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• With patients who have excessive edema with exercise,

therapy sessions should be limited in duration and should

concentrate on functional mobility. The use of a CPM in

submax.imal ranges in conjunction with ice will maintain

knee ROM while assisting in edema reduction.

• If a brace or knee immobilizer is being used, the therapist should always check that ir is applied properly. If the brace is not appropriately fitted to the patient or applied

properly, it may keep the knee flexed. The therapist should

adjust the brace or immobilizer ro be certain that knee

extension is maintained when worn by the patient. Nursing staff may need to be educated to different types of braces and the proper donning and doffing of the brace.

• Treatment sessions should be coordinated with administration of pain medication to increase patient comfort

and compliance with ROM exercises.

202

AClJTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Shoulder Arthroplasty

Total shoulder arthroplasty (TSA) is indicated for patients with severe

pain and limited ROM caused by osteoarthritis, rheumatOid arthritis,

fracture, AVN, or traumatic arthritis. Conservative treatment should

attempt to alleviate pain while increasing function. Only when these

measures have failed should TSA be considered. If only the humeral

head shows significant degeneration, a shoulder hemiarthroplasty

may be consIdered. Prosthetic wear after TSA or shoulder hemiarthroplasty is of less concern than after THA or TKA, because the shoulder is nOt a weight-bearing structure." The goal of surgery is to

relieve pain and regain lost function.

TSA involves the replacement of the glenoid articulating surface and

the humeral head with prosthetic components. A polyethylene glenoid

unit with metal backing and keel articulates with a humeral prosthesis.

Fixation of these components is either cemented or press-fit, processes

similar to those in the other joint replacement sllrgeries.48

There are three types of TSA prostheses available: unconstrained,

semiconstrained, and constrained. The mOSt commonly used prosthesis is the unconstrained type that relies on soft tissue integrity of the rotaror cuff and deltoid muscles. If these structures are insufficient or damaged, repair may take place during shoulder arthroplasty surgery and may prolong rehabilitation. The success of all TSA involves accurate surgical placement of the prosthesis and the

ability of the surgeon to reconstruct the anaromic congruency of the

joint. Proper orientation of the prosthetic components and preservation of structural length and muscular integrity are key aspects of the surgery that predispose favorable outcomes. The technical skill

of the surgeon and advances in prosthetic components have

improved outcomes with TSA. With appropriate patient selection

and a properly functioning rotatOr cuff, a patient with a TSA can be

rehabilitated to improve ROM and strength equal to that of the

unaffected side."

A proximal humeral hemiarthroplasty (Figure 3-17) can be performed when arthritic changes have affected only the humeral head.

The humeral head is replaced with a prosthetic component through a

similar technique as in TSA. Results are dependent on the integrity of

the rotatOr cuff and deltoid, the precision of the surgeon, and the willi ngness of the patient to commit to a continual rehabilitation program. Rehabilitation of the shoulder hemiarthroplasty is similar to that of a TSA.

MUSCULOSKELE.TAL SYSTEM

203

Figure 3-17. Proximal hemiarthroplasty of the right shoulder.

Physical Therapy Intervention after Shoulder Arthroplasty

The rehabilitation after TSA or shoulder hemiarthroplasty should

emphasize functional independence and patient education on therapeutic exercise. The physical therapist should confirm the presence of any precautions with the surgeon and educate the patient in passive

and active-assisted ROM exercises to prevent the formation of adhesions. The stability of the shoulder is dependent on the rotator cuff and deltoid muscles, and the rehabilitation program may be dictated

by their integriry. Maximum results from a TSA occur approximately

18-24 months after the surgery and a dedicated program of physical

therapyY

• Edema can be controlled with wrist and elbow ROM exercises

and ice packs used in conjunction with elevation.

• A sling may be used for patient comfort but should be discontinued as soon as possible, following surgeon protocol, to increase ROM and strength. If there was extensive repair to the rotator cuff

or deltoid, an abduction brace may be prescribed.

204 AClJTE CARE HANDBOOK FOR PHYSICAL THFRAPISTS

• The patient should be taught wand and pendulum exercises to

promote shoulder flexion and abduction. With most TSAs, active

external rotation should be performed in a pain-free ROM, but

active abduction and flexion should be limited according to surgeon protocol. Outpatient physical therapy should begin shortly after the follow-up visit with the surgeon.

Clinical Tip

•

A shoulder CPM can be ordered by the surgeon and

applied postOperatively or for home use to assist with

ROM and to prevent formation of adhesions.

• The physical therapist should initiate a consult for

occupational therapy to instruct the patient on ADLs,

especially if the patient'S dominant arm is affected.

Total ELbow Arthroplasty

The reliability of TEA has progressed to outcomes comparable to

those of other types of joint arthroplasty.·' Indications for TEA are

pain, instability, and elbow ankylosis. The parient population thar

demonstrates optimal results after TEA is those severely affected by

rheumatoid arthritis,50 Post-traumatic arthritis is also an indication

for elbow arthroplasty; however, patient satisfaction and outcomes

are inferior compared to those with rheumatoid arthritis.51 The goal

of TEA is the restoration of function through decreasing pain and

increasing joint ROM and stability.

Early results of TEA with a fully constrained prosthesis have shown

aseptic loosening. Conversely, an unlinked or less-constrained prosthesis demonstrates a decreased rate of loosening but has showed increased rates of failure secondary to weak collateral ligaments, anterior capsule, and reduced bone stock. Therefore, a semiconstrained prosthesis (Figure 3-18) is now favored for TEA to dissipate stress to

the muscular and ligamentous structures surrounding the elbow, thus

decreasing the rate of prosthetic loosening,52 Unconstrained or resurfacing arthroplasties attempt to duplicate the anatomic surfaces within the joint and depend on intact ligaments and the anterior capsule for

stability. A semiconstrained prosthesis may have a metal-to-polyethy-