Two quick paragraphs as a prelude to the next steps in the Case:
- Once again, I have to start off by saying how impressed I am with your thought processes and professionalism. I’ve received many private emails from PTs who are learning from all of you who comment (as a matter of fact, the over 2,000 page views within the first 24 hours of posting indicates people are really interested in what you have to say!)
- I’m going to interject a wee bit about myself here: while I am very comfortable with the shoulder (especially with sports and biomechanics) I am BY NO MEANS an expert in the kind of case presented here. This case was purposefully selected so the YOU have a place to educate all of us. So, Thanks, on behalf of all of us PTs!
Now, back to the Case:
As many of you wrote, the MRI indicated a need for referral to an orthopaedic surgeon who performs rTSAs. The reverse total shoulder is a ‘last chance’ procedure for folks without much rotator cuff. And, Mr. G. clearly was lacking in the rotator cuff department. Candidates for the rTSA need to be medically sound and have demonstrated precise follow-through to instructions/limitations post surgery. Because if something happens to the rTSA, there is no re-do —- there is no second chance with it.
The rTSA entails the ‘ball’ of the socket to be inserted into the scapula and the ‘dish’ of the joint into the humerus (you can see that in the x-ray above – and some of the references below give even clearer pictures).
This is a relatively new procedure and Mr. G. was encouraged to interview multiple surgeons, ask about the number of rTSA procedures each surgeon performs and the outcomes. Fortunately for Mr. G., one of the surgeons is a leader in the field of rTSA, a member of the American Shoulder and Elbow Surgeons, has performed research, does over 160 rTSA’s/year and has excellent outcomes. Dr. Itamura is an Associate Professor of Clinical Orthopaedic Surgery at the University of Southern California School of Medicine, Department of Orthopaedics. Operating room staff and therapy staff also recommended Dr. Itamura without reservation.
Here is a word from his surgeon, Dr. John Itamura:
Mr. G. was an ideal candidate for the rTSA. First of all, he is medically sound. This is a difficult procedure and if he had had medical co-morbidities, I would not have done the procedure on him. Secondly, his lack of rotator cuff make the rTSA the most viable procedure. Third, he has had other total joint replacements, so he knows what it will take to get back on the road. He is aware that it will take a year before we know exactly how far he will progress. Fourth, he listens. I believe he will be very conservative and careful with his reconstruction. Even though he is basically an over-achiever with exercise, the consequences of that have been explained to him and he agrees not to overdo things. He knows there is no second chance at this point.
I’m not a big proponent of PT for the rTSA, since conservatism is the route I go. And if the patient does receive PT, it HAS to be slow, easy and the patient must listen carefully to the therapist – so, we’d need to all be on the same page. I have my patients perform the Anterior Deltoid Exercises for Patients with Massive Rotator Cuff Tears 5 times a day (the reference for that is below). Yet, I know other excellent surgeons are more aggressive. Boudreau et al 2007, JOSPT (which is not research, but a Clinical Commentary) is much more aggressive than I choose to be at this point, and there are surgeons who go that route. But, give me some evidence, and I’m happy to reconsider — I may do some research on the rehab myself!
For four weeks post-op, Mr. G. wore an abduction splint (image above), even at night. After 4 weeks in the splint, here is the resting position of his arm (image below). At 6 weeks post op, his arm had naturally dropped to < 10 degrees of abduction.
Now, as a member of American Shoulder and Elbow Surgeons myself, I see a huge difference in rehab opinions even among this specialized group of orthopaedic surgeons. However, in my simple opinion, I’d still like to do some work on Mr. G.’s scapular stabilization. So, once again, armed with literature, Dr. Itamura and I are scheduled to meet the end of this month. We will discuss scapular mechanics, the effect of lack of scapular stabilization (Dr. Jacquelin Perry calls it a ‘floating scapula’) on the axis of rotation (and how that may affect the longevity of the prosthesis as well as the success of the outcomes), the probable fact that Mr. G. has been using his anterior deltoid (hence ‘retraining’) in place of his rotator cuff for years (thus some questionability about the ‘anterior deltoid’ retraining as seen in www.readingshoulderunit.com) and the potential for precise, practical, low risk scapular exercises for Mr. G. – and all folks receiving a rTSA. Dr. Itamura and I may actually do some research on this since I suspect Mr. G. is not alone – that most rTSA candidates have been ‘re-educating’ their deltoids for awhile and I’d hypothesize that a large percentage of these patients have a ‘floating scapula’ (i.e. not enough scapular stabilization to allow for precision in the axis of rotation with humeral motion.)
So, we will see where that goes!
Here are some articles available for you regarding the rTSA. Unfortunately, there is very limited evidence based information out there (probably because the procedure is relatively new – it was performed in Europe for about 20 years before it was approved by the FDA in the United States). These articles are available for free as part of the physical therapy continuing education resources at EDUCATA’s library. You will need to log in, but membership is free too.
- Consequences of scapular anatomy for reversed total shoulder arthroplasty
By: Middernacht B, De Roo PJ, Van Maele G, De Wilde LF.
Clin Orthop Relat Res. 2008 Jun;466(6):1410-8.
- Contribution of the reverse endoprosthesis to glenohumeral kinematics
By: Bergmann JH, de Leeuw M, Janssen TW, Veeger DH, Willems WJ.
Clin Orthop Relat Res. 2008 Mar;466(3):594-8.
- Evolution of the reverse total shoulder prosthesis
By: Jazayeri R, Kwon YW.
Bull NYU Hosp Jt Dis. 2011;69(1):50-5.
- Reverse shoulder arthroplasty
By: Smithers CJ, Young AA, Walch G.
Curr Rev Musculoskelet Med. 2011 Dec;4(4):183-90.
- Rotator cuff deficient arthritis of the glenohumeral joint
By: Macaulay AA, Greiwe RM, Bigliani LU.
Clin Orthop Surg. 2010 Dec;2(4):196-202.
- Total shoulder arthroplasty
By: Sanchez-Sotelo J.
Open Orthop J. 2011 Mar 16;5:106-14.
- What is a successful outcome following reverse total shoulder arthroplasty?
By: Roy JS, Macdermid JC, Goel D, Faber KJ, Athwal GS, Drosdowech DS.
Open Orthop J. 2010 Apr 23;4:157-63.
Additional resources include the following two articles as well as the exercises that Dr. Itamura utilizes.
Boudreau, S, Boudreau E, Higgins LD, Wilcox RB 3rd: Rehabilitation Following Reverse Total Shoulder Arthroplasty. JOSPT, 37(12), 2007, 734-743
www.readingshoulderunit.com which is out of England and I think the exercises are there under Physiotherapy.
All right – it’s YOUR TURN again! I love reading your posts! What do you think should be done next?
Coming next week: Mr. G. discusses the outcome of his treatments and present condition