BO6 106 Rzepkowki

106: Shoulder & Elbow Joint Replacements – New Advancements in Rehab Terry Rzepkowski, DPT, MS, BS To comply with professional boards/associations standards: • I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. •Requirements for successful completion are attendance for the full session along with a completed session evaluation. •PESI and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. 106: Shoulder & Elbow Joint Replacements – New Advancements in Rehab Terry Rzepkowski, DPT, MS, BS Financial: Terry Rzepkowski is an Assistant Professor for Nova Southeastern University Tampa; and an Assistant Professor for South University Tampa. He receives a speaking honorarium from PESI, Inc. Non‐financial: Terry Rzepkowski is a member of the American Physical Therapy Association (APTA). UE joint replacements and post‐op management Dr. Terry Rzepkowski, DPT Associate Professor [email protected] 1 About the instructor Dr. Terry L Rzepkowski, DPT, MS, BS Dr. Terry L Rzepkowski, DPT, MS, BS, is a Doctor of Physical Therapy with specialization in Orthopedic Physical Therapy. Throughout his 38‐year career, he has specialized in Orthopedics, specifically: Musculoskeletal out‐patient rehab as an independent private practitioner, Total Joint Replacement Surgery, Sports Medicine, and Orthopedic Homecare. This extensive background allows him to relate his knowledge of the complex rehab patient from prevention strategies including rehabilitative exercises, lifestyle and activity modifications through all phases of post‐op rehabilitation. About the instructor, Continued A professor in the Health Science department for Nova Southeastern University Terry provides instruction in Anatomy, Biomechanics, and Kinesiology; Terry has extensive knowledge in relating the complexities of the shoulder patient. Terry’s current clinical role as home care therapist working exclusively with orthopedic surgical patients in Tampa FL, provides a platform for staying abreast of the latest techniques, protocols, and medication guidelines utilized in joint care rehab. As a sought-after presenter, he enjoys sharing his knowledge with interdisciplinary audiences around the country. Terry has spoken professionally on pharmacology for clinicians, shoulder, knee, and hip injuries with advances in arthroscopic repair. UE Objectives Understanding: • Shoulder complex mechanics • Function of the Rotator cuff • Indications and procedures of TSA and Rev TSA • Surgical procedures through video presentation • 3D modeling for shoulder replacement • Keys to returning functional motion following TSA • Total elbow replacement • Same day surgery and use of nerve blocks • Post-operative pain management 2 The Shoulder Anatomy Clarification of Terms Shoulder Complex = Shoulder girdle (scapula and clavicle) and Shoulder joint (scapula and humerus) Clarification of Terms (cont’d) Shoulder Complex A. Sternoclavicular joint B. Acromioclavicular joint C. Glenohumeral joint D. Scapulothoracic articulation 3 Scaption Position Natural position is scaption: 30 degrees anterior to the Frontal plane1,2 Often imitated, never duplicated 4 Shoulder Girdle • Term used to discuss activities of the scapula, clavicle, and sternum • The sternoclavicular (SC) and acromioclavicular (AC) joints allow shoulder girdle motions3‐5 – Elevation and depression – Protraction and retraction – Upward and downward rotation – Upward tilt‐Reduction of Upward Tilt Joint Motions Shoulder Girdle A. Elevation‐depression B. Protraction‐retraction C. Upward rotation‐downward rotation D. Upward tilt‐Reduction of Upward Tilt D Companion Motions Shoulder Joint and Shoulder Girdle • Movement of the scapula is accompanied by movements of the glenohumeral joint and vice‐versa • Example: Shoulder flexion is accompanied by upward scapular rotation • Impairment of one joint will also impair function at the other 5 Muscular Considerations • Poor Posture – Pec Minor tightness – Biceps (short head) tightness • Result – Scapular protraction – Decrease posterior tilt of scapula – Decreased S‐A space height • Patient education point – “Slouching active elevation test” Scapulohumeral rhythm • Shoulder Joint • Shoulder Girdle – abduction – upward rotation – Adduction – downward rotation – flexion – elevation/upward rot. – extension – Depression/downward rot. – internal rotation – Abduction (protraction) – external rotation – adduction (retraction) – horizontal abduction – adduction (retraction) – horizontal adduction – abduction (protraction) Active ROM Tests *Performed Bilaterally • Apley’s Stretch Test – Touch opposite acromion with hand of affected shoulder (add/IR) – Reach behind the head and touch opposite shoulder from behind(abd/ER) – Reach behind back and touch opposite scapula(add/IR) 6 Appley Scratch Test Exam for Shoulder DJD • Clinical diagnosis • Range of motion is jerky and painful, then stops suddenly • No further passive ROM possible • Weakness in the pain‐free range of movement. Polling Question 1. The shoulder complex has how many moving articulations? A. 1 B. 2 C. 3 D. 4 7 The Shoulder Joint • Also called the glenohumeral joint – Ball‐and‐socket diarthrosis between head of humerus and glenoid cavity of scapula. – Natural position is scaption: 30 degrees anterior to the Frontal plane – Allows more motion than any other joint – Is the least stable – Supported by 2 types of stabilizers: 1. Dynamic skeletal muscles and tendons 2. Static stabilizers of ligaments, labrum 2 types of Impingement • Primary (Bony) • Anatomical cause of rotator cuff injury – Mechanical compression of r/c tendons • Primarily which one? • Secondary • Kinesiological cause of injury – Poor RTC kinematics, GH instability, muscle imbalance and scapular positioning Subacromial Space Primary Bony Impingement • Causes for decreased subacromial space – Degenerative changes – Osteophyte formation • On Acromion process – Shape of acromion process • Straight (Type 1) • Slight hook (Type 2) • Hooked (Type 3) – Loss of scapular stabilization 8 Secondary Rotator Cuff Impingement • Scapular Weakness – Affects humeral head stabilization – “functional scapular instability” • Affects – Scapular position during activities that causes » “relative decrease in subacromial space” • This can cause secondary impingement – Weak scapular muscles (serratus anterior, traps (3), rhomboid) with postural imbalance of levator and pec minor The Muscles of the RTC Rotator cuff = S.I.T.S. Supraspinatus Infraspinatus Teres Minor Subscapularis 26 Roll/slide mechanics 9 Impingement: Roll‐Slide Kinematics “Roll” created by abduction not countered with “Slide” action Function of Rotator Cuff • Large external muscles (e.g., lats, delts) create shear forces • Rotator cuff provides – Joint compression – Tangential restraint (Ant, Post, Sup) Deltoid produces superior shear force at GH joint. 10 Subscapularis • Resists superior shear • Produces simultaneous internal rotation Infraspinatus & Teres Minor • Resists superior shear • Neutralizes SUBSCAP internal rotation Summary of Active Arthrokinematics Resisting Shear 11 Destabilizing Action of Latissimus Dorsi • LD pulls humerus INF • SSP resists INF force • INF & SUBSCAP create compressive force Rotator cuff injuries • Acute tear: These tears are caused by injury/trauma, such as a fall or lifting something too heavy too quickly or awkwardly. Usually resulting in a complete tear • Partial and degenerative tears are usually the result of altered kinematics MRI of RTC Tear ROTATOR CUFF TENDON 12 Clinical evidence of RTC Insufficiency • Common tests: • Resistive = Empty can, Gerber lift off • Lag principle ( muscle cannot hold in a shortened position and lags to a position of optimal strength) Examples: • Drop arm 1 and 2 • ERLS = external rotation lag sign • IRLS = internal rotation lag sign Polling Question 2. The main function of the rotator cuff at the shoulder is to provide A. Tangential compressive forces B. Shear forces C. Internal rotation D. External rotation Xray and MRI for Arthritic shoulder 13 Total Shoulder Arthroplasty (TSA/TSR) • Indications for both: – Degenerative changes in articular surfaces – Late‐stage OA, RA, Traumatic Arthritis – Osteonecrosis (avascular necrosis) of the head of the humerus – Goal is to: • Relieve pain • Improve shoulder mobility and stability • Improve functional use for ADL’s • Indications for the reverse total shoulder TSR: – Cuff‐Tear Arthropathy (CTA), incapable of repair or normal function TSA Prosthetic Designs • Unconstrained‐stemmed humeral component, used with intact/strong RC • Semi‐constrained‐erosion of the glenoid fossa but still can have rotator cuff repair • Reversed ball and socket ‐appropriate for patients with very damaged and irreparable RC To Reverse or not to Reverse that is the question 14 TSA/TSR Implant design, materials, fixation • Implant Design‐ high‐density polyethylene glenoid/humeral component (usually all plastic) with a humeral/glenoid component made of a metal (Cobalt Chromium) Humeral stem is Titanium • Fixation‐ press‐fit, bio‐ingrowth, cement • Depends upon surgeon’s preference of design as well as strength and integrity of patient’s bone‐‐‐‐?????bone cement TSA/RSA Surgical Approach • Anterior Approach‐Deltopectoral Incision • Tenotomy –Release the subscap tendon from

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