Should an anatomic or reverse total shoulder be used to treat stiff shoulders?

Many arthritic shoulders are not only painful but stiff.

Documenting the preoperative loss of passive range of motion (stiffness) in different directions indicates the type and severity of the limitation of motion (see these drawings by Steve Lippitt).


Flexion



Abduction





External rotation with the arm at the side




External rotation with the arm abducted




Internal rotation with the arm abducted



Reach up the back (the posterior segment that can be reached by the thumb)

and cross body adduction (the distance between the antecubital fossa and the contralateral acromion note the two-headed arrows).




Stiffness of the arthritic shoulder can be caused by muscle and capsular contracture,



osteophytes blocking motion


irregular joint surfaces,



bony deformities



prior surgical procedures


and scarring in the humeroscapular motion interface



It is often worthwhile to offer the patient with a stiff arthritic shoulder a trial of gentle stretching exercises for two reasons: (1) it may substantially improve their comfort and function and (2) it familiarizes them with the exercises that will be part of their postoperative recovery if they proceed with surgery. See Essential Shoulder Exercises.

Our approach to anatomic shoulder arthroplasty is shown here.

Surgical management of stiffness begins with the approach, including a 360 degree release of the subscapularis, which is often tethered





and release of the contracted capsule while protecting the axillary nerve (yellow)




With the trial components in place, the 40, 50, 60 rules can be useful targets for achieving a flexible and stable arthroplasty:

40 degrees of external rotation with the subscapularis approximated to the lesser tuberosity



50% translation on posteriorly directed loading of the proximal humerus



60 degrees of internal rotation with the arm in 90 degrees of abduction




The tightness/laxity of the shoulder can be adjusted by selecting the thickness of the humeral component that provides the desired mobility and stability.



Important causes of stiffness after an anatomic shoulder arthroplasty include

Overstuffing - too much component volume for the space available in the joint (similar to the scene in Alice in Wonderland when Alice eats a cake that makes her grow excessively).





Overstuffing can result from an inadequate humeral neck cut



from an excessively large humeral component


from a too thick glenoid component




from failure to seat the humeral component fully


from inserting the component in varus



from failure resect osteophytes at Pooh Corner



posteriorly, resulting in open booking when the arm is externally rotated



or globally



The authors of Clinical Outcomes of Anatomic Versus Reverse Total Shoulder Arthroplasty in Primary Osteoarthritis with Preoperative Rotational Stiffness and an Intact Rotator Cuff: A Case Control Study compared clinical outcomes of anatomic (aTSA) and reverse (rTSA) total shoulders performed in stiff versus non-stiff shoulders with rotator cuff intact (RCI) glenohumeral osteoarthritis (GHOA). The indications for choosing an aTSA or a rTSA are not specified. The techniques for addressing shoulder stiffness were not reported.

They defined preoperative stiffness as external rotation ≤0 degrees. They conducted a retrospective review of 1608 aTSAs and 600 rTSAs performed for RCI GHOA.

They found that patients with limited preoperative ER and RCI GHOA had lower postoperative ROM compared with non-stiff shoulders when treated with either aTSA or rTSA. Stiff shoulders treated with aTSA had better postoperative IR and ER compared to a matched cohort of stiff shoulders treated with rTSA. All groups, regardless of preoperative stiffness, had similar postoperative clinical outcome scores. They concluded that preoperative limitation in passive ER does not appear to be a limitation to utilizing aTSA in patients with RCI GHOA.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Successful stretching

Shoulders tend to get stiff - after an injury, after surgery or for no apparent reason. Gentle, frequent stretching is very often successful in reducing stiffness. The key to a successful stretching program is relaxing while holding the stretch for a full two minutes (by the clock) and repeating the stretches every few hours during the day. The stretching programs we favor are those that require no equipment and that can be done anywhere.

These are shown here:

    A. Forward Elevation: Supine
    B. Forward Elevation: Forward Lean

    C. Forward Elevation: Over Door Pulley
    D. External Rotation

    E. Cross Body Adduction

    F. Internal Rotation Up Back 

    G. Internal Rotation Lying On Your Side 

Of these the ones we've found most successful in improving elevation of the arm are the forward lean (B in the list above) and the sleeper stretch (G in the list above).

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Stiff shoulder, painful shoulder, frozen shoulder, shoulder arthritis

Shoulder stiffness means that the shoulder is not able to move through its normal range of motion.  There are many causes of shoulder stiffness, including shoulder arthritis and frozen shoulder.  These two diagnoses can be distinguished by obtaining standardized shoulder x-rays which should be normal in a frozen shoulder but show a narrowed joint space in arthritis.

In deciding if a shoulder is stiff, it is helpful to compare its ability to perform several motions in comparison to the opposite normal shoulder. 

Here are the most important motions to compare:

      I. Internal and external rotation with the arm at the side (measured in terms of degrees from vertical)

    II. Forward elevation (measured in terms of degrees from the horizontal)

   III. Internal rotation up the back (measured in terms of the part of the back that can be reached with the thumb).

IV. Cross-body reach (measured as the distance from the elbow to the opposite shoulder).

V. Internal rotation with the arm out to the side (measured as degrees from the vertical).

The last three of these are often the motions limited early on in the process, so checking them may be revealing.

If your shoulder is stiff, check with your doctor to see how it may be best managed. 

We have found that whether the stiffness is due to arthritis or to a frozen shoulder, gentle stretching exercises are often helpful. 

Here are some other posts on stretching

Forward lean

How to stretch and how not to stretch

Shoulder exercises

Exercise videos

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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

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Revision surgery for stiff shoulder replacement arthroplasty - our approach, Part 3

Before embarking on a surgical revision to regain motion, it is important to determine the cause of the residual stiffness.  Previous operative notes are reviewed to discover if the joint was intentionally tightened and if so how this was carried out.  Particular note is made of whether the subscapularis was advanced lateral to the bicipital groove and whether thermal or laser capsular cauterization was carried out.  Excellent anteroposterior and axillary radiographs are needed to exclude bony or articular causes of shoulder stiffness.  The location of hardware and other implants is determined.

Prior to prepping and draping the shoulder, the ranges of flexion, cross body adduction, internal and external rotation in 90 degrees of abduction, and external rotation at the side as well as the excursion on posterior drawer testing are recorded for both shoulders.

The surgical procedure is performed sequentially, with the range of motion being reexamined after each step of the release.  When the desired range is achieved, the procedure may be concluded. The initial step is to completely free the humeroscapular motion interface.

Any prominent suture, suture anchors, hardware, bone or soft tissue is resected from the proximal humerus to assure smooth passage within the coracoacromial arch.  A nerve-to-nerve release is performed.

The second step is to incise the coracohumeral ligament from around the coracoid process.

Next the subscapularis is identified. and incised from its humeral attachment, preserving maximal length.  A 360-degree release of the subscapularis and anterior capsule is carried out, assuring that the subscapularis moves freely with respect to the coracoid, the glenoid lip, the inferior capsule and the axillary nerve.

In this release the anterior capsule is incised just lateral to the labrum, leaving the labrum on the bony glenoid to maintain the glenoid concavity.  After the release, the subscapularis should have a nice ‘bounce’ when traction is applied to it.  Recall that if the subscapularis is to allow a range of rotation of 115 degrees (two radians) it must have an excursion of twice the radius of the humeral head.  Thus, if a humeral head has a radius of 25 mm, a subscapularis excursion of 50 mm will allow a 115-degree range of internal and external rotation.

After this complete release, additional subscapularis lengthening is rarely needed.  However, if additional lengthening of the subscapularis tendon is needed, an inside-out coronal plane Z-plasty is considered if there is adequate thickness of the capsule and tendon. Sometimes a hamstring autograft is used to robustly connect the subscapularis to the lesser tuberosity with additional tendon length.  It must be noted, however, that adding tendon length does not increase the functional excursion of the muscle.

If the long head tendon of the biceps does not slide freely in the bicipital groove, the adhesions in the groove are released.  If freedom cannot be achieved, the tendon is incised at its insertion to the supraglenoid tubercle and tenodesed to the proximal humerus in its groove.

The next step is, while protecting the axillary nerve with the non-dominant index finger, to release the inferior capsule from the inferior glenoid labrum.

Inserting a humeral head retractor into the joint and rotating its inferior aspect away from the glenoid puts the inferior capsule under tension, facilitating this release.  The anterior and posterior bands of the inferior glenohumeral ligament are released.  Exposure of the origin of the long head of the triceps signals a complete release.

The articular aspect of the joint is inspected and any bony prominences that potentially block motion are resected.  Note is made of the condition of the glenoid and humeral joint surfaces.

Finally, the posterior capsule is released from the posterior glenoid labrum. The capsule is placed under tension by rotating the humeral head retractor away from the glenoid, first inferiorly and then superiorly.

At the conclusion of the procedure, the shoulder is put through a full range of motion.  The subscapularis tendon is closed robustly to the lesser tuberosity so that immediate, postoperative motion maintaining exercises can be implemented.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.