A standard total shoulder replacement depends upon muscles and tendons around the shoulder joint to be intact. These muscles and their tendons function to move the shoulder and are together called the rotator cuff. When these tendons become extensively torn so that they do not attach to the bone any longer, the shoulder often does not function normally. The loss of the rotator cuff can produce pain and also loss of motion. A normal shoulder replacement is designed to work only if those tendons are intact.
Reverse Shoulder Replacement (Arthroplasty) has emerged as a very attractive alternative for patients with cuff-tear arthropathy, selected proximal humerus fractures and nonunions. Its indications continue to expand, especially for revision surgery.
REVERSE SHOULDER ARTHOPLASTY
Reverse shoulder arthroplasty is an attractive option in patients. Since this kind of shoulder replacement does not rely on the function of the rotator cuff, it provides predictable results in terms of pain relief and shoulder function in one operation. The results of reverse shoulder replacement are fairly predictable and good especially in patients suffering from chronic shoulder joint problems since the function of the joint is less dependent on healing of the tuberosities.
The main reason to consider a reverse prosthesis is when there is arthritis of the shoulder joint and the rotator cuff tendons are torn or gone. This is the most common surgical indication for a patient considering a reverse prosthesis. In this situation this operation will give the patient significant pain relief and may also help with range of motion of the shoulder.
Another reason to have a reverse prosthesis is if the rotator cuff tendons are all torn and one cannot lift the arm high enough to function. Typically in this case the shoulder is not painful but the inability to lift the arm is very disrupting to the ability to function in life. When the patient goes to lift the arm there is a prominence on the front of the shoulder, and this is called an anterior-superior migration or subluxation of the shoulder. In these cases pain may or may not be a major factor for the reverse prosthesis, but the main reason for the replacement is to regain motion and function.
The third most common reason to have a reverse prosthesis is if the shoulder has already had a replacement prior to the time a reverse prosthesis was available and the patient still has pain and loss of motion. Sometimes the regular shoulder replacement was placed for a fracture or for torn rotator cuff tendons and the shoulder continues to be painful. In this case, if a reverse prosthesis is needed, the surgery to place a reverse prosthesis is a little more complicated. The reason for this is that the first, more traditional shoulder replacement has to be removed at the time of surgery, and the reverse can then be placed in the shoulder.
Other reasons to have a reverse prosthesis are some fractures of the shoulder area, particularly ones that involve the proximal humerus (arm bone) where the ball attaches to the shaft of the bone. In some instances, the bone is broken into many pieces or the ball may be split into parts.
The last reason to have a reverse prosthesis is because of a tumor in the proximal humerus that involves the bone of the shaft of the bone or the ball of the humerus itself
PRE-OPERATIVE STEPS
Every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure.
1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed in elderly patients.
2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since shoulder arthroscopy is an elective procedure. If any risk is involved, the patient/ attendants will be informed so.
3. Blood transfusion though rarely required, may be done depending on the reports.
4. X-rays and MRI will be done ideally in order to guide the surgical plan and the prognosis.
5. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any.
INTRA-OPERATIVE STEPS
1. The patient is positioned in a beach chair position.
2. For this procedure the deltopectoral approach is normally used.
3. It is crucial to evaluate the fracture. The fracture lines are identified as well as the long head of the biceps and the condition of the rotator cuff.
5. The biceps tendon is temporarily attached to the superior border of the pectoralis muscle. A tenotomy of the long head of the bicipital tendon close to the rotator interval is performed.
6. The glenohumeral joint is opened through the fracture.
7. Preparation of the joint for placement of prosthesis is performed.
8. A complete soft-tissue release around the glenoid is performed.
9. The guide plate is placed on to the glenoid surface so that it is flush with the circle of the lower glenoid . The guide plate is fixed with a central K-wire.
10.A cannulated glenoid resurfacing reamer is used to remove the cartilage and to create a smooth surface of the glenoid to provide full contact with the base plate.
11.The glenosphere is implanted. A trial glenosphere may be used instead of the definitive one.
12. The intramedullary canal is prepared with reamers of increasing diameters.
13. The humeral trial prosthesis is inserted as determined by the size of the last reamer.
14. Reduce the prosthesis and confirm proper joint tension and stability. Do not overtension the deltoid muscle. Check if there is any unwanted impingement.
14. After hardening of the cement, reduce the prosthesis. Confirm correct soft-tissue tension and stability.
POST OPERATIVE PHASE
Care after surgery:
• Wear your sling or brace at all times for as long as directed. This helps to remind you not to use the arm. It also allows your shoulder to heal and decreases pain.
• Apply ice on your shoulder for 15 to 20 minutes every hour or as directed. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a towel. Ice helps prevent tissue damage and decreases swelling and pain.
• Place a small pillow or towel behind your elbow when you lie on your back. This keeps your shoulder in proper position. You may need to sleep in an upright position if you cannot sleep on your back. Place 2 to 3 pillows lengthwise behind your back when in bed. Make sure the pillows do not move your shoulder forward. Instead, you can sleep in a reclining chair.
• Avoid moving your shoulder. Do not stretch or shrug your shoulder. Do not do exercises on your own until your healthcare provider says it is okay.
• Do not lift with your hand on your surgery side. You put pressure on your shoulder muscles when you lift.
• Do not lean on the hand of your surgery side. Pressure will cause pain and may cause damage to your shoulder.
• Do not drive until your healthcare provider says it is okay.
Shoulder bandage care:
Keep your dressing clean and dry. Your healthcare provider will tell you when it is okay to take a bath or shower. Once you are able, let soap and water run over your surgery area. Do not scrub the area. Pat the area dry and put on a clean bandage as directed.
Pain Management
• Some amount of pain is expected after the surgical procedure.
• Ice packs can be used for pain reduction
• Paracetamol or Nsaids can be considered for pain management especially during the first four weeks.
Shoulder rehabilitation protocol
The shoulder is perhaps the most challenging joint to rehabilitate both postoperatively and after conservative treatment. Early passive motion according to pain tolerance can usually be started after the first postoperative day. The program of rehabilitation has to be adjusted to the ability and expectations of the patient and the quality and stability of the repair.
The full exercise program progresses to protected active and then self-assisted exercises. The stretching and strengthening phases follow. The ultimate goal is to regain strength and full function.
Activities of daily living (ADL) can generally be resumed while avoiding certain stresses on the shoulder. Mild pain and some restriction of movement should not interfere with this. The more severe the initial displacement of a fracture, and the older the patient, the greater will be the likelihood of some residual loss of motion.
Generally, shoulder rehabilitation protocols can be divided into three phases. Gentle range of motion can often begin early without stressing fixation or soft-tissue repair. Gentle assisted motion can frequently begin within a few weeks, the exact time and restriction depends on the injury and the patient. Resistance exercises to build strength and endurance should be delayed until bone and soft-tissue healing is secure. This may need to be adjusted for each patient.
Phase 1 (approximately first 6 weeks)
Bandage
• Immobilization on a shoulder abduction pillow in neutral position of rotation
Range of motion
• Passive motion within the pain free interval for abduction, adduction and flexion
• No internal or external rotation
• Shoulder joint motion up to 90°
• ADL for eating and writing allowed
Physiotherapy
• Passive motion up to 90°
• Relaxation/stretching of neck muscles
• Training of elbow and hand functions
• Specific stabilization therapy for the shoulder joint
• Isometric exercises in all directions
• CPM up to 90° of abduction
Massage
• Neck
• Shoulder girdle
• Thoracic spine
Training therapy
• Training of the contralateral arm (overflow cardiovascular training)
Phase 2 (approximately week 7-11)
Bandage
• No longer required
Range of motion
• Assisted/active motion within the pain free interval, also beyond 90°
• Careful rotation
Physiotherapy
• Free motion of shoulder girdle (scapula, clavicle, cervicothoracic junction, cervical and thoracic spine) with specific mobilization
• Strengthening exercises especially for ADL
• Eccentric muscle activity
Massage
• As required
Ice/warmth
• As required
Training therapy
• Mobilization bath, wound permitting
• Training of hand and forearm muscles
• Set for shoulder therapy
Phase 3 (after week 11)
Range of motion
• No restrictions on Shoulder movement
• Muscle growth for shoulder girdle and all arm muscles
Physiotherapy
• All physiotherapeutic techniques allowed, active and against resistance
• Increasing eccentric muscle activity
Training therapy
• Handcycling
• Training for specific ADL and sports
• Machine training
• Free weight training
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