shoulder surgery and rehab handout 2012
TRANSCRIPT
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Lennard Funk Shoulder Surgeon, Wrigh3ngton Hospital
Professor, Salford University
Accelerated
ehab a3onale R
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So why need Physio?
ACJ Arthri3s:
Surgery & Physio
• Shoulder comprises: 5 ar3cula3ons and numerous muscles, tendons and ligaments.
• Injury to any one of these effects the others.
This is where Physiotherapy comes in.
Shoulder Surgery Outcomes
Patient
Therapist
Surgeon
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Need... • Surgeons should understand Rehab
• Physios should understand Surgery
Aims of Shoulder Surgery
1. Pain Relief – Decompression – Removing worn joint (ACJ) – Replacing worn joint
(Shoulder replacement)
2. Restore Func3on
– Stabilising loose joint
– Glenohumeral Instability
– ACJ Disloca3ons
– Releasing 3ght joint
– MUA
– Capsular Release
Common Shoulder Procedures
1. ASD +/-‐ ACJ Excision Impingement +/-‐ ACJ OA
2. Rotator Cuff Repair Rotator Cuff Tear
3. Shoulder Replacement Shoulder Arthri3s
4. Bankart repair Recurrent Disloca3ons
5. MUA Frozen Shoulder
6. Proximal humerus fracture fixa3on Proximal humeral fractures
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Subacromial Decompression
ACJ Excision
Open Subacromial Decomp. / ACJ Excision
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Open Subacromial Decomp. / ACJ Excision
REHAB:
• Protect reabached Deltoid & Deltotrapezial fascia:
– Immobilise for at least 3 weeks.
– Avoid Deltoid resistance exercises for at least 6 weeks.
• Surgical wound with sutures removed at two weeks
• Haematoma care & bruising
ASD / ACJ Excision
Scope Shaver
ASD / ACJ Excision REHAB: • No detached muscles to protect • Commence ac3ve movement and discard sling as soon as possible – day 1 or 2 post-‐op. • No sutures / wound complica3ons
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Sod Tissue Repairs
• Rotator Cuff • Labral / Stabilisa3on / SLAP • Pec Major • Tendon Transfers
Goals
• Protect the integrity of the rotator cuff repair • Minimize postopera3ve pain and inflammafon • Restore passive range of mo3on • Restore strength and dynamic stability of the shoulder • Restore ac3ve range of mo3on • Return to func3onal/spor3ng ac3vi3es
Tendon Healing
• Tendon – bone healing:
– 50% at 3 weeks
– 90% at 6 weeks
" Affected by:
" Tissue & muscle quality
" Quality of repair
" Smoking
" NSAIDs
" Loading condi3ons
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Factors affec3ng rehab
• Tissue integrity • Size of repair • Loca3on of tear • Tension of repair • Tendon to bone healing • Pain
effects of immobilisa3on
Tendon loading
• Immobilisa0on:
• Decr. Tendon weight
• Decr. S3ffness & tensile strength
• Irregular collagen fibres
• Type 3 > Type 1 collagen
• Degenera3ve changes
Mehta. Clin J Sports Med. 2003
Exercise: Incr. Growth Factors Incr. tensile strength Incr. cross-‐sec3onal area Realign collagen Type 1 > Type 3 collagen
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Repair Strength
• Anchors • Sutures • Synthe3c Ligament Grads
High-‐Strength Sutures
Suture-‐Anchors
• Materials – Biodegradable – PEEK
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Rotator Cuff Repair
Rotator Cuff Tears • Open Surgery • Arthroscopic • Open
Single vs Double Row
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Releases
Important to perform complete releases of: • all adhesions • Coracoacromial Lig • Coracohumeral Lig • Posterior bursa • Anterior bursa
Rotator Cuff Repair Rehab
REHAB: • Protect Repair un3l healed • Early Mobilisa3on
• Depends on size of tear and cuff quality.
Be Aware: • Elderly • Smoker • Faby Infiltra3on of Muscle • Quality of Tendon at Surgery • Size of Tear
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Muscle Atrophy & Faby Infiltra3on
Stabilisa3on Surgery
Lesions
• Bankart – Sod Tissue – Bony – ALPSA
• Capsular Stretch • HAGL
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Bankart
Bony Bankart
ALPSA -‐ Displaced Bankart
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Beware the HAGL!
Key points: • Full mobilisa3on
• Prepara3on
– Labrum
– Glenoid
• Shid
• Solid Fix
HAGL
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Hill-‐Sachs -‐ Remplissage
Latarjet Procedure • Glenoid Bone Loss
Safe Zone
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Phase & Sport Specific Rehab " Phase 1: (Level 1 Exercises)
" Core stability & Scapula control
" Proprioceptive exercises (minimal weightbearing below 90 degrees)
" Active assisted ROM as comfortable (in 'safe zone' )
" Do not force or stretch
" No combined abduction & external rotation
" Phase 2: (Level 2 Exercises)
" Progress active assisted to active ROM as comfortable
" Phase 3: (Level 3+ Exercises)
" Regain scapula & glenohumeral stability working for shoulder joint control rather than range
" Gradually Strengthen
" Plyometrics and pertubation training
Rehab • Based on maintaining safe range of movement in the
first phase and then gradually building strength in the middle to the last phase.
• Pre-‐op:
– ROM Exercises
– Maximise shoulder strength of deltoid, intact cuff muscles and scapula stabilisers.
< 3 weeks -‐ Level 1
• Passive / Ac3ve Assisted ROM in all direc3ons as tolerated
• Shoulder girdle exercises & Scapula sefng exercises
• Closed chain exercise
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Level 1 < 20% EMG
3-‐6wks -‐ Level 2-‐3
• Wean off Sling
• Do not force or stretch
• Isometric exercises in neutral as pain allows – up to 50% maximum voluntary contrac3on
• Open Chain Exercises as tolerated
Level 2 20-‐40% EMG
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6+ weeks = Level 3+
• Progress to full ac3ve and resistance exercises in all ranges
6+ weeks
Shoulder classes
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Athletes Phase 1
Phase 2
Phase 2
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Phase 2
Phase 3
Phase 3
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Phase 4
Phase 5
ACJ Reconstruc3on
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Coracoclavicular Ligaments
• Strength – 500N (+/-‐ 134) • S3ffness – 103N/mm (+/-‐ 30) • Uniaxial Tension 25mm/min
Harris et. al. Am J Sports Med. 2000
Harris et al. AJSM 2000
“None of the reconstruc3on techniques analyzed in the present study were able to restore the normal mechanical func3on of the intact coracoclavicular ligament complex”
Func3onal Anatomy
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CC Lig Posi3ons
CA Ligament Transfer (Weaver-‐Dunn)
• 20% loss of reduc3on
• 20% of CC Lig strength
• Immobilisa3on
1. Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU. Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med 1995;23:324-31 2. Deshmukh AV, Wilson DR, Zilberfarb JL, Perlmutter GS. Stability of acromioclavicular joint reconstruction: biomechanical testing of various surgical techniques in a cadaveric model. Am J Sports Med 2004;32:1492-8. 3. Grutter PW, Petersen SA. Anatomical acromioclavicular ligament reconstruction: a biomechanical comparison of reconstructive techniques of the acromioclavicular joint. Am J Sports Med 2005;33:1723-8.
CC Lig Reconstruc3on
Hamstrings Donor site morbidity
Allograd Access; cost; Prion risk
Synthe3cs Non-‐biological 3ssue
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LARS Ligament (Corin)
• Braided Polyester • 1500N tensile strength (30 LAC) • No reduc3on in mechanical resilience ader over 10 million wear cycles loaded in torsion, trac3on and flexion
• Vascularisa3on & Fibrous ingrowth -‐ Collagen Type 1
Incision
Shoulderdoc.co.uk
Nofngham Approach
Shoulderdoc.co.uk
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Standard repair
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Modifica3on 1
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Modifica3on 2
Shoulderdoc.co.uk
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Closure
• Repair the Superior AC Ligaments • Repair the Delto-‐Trapezial Fascia
3 weeks post-‐op
Shoulder Replacement
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Shoulder Replacement -‐ Points
• Subscapularis divided
Shoulder Replacement Post-‐Op
• Sling for TWO DAYS
• SIX WEEKS Avoid: – Passive External Rota3on – Ac3ve Internal Rota3on
Shoulder Replacement – Capsule
• Capsule is released at surgery circumferen3ally to improve ROM post-‐op
• -‐> Early ROM to prevent S3ffness.
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Summary
• Understand the Procedure • Muscles cut/detached -‐ protect • Safe ROM for repair • Avoid Stretching and Forcing • Communicate with Surgeon
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