SHOULDER

ARTHROPLASTY
Pembimbing :
dr. Rr. Indrayuni Lukitra W., Sp.KFR-K
 References
Ellenbecker, TS., and Wilcox, RB., 2018. Rehabilitation Following Total Shoulder and Reverse Total
Shoulder Arthroplasty in Clinical Orthopaedic Rehabilitation : A Team Approach 4 th ed.
Philadelphia, PA : Elsevier

Di Giacomo, G., & Bellachioma, S. (Eds.). (2016). Shoulder Surgery  Rehabilitation.

doi:10.1007/978-3-319-24856-1 

Lin et al . 2016. Shoulder Arthroplasty, from Indications to Complications: What the Radiologist
Needs to Know.. RadioGraphics 2016; 36:192–208 . RG • Volume 36 Number 1

Carpenter et al, 2016. Porous Metals And Alternate Bearing Surfaces In Shoulder Arthroplasty.
Curr Rev Musculoskelet Med (2016) 9:59–66 DOI 10.1007/s12178-016-9319-x

Werthel et al, 2017. Long-term Outcomes Of Cemented Versus Cementless Humeral Components
In Arthroplasty Of The Shoulder. Bone Joint J2017;99-B:666–73.
Indications for Shoulder
Arthroplasty

1) Osteoarthritis
2) Rheumatoid arthritis
3) Irreparable Rotator Cuff Tears and Rotator Cuff Arthropathy
4) Humeral Head Avascular necrosis
5) Post-traumatic arthritis
6) Severe proximal humeral fractures
 Contraindications to
Shoulder Arthroplasty

Younger age (masih dalam masa pertumbuhan)

higher activity levels
active infection, and
patients with neuromuscular disease and/or Charcot arthropathy
Tear total yang tidak bisa disembuhkan
Neuropathic arthropathy
Rotator cuff yang tidak intak
Three different types of approaches to the prosthetic replacement of the shoulder:

1) Hemiarthroplasty :
where only part of the glenohumeral joint is replaced, typically the humeral head

2) Anatomic Total Shoulder Arthroplasty :

where the humeral head and glenoid are replaced with implants that resemble
the patient’s normal anatomy; and

3) Reverse Shoulder Arthroplasty :

where the glenohumeral joint is flipped such that the ball is placed on the glenoid
and the cup part of the joint is placed on the humerus.
 Arthroplasty Options

Hemiarthroplasty
Reverse Total Shoulder
Arthroplasty
Total Shoulder
Arthroplasty
 Hemiarthroplasty vs Total Shoulder
Arthroplasty

Easy procedure More consistent pain relief

Short Operating time Better fulcrum for active motion
Less risk of instability
Can be revised to TSA

Less reliable pain relief Difficult procedure

Progressive glenoid erosion Longer OR time
may cause results to
Can cause loosening of both
deteriorate over time
components
 Porous Metals
 Porous metals are metals used in prostheses that have different size and
number of holes in them to allow for interaction with the periprosthetic
bone.

 They provide a truly biologic method of prosthesis implantation in which the

metal surface is conducive to ingrowth of the bone into the porous channels.

 This living interface is thought to retain remodeling potential, allowing for

the theoretical increased duration of fixation over cemented implants

 The next-generation prosthesis contained a circumferential porous coating

around the proximal one fourth of the stem in an effort to improve humeral
fixation.
 Cemented Versus Cementless Humeral Components
In Arthroplasty Of The Shoulder

In the initial development of total shoulder arthroplasty (TSA), the humeral component
was usually fixed with cement. Cementless components were subsequently introduced.
The aim of this study was to compare the long-term outcome of cemented and
cementless humeral components in arthroplasty of the shoulder.

Conclusion : Both types of fixation give rates of long-term survival of > 90%.
Cemented components have better rates of survival without loosening but this should
be weighed against increased operating time and the risk of bony destruction of the
proximal humerus at the time of revision of a cemented humeral component.

Werthel et al, 2017. Long-term Outcomes Of Cemented Versus Cementless Humeral

Components In Arthroplasty Of The Shoulder. Bone Joint J2017;99-B:666–73.
 Choice of Prosthesis
Consider :
Patient age
Glenoid bone stock
Humeral bone stock
Rotator cuff
Deltoif function
 Complications
1) Glenoid Loosening (11.5 %),
2) Humeral Loosening (1.5 %),
3) Secondary Rotator Cuff Pathology (4.6 %),
4) Glenohumeral Instability (3.1 %),
5) Stiffness (1.6 %),
6) Intraoperative Fracture (1.4 %),
7) Postoperative Humeral Fracture (0.9 %)
8) Infection (1.2 %)
9) Neurological Complications (1.6 %),
 Glenoid and Humeral Loosening

 Glenoid prosthetic component loosening is the most common

complication of total shoulder arthroplasty.
 Specifically, prosthetic loosening accounts for 39% of all total shoulder
arthroplasty complications, with glenoid component loosening seen far
more frequently than humeral component loosening (32% vs 7% for the
humeral component)
 Rotator Cuff Pathology
 Important complication of total shoulder arthroplasty because the
prosthesis will not function properly in the absence of an intact rotator cuff.

Subscapularis insufficiency is the most common rotator cuff abnormality

after anatomic total shoulder arthroplasty (41), manifesting with diminished
internal rotation and anterior instability.
 Glenohumeral Instability

Postoperative tears of the subscapularis caused by multiple surgeries, overzealous

physical therapy in the early postoperative period with aggressive external
rotation, and tendon compromise from humeral lengthening.

Anterior dislocation is the most common early complication of reverse total

shoulder arthroplasty, occurring in nearly 20% of patients, often without
preceding trauma. A reverse arthroplasty dislocates anteriorly and superiorly
along the axis of the deltoid muscle because of unopposed deltoid contraction
 Periprosthetic Fracture

 Can occur in the setting of any type of shoulder arthroplasty.

 Can occur during surgery, after surgery in the setting of trauma, or
insidiously as the result of stress shielding.
 The risk of intraoperative fracture during arthroplasty revision is higher than
during primary arthroplasty,
 The fractures are often centered about the distal aspect of the prosthetic
humeral stem.
 Stiffness
Caused by subscapularis shortening and oversized prosthetic components

Infection
Infection can occur in the setting of any type of shoulder arthroplasty but
is most commonly seen after reverse arthroplasty

Neurological Complications
Axillary nerve injury. Rare, higher risk during revision surgery. Usually a neuropraxia
 Subscapularis Precautions

 For the first 6 weeks postoperatively, subscapularis precautions must be followed.

 Limitation of passive or active external rotation ROM and no active internal rotation
resistive exercise.
 Although gentle attempts at passive external rotation can occur to as far as 30 to 45
degrees of external rotation beyond neutral, techniques that place increased or
undue tension on the anterior capsule and subscapularis are avoided.
 Specifically, resistive exercises for the biceps brachii are not performed for the first 6
weeks postoperatively if a release of the biceps long head or tenodesis has been
performed to minimize the chance of rerupture and reappearance of a “Popeye”
deformity.
 Shoulder Surgery  Rehabilitation, 2016

Postoperative (Weeks 0–4)

 Initial rehabilitation goals include pain control, restoration of range of

motion of the glenohumeral joint through both passive and active-
assistive exercises, and light muscle activation of the glenohumeral and
scapulothoracic joints.
 In the first postoperative visit, the dressing is removed and wound
inspection is performed.
 The patient should be educated in sling donning/doffing and icing.
A home exercise program :
 pendulum exercises (all motions),
 active range of motion exercises of the wrist and elbow, and
 active-assistive exercises of the glenohumeral joint into flexion, abduction, and
external rotation up to 20° to protect the subscapularis repair.

These active-assistive exercises can be performed with cane exercise and or table
walkouts.
The patient should also start scapular mobility in the sling including elevation and
depression and scapular retraction.
 At 1 week, the patient may start submaximal isometric exercises into
flexion, extension, abduction, and external rotation.

 No internal rotation is performed at this time for continued protection of

the subscapularis.

 Patient may also begin prone scapular retraction

 Use of the upper body ergometer and overhead pulleys may be added as
patient tolerance allows

 Passive range of motion is performed in the clinic by the physical

therapist, taking care not to place stress on the surgical implant or soft
tissue structures that have been affected by the procedure.
 Fig. 2.14 Table walkouts—with hands on the table,
slowly walk backward and lean forward for passive
shoulder flexion to tolerance

Fig. 2.12 Supine cane flexion

Fig. 2.13 Supine cane external rotation towel roll to

maintain motion in the scapular plane
Fig. 2.16 Scapular retraction

Fig. 2.15 Scapular elevation and depression

can be performed in or out
of the sling
Fig. 2.17 Isometric shoulder flexion Fig. 2.18 Isometric shoulder extension

Fig. 2.19 Isometric shoulder abduction/external rotation

Fig. 2.20 Prone scapular retraction with arm
suspended off edge of table scapula is retracted

Fig. 2.21 Pulley flexion

 Postoperative (Weeks 4–8)
At 4 weeks, start active range of motion on the glenohumeral joint.
 supine serratus punches
 prone rows,
 abduction and extension with focus on middle and lower trapezius
recruitment with motion
 lawn mower exercise for scapular stabilization, and
 sidelying external rotation with towel roll under arm

 Patient will also need to initiate active flexion and scaption.

 This may be better accomplished starting in supine or side-lying position with
focus on good motor control, with progression into upright position
 Any active external rotation should be limited to 30° or as directed by
physician based on operative technique.
 Passive range of motion should be continued until full range is achieved in all
other motions.
 Fig. 2.22 Supine serratus punches

Fig. 2.23 Prone row with Fig. 2.24 Prone abduction with Fig. 2.25 Prone extension
focus on good middle focus on middle and lower with focus on middle and
trapezius recruitment trapezius lower trapezius
Fig. 2.26 Lawnmower starting position— Fig. 2.27 Lawn mower ending position—with
cue to pull up like starting a lawn scapula retraction
mower
 Fig. 2.28 Side-lying external rotation Fig. 2.30 Supine shoulder flexion

Fig. 2.31 Supine active fl exion on incline

Fig. 2.29 Side-lying active-assistive flexion initial incline at 20–30° with progression to
upright
Figs. 2.32 and 2.33 Resisted external rotation with towel roll

Fig. 2.34 Wall push-ups with serratus plus

Fig. 2.36 Bodyblade in 90° flexion double hand

Fig. 2.35 Bodyblade in neutral at side

Fig. 2.37 Rhythmic stabilization patient holds arm
still in serratus plus, therapist changes direction of
pressure

Fig. 2.39 Proprioception exercises with

laser pointer

Fig. 2.38 Rhythmic stabilization progression into

increased flexion
 Postoperative (Weeks 8–12)

 Full passive and active range of motion with the restriction of 60° of exercise
rotation should be obtained.
 Progressive resistive exercises and proprioceptive activities continue for the
rotator cuff and periscapular musculature with body blade exercises
progressing into higher angles of elevation.
 Scapular control exercises in closed chain position should be initiated as well
 As the patient shows improved strength and motor control, closed
chained activities can be moved into quadruped.
 Weakness may still be present in the subscapularis if it was resected
during surgery, so attention should be paid to restore strength with
dynamic hug-type exercises
 Exercises should also reflect more functional movement strength such
as diagonal patterns
Fig. 2.40 Patient can perform circles, serratus Fig. 2.42 Dynamic hug exercise—cue is
press/scapular retraction, to reach around like a hug
or rhythmic stabilization with therapist

Fig. 2.41 Quadruped position for serratus plus

or rhythmic stabilization with therapist
 Figs. 2.43 and 2.44 Medicine ball diagonals

Fig. 2.45 Bodyblade at 90° abduction Fig. 2.46 Bodyblade at 90° flexion
single hand single hand
 Postoperative (Weeks 12+)

 Focus at this point should be returning the patient to their individual goals,
recreational activity, and job duties if applicable.
 Patient will most likely be on a home program by this point for gradual
return to full strength and regular daily activities.
 Sport- or recreational activity-specific exercises should be part of the overall
program.
 Weight-Bearing Upper Extremity

 Wheelchair-reliant patients often depend heavily on the use of their upper

extremities for mobility and transfers.
 Kemp et al. and Alentorn-Geli et al. used sling immobilization with wheelchair-reliant
patients for 6 weeks following RTSA, while allowing limited passive range of motion.
 Both studies discontinued sling immobilization and started active and
active-assisted range of motion at 6 weeks, and allowed patients to use their
arm for transfers at 3 to 4 months.
 Kemp et al. reported 2 dislocations at approximately 3 months postoperatively, which
coincided with the time period for starting to use the arm for weightbearing.

Kirsch and Namdari, 2020. Rehabilitation After Anatomic and Reverse Total Shoulder Arthroplasty :
A Critical Analysis Review. JBJS REVIEWS 2020;8(2):e0129 · http://dx.doi.org/10.2106/JBJS.RVW.19.00129
rTSA
 The role of rTSA in the management of CTA is clinically sound as it alters
the mechanics of the shoulder to enhance deltoid function in the
absence of a competent RC.
 Hence, the postoperative course for a patient following rTSA is different
from the rehabilitation following a traditional TSA.
 The physical therapist, surgeon, and patient should work together
when establishing the postoperative rehabilitation plan focused on
joint protection, deltoid function, and the establishment of appropriate
functional and measurable goals.
 Avoid Positions that Lead to Instability

 Anatomic shoulder arthroplasty, postoperative protocols limit abduction

and external rotation for 6–8 weeks postoperatively.

 Reverse shoulder arthroplasty is at risk for instability when the arm is

adducted and extended. Avoid this position in the first 6–8 weeks
postoperatively. This may require the use of a sling or abduction sling. It is
important to stress to reverse arthroplasty patients that they should not
reach behind to push themselves out of a chair.
 Sequence of Activity and Return to Sports or Work

Most authors recommend early mobilization (passive and active assisted),

minimizing fulltime immobilization, and achieving maximal passive range of
motion prior to advancing to the strengthening phase.
The return to sporting activities/ work is typically between 4 and 6 months after
surgery.
Healy et al. surveyed the American Shoulder and Elbow Surgeons to get their
recommendations on return to sport after anatomic shoulder arthroplasty
 Football, gymnastics, hockey, and rock climbing were not recommended.
 Golf, ice skating, shooting sports, and downhill skiing were recommended in
experienced players.
 Other sports, including cross-country skiing, swimming, doubles tennis,
canoeing, and dancing, were allowed
It is important to note that surgeon variation is extensive with regard to
participation and as such, recommendations should come from the surgeon on
what is permissible and what is not.
 Time for recovery following shoulder arthroplasty is generally 9–12 months.
 In this procedure, the subscapularis is detached for exposure of the
glenohumeral joint and then reattached after the surgery is complete.
 This reattachment must be protected for 6 weeks.
 During this time, strengthening activities that stress the subscapularis such
as resisted internal rotation or excessive stretching into external rotation
must be avoided.
 A sling should be worn for the first 48–72 h for protection while the effects
of anesthesia, possible nerve blocks, and other medications wear off.
 After 3 days, the sling can be removed for light activity such as deskwork as
long as the hand is kept in front of the body.
 Sling should be worn as needed during the day, whenever the patient is
active or in an unprotected environment; it should always be worn at night
for the first 6 weeks.
 The sling can be discontinued completely at 6 weeks postoperatively.
 Active range of motion of the glenohumeral joint is allowed starting around
week 4.
 Early Rehabilitation Versus Immobilization
After Reverse Total Shoulder Arthroplasty

Conclusions:

Both early (immediate physical therapy for passive and active ROM) and
delayed-ROM protocols (no ROM for 6 weeks) after RTSA demonstrated
significant, similar improvements in ROM and outcomes.

Early initiation of postoperative rehabilitation may benefit the elderly

population by avoiding the limitations of prolonged immobilization
postoperatively.

Hagen et al. 2019. A Randomized Single-blinded Trial Of Early Rehabilitation Versus Immobilization After
Reverse Total Shoulder Arthroplasty. J Shoulder Elbow Surg (2019) -, 1–9
THANK YOU
 Humeral Components
CEMENTED PROX POROUS FULLY POROUS
COATED COATED

Good for osteopenic Need good bone Need good bone

bone stock stock

Higher risk of intra-

Lower risk of intra- Higher risk intra-
operative fracture
operative fracture operative fracture

Less stress-shielding
More stress-shielding More stress-shielding
Easier to revise
Hard to revise Hard to revise