Shoulder Post-operative Guidelines Total Shoulder Arthroplasty and

East Lancashire Hospitals NHS Trust Upper Limb Service, Royal Blackburn Hospital Shoulder Post-operative Guidelines Total Shoulder Arthroplasty and Hemiarthroplasty For Osteoarthritis & Rheumatoid Arthritis Indications Patients with osteoarthritis/rheumatoid arthritis in severe pain. Considerations A delto-pectoral approach with a subscapularis tenotomy. The subscapularis reattachment needs to be protected therefore passive external rotation is restricted to neutral for 3 wks, then 40° by the end of 6 wks, and isometric resisted internal rotation is avoided, for 6 weeks. No active movements for the first 6 weeks, and no resisted cuff/deltoid strengthening for 12 weeks. 1 The rotator cuff may be repaired and this will need protection initially depending on the size and security of the repair. (Check the post-operative notes) 2 If it has not been possible to repair the rotator cuff the patient will not progress as quickly and the final outcome will also be affected 3 Patients with rheumatoid arthritis will progress more slowly, they may be unable to perform auto-assisted exercises and may require more passive movements and sling suspension prior to active exercises. Complications: Infection. Neurovascular. Humeral shaft fracture. Damage to glenoid or humeral component. Duration Treatment Goals In-patient to  Passive forward flexion elevation  Patient education & precautions 1 – 2 weeks  Passive external rotation to neutral (Check with  Permit healing of subscapularis tenotomy the Surgeon or in post-op notes  Control pain & inflammation  Commence pulleys only if performed  Initiate passive range of passive movement passively exercises  Transfer from shoulder immobilizer to broad arm sling 3 – 4 weeks  Discard sling at home  Improve passive range of movement  Isometric exercises <30% of max. voluntary  Improve neuromuscular control & stability contraction  No isometric internal rotation  Passive external rotation to 40° at the end of 6 weeks  Active assisted exercises 6 weeks  Commence active exercises. Increase  Initiate full range of movement Isometric exercises to maximum effort.  Optimise neuromuscular control  Progress external rotation as able  Initiate return of functional activities  Discard sling 8 weeks +  Progress reconditioning of the rotator cuff  Continue overall fitness core control, kinetic through range chain exercises to restore full function  Rotator cuff and scapula conditioning  Dynamic scapula control  Increase proprioceptive work  Initiate return to functional activities 12 weeks  Rotator cuff strengthening (pain free)  Check the patient’s operative notes. Exercises 3 – 4 times daily Pre-operative  Document range of active and passive movement  Assess the rotator cuff strength  Assess pain and functional levels  Teach postural correction, scapular stabilisation, rotator cuff, elbow, wrist and hand exercises. Post-operative boothp/TOTAL SHOULDER ARTHROPLASTY AND HEMIARTHROPLASTY FOR OSTEOARTHRITIS & REHEUMATOID ARTHRITIS Copyright @ Helen Thompson/Gillian Haworth/Rachel Dean/2006 1 East Lancashire Hospitals NHS Trust Upper Limb Service, Royal Blackburn Hospital Sling with body belt applied in theatre is retained for 3- 6 weeks. It can be removed for washing, dressing and exercises.  Elbow, wrist and hand  Pendular exercises  Discharge usually at day 2. An outpatient clinic appointment is arranged prior to discharge for removal of sutures. Clinic review 2 – 3 weeks. Physiotherapy appointment arranged. Day 3 or as pain allows  Passive external rotation to neutral. This is carried out in supine lying with a pillow under the humerus. The arm in slight abduction in the plane of the scapula.  Passive ½ lever exercises 1 week  Commence passive pulleys. If the patient is unable to relax the therapist performs passive movements 2 weeks  Transfer from shoulder immobilizer to broad arm sling 3 weeks  Discard sling at home. Warn patient not to move arm actively or lean through it. The patient is encouraged to use a pillow under the arm when lying supine. During ambulation the arm should be by the side of the body as normal.  Isometric exercises < 30% of maximum voluntary contraction. Exclude isometric internal rotation.  Passive external rotation to 40° by the end of six weeks 4 weeks  Active assisted exercises  Pulleys can be used for patients who were unable to use pulleys passively at week 1 6 weeks  Discard sling  Commence active exercises, emphasise correct movement pattern in activities of daily living  External rotation beyond 40°  Increase Isometric exercises to maximum effort. Commence Isometric internal rotation  Patient can drive  Rotator cuff, deltoid and scapula rehabilitation throughout the active range of movement (pain free)  Increase proprioception through open and closed chain exercises  Self stretching exercises of the shoulder joint to the end of available range Week 12  Gradual rotator cuff strengthening. Some effort to recondition the rotator cuff with remedial exercises. Less emphasis is placed on this area of rehabilitation following repair of large rotator cuff tears. Milestones 3 weeks  50% of pre-op active ROM 6 weeks  Passive range of movement to at least pre-operative level 12 weeks  Active range of movement at least pre-op level  Patients with Rheumatoid Arthritis 110° elevations is a good result  Patients with Osteoarthritis should regain 160°  Improvement continues for 18 months to 2 years  Patients should continue exercising until their maximum potential has been reached Return to Functional Activities Driving  6 – 12 weeks Swimming  Breaststroke 12 weeks Golf  6 months Lifting  Light lifting can begin at 4 weeks  Avoid lifting heavy items for 6 months Work  Sedentary job 6 weeks or as tolerated  Manual job guided by surgeon Walking aides  6 – 9 months Avoid if possible Bibliography: T Bradley Edwards, Aziz Boulahia. Jean-Francois Kempf. Pascal Boileau. Chantal Nermoz and Giles Walch. The influence of Rotator Cuff Disease on the Results of Shoulder Arthroplasty from Primary Osteoarthritis. The journal of Bone & Joint Surgery. Vol 84-A Number 12. Dec 2002. P2240-2248. Julie Y Bishop. Evan L Flatow. ‘Humeral Head replacement versus total shoulder Arthroscopy: Clinical outcomes-A review. Journal Shoulder Elbow Surgery. Vol 14, No. 1 S. Jan/Feb 2005 boothp/TOTAL SHOULDER ARTHROPLASTY AND HEMIARTHROPLASTY FOR OSTEOARTHRITIS & REHEUMATOID ARTHRITIS Copyright @ Helen Thompson/Gillian Haworth/Rachel Dean/2006 2