In the name of God

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In the name of God
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Shoulder Arthroplasty in Geriatrics

• Mohsen Mardani-Kivi M.D.
• Assistant Prof. Orthopaedic Dept.
• Guilan University of Medical Sciences

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Background

• The most common fractures in the elderly
  osteoporotic patient include
• Hip Fractures
• Femoral neck fractures
• Intertrochanteric fractures
• Subtrochanteric fractures
• Ankle fractures
• Proximal humerus fracture
• Distal radius fractures
• Vertebral compression fractures

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Proximal Humerus

• Background
• Very common fracture seen in geriatric
  populations
• 112/100,000 in men
• 439/100,000 in women
• Result of low energy trauma
• Goal is to restore pain free range of shoulder
  motion

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Background

• Fractures in the elderly osteoporotic patient
  represent a challenge to the orthopaedic surgeon
• The goal of treatment is to restore the
  pre-injury level of function

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• Lesions of the shoulder requiring arthroplasty
  are much less common than lesions involving the
  weight-bearing joints of the body, such as the
  hip and knee.

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Indications for Shoulder Arthroplasty

• Osteoarthritis
• Rheumatoid arthritis
• Rotator cuff tear arthropathy
• Avascular necrosis
• Post-traumatic arthritis
• Severe proximal humeral fractures

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Arthroplasty Options
Hemiarthroplasty
Reverse Total Shoulder
Total Shoulder
Resurfacing
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Surgical Approach
Deltopectoral
Coracoid
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A little history

• 1893- French surgeon Pean inserted platinum and
  rubber components to replace a shoulder joint
  destroyed by tuberculosis.
• 1951- Neer I, Vitallium Hemiarthroplasty
  prosthesis which resulted in pain relief and good
  function compared to previous options.

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• 1974- Neer II Prosthesis. Modified Neer I to
  conform to a glenoid component.

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• 1970s - constrained components were popular, but
  follow-up reports demonstrated high rates of
  loosening, particularly of the glenoid component.

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• 1980s Modular humeral components were
  developed, along with cementless glenoid fixation
  using polyethylene on a metal backing.

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Humeral Components
PROX POROUS COATED
FULLY POROUS COATED
CEMENTED
Good for osteopenic bone Lower risk of
intra-operative fracture More stress-shielding Ha
rd to revise
Need good bone stock
Need good bone stock Higher risk intra-operative
fracture More stress shielding Hard to revise
Higher risk of intra-operative fracture Less
stress-shielding Easier to revise
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Cemented vs Press-fit Humeral Components

• Harris, Jobe and Dai reported less micro-motion
  with proximally-cemented stems.
• Fully cemented stems provide no additional
  benefit or stability over proximally- cemented
  stems.
• Sanchez-Sotelo reported a low rate of stem
  loosening regardless of fixation, but press-fit
  prostheses developed more radiolucent lines in
  the first 4 years.

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The Need for Modularity

• F-H Offset
• B-C Head thickness
• D-E 8mm
• Top of humeral head is higher than greater
  tuberosity

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The Need for Modularity

• Reestablishing normal glenohumeral anatomic
  relationships is important to ensure optimal
  results. Iannotti JP JBJS 74A 1992

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Other Anatomic Variables to Consider

• Glenoid 2 anteversion to
• 7 retroversion
• Humeral Head 20 - 40 retroversion
• Axial CT of the glenohumeral joint is a valuable
  pre-op planning tool.

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Contraindications to Shoulder Arthroplasty

• Active or recent shoulder joint infection
• Paralysis with complete loss of rotator cuff and
  deltoid function
• A neuropathic arthropathy
• Irreparable rotator cuff tear is a
  contraindication to glenoid resurfacing.

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Resurfacing

• Young patients
• Preserve bone
• Glenoid?

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Hemiarthroplasty

• INDICATIONS
• Uninvolved Glenoid
• Osteonecrosis
• Proximal Humerus Fx
• Osteoarthritis
• Rheumatoid Arthritis?
• Unstable forces on Glenoid
• Significant Rotator Cuff Tear

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Hemiarthroplasty

• Neer type of prosthesis has been available for
  over 40 years
• Utilization in old trauma
• - typically provides pain relief but
  incomplete motion
• - surgical procedure often difficult due to
  fibrosis of tissue and bone deformity

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Hemiarthroplasty

• Utilization in old trauma
• Tanner Cofield(1983) 28 shoulders, 89 pain
  relief, avg. 112 degrees of active abduction, 1
  nerve injury, 3 tuberosity/cuff problems, 2
  instability, 1 ectopic bone
• Hawkins et al.(1987) 9 shoulders, 67 pain
  relief, avg. 140 degrees of active abduction, no
  complications

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Hemiarthroplasty

• Utilization in AVN
• - typically provides pain relief and near
  normal return of movement
• - rotator cuff and glenoid surface are
  usually intact
• Rutherford Cofield(1987) 11 shoulders, 100
  pain relief, 161 degrees of active abduction, no
  complications

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Hemiarthroplasty

• Utilization in osteoarthritis
• results similar to those found with AVN because
  the rotator cuff remains intact and a relatively
  painless articulation is created
• Zuckerman Cofield(1986) 36 shoulders, 83
  pain relief, avg. 132 degrees of active
  abduction, no complications

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Osteoarthritis

• In addition to the universal features of
  osteoarthritic joints (joint space narrowing,
  cysts, osteophytes), the shoulder can also
  demonstrate
• Posterior glenoid erosion
• Flattening of the humeral head
• Enlargement of the humeral head
• Rotator cuff tears are uncommon in OA

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Hemi vs Total Shoulder

• Easy procedure
• Short Operating time
• Less risk of instability
• Can be revised to TSA
• Less reliable pain relief
• Progressive Glenoid erosion may cause results to
  deteriorate over time
• Need concentric glenoid

• More consistent pain relief
• Better fulcrum for active motion
• Difficult procedure
• Longer OR time
• Poly wear can cause loosening of both components
• More Glenoid bone loss

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Recommendation based on Experience

• Neer, 1998
• When the articular surface of the glenoid is
  good, the results of hemiarthroplasty are similar
  to those of TSA. Wear on the glenoid has not been
  a problem if the articular surface was good at
  the time of surgery and glenohumeral motion was
  re-established

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Recommendations based on Evidence

• Kirkley et al, 2000
• 42 pts, 3 surgeons (stratified)
• One year follow-up
• No significant difference in WOSI, ASES, DASH
  Constant Score or ROM.
• Trend towards better pain relief with TSA.
• 2 Hemi patients crossed over to TSA after 1 year
  follow-up.

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Recommendations based on Evidence

• Gartsman, 2000
• 51 shoulders
• Average f/u of 35 months
• No difference in ASES or UCLA scores.
• Significantly better pain relief with TSA
• 3 pts crossed over to TSA by 35 months

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A comparison of pain, strength, range of motion,
and functional outcomes after hemiarthroplasty
and total shoulder arthroplasty in patients with
osteoarthritis of the shoulder. A systematic
review and meta-analysis.

• Bryant D, Litchfield R J Bone Joint Surg Am.
  2005 Sep87(9)1947-56.
• Included 4 RCTs
• Average 2 year follow-up.
• TSA resulted in significantly improved UCLA
  scores, pain relief and increased forward
  elevation (by 13).
• This meta-analysis concluded that at 2 years of
  follow-p, TSA provided a better functional
  outcome, however the problems of glenoid
  component loosening in the TSA group and
  progressive glenoid erosion in the hemi group may
  affect the eventual long-term outcome.
• Longer follow-up is necessary

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Recommendations based on Evidence

• The results of arthroplasty in osteoarthritis of
  the shoulder. Haines JF et al. J Bone Joint Surg
  Br. 2006 Apr88(4)496-501
• Prospective study of 124 shoulder arthroplasties
  for OA (Hemi and TSA)
• Similar improvement in pain and function in both
  groups if rotator cuff was intact . Better
  results with Hemi if rotator cuff tear
• Hemi ? Revision at mean of 1.5 years for glenoid
  pain
• TSA ? Revision at mean of 4.5 years for glenoid
  loosening

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Technical Issues to Consider

• OA tends to result in posterior glenoid
  wear/erosion, which, if accepted, will lead to a
  retroverted glenoid component.
• Compensate by anterior reaming or placing the
  humeral component in LESS retroversion.
• Failure to do so will result in Posterior
  Instability

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Hemiarthroplasty

• Utilization in rheumatoid arthritis
• - pain relief often provided
• - return of motion depends on the extent of
  disease involvement of the rotator cuff and
  capsular tissues
• Zuckerman Cofield(1986) 36 shoulders, 89
  pain relief, avg. 106 degrees of active
  abduction, 1 infection, 1 nerve injury, 1
  fracture

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Rheumatoid Arthritis

• Peri-articular erosions
• Peri-articular osteopenia
• Thin cortices
• Adjacent joint involvement

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Rheumatoid Arthritis

• Cemented short-stemmed prosthesis
• Gill, Cofield et al recommend at least 60mm
  between the cement mantles of ipsilateral
  shoulder and elbow arthroplasties.
• If this cannot be achieved, join both cement
  mantles together.

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Rheumatoid Arthritis

• Generally, TSA performed due to destruction of
  the glenoid articular surface by the disease.
• Glenoid erosion may require bone grafting,
  however, if glenoid is eroded to the level of the
  coracoid process, glenoid resurfacing is
  contraindicated

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Hemiarthroplasty

• Complications are infrequent
• - infection
• - nerve injury
• - iatrogenic fracture
• - ectopic bone formation
• - component failure and loosening

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TOTAL SHOULDER ARTHROPLASTY
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Complications TSA

• Glenoid loosening
• Humeral loosening
• Glenoid wear (hemi)
• Instability
• Rotator cuff tears
• Periprosthetic Fx
• Infection
• Nerve Injuries

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Complications

• Instability 1.2
• Excessive Retro/Anteversion
• Head too small
• Head too low (post fracture)
• Subscap rupture

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Complications

• Rotator Cuff Tear 2
• Results in superior migration of humerus and
  glenoid loosening
• Glenoid loosening

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Complications

• Infection 0.5
• Staph Aureus
• More common after revision surgery

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Complications

• Heterotopic Ossification 10 -45
• Males
• Dx osteoarthitis
• Low grade
• Non-progressive
• Does not affect outcome
• Sperling, Cofield et al

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Complications

• Stiffness
• Depends on indication for arthroplasty
• Subscap shortening
• Oversized components
• Inappropriate rehab

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Complications

• Periprosthetic Fracture
• Intra-op 1
• Post-op 0.5 - 2
• Most common in RA
• 85 women
• Glenoid fractures are rare

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Complications

• Axillary nerve injury
• Rare
• Higher risk during revision surgery
• Usually a neuropraxia

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REVERSE TSA
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Reverse Shoulder Replacement

• Great solution to difficult problems
• Expanding list of uses
• Beware high complication rate

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Grammont reverse TSA
Grammont Reverse Shoulder Arthroplasty

• Designed in 1985 by Paul Grammont
• Used in Europe for past 20 years, approved by FDA
  in March, 2004 in U.S.
• Components Humeral component, polyethylene
  insert, glenosphere, metaglene (baseplate)

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Biomechanical Theory
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Grammont reverse TSA
Grammont Reverse Shoulder Arthroplasty -
Biomechanics

• The lever arm distance (L) is increased and
  deltoid force (F) is increased by lowering and
  medializing the center of rotation which is now
  also fixed
• Torque (F x L) in abducting the arm is increased.

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Grammont reverse TSA
Grammont Reverse Shoulder Arthroplasty -
Biomechanics

• Large glenoid ball component offers a greater arc
  of motion

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Reverse TSA recruits more deltoid fibers
Grammont Reverse Shoulder Arthroplasty -
Biomechanics

• Medializing the center of rotation recruits more
  of the deltoid fibers for elevation or abduction

Pos.
Ant.
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Drake GN, OConnor DP, Edwards TB. Indications
for reverse total shoulder arthroplasty in
rotator cuff disease. Clin Orthop Relat Res.
20104681526-1533.
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Indications of rTSA

• Rotator cuff tear arthropathy
• Failed hemiarthroplasty with irreparable rotator
  cuff tears
• Pseudoparalysis (i.e., inability to lift the arm
  above the horizontal) because of massive,
  irreparable rotator cuff tears
• Some reconstructions after tumor resection
• Some fractures of the shoulder (Neer three-part
  or four-part fx)

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Rotator Cuff Arthropathy

• Described by Neer, Craig and Fukada in 1983.
• A distinct form of osteoarthritis associated with
  a massive chronic rotator cuff tear.
• Generally, rotator cuff tears occur in less than
  10 of shoulders with OA

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Rotator Cuff Arthropathy

• A function of the rotator cuff is to depress the
  humeral head and keep it centered on the glenoid
  fossa.
• Massive rotator cuff tears result in proximal
  migration of the humeral head.
• This is a contraindication to glenoid resurfacing
  as it results in eccentric (superior) glenoid
  loading and early component loosening.

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Surgical Options

• Hemiarthroplasty with a large head
• Repair of rotator cuff and TSA
• Reverse TSA

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Outcomes of Hemiarthroplasty

• Rockwood 86 satisfactory results after 4 years
• Zuckerman 93 adequate pain relief and 90 had
  improved function for ADLs.
• Sanches-Sotelo 75 modest improvements in ROM
  and strength for ADLs. Good pain relief.

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Outcomes of Hemiarthroplasty

• Field et al, and Sanchez-Sotelo reported that
  impaired deltoid function and previous
  subacromial decompression (loss of
  coracoacromial ligament) were significantly
  associated with clinical shoulder instability
  post hemiarthroplasty.

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Outcomes of the Reverse Total Shoulder

• The Reverse Shoulder Prosthesis for glenohumeral
  arthritis associated with severe rotator cuff
  deficiency. A minimum two-year follow-up study of
  sixty patients.Frankle M, Siegel S, J Bone Joint
  Surg Am. 2005 Aug87(8)1697-705
• Average age 70
• Improved ASES scores
• Improved ROM Flex 55 ?
  105
• 
  Abd 41 ? 102
• 17 Complication rate
• 7 failures ? 5 revised to new Reverse
  TSA
• ? 2 revised to
  Hemiarthroplasties

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Outcomes of the Reverse TSA (Delta III prosthesis)

• Treatment of painful pseudoparesis due to
  irreparable rotator cuff dysfunction with the
  Delta III reverse-ball-and-socket total shoulder
  prosthesis.Werner CM, Glbart M, J Bone Joint
  Surg Am. 2005 Jul87(7)1476-86.
• 58 consecutive patients, average age 68
• 41 cases were revisions
• Follow up 38 months
• Improved Constant Score, Pain reduction and
  improved ROM.
• ROM Flex 42 ? 100
• Abd 43 ? 90
• 50 complication rate (including minor)
• If a 1 surgery 18 re-operation rate
• If a Revision surgery 39 re-operation rate

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--

• Cuff Tear Arthropathy Clinical Presentation
• Physical Exam
• Swelling about the glenohumeral joint
• Atrophy of the supraspinatus and infraspinatus
  muscles
• Pseudoparalysis

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--

• Imaging
• Superior migration of humeral head
• Severe destructive GJH osteoarthritis
• Anterior or posterior humeral head subluxation

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--

• Imaging
• Massive tears of the supraspinatus and
  infraspinatus tendons with muscle atrophy
• Glenohumeral joint destruction
• Fatty infilitration cuff of muscle

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--

• Treatment

• Medical management of the pain / physical therapy
  
• Arthroscopic lavage / arthroscopic débridement
• Hemiarthroplasty
• Arthrodesis
• Total shoulder arthroplasty

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Conventional Total Shoulder Arthroplasty

• Because of superior humeral head migration,
  eccentric loading on the glenoid component
  resulted in rocking-horse glenoid loosening

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Unconstrained TSA abandoned b/c of glenoid
loosening

• Limited pain relief
• Modest improvement in active elevation or
  abduction

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60 y/o Female With Rheumatoid Arthritis and Pain
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Metastatic renal cell
Metastatic Renal Cell Cancer to Right Humerus
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Contraindications of rTSA

• Marked deltoid deficiency
• History of previous infection
• Use sparingly in patients less than 65 years old
• Advanced glenoid destruction

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Complication rates
Complication Rates for Reverse TSA Higher
intraoperative and postoperative complication
rates for reverse TSA (mean 24) vs. conventional
TSA (mean 15)
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Surgical Outcomes

• -Post-op complications
• -Hardware instability or dislocation (abd with
  ER)
• -Nerve damage
• -Infection
• -Hematoma
• -Intra-operative fracture
• -Complication rates are 2-681

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Dislocation
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Scapular Notching

• Nerot Classification of Scapular notching
• Grade 1 Confined to the scapular pillar
• Grade 2 Notch outline contacts lower
• Grade 3 Notch over the lower screw
• Grade 4 Notch extends to baseplate.

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Acromial Stress Fracture

• Increased load on the acromion may also explain
  rare complication of scapular spine fracture

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Reverse Total Shoulder Arthroplasty is Hard to
Revise

• Little Glenoid bone stock once component is
  removed.

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Review

• -What are some indications for a rTSA?
• -GH joint arthritis with irreparable RC
• -Revision of failed TSA or hemiarthroplasty
• -Over the age of 70 years
• -Who is not appropriate for a rTSA procedure?
• -Glenoid destruction
• -Deltoid that is not intact
• -Patient wanting high functional return
• -What is the most common surgical complication?
• -hardware instability or dislocation

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Post Operative Rehab

• TSA
• Check range in OR
• Start AAROM POD 1
• Active ROM as tolerated
• Protect Subscap 4-6 weeks
• Strengthening at 4-6 weeks

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Activities after TSA
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Activities after TSA
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Decision Algorithm in Rotator Cuff Tears with OA
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Decision Algorithm in Rotator Cuff Tears with OA
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The future?

• New or coming trends in treatment of proximal
  humeral fracturs
• Locking plates? Increasing
• Arthroplasty? Increasing
• Early arthroplasty surgery? Better than late!
• Reversed shoulder arthroplasty?Even better?

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Thank You