Postoperative Care and Rehabilitation



Postoperative Care and Rehabilitation


Laura Vasquez-Welsh, MS, OT/L, CHT

James Koo, PT, DPT



INTRODUCTION

Although initially designed as a salvage procedure to manage arthritis in the rotator cuff (RC)-deficient shoulder, the indications for use of reverse total shoulder arthroplasty (RTSA) have expanded over the years. As discussed in previous chapters, there are multiple clinical indications for RTSA including management of massive irreparable RC tears in the absence of osteoarthritis, primary osteoarthritis with excessive posterior glenoid erosion, and complex fractures of the humerus.1 Due to the growing acceptance of this procedure to treat a variety of conditions, there has been a concomitant increase in the number of RTSAs performed in the United States.2 With greater utilization of this technique, it is undeniable that an understanding of proper postoperative care and rehabilitation has become increasingly imperative for rehabilitation professionals.


REHABILITATION: RTSA VERSUS ATSA

The primary goal of RTSA is to decrease pain and increase functional elevation of the shoulder as the deltoid becomes the primary mover of the arm. While similarities do exist between RTSA and anatomic total shoulder arthroplasty (ATSA) rehabilitation, the postoperative course is different. One of the inherent reasons for this difference lies within the newly established mechanics of the glenohumeral joint. The RTSA design reverses the orientation of the glenohumeral joint by replacing the glenoid fossa with a glenoid base plate and glenosphere and the humeral head with a stem and concave cup.3 This design moves the center of rotation of the shoulder joint medially and inferiorly. As a result, the deltoid moment arm and deltoid tension both increase to enhance the torque and line of pull produced by the deltoid.4,5 Since the deltoid now acts as the prime elevator of the shoulder, it is able to substitute for a deficient RC. Due to this newly established anatomy, there are certain differences in postoperative precautions as well as therapist focus when selecting specific therapeutic interventions.

Another procedural difference that alters the therapeutic approach is that unlike ATSA, RTSA is much less reliant on an intact subscapularis tendon. Naturally, the rehabilitation protocol reflects this. A 2017 study that compared RTSA outcomes with and without subscapularis repair found that all patients showed significant improvements in pain and function after treatment with RTSA regardless of whether a subscapularis repair was performed.6 When rehabilitating a shoulder following RTSA, quite often protection of the subscapularis is unnecessary, unless indicated by the surgeon. This is contrary to the protocol followed for a patient who has undergone ATSA. As discussed in Chapter 15, if the surgeon does not utilize a subscapularis-sparing technique for ATSA, protection of the subscapularis becomes a priority during the early postoperative period. As a result, external rotation (ER) is progressed more slowly and cautiously as detailed in Chapter 15. Following RTSA, protocols can be much more liberal with the progression of ER, which can often be progressed as tolerated.

The concept that the RC is either absent or minimally functional after RTSA also alters the therapeutic approach.3 Although some believe that this reduced need to protect healing structures justifies a faster, more aggressive rehabilitation protocol, the complication rates following this operation including risk for dislocation and stress fracture are higher.7 Therefore, rehabilitation professionals must rely on their clinical judgment and close communication with the surgeon in order to advance this patient population appropriately.


ENGAGING THE PATIENT AS A PARTNER/PSYCHOSOCIAL IMPLICATIONS

When possible, prehabilitation sessions with an occupational or physical therapist can be valuable to begin to establish expectations as well as to engage the patient as a partner in the rehabilitation process. When meeting the patient for the first time, the clinician is able to establish a preoperative baseline for range of motion (ROM) and function, review expectations, and promote an environment in which the patient is able to practice exercises prior to surgery. During this session, the therapist should place emphasis on a few key components. These include protecting the newly established joint from dislocation,
emphasizing the role of the deltoid, and establishing realistic ROM and functional expectations.4 There is a link between setting patient expectations early in the process and successful outcomes following shoulder arthroplasty.8 If the therapist and surgeon clearly define realistic expectations for recovery prior to the operation, patient-reported outcomes may be more favorable.1

The role that the patient plays in the rehabilitation process is not to be underemphasized. Patients who are active participants in their recovery tend to achieve optimal results and are more satisfied with their outcome overall.1 It can also be beneficial to highlight that, ultimately, the patient and multidisciplinary team’s goals are the same—to relieve pain and return the patient to an independent lifestyle safely.


POSTOPERATIVE PRECAUTIONS AND FUNCTIONAL IMPLICATIONS

The primary precaution following RTSA is to avoid combined shoulder extension and adduction (ADD), ER, and also to avoid placing the hand behind the back for approximately 4 to 6 weeks postoperatively as these are positions of potential instability. In rehabilitation, it is a common misconception that the risk for dislocation after RTSA is greatest with internal rotation (IR) of the shoulder. However, these replacements are most unstable and likely to dislocate anteriorly with shoulder hyperextension or with end-range ER in either an adducted or abducted position (J. D. Zuckerman, personal communication, May 28, 2020). Nevertheless, clearance from and close communication with the surgeon is always required prior to initiating these motions and positions, especially if initiated prior to 6 weeks postoperatively. Though temporary, the functional impairments that often stem from this precaution may include difficulty with clothing management, especially upper body dressing behind the back (ie, garment fastening, tucking in shirts, donning a belt, and reaching for items in a back pocket), eating, bathing, grooming, and toileting. In order to provide comprehensive care, the therapist should be prepared to discuss strategies for activities of daily living (ADLs) following such an operation. Accounting for and discussing the functional impact that this operation has on the patient’s quality of life in the early phases of rehabilitation can help to enhance the therapeutic alliance, guiding the patient through this phase of the process on both a personal and psychological level.


Strategies for Self-Care

In the immediate postoperative phase, it is helpful to educate the patient so that they are equipped with strategies for self-care. As mentioned, the therapist should be prepared to discuss considerations for dressing (FIGURES 26.1, 26.2, 26.3, 26.4 and 26.5; VIDEO 26.1), sling management (FIGURES 26.6, 26.7, 26.8, 26.9 and 26.10; VIDEO 26.1), eating, bathing, grooming, toileting, sleep positioning (FIGURES 26.11 and 26.12), and home management in order to improve the patient’s quality of life in the first few weeks following surgery (TABLE 26.1). Toileting is one of the most commonly reported impairments in the immediate weeks following surgery. This fundamental ADL significantly affects a patient’s sense of independence and quality of life. The therapist should reassure the patient that after primary RTSA, over 90% of patients are able to manage toileting following the procedure and that toileting inability after the procedure is rare at 1.3%.9







INITIATION OF REHABILITATION FOLLOWING SURGERY

Timeline for patient examination by the therapist following surgery can vary. Some hospitals have moved to a same-day discharge model in which the therapist’s main contact with the patient is prior to surgery in the form of a prehabilitation session and then potentially not again until

they are ready to begin formal outpatient therapy. Outside of a same-day discharge program, patient examination by the therapist will typically begin on postoperative day zero (POD #0). At this phase, rehabilitation goals include protection of healing structures, pain control, functional mobility, independence with basic ADLs, patient education, and independence with a home exercise program (HEP). Under the discretion of the surgeon, passive range of motion (PROM) of the operative upper extremity (UE) typically begins on POD #0 or #1 with a progression to self-assisted or caregiver-assisted ROM exercises (FIGURES 26.13, 26.14, 26.15 and 26.16). Following discharge from the hospital, a period of immobilization may continue for 2 to 6 weeks. The patients continue with their home exercises during this period until they are ready to begin a formal outpatient therapy program (TABLE 26.2; VIDEO 26.2).



















































When arriving to outpatient therapy, clinical examination will begin with a thorough chart review as described in Chapter 15. The patient relays subjective history including events leading up to surgery, prior and current level of function, and pain levels. A standard postoperative examination is then performed, which includes palpation, visual inspection, bilateral ROM assessment, strength testing of noninvolved joints as appropriate, postural alignment, neurological assessment, and assessment of pain and function.


PHASES OF REHABILITATION

For RTSA rehabilitation, the literature does not support one standardized protocol. Most protocols described in the literature include three to four phases of rehabilitation. There are significant differences in protocols specifically for initiation of exercises, the degree of shoulder motion permitted, the timing of resisted exercises, and the long- and short-term precautions.1 Collaboration
between the surgeon and occupational or physical therapist is therefore essential to ensure optimal patient outcomes and appropriate rehabilitation following RTSA. In order to individualize the program to best suit the patient’s needs, the therapist should be aware of the patient’s preoperative status, bone quality, the integrity of the remaining or repaired RC, and the overall stability achieved intraoperatively.4 When progressing treatment, it is important that the therapist meet the patient at the current level of need rather than relying solely on protocol alone. For example, if a patient begins therapy at 6 weeks following surgery and has 70° of passive forward elevation, the therapist must have the wherewithal to hold progression to the next phase of rehabilitation until PROM goals are achieved and communicate findings to the physician. It is imperative that the clinician
calls upon their knowledge of the underlying biomechanics, physiological healing process, and the patient’s preexisting pathology and tolerance for exercise and activity in order to progress the patient appropriately.7