Saturday, October 15, 2016

Early versus delayed range of motion after total shoulder arthroplasty

Immediate versus delayed passive range of motion following total shoulder arthroplasty

These authors compared immediate with delayed range of motion (ROM) following total shoulder arthroplasty (TSA) performed in association with a lesser tuberosity osteotomy. Sixty patients were randomized to immediate motion (IM) or delayed motion (DM) after surgery.

In the IM group a sling was worn for 4 weeks following surgery. On the first postoperative day, patients began passive forward flexion and passive external rotation to 30°with a stick.  At 4 weeks the sling was discontinued, passive external rotation was allowed as tolerated, and forward flexion was progressed from active to assist to active motion as tolerated.

In the DM group a sling was worn for 4 weeks following surgery. The patients performed only active hand, wrist, elbow, and shoulder retraction exercises. At 4 weeks postoperatively, the sling was discontinued and passive forward elevation and passive external rotation were initiated as tolerated.

For both groups, strengthening was initiated routinely at 8 weeks postoperatively. Activities were allowed as tolerated at 12 weeks postoperatively with a lifetime recommendation for no repetitive lifting over 25 lb (11.3 kg).

They found no significant differences in final ROM or functional outcome scores between the 2 groups. The IM group had higher functional outcome scores initially, but by 3 months postoperatively, there was no difference.

The rate of lesser tuberosity osteotomy healing was 81% in the IM group compared with 96% in the DM group (P = .101).

Comment: Hat's off to these authors for a nicely done randomized study and for the quality of their results.

We continue to aim for at least 150 degrees of assisted flexion before discharge after shoulder arthroplasty, starting the afternoon of the procedure. This is especially important for the ream and run procedure selected by motivated patients who desire no surgeon-imposed limitations on their activities. The desired motion is shown in this video (see link) and in the photographs below.

Complications are always of interest. There were no infections in this group.
Six of the 55 lesser tuberosity osteotomies (LTO) did not heal, one of which failed an attempt at surgical revision for displacement noted two months after surgery. The patients with unhealed LTOs had significantly lower ASES scores at followup.
One patient had a brachial plexus injury from an interscalene block (ISB), the symptoms of which resolved by 2 months postoperatively.

We do not use LTOs because we want to preserve the circumference of the metaphysis for secure impaction grafting and avoid the risks of non-healing. We do not use ISBs because we find adequate postoperative comfort can be achieved by PCA, transitioning to oral medications on the evening of surgery and because we are aware of the risk of neurologic injury from this procedure.