Shoulder arthroplasty in the athletic shoulder



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SHOULDER ARTHROPLASTY IN THE ATHLETIC SHOULDER

Todd S. Ellenbecker, MS, PT, SCS, OCS, CSCS

Clinic/Group Director

Physiotherapy Associates Scottsdale Sports Clinic

Scottsdale Arizona

National Director of Clinical Research

Physiotherapy Associates

Memphis, Tennessee
David S. Bailie, MD

The Orthopaedic Clinic Association (TOCA)

Scottsdale Arizona

DSB – to check and add to affiliation if needed?

Introduction
The most common reasons and diagnostic classifications for which shoulder arthroplasty is performed are degenerative osteoarthritis, secondary degenerative osteoarthritis, capsulorraphy arthropathy, and rheumatoid arthritis (Parsons et al, 2005). While all four of these can be found in the athletic shoulder, degenerative osteoarthritis either occurring solely from repetitive overuse and wear or secondary to athletic trauma as well as capsulorraphy arthropathy are particularly common indications in the athlete. A brief overview of each has implications on the role of shoulder arthroplasty in the treatment of arthritis in the athletic shoulder.

Degenerative Glenohumeral Osteoarthritis

Degenerative osteoarthritis of the glenohumeral joint is less common than in the weight-bearing joints (i.e. hip, knee) of the lower extremity , accounting for only 3% of all osteoarthritis lesions (Badet & Boileau, 1995). Osteoarthritis of the glenohumeral joint (GHOA) can be classified as primary or secondary. Primary usually presents with no apparent antecedent cause while secondary results from a pre-existing problem, i.e. previous fracture, avascular necrosis, “burned-out” rheumatoid arthritis, or crystalline arthropathy.

Athletes at risk include weight lifters, throwing athletes (baseball players, softball players) and racquet sports (tennis, racquetball, and squash) (Andrews, 1990). This degenerative osteoarthritis seems to be the end result of trauma; whether it’s from pure instability, repetitive loading, fracture, rotator cuff arthropathy, or post-surgical. At the macroscopic level of osteoarthritis, cartilage is noted to have irregularity, with delamination of the cartilage surface and eventually, frank cartilage loss resulting in “bone-on-bone” contact in the joint. Early in the degenerative process, inflammatory cells are seen, but this effect is transient and inflammation is not considered to play a major role long term. Biochemically, OA is associated with a decrease in glycosaminoglycan (GAG’s) (including chondroitin sulfate and hyaluronic acid) increased water content (from increased permeability of water to diffuse into the cartilage as the GAG’s are lost, and increased enzymatic activity from metalloproteinases (MMP). The MMP’s play an important role in degeneration of the extracellular matrix of cartilage (Carfagno & Ellenbecker, 2002).

Wear patterns in the human shoulder vary based on the type of underlying arthritic condition and causation. Characteristic wear of the subchondral bone and glenoid cartilage in the shoulder with degenerative osteoarthritis occurs posteriorly, often leaving an area anteriorly of intact cartilage (Rockwood, 1990). The cartilage of the humeral head is typically eroded in a pattern of central baldness, the so-called Friar Tuck Pattern. This differs from the pattern of humeral head wear in cuff tear arthopathy where a chronic large rotator cuff defect subjects the uncovered humeral head to abrasion against the acromion and coracoacromial arch resulting in superior rather than central wear patterns. Recent research by Mochizuki et al (2005) identified specific patterns of glenoid load distribution in the throwing shoulder. Their study identified specific glenoid load patterns at the anterior, anteriorinferior, posterior and posteriorinferior aspects of the dominant glenoid as compared to more central glenoid load patterning in the contralateral shoulder and in the shoulder of non-throwing subjects. The repetitive loading of the athletic shoulder is further compromised in instances of glenohumeral instability (Mochizuki et al, Muller-Gerbl et al).

Another important diagnosis for which shoulder arthroplasty is peformed is capsulorraphy arthropathy (Parsons et al). Neer et al (1982) initially reported glenohumeral arthritis after anterior shoulder instability and in 1982 reported on an initial series of 26 patients who underwent shoulder arthroplasty who had prior anterior or posterior instability. Many of the patients in this series had had prior stabilization surgery . Samilson and Prieto (1983) later developed the term dislocation arthropathy after presenting their series of 74 patients with glenohumeral arthritis with prior anterior and posterior instability.

Neer (1990) further reported on the association of osteoarthritis and glenohumeral instability by finding subluxation of the humerus in the direction opposite of the initial instability due to excessive tightening at the time of initial stabilization surgery. Matsen et al (1998) have coined the term “Capsulorraphy Arthropathy” for patients developing osteoarthritis as a consequence of overly tightened soft-tissue structures in the treatment of glenohumeral joint instability. Buscayret et al (2004) reports the incidence of glenohumeral osteoarthritis to range between 12 and 62% following operative treatment of shoulder instability. Factors specific to stabilization procedures that may contribute to the development of glenohumeral arthritis include encroachment on the articular cartilage by hardware, laterally placed bone block in a Brsitow or Latarjet procedure and excessive soft-tissue tensioning imparted by a Putti-Platt procedure (Matsoukis et al, 2003).



Concept of Obligate Translation
The concept of obligate translation has been applied extensively in orthpaedic and sports physical therapy and in orthopaedics in general since the publication of the study by Harryman et al, (1990) identifying an increase in anterior humeral head translation and shear following a controlled posterior capsular placation in cadaveric specimens. Obligate translation, defined as the translation of the humeral head in the direction opposite of the tight capsule and soft tissue structures, has been a paramount concept applied in the treatment of the overhead athlete with subtle anterior glenohumeral joint instability secondary to adaptive posterior rotator cuff and posterior capsule tightness (Ref CC, ell 2006) Harryman et al (54) also reported the presence of obligate translation in flexion, internal and external rotation and maximal elevation with shoulder arthroplasty following insertion of an oversized humeral head prosthesis. Shoulder arthroplasty can tend to cause global capsular restriction due to the substitution of a humeral head prosthesis for a degenerative and collapsed humeral head. This overstuffing can prohibit return of optimal range of motion unless adequate capsular release and early post-operative physical therapy to address capsular tightness are followed (Rockwood).

Indications for Shoulder Arthroplasty

Patients who do not respond to non-operative therapy and have a progressive loss of range of motion and strength are candidates for shoulder arthroplasty. Shoulder arthroplasty and hemiarthroplasty can provide both symptomatic relief as well as restoration of function in individuals with glenohumeral arthritis. The type of surgical procedure chosen is dependent on overall shoulder function, anatomy, condition of bone & rotator cuff tissue, stability, activity level/desire and age. Hettrich et al (2004) studied pre-operative factors in 71 shoulders from 68 patients who underwent shoulder hemiarthroplasty to determine which factors contributed to greater post-operative success. Patients with a preoperative absence of glenoid erosion, no previous surgery, and intact rotator cuff showed significantly greater improvement in active range of motion, greater post-operative comfort and ability to lift weight above shoulder level than patients with glenoid erosion, prior surgery, and rotator cuff tears.

Indications for humeral hemiarthroplasty are primary glenohumeral osteoarthritis, secondary degenerative joint disease, osteonecrosis of the humeral head, and a combined loss of glenohumeral joint surface and rotator cuff (Hettrich et al, 2004). Hemiarthroplasty remains an attractive option for younger patients due to the concerns over the longevity of the glenoid prosthesis. Additionally, cementless surface replacement arthroplasty provides replacement of only the damaged portion of the joint-bearing surface with the advantage of minimal bone resection, restoration of normal anatomy including humeral head version, inclination and offset without a humeral stem (Levy and Copeland, 2004).

Use of the Simple Shoulder Test (SST) in patients with glenohumeral joint osteoarthritis to determine shoulder function has identified specific questions highlighting the areas with the most disability. These specific questions include overhand throwing, sleeping on the involved side, washing the opposite shoulder and placing 8 pounds on a shelf.



Surgical Considerations

Atheletes represent a unique subset of patients with shoulder arthritis that may require arthroplasty. The goal must be to restore full motion and strength and preserve the anatomy for potential revision in the future. One must also consider the types of sports involved (collision versus noncollision) and dominance of the extremity.

Conservative measures such as nonsteroidal anti-inflammatories, steroid injections (occasional), hyaluronic acid preparations (ie. Viscosupplementation), physical therapy to increase motion and restore strength and arthroscopic debridement must have failed before considering arthroplasty in the athletic population. Optimizing rotator cuff status with arthroscopic subacromial decompression and/or repair of rotator cuff tears may preceed the arthroplasty or be done concurrently.

The selected implant should provide immediate stability to limit micromotion with therapy and sports, be durable, revisable and allow for anatomic reconstruction. The need to replace the glenoid may dictate overall postoperative ability to participation in sports, as this is still the “weak link” in shoulder arthroplasty. PLacememt of a glenoid component brings with it the risk of early loosening with more physical activities. Performing a more anatomic reconstruction theoretically may reduce the incidence of radiographic and real glenoid loosening by limiting eccentric loading of the component. Restoring the anatomy will also ensure optimal kinematics in order to maximize motion, strength and recovery potential.

In general, surgical considerations must first include anatomic joint reconstruction with a well fixed, stable implant. This is done with either a humeral head resurfacing implant or a 3rd or 4th generation stemmed implant. The ultimate goal is to match the native humeral version, inclination, offset and height. The glenoid then can be resurfaced with a prosthesis or can be managed with a number of non-implant resurfacing techniques. Finally, the soft tissues must be released, balanced and repaired to allow for adequate restoration of long term function.

While every surgeon may have their preference, we have used resurfacing primarily in those patients who desire to return to high demand activity such as strength training, collision sports (skiing, football, mountain biking, etc), tennis, basketball and martial arts. We also have chosen to avoid placing a glenoid component in these individuals so as to avoid the potential pitfalls of loosening and revision. Other alternatives we have utilized include microfracture, reaming the glenoid to restore version and bone graft of cysts and defects with biologic covering of the glenoid surface (with either autograft or allograft tissue).

Key to the success of arthroplasty in any patient, but especially in those that desire to return to more demanding sports, is restoring soft tissue tension. Specifically, a complete 360 degree subscapularis release is needed to increase excursion and restore external rotation. Lengthening the tendon is not needed and will weaken this structure with the potential for delayed rupture. This release will allow the humeral head to return to the center of the glenoid and permit the normal obligate translation that occurs with rotational motion. This, in turn, helps to restore the normal forces across the glenohumeral joint and leads to decreased pain, improved strength and function.

Rehabilitation considerations must take into account the amount of motion obtained under anesthesia after subscapularis closure. This should be communicated to the patient and the therapist. The goal is to obtain normal motion and can be achieved in almost all cases. The subscapularis repair must be sound and protected for the first 6 weeks (limit external rotation to 45 degrees). If a larger rotator cuff repair is performed, these precautions should also be instituted according to the surgeon’s confidence in the repair. Full passive motion can be performed immediately, with rapid progression to active assisted and active by 6 weeks. Communication with the therapist is critical and we encourage preoperative evaluation in order to meet the specific needs and desires of the patient after surgery.
(TODD-no comments on the biceps since it is controversial)

I have included some picts of the promos & Copeland

Include photos, figures from Biomet or Promos at end
Rehabilitation Following Shoulder Arthroplasty

The surgical exposure used during shoulder arthroplasty has significant ramifications for the immediate post-operative management of these patients. Two approaches are typically used; the deltopectoral approach, and anterior-superior or Mackenzie approach (Levy et al, 2004). The skin incision for the anterior-superior approach extends distally in a straight line from the AC joint for a distance 9 cm. The anterior deltoid fibres are split for a distance of not more than 6 cm to protect the axillary nerve. The acromial attachment of the deltoid is detached to expose the anterior aspect of the acromion. The subscapularis is completely released and held by stay sutures and detached. The long head of the biceps can be dislocated posteriorly over the humeral head as the humeral head is dislocated anteriorly (Levy et al, 2004, Levy & Copeland, 2004).

The complete release and detachment of the subscapularis with this approach which is required to gain exposure for preparation of the humeral head and in full shoulder arthroplasty, the glenoid component necessitates specific precautions post-operatively.

Subscapularis Precautions

For the first 6 weeks, specific subscapularis precautions must be followed to protect this important structure post-operatively. This entails no passive external rotation stretching, and no active resistive exercise for internal rotation. While gentle attempts as passive external rotation can occur, techniques which place increased or undue tension on the anterior capsule and subscapularis are avoided for the first 6 weeks following surgery. Additional precautions may be needed depending on the repair of additional rotator cuff tendons at the time of surgery, as well as whether bicep tenolysis, tenodesis or tenotomy has been performed. Specific resistive exercise for the biceps brachii is not performed for the first 6 weeks post-op if a release of the biceps long head or tenodesis has been performed to minimize the chance of re-rupture and reappearance of a “Popeye” deformity. Since it is beyond the scope of this chapter to completely discuss the entire rehabilitation process following shoulder arthroplasty, the complete details of the authors post-operative protocol are summarized in Table X.


Table X. REHABILITATION FOLLOWING GLENOHUMERAL JOINT

ARTHROPLASTY


General Guidelines:


  • Sling use and duration directed by surgeon in post-operative instructions

  • Immediate post-operative Passive and Active Assistive Range of Motion consisting of Stomach Rubs, Sawing Movements, and Elbow Range of Motion instructed following hospital discharge.

Post Op Weeks 1-4:




  1. Modalities to decrease pain and inflammation

  2. Passive range of motion initiated with no limitation in flexion, abduction, or internal rotation. NO EXTERNAL ROTATION stretching or anterior capsular mobilization in this rehabilitation phase to protect the subscapularis repair

  3. Elbow, wrist and forearm range of motion / stretching

  4. Manually applied scapular resistive exercise for protraction / retraction and submaximal biceps/triceps manual resistance with shoulder in supported position supine.

  5. Ball approximation (Closed Chain Codman’s) using Swiss Ball or Table Top

Post OP Weeks 2-4




  1. Initiation of active assistive range of motion using pulley for sagittal plane flexion and scapular plane elevation

Post Op Weeks 4-6




  1. Continuation of above program

  2. Initiation of submaximal multiple angle isometrics and manual resistive exercise for shoulder external rotation, ab/adduction, flexion/extension

  3. Upper body ergometer (UBE)

  4. External rotation isotonic exercise using pulley or weight/tubing with elbow supported and glenohumeral joint in scapular plane and 10-20 degrees of abduction (towel roll or pillow under axilla)

Post Op Weeks 6-8




  1. Initiation of passive external rotation range of motion and stretching beyond neutral rotation position

  2. Initiation of internal rotation submaximal resistive exercise progression

  3. Traditional rotator cuff isotonic exercise program

    1. Sidelying external rotation

    2. Prone extension

    3. Prone horizontal abduction (limited from neutral to scapular plane position initially with progression to coronal plane as ROM improves)

  4. Biceps / Triceps curls in standing with glenohumeral joint in neutral resting position

  5. Oscillation exercise with resistance bar or body blade

  6. Rhythmic stabilization in open and closed kinetic chain environments

Post Op Weeks 8-12




  1. Continuation of resistive exercise and range of motion progressions

  2. Addition of ball dribbling and upper body plyometrics with small Swiss ball

Post Weeks 12 - 24




  1. Continuation of Rehabilitation

  2. Isometric Internal / External rotation strength testing / assessment in neutral scapular plane position.



Range of Motion/Optimization of Capsular Relationships

Concomitant with modality care during the initial stages of post-operative rehabilitation is the use of mobilization and passive stretching to decrease abnormal glenohumeral joint shear forces (Harryman et al, 1990), and improve gross glenohumeral joint ROM. Typical patterns of range of motion loss following shoulder injury follow a predictable pattern described by Cyriax. This pattern states that external rotation, abduction and internal rotation are most limited, followed by forward flexion, which is least limited (Cyriax & Cyriax 1983). To address selective capsular tightness, posterior glides of the humeral head relative to the glenoid, with varying degrees of internal rotation of the glenohumeral joint, are used to mobilize the posterior capsule and address limitations in internal glenohumeral joint rotation. Anterior glides of the humeral head are often used to address limitations in external rotation as indicated. Optimization of capsular length between the anterior and posterior capsule is theoretically purported to minimize humeral head shear within the glenoid with glenohumeral joint movement (Harryman et al, 1990). In addition to the use of glenohumeral joint mobilization, application of passive stretching using the low-load, long duration stretching concept is also recommended (Bonutti et al, 1994). The effectiveness of manual therapy techniques for patients with knee joint osteoarthritis has been previously studied with favorable results, however no such investigation is currently available for GHOA (Deyle et al, 2000).



Strengthening

Of all the non-operative physical therapy treatments recommended for patients with GHOA, progressive strengthening of the rotator cuff and scapular musculature holds the greatest theoretical advantage. The important role of the rotator cuff muscle-tendon units in controlling and centering the humeral head, especially during mid-range movement patterns, cannot be underestimated (Lee et al, 2000). The use of sub-maximal strengthening methods to selectively recruit the rotator cuff musculature, using exercise patterns placing the shoulder in neutral, non-impinging positions, forms the basis for in-clinic and home based rehabilitative exercise. Exercises such as sidelying external rotation, prone extension, and prone horizontal abduction are used and recommended and are based on research using EMG that documented high levels of posterior rotator cuff activation (Townsend et al, 1991). As a general rule, exercises for the shoulder that keep the shoulder below 90 degrees of elevation and the arm slightly anterior to, and in the scapular plane are recommended. Use of positions with 90 degrees of glenohumeral joint abduction in the coronal plane, with 90 degrees of external rotation, have been found to experimentally create increases in joint compressive load and may not be indicated for patients with GHOA (Conzen & Eckstein, 2000).

Exercise for the muscles that stabilize the scapula are also indicated. Exercises that strengthen the serratus anterior and lower trapezius are particularly recommended to improve scapular upward rotation during elevation (Kibler, 1998). Resistance patterns with light weights, medicine balls or Thera-band can be used to perform shoulder punches with emphasis on the position of maximal scapular protraction (termed the “plus” position) to recruit the serratus anterior (Moesley et al, 1992). Scapular retraction exercises, such as rowing with multiple positions of arm abduction, are also indicated.

Resistive exercises are performed using several sets of 15 to 20 repetitions, to encourage improvements in both strength and local muscular endurance. The use of the low-resistance, high-repetition strengthening program is applied, with particular emphasis on proper glenohumeral joint arthrokinematics. Lower resistance levels allow rotator cuff activation, with less compensation and shoulder girdle elevation that often accompanies independent exercise programs with higher resistance levels and movement patterns characterized by full, end range, overhead elevation. Care must be taken to ensure that resistive exercise does not elevate pain levels, which lead to muscular inhibition and compensation.


Shoulder Fractures

Neer (1982) developed the stemmed, uncontrained prosthetic replacement of the proximal humeral to specifically address the patient with acute 4 part fractures. These complex fractures did not allow for recreation of acceptable anatomical alignment and reduction and hence, the stemmed, uncontrained design was helpful in providing a scaffold to rebuild the fractured fragments of the proximal humerus (Levy & Copeland 2004). Similar to the rehabilitation schemes for all human fractures, the critical healing timeframes govern the immediate post-fracture immobilization is also a major consideration for rehabilitation of the patient following proximal humeral fracture. The period of immobilization for the shoulder however makes the patient very vulnerable for the development of a secondary frozen shoulder (Neviaser & Neviaser, 1987). Optimal balancing between the period of complete immobilization to promote healing and protect the fracture particularly in complex fractures of the proximal humerus with early post-fracture range of motion is the critical initial decision making required by the physical therapist and physician team. Close communication between the orthopaedic surgeon and the physical therapist is required to allow for a full understanding of the stability of the fracture and the tolerance for external stress early in the healing process. Use of passive range of motion and glenohumeral joint mobilization coupled with judicious use of distal range of motion and submaximal grip and forearm work to mimimize the effects of immobilization on the whole limb.

Techniques discussed throughout this chapter are applied to patients with both glenohumeral arthritis or fracture. The stabilization provided through enhanced rotator cuff and scapular muscular strength and neuromuscular control coupled with optimal capsular tension achieved with physiologic and accessory mobilization of the glenohumeral joint can lead to improved shoulder function in patients with glenohumeral arthritis and shoulder fracture.

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