Felix Savoie, MD
A recent article from Denard and Ladermann looked at the difference in ROM, VAS pain scores and ASES scores between differing post-op protocols of immediate motion and delayed motion.
The immediate motion group wore a sling for four weeks following surgeries; passive forward flexion and passive external rotation of the shoulder joint was started on day one post-op. Active hand, wrist and elbow exercise and active scapular retraction were allowed immediately as well. At four weeks, the sling was discontinued and passive external rotation was allowed as tolerated. Strengthening was initiated routinely at eight weeks post-op.
In the delayed motion group, a sling was worn for four weeks following surgery. During these four weeks, patients only performed active hand, wrist and elbow exercises, as well as scapular retraction exercises. At four weeks, the sling was discontinued and passive forward elevation and external rotation was allowed as tolerated. At eight weeks pot-op, active assisted progression to active ROM was allowed and strengthening was routinely started. Activities were allowed as tolerated at 16 weeks post-op with a lifetime recommendation of no overhead lifting of 25lbs or more.
The findings of the article showed that at one year post-op there was no difference between the two groups in ROM, ASES and VAS pain. An interesting finding in this paper was that the immediate motion group had a higher failure rate of the tuberosity osteotomy used to repair the subscapularis. The authors point out that immediate motion group saw initial improvements in ROM, but after three months both groups had relatively the same ROM. The benefit of early motion may not outweigh the risk of the subscap failure, which in my opinion, is a major risk of total shoulder arthroplasty.
I also employ a subscapularis sparing technique on high-demand younger patients where early motion is achievable and risk to the subscapularis is minimal.
My current post-op protocol is to protect the subscapularis for approximately six weeks if I have to detach it. I usually use a thin LT osteotomy, but I also employ a subscapularis sparing technique on high-demand younger patients where early motion is achievable and risk to the subscapularis is minimal. The technique uses a modified technique through the delto-pectoral approach approximately 50 percent of the inferior subscapularis is taken down while keeping the top 50 percent attached.
The humeral head is then flipped under the subscapularis to address the cut and placement of the stem. Tests have been done looking at the strength of the subscap when only 50 percent is removed and when the subscapularis is taken down and repaired with sutures. The strength to failure was greater in the test that used 50 percent attached subscapularis. This technique can be technically difficult and I have reserved using this for my higher demand and younger patients. The results in my hands using this technique have been impressive.
In conclusion, I think the authors are correct that if ROM is no different as early as three months post op, then I also would be unlikely to want to risk the subscapularis repair. I do think that we all have patients who will not want to sit for four weeks before motion can begin, and in my experience, using a technique that preserves the subscapularis and allows for early ROM will lead to a benefit for the patient and will mitigate the downside risks to the repair.
Felix Savoie, MD, is a practicing extremity surgeon and the chief of sports medicine at Tulane University’s School of Medicine. Dr. Savoie completed fellowships in the areas of arthroscopy, AO and hand and microvascular. He is an accomplished teacher, author and presenter.