movement

-Avoid dual tasks (BG controls one, attention on the other)


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-rTSA: concave humeral cupmoving on convex glenosphere

(same direction)*superior rotation, superior glide

-TSA: convex humeral headmoving on concave glenoid

fossa (opposite direction)*superior rotation, inferior glide

Boudreau S, et al. JOSPT2007;37:734-743.


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- Shoulder mechanics & function will have some

limitations when compared to unaffected shoulder

- Establish appropriate functional & ROM

expectations


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-Sling 4 weeks

-Potential for instability due to design

-No active IR or extension for 6 weeks1

-Pt must be able to visualize elbow while lying supine(no hyperextension)

-No resisted IR or extension for 12 weeks

-No IR, adduction, extension (tucking in shirt) for 12 weeks


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-STG: 5 weeks

1-MinA with

established HEP

2- Decrease in painby 50%

-LTG: 10 weeks

1- Able to wash &

comb hair with R UE

independently2- R UE AROM within

75% of L UE AROM

3- Decreased Quick-

DASH by 50%


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-Dislocation precautions for 12 weeks post-op

-no combined add/IR/ext (tucking in shirt)

-no GH joint extension beyond neutral

-Phase 1: Joint Protection (day 1 to week 6)-joint protection, PROM, edema/pain management-PROM: flex 120, ER to tolerance, IR


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-Phase 2: AROM, Early Strength (weeks 6-12)-Gradual AROM, control pain & inflammation, re-establish

dynamic stability

-Begin AROM when gleno-humeral rhythm is restored

-Flex, abd, ER isotonic strengthening

-Criteria to move to next phase:-Improving functional ability

-Pt is able to isotonically activate each component of the

deltoid & scapular muscles


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-Phase 3: Moderate Strengthening (weeks 12-16)-Enhance functional use, increase strength/power/

endurance

-Begin gentle resisted flexion/abduction (5+lbs) in standing

-Phase 4: Independent HEP (months 4+)-3-4x/wk

-strength gains, return to functional/recreational activities

-Criteria for discharge:

-Pt is able to maintain pain-free AROM with proper shouldermechanics

-ROM: 80-120 of flexion, 30 of ER


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0

10

20

30

40

50

60

70

80

90

100

110

120

130

140

Flex Abd ER Pain (x/10)

Initial

4 weeks

6 weeks


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-PIPs

1- Difficulty washing & combing hair

2- Difficulty with household chores

3- Shoulder pain

-Non- PIPs

1- Swinging arms during gait MET

2- Right arm strength

-STG: 5 weeks

1-MinA with established HEP MET

2- Decrease in pain by 50% MET-LTG: 10 weeks

1- Able to wash & comb hair with R UE independently ?

2- R UE AROM within 75% of L UE AROM ?

3- Decreased Quick-DASH by 50% 72% > 52%

(MCID=15pts)5


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-Improvement in passive range of motion, pain scores, and functional

outcome scores

-Pt has met all STG, progressing towards LTG

-Pt is progressing consistently, but may reach plateau due to comorbidities

-Primary focus needs to be on patient education and precautions, high

functional return is unlikely

-No setbacks in POC, compliance with HEP is questionable


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-60 pts (mean age 70yrs) with glenohumeral arthritis associated with severe RCdeficiency treated with rTSA, followed for minimum of 2 yrs-2 groups: previous RC repair, no previous surgery

-Intervention: PROM started day 2, sling worn for 4 weeks, AAROM began @4wks, AROM started @ 8wks, resisted exercises @ 12wks

-All measures improved significantly (p


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-45 pts w/ rTSA-21 massive & irreparable RCT associated with arthritis treated

-5 complex humeral fracture with arthritis

-19 failure of revision arthroplasty

-Mean follow-up was 40 months

-Outcomes: ROM , VAS pain scale, Constant functional score-Intervention: sling for 6 weeks, pendulum exercises started day 2, physical

therapy @ wk 3, no abd @ 90 with ER

-Results: all groups showed significant increase in flexion by 66, no

significant change in ER or IR-rTSA can improve function and restore active flexion in patients with

cuff-deficient shoulders

-rTSA should not be offered to a young individual who wants a normal

shoulder or who will demand more out of the prosthesis that it was

designed to do


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-15 TSA in patients with PD-Mean follow-up: 5.3yrs

-Results: significant improvement-Pain-Poor functional results

-Duration of PD, rigidity, arm swing & rapid alternating movement scoreswere not found to be significant predictive factors

-Increased failure rates of TSA in PD- increased muscle tone, severity oftremor, increased mortality rate of 1.6 to 3x that of general population

-Increase in subluxation rates & associated complication- result ofincreased tone of shoulder girdle musculature, difficulties w/ rehab,stretching of RC-capsule arthrotomy site

-Similar results found by Kryzak, et al in 2009


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-Enhance deltoid function in absence of RC

-Biofeedback: to assist pts in learning recruitment strategies1

-PT started @ day 2 or 3rdweek, no significant

difference in LT outcome-LTG may be limited by severity of PD (tone, rigidity,

akinesia, dementia)

-Use rhythmic cues to increase cadence of activity

-Amplitude of movements: think BIG concept9

-HEP compliance issue: suggest 5x/wk for 20min1


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THANK YOU!


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1. Boudreau S, Boudreau E, Higgins LD, Wilcox RG. Rehabilitation following reverse total shoulderarthroplasty. JOSPT2007;37:734-743.

2. Drake GN, OConnor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator

cuff disease. Clin Orthop Relat Res. 2010;468:1526-1533.

3. Volpe S, Craig JA. Postoperative physical therapy management of a reverse total shoulder

arthroplasty (rTSA). Ortho Practice. 2007;21:11-17.

4. Boileau P, Watkinson D, Hatz AM, Hovorka I. Neer Award 2005: The Grammont reverse shoulder

prosthesis: Results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J ShoulderElbow Surg. 2006;15:527-540.

5. Beaton DE, Katz JN, Fossell AH, et al. Measuring the whole or the parts? Validity, reliability and

responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in

difference regions of the upper extremity. J Hand Ther. 2001;14:128-146.

6. Frankle M, Siegal S, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis

associated with severe rotator cuff deficiency. J Bone Joint Surg. 2005;87:1697-1704.

7. Koch LD, Cofield RH, Ahlskog JE. Total shoulder arthroplasty in patients with ParkinsonsDisease. J Shoulder Elbow Surg. 1997;6:24-28.

8. Kryzak TJ, Sperling JW, Schleck CD, Cofield RH. Total shoulder arthroplasty in patients with

Parkinsons Disease. J Shoulder Elbow Surg. 2009;18:96-99.

9. Farley BG, Koshland GF. Training BIG to move faster: the application of the speed- amplitude

relation as a rehabilitation strategy for people with Parkinsons Disease. Exp Br Res

2005;167:462-467.

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TSA Case Study

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