Total+Shoulder+Arthroplasty+vs.+Reverse+Shoulder+Arthroplasty+Prognosis?


 * What prognostic factors affect patients being able to return to normal function following a total shoulder arthroplasty or a reverse shoulder arthroplasty? **

[] TSA Surgical Procedure [|TSA Demo (nonsurgical)] - for those with sensitive stomachs
 * __Total Shoulder Arthroplasty (TSA)__**
 * Background:**

1. Sufficient debilitating pain that limits function 2. Loss of glenohumeral cartilage or severe distortion of the articular surfaces 3. Potential for a high degree of improvement
 * Indications** :

1. Active or recent shoulder joint infection 2. Neurologic condition resulting in severe weakness of the deltoid and rotator cuff 3. Motion disorder that would prevent rotator cuff healing 4. Severe, uncorrectable glenohumeral instability
 * Contraindications** [1] **:**

__Age__ Demirhan et al. found no significant correlation between age and general outcomes post-TSA following proximal humeral fracture. Foruria et al. found that TSA in patients 80 years or older suffering from OA increased patient comfort and shoulder mobility for the duration of their lives. However, these elderly patients had more complications post-surgery that required increased hospitalization time.
 * Prognostic Factors:**

__Sex__ Demirhan et al. [2] found no significant correlation between gender and general outcomes post-TSA following proximal humeral fracture.

__Preoperative delay __ Preoperative delay was found to be an important correlate with functional outcome [2] . Researchers found that patients had their TSA surgery on or before the 14th day post-fracture hand generally better outcomes. “Better outcomes” was defined as excellent or satisfactory and not unsatisfactory, according to [|Neer’s criteria] (pictured below) and the Constant-Murley scoring system [2, ]



__Radiologic parameters __  Moineau et al. found that patients with an acromiohumeral post-op distance of less than 7 mm had significantly poorer outcomes than those with greater than 7 mm.

   Position of the greater tuberosity relative to the humeral head, the humeral offset, and the humeral head height correlated significantly with elevation degree and Constant score [2]. Elevation degree and Constant score increased with increased humeral offset (A and B pictured above). Patients’ with good or excellent outcomes had an average humeral offset that was significantly higher than the average humeral offset of those with unsatisfactory outcomes. A cutoff score of 23 millimeters was calculated: those patients with 23 mm or more of humeral offset had significantly better outcomes than those with less than 23 mm.  Elevation degree and Constant score decreased with increased humeral head height (C and D pictured above) [2]. The average humeral head height was not significantly different across excellent, good, or unsatisfactory cases, but a cutoff of 14 millimeters was calculated. Those patients with a humeral head height of 14 mm or less were expected to have better outcomes than those with a head height of more than 14 mm.

 Moineau et al. [5] examined 55 patients that experienced proximal humeral fractures. Four types of fracture sequelae were recognized by the surgeon who performed all of the subsequent shoulder arthroplasties or hemiarthroplasties: posttraumatic cephalic collapse, osteonecrosis, or posttraumatic glenohumeral osteoarthritis (type 1), locked chronic dislocation or fracture-dislocation (type 2), surgical neck nonunion (type 3), and severe tuberosity malunion (type 4). The patients in this study all experienced a form of type 1 sequelae, so they were further subdivided into: isolated osteonecrosis of the humeral head but did not have tuberosity malunion (type 1A), isolated posttraumatic osteoarthritis without osteonecrosis or tuberosity malunion (type 1B), valgus malunion due to valgus impacted fracture (type 1C), and varus malunion due to varus impacted fracture (1D) [5].



 __Rotator cuff muscles and tendons__  Patients with fatty infiltration of the rotator cuff muscles preoperatively had poorer results than those without fatty infiltration [5]. This study lacked power to determine if the integrity of the rotator cuff tendons had a significant effect on outcomes.  Franklin et al. compared cases of TSA where patients had severe rotator cuff tears at the time of surgery vs. TSA surgeries where rotator cuffs were intact. They found that those patients with rotator cuff tears also experienced "upward riding" of the prosthetic humeral head and this may have contributed to glenoid loosening. Glenoid loosening was observed in those patients with rotator cuff tears, and not in those with intact rotator cuffs.

 __Glenoid cavity__  Glenoid resurfacing was used in most patients, but the study lacked power to determine whether hemiarthroplasty or total shoulder arthroplasty yielded better results [5]. However, the researchers felt that glenoid resurfacing played an important part in restoring motion in the shoulder and decreasing pain.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Fracture type and fracture healing__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> No significant correlation between fracture type (comparing type III and IV fractures and fracture-dislocations) and general outcome post-TSA following proximal humeral fracture [2]. Mechanisms of injury included falls, motor vehicle accidents, and seizure. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Patients without proximal humeral deformity (isolated humeral head necrosis or posttraumatic osteoarthritis) had better outcomes than those patients with humeral deformity following various proximal humeral fracture sequelae [5]. These outcomes were measured with active elevation, strength constant score, and absolute constant score. Of those patients with deformity, those with valgus malunion had significantly better outcomes than those patients with varus malunion.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Tuberosity problems__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In the Demirhan et al. study [2], 12 complications occurred in 11 cases. Half of the complications were related to tuberosity problems (including resorption of the greater tuberosity, displacement of the greater tuberosity, and inaccurate reduction of the greater tuberosity in a comminuted fracture). Tuberosity problems had a significant adverse effect on the patient’s clinical outcome (excellent, satisfactory, or unsatisfactory). Patients with tuberosity problems tended to have an unsatisfactory outcome [2] .<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;">

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Increased severe greater tuberosity malunion in proximal humeral deformity was correlated with poorer outcomes than those patients with better union post surgery[5].

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Position of tuberosities relative to prosthesis__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> It is difficult to generalize results based on radiographic findings due to variance in patient position, posture or rotation of the humerus, patient general size, exposure distance, etc., so it would be foolish to put too much stock into the “cut off values” mentioned above in the Radiologic Parameters section. However, it is shown clearly that the tuberosity and humeral head measurements do have an effect on functional outcome [2]. Therefore, it can be said that lateralizing the tuberosities results in a better outcome and moving the tuberosities distally results in a poorer outcome, as concluded by Demirhan et al [2]. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In cases where the humeral head has been severely impacted, an osteotomy may not be necessary and should not be performed. The more normal anatomy can be restored, the better the outcomes [5].

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Osteoarthritis__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Total shoulder arthroplasty has become a typical and successful treatment with proven clinical results for patient’s who have end-stage osteoarthritis of the shoulder. In a study done by Mansat et al, hemiarhtroplasty was compared to TSA for osteoarthritis management. When compared to hemiarthroplasty, TSA showed significant increases in pain relief, ROM, improved function, as well as patient satisfaction. TSA also indicated a lower rate of revision surgery.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Rheumatoid Arthritis__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In the systematic review within the framework of the Cochrane Collaboration, Beneficial and Harmful Effects of Shoulder Arthroplasty in Patients with Rheumatoid Arthritis by Christie et al. it was concluded that there is not sufficient evidence to make clinical decisions over the use of total shoulder arthroplasty for patients with RA. This can be due to RA not specifically affecting the shoulder joint until late in the disease.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Post-Operative Rehabilitation Following TSA__

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> From the clinical commentary //Rehabilitation Following Total Shoulder Arthroplasty// by Wilcox, Arslanian, et al.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> The majority of references in regards to rehabilitation following TSA are empirical descriptions of the rehabilitation versus clinical trials evaluating the protocols’ effectiveness. It is agreed that post-operative rehab is critical to functional outcomes after a total shoulder, however specific protocols and measures of functional outcomes are not widely agreed upon. Most physical therapy programs are based on Neer’s protocol presented in 1975 <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;">and standard practice is to begin early PROM but there is little to no consensus on progression after this. There are several published protocols but one has not been established as most effective through RCTs. Most programs referenced appear to be very structured with constant supervision by the PT and surgeon, however Boardman et al looked at the effectiveness of a less traditional home-based exercise program after TSA. Wilcox et al proposed that a standard protocol that takes into consideration the underlying pathology and focuses on meeting specific impairment and functional goals before progressing to the next stage of rehab will result in maximal functionality and prognosis for the patient.[10] Their detailed protocol and algorithm can be found [|here.]

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> The study //Rehabilitation Following Shoulder Arthroplasty// done by Boardman et al is summarized here. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> The hand, forearm, elbow AROM and shoulder PROM continued through week 5. At 3 weeks, assisted pulley exercises were added to facilitate shoulder elevation. At 5 weeks, AAROM and stretching with wand/cane were initiated to facilitate flexion-extension, elevation-adduction, external and internal rotation with arm in anatomical, and external and internal rotation with shoulder abducted to 90. Light strengthening and isometrics also began at 5 weeks and eventually progressed to the use of thera-band for strengthening by week 10. Patients were instructed in the first 4 weeks home exercise program by an inpatient PT during their hospital stay. They returned at 5 weeks for instruction in the final portion of the home exercise program. Patients were evaluated pre- and post-operatively on pain, range of motion, and patient satisfaction. Range of motion was also evaluated intra-operatively to assess maintenance of motion gained through TSA. [12]
 * **Postoperative Rehabilitation Sequencing** ||
 * //Exercise// ||  //Days Postoperatively//  ||  //Weeks//  ||
 * Hand, forearm, elbow AROM ||  1  ||  ---  ||
 * Shoulder PROM ||  1  ||  ---  ||
 * Pulley ||  21  ||  3  ||
 * Wand/cane ||  35  ||  5  ||
 * Isometrics ||  35  ||  5  ||
 * Thera-band ||  ---  ||  10  ||

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Based on results of this study, a home-based program provides an effective means of maintaining motion achieved intraoperatively after TSA. 70% of patients maintained motion in elevation and 90% maintained motion in external rotation. This may especially be effective for patients with OA (85% maintained motion in elevation). For patients with RA and traumatic arthritis/osteonecrosis it may not be as effective as elevation was maintained in only 65% and 50% respectively. Higher ROM values are one indicator of better prognosis for the patient. [12]
 * **Difference Between Intraoperative and Postoperative Motion** ||
 * //Diagnosis// ||||  //Change in Active Elevation//  ||||  //Change in External Rotation//  ||
 * ^  ||  //< 20//  ||  //>20//  ||  //<20//  ||  //>20//  ||
 * OA ||  31  ||  7  ||  34  ||  3  ||
 * RA ||  13  ||  7  ||  17  ||  3  ||
 * Traumatic arthritis ||  6  ||  6  ||  11  ||  1  ||
 * Osteonecrosis ||  3  ||  3  ||  6  ||  0  ||
 * Cuff arthropathy ||  0  ||  1  ||  0  ||  1  ||
 * Others ||  4  ||  1  ||  5  ||  0  ||
 * //Totals// ||  //57 (70%)//  ||  //24 (30%)//  ||  //73 (90%)//  ||  //8 (10%)//  ||

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> A retrospective analysis done by Mulieri, et al evaluated the postoperative clinical outcomes of patients who underwent a formal physical therapy program versus patients who underwent a home-based, physician-directed protocol.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> The specific protocols followed for each group can be found [|here.]Post-op data was collected at 3, 6, and 12 months and at the latest follow-up visit. Group A (formal PT group) had significant improvements in ASES, [|SST], abduction, and forward flexion at 3, 6, and 12 months but did not reach significance in flexion and abduction at final follow-up (52 months post-op). Group B (home-based, physician-directed group) had significant improvements in ASES, SST, forward flexion, and abduction at all time points (final follow-up was 39 months). Although no between group differences were detected in forward flexion and abduction at 3, 6, and 12 months, significant differences were seen at final follow-up indicating group B exhibited better maintenance of forward flexion and abduction results. However it is important to note the difference in final follow-up time of 52 months for group A versus 39 months for group B. [13] This study suggests that formal post-operative PT may not have a significant effect on the outcome of TSA for primary osteoarthritis. Based on their results, a simple home-based program does not negatively affect the outcomes and may be a sufficient form of rehabilitation post TSA.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> **<span style="font-family: Arial,sans-serif; font-size: 10pt; line-height: 1.5; vertical-align: super;">__Reverse Shoulder Arthroplasty (RSA)__ **

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;">

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> **<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> [|Summary of RSA and its uses (video)] ** <span style="font-family: Arial,sans-serif; font-size: 10pt; line-height: 1.5; vertical-align: super;"> The procedure reverses the traditional ball and socket aspects of the shoulder and shifts the glenohumeral axis of rotation distally and medially, allowing the deltoid to secure the joint during elevation of the arm without a rotator cuff. This provides stability and increased function in patients with severely damaged rotator cuffs with or without additional joint pathologies and in patients for which alternative treatment options are unsuccessful or not feasible. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> **<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __[|RSA application lecture]__ ** <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> The standard surgical approach involves accessing the joint space through the delto-pectoral margin and entering joint through the subscapularis insertion. The anatomic humeral head (cartilaginous surface) is removed and replaced with concave insert. The glenoid cavity is hollowed out, replaced with a baseplate, and glenosphere prosthesis is fixed to the baseplate. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> **<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> [|Headcam video of RSA procedure] **

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Contraindications__ include severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis 9.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;">Primary Indications __** 2, 16, 9 **:** <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> **__Prognostic factors__:** <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Pseudoparalysis__: <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> <span style="font-family: Arial,sans-serif;">RSA benefits patients who display pseudoparalysis for of the shoulder and are limited to <90°active elevation range of motion due to weakness of the rotator cuff musculature, which should be detected on physical examination. These patients typically have full passive range of motion. Individuals with >90° of active elevation who have rotator cuff tears do not have full tears or have balanced shoulder mechanics, and tend to have poorer o utcomes 115.
 * 1) Massive rotator cuff tear with or without arthropathy
 * 2) Revision arthroplasty
 * 3) Proximal humerus fracture with rotator cuff tear
 * 4) Glenohumeral osteoarthritis with rotator cuff tear
 * 5) Glenohumeral rheumatoid arthritis with cuff tear

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Age and Surgery history__: <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In a study of patients 60 years and younger (n=66, mean age: 52.2), patients showed significant improvements in active shoulder flexion, external rotation, [|ASES scores], and [|VAS pain scores] regardless of having prior surgery or not. However, analysis showed a negative correlation between increasing number of prior surgical procedures and change in [|ASES scores]. Overall, the younger population had lower satisfaction scores than a more elderly population. This is thought to be due to higher expectations of functional outcome over a longer remaining lifespan 11. Limited long term data also shows that RSA have a survival time of 6-10 years, therefore a younger patient population is more likely than an elderly population to experience failure of the prosthesis due to usage over time. Reverse total shoulder arthroplasty is best indicated for low-demand, elderly patients with rotator cuff arthropathy 13. Younger patients report poorer functional scores in RSA, and this is thought to be contributed to having higher expectations than an elderly population 18. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> RSA as a revision to a previous shoulder arthroplasty resulted in significantly higher complication rates than did primary RSA surgeries. Previous surgery had no apparent effect on the relative degree of improvement following RSA when performed as a revision procedure, but patients with a previous hemiarthroplasty failure had lower preoperative ratings and thereby had a worse final outcome in comparison with those with a previous total arthroplasty failure 16.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Fracture:__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Limited high quality evidence exists for use of RSA in proximal humerus fracture repair. Based on the available evidence the use of RSA in acute fractures is questionable. In a literature review, the complication rate was high and the implications for scapular notching implicated poorer outcomes. Intact or repaired tuberosities increases functional long term outcome 13. Repair of traumatic fracture and dislocation with RSA in the elderly population was associated with high complication rate. Scapular notching was also present in 56% of patients and is associated with poor clinical outcome scores 8.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Rotator cuff tear:__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Analysis shows that patients undergoing RSA for rotator cuff insufficiency seemed to have the most reproducible change in active forward elevation. Additionally, patients with a prior failed primary arthroplasty had the least improvement with regard to ASES scores. This information could prove valuable in managing patient expectations prior to total shoulder arthroplasty 11. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Patients with primary rotator cuff tear arthropathy, primary osteoarthritis with a rotator cuff tear, and a massive rotator cuff tear without arthritis had the best final outcomes. In contrast, the patients in the posttraumatic arthritis and revision arthroplasty groups had significantly worse postoperative [|Constant scores] (53 and 52, respectively) in comparison with the other three groups 16.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __OA with tear:__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Age was not a risk factor in determining failure or revision of RSA in patients with OA 2. No difference in change in [|Constant scores] was detected between diagnoses groups, but did show the arthritic shoulders had more complications. This suggests the presence of arthritis plays a detrimental role in functional long term outcomes following RSA 16.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __RA with tear:__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Rheumatoid arthritis patients with intact teres minor muscle showed significant improvement over the patients with atrophied teres minor based on change in [|Constant score] from preoperative to postoperative measures. No serious complications occurred intraoperatively or postoperatively. However, in RA patients, poor bone quality leaves patients more susceptible to intraoperative and postoperative fractures 17.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Active Range of Motion (AROM):__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Patients who achieved a postoperative active elevation of at least 100° showed improvements in [|ASES] (p < 0.05) and [|VAS pain scores] (p < 0.05) compared with those who did not reach 100°. Patients with <100° of postoperative forward elevation also had significant improvements in VAS pain scores (p < 0.05). However, subjective postoperative satisfaction scores showed that 92.7% of patients who had forward elevation of at least 100° were either satisfied or very satisfied with the outcome, whereas only 25% of patients who had <100° of forward elevation were satisfied or very satisfied with the outcome 11. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Alternative methods of treatment are advised for patients with full AROM. These patients are more likely to fail with RSA and will benefit from more conservative approaches 9.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Sex:__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In a 5 year follow up, males have a significantly higher rate of revision surgery compared to females 2.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Obesity:__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Obese patients did show significantly increased AROM following RSA, however, the obese group experienced significantly greater complication rates compared to the normal group (35% to 4%). Average blood loss was significantly greater in obese group compared to overweight group. No significant differences were detected between scapular notching, surgical time, length of hospitalization, humeral component loosening, postoperative abduction, forward flexion, internal and external rotation, pain relief, or instability between groups 3.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Surgical approach:__ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> The deltopectoral approach is the gold standard and is currently supported by more evidence than other approaches, however, the antero-superior approach is being performed with success and has some evidence of increased stability over the deltopectoral approach 11.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __Complications__ include neurologic injury, infection, hematoma, periprosthetic fracture, scapular notching, dislocation, mechanical baseplate failure. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In a study of patients under 60 years old with rotator cuff tears (n=66), 15% of cases had complications, most were serious 11. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In a systematic review of proximal humeral fractures in an elderly population, 19.4% (30/155) had complications, 5.8% required reoperation. Higher grade scapular notching was associated with poorer outcomes 13. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In a study on rheumatoid arthritis and cuff tear, ~50% of shoulders had complications (Mean age 71, n=18), however none were serious enough to cause revision surgery. They were mostly fractures of the humerus or acromion related to poor bone quality, but no fractures of the glenoid occurred 17. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In a study of severe rotator cuff tears with and without additional joint pathologies (Mean age 72.7, n=232), complications occurred in 19.1%. The risk of complication associated with revision surgery (36.7%; eighteen of forty-nine) was significantly higher than the risk of complication associated with primary surgery (13.3%; twenty of 150) (p < 0.001). In this study, repair of the subscapularis was not related to the occurrence of postoperative complications (p = 0.123) or dislocations (p = 0.115) 16. <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In a study of elderly patients status post traumatic proximal humerus fracture, 23% experienced complications (n=35, mean age=75) and 17% reoperation 8.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Common functional assessment tools: [|SF-36]; [|ASES scores]; [|VAS pain scores]; [|Constant scores].

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Note: data is retrospective, narrative, case study etc. No RCTs exist for RSA. Limited high quality quantitative research exists regarding the benefits and costs of reverse shoulder arthroscopy for proximal humeral fractures. Available data suggests high complication rates and poor long term outcomes are a risk with this relatively new technology, but it offers functional improvements and pain reductions in patients with full rotator cuff tears with and without additional joint pathologies. Further research is required.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> __<span style="font-family: Arial,sans-serif; font-size: 10pt;">Postoperative Rehabilitation following RSA __ <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Patients who receive RSA rely on the function of other musculature postoperatively to move the arm, specifically the deltoid muscle because of rotator cuff arthropathy.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> General guidelines have been stated pertaining to rehabilitation following reverse total shoulder arthroplasty, however research is needed to maximize postoperative rehabilitation outcomes specifically for plan of care and its long-term affects.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> In a clinical commentary found in the Journal of Orthopaedic and Sports Physical Therapy, Boudreau et al recommended a rehabilitation protocol specifically for postoperative RSA based on their experiences and basic science principles. It was stated that the physical therapist must take into account many factors concerning each individual patient before initiating a plan of care. These factors include: patient’s prior level of function, bone quality, integrity of the remaining rotator cuff, and postoperative activity level expectation. Along with the factors, three main concepts should also be considered:

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> - Joint protection – internal rotation and adduction along with extension is the most vulnerable position that can lead to dislocation in which the prosthesis moves anteriorly and inferiorly <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> - Deltoid function – important for stability and movement of the shoulder joint <span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> - Establishment of appropriate function and ROM expectations – this will vary from case to case

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> The [|rehabilitation protocol] and information is referenced here.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> Outcomes of physical therapy rehabilitation following RSA have not been well researched or established thus far and can be due to the relatively new surgical approach, but it is known that postoperative rehabilitation is important for patients to regain ROM, strength, and function.

<span style="font-family: Arial,sans-serif; font-size: 10pt; vertical-align: super;"> **RSA REFERENCES:**


 * 1) Acevedo DC; VanBeek C; Lazarus MD; Williams GR; Abboud JA. Reverse shoulder arthroplasty for proximal humeral fractures: update on indications technique and results. J Shoulder Elbow Surg 2014 Feb 23(2):279-289. [].
 * 2) Australian Orthopaedic Association. Demographics and outcomes of shoulder arthroplasty: supplementary report. 2013.
 * 3) Beck JD; Irgit KS; Andreychik CM; Maloney PJ; Tang X; Harter GD. Reverse total shoulder arthroplasty in obese patients. Journal of Hand Surgery. 2013 May 38(5):965-970. http://dx.doi.org/10.1016/j.jhsa.2013.02.025
 * 4) Boileau P; Gonzalez JF; Chuinard C; Bicknell R; Walch G. Reverse total shoulder arthroplasty after failed rotator cuff surgery. J Shoulder Elbow Surg. 2009;18:600-6.
 * 5) Boileau P; Chuinard C; Roussanne Y; Bicknell RT; Rochet N; Trojani C. Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm. Clin Orthop Relat Res. 2008 Mar;466(3):584-93. doi: 10.1007/s11999-008-0114-x. Published online Jan 25, 2008.
 * 6) Brorson S; Rasmussen JV; Olsen BS; Frich LH; Jensen SL; et al. Reverse shoulder arthroplasty in acute fractures of the proximal humerus: a systematic review. Int J Shoulder Surg. 2013 Apr-Jun; 7(2):70-78. doi: 10.4103/0973-6042.114225.
 * 7) Boudreau S; Boudreau E; Higgins LD; Wilcox III RB. Rehabilitation following reverse total shoulder arthroplasty. Journal of Orthopaedic and Sports Physical Therapy. 2007 Dec; 37(12):734-743.
 * 8) Cazenueve JF; Cristofari DJ. Long term functional outcome following reverse shoulder arthroplasty in elderly. Orthopaedics and Traumatology: Surgery and Research. 2011 Oct 97(6):583-589. [].
 * 9) Drake GN; O’Connor DP; Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010 Jun 468(6): 1526–1533. Published online Jan 5, 2010. doi: 10.1007/s11999-009-1188-9.
 * 10) Harreld KL; Puskas BL; Frankle M. Massive rotator cuff tears without arthropathy: when to consider reverse shoulder arthroplasty. J Bone Joint Surg Am. 2011;93(10):973-984.
 * 11) Muh SJ; Streit JJ; Wanner JP; Lenarz CJ; Shishani Y; et al. Early follow-up of reverse total shoulder arthroplasty in patients sixty years of age or younger. J Bone Joint Surg Am, 2013 Oct 16;95(20):1877-1883. doi: 10.2106/JBJS.L.10005.
 * 12) Mulieri P; Dunning P; Klein S; Pupello D; Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg am, 2010 Nov 03:92(15):2544-2556. Doi: 10.2106/JBJS.I.00912
 * 13) Namdari S; Horneff JG; Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am, 2013 Sep 18;95(18):1701-1708. doi: 10.2106/JBJS.L.01115.
 * 14) Routman HD. Indications, technique, and pitfalls of reverse total shoulder arthroplasty for proximal humerus fractures. Bulletin of the Hospital for Joint Diseases 2013;71(Suppl 2):S64-7.
 * 15) Roy JS; MacDermid JC; Goel D; Faber KJ; Athwal GS; Drosdowech DS. What is a successful outcome following reverse total shoulder arthroplasty? Open Orthop J. 2010; 4:157-163. Published online Apr 23, 2010. doi: 10.2174/1874325001004010157.
 * 16) Wall B; Nove-Josserand L; O’Connor DP; Edwards TB; Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am, 2007 Jul 01;89(7):1476-1485. doi: 10.2106/JBJS.F.00666
 * 17) Young AA; Smith MM; Bacle G; Moraga C; Walch G. Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Am, 2011 Oct 19;93(20):1915-1923. doi: 10.2106/JBJS.J.00300.
 * 18) Young S; Zhu M; Walker CG; Poon PC. Comparison of Functional Outcomes of Reverse Shoulder Arthroplasty with Those of Hemiarthroplasty in the Treatment of Cuff-Tear Arthropathy: A Matched-Pair Analysis. J Bone Joint Surg Am, 2013 May 15;95(10):910-915. doi: 10.2106/JBJS.L.00302