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Management of Glenohumeral Arthritis

Edited by Frederick A. Matsen, III, M.D.
Last updated August 27, 2001

Arthroplasty
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Historical review

In 1893, one of the first prosthetic shoulder replacements was performed by the
French surgeon Pean. (Lugli, 1978) Pean was the subject of a painting called "Une
Operation de Tracheotomie" by Henri de Toulouse-Lautrec. (Bankes and Emery,
1995) A platinum and rubber total joint and proximal humeral implant was fashioned
for him by J. Porter Micheals, a dentist from Paris, and inserted by Pean in a 37 year
old Baker after his tuberculous arthritis had been debrided. The patient gained
increased strength and range of the arm. However the infection recurred. After one of
the first Xray machines documented an overwhelming reactive process, the
prosthesis was removed two years after implantation.

In 1953, Neer presented the option of replacement of a fractured humeral head with a
Vitallium prosthesis. (Neer, Brown and McLaughlin, 1953) Use of this prosthesis was
next applied to patients with irregular articular surfaces as a result of fracturing and
osteonecrosis. (Neer, 1955) In 1971 and 1974, Neer described the results of the use
of this proximal humeral implant for patients with rheumatoid arthritis and
osteoarthritis of the glenohumeral joint. (Neer, 1971; Neer, 1974) In these articles,
Neer also described the use of a high density polyethylene glenoid in the
management of osteoarthritis of the glenohumeral joint. Also in 1974, Kenmore and
associates published a brief article reporting on the development of a polyethylene
glenoid liner for use with a Neer humeral replacement in the treatment of
degenerative joint disease of the shoulder. (Kenmore, MacCartee and Vitek, 1974;
Neer, Watson and Stanton, 1982) Other early descriptions of shoulder arthroplasty
components include prostheses of Vitallium as reported by Krueger (Krueger, 1951)
and acrylic as reported by Richard and Rene Judet. (Richards, Judet and Rene,
1952)

The initial Neer prosthesis had three sizes, and two more were added. In the early
1970s, the implant was redesigned to better use the alternative of cement fixation,
and the articular portion was made spherical. (Neer, 1974) This implant proved its
versatility over time. It was initially used for acute fractures but subsequently has
been shown to be effective for the care of patients with chronic fracture problems,
(Hawkins, Neer, Pianta, et al., 1987; Pritchett and Clark, 1987; Rowe and Zarins,
1982; Tanner and Cofield, 1983) osteoarthritis, (Neer, 1974; Zuckerman and Cofield,
1986) rheumatoid arthritis, (Neer, 1971; Zuckerman and Cofield, 1986) osteonecrosis,
(Cruess, 1976; Cruess, 1985; Rutherford and Cofield, 1987) and a variety of the more
rare forms of disease affecting the shoulder joint. A number of other shoulder implant
systems include a metallic humeral component that can be used without a glenoid
replacement. (Amstutz, 1982; Amstutz, Sew Hoy, Clarke, 1981; Amstutz, Thomas,
Kabo, et al., 1988; Bateman, 1978; Cofield, 1986; Cofield, 1987; Gristina, Romano,
Kammire, et al., 1987; Gristina, Webb and Carter, 1985) Bipolar implants have been
described as well. (Lee and Niemann, 1994; Swanson, 1984; Swanson, deGroot,
Maupin, et al., 1986; Swanson, deGroot Swanson, Sattel, et al., 1989)

Some authors suggested a cup arthroplasty might be a satisfactory alternative for

prosthetic shoulder surgery. (Jonsson, 1988; Jonsson, Egund, Kelly, et al., 1986).

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Initially, hip cups were used,(Steffee and Moore, 1984) and then cups were
manufactured specifically for the shoulder. (Steffee and Moore, 1984) Rydholm and
Sjogren (Rydholm and Sjogren, 1993) described a surface replacement for the
humeral head. At an average of 4.2 years after surgery, 72 rheumatoid shoulders
demonstrated substantial improvement. 25% of the cups were loose at followup.
However, neither cup loosening, nor proximal migration of the humerus nor central
glenoid wear apparently affected the clinical result.

A number of plastics and other softer materials have been used as implants.
Swanson designed an all-silicon rubber humeral head implant in extension of the
concept of flexible implants as an adjunct to resection arthroplasty. (Swanson, 1973)
Apparently, this design was used only on rare occasions, and no results are available
for a series of patients. Varian reported on a clinical trial of the use of a Silastic cup in
patients with rheumatoid arthritis of the shoulder. (Varian, 1980) Early results were
promising, but another series by Spencer and Skirving described a number of
complications, and the authors recommended restricted use ofthe device. (Spencer
and Skirving, 1986)

Isoelastic shoulder implants have been used in Europe. (Burri, 1985; Cockx, Claes,
Hoogmartens, et al., 1983; Tonino and van de Werf, 1985)

After these pioneering efforts, many additional shoulder prostheses were constructed.
Some mirrored the implants used by Neer, including the St. Georg (Engelbrecht and
Stellbrink, 1976), the Bechtol (Bechtol, 1976) prostheses, the DANA (Thomas,
Amstutz and Cracchiolo, 1991), the Cofield (Cofield, 1986; Cofield, 1987) and the
Monospherical. (Gristina, Romano, Kammire, et al., 1987; Gristina, Webb and Carter,
1985) Other designs included a captive ball-in-socket unit to replace the stabilizing
functions of the rotator cuff and shoulder capsule. (Beddow and Elloy, 1977; Beddow
and Elloy, 1982; Buechel, Pappas and DePalma, 1978; Cofield and Stauffer, 1977;
Coughlin, Morris and West, 1979; Engelbrecht and Heinert, 1987; Fenlin, 1975;
Gerard, Leblanc and Rousseau, 1973; Gristina and Webb, 1982; Kessel and Bayley,
1982; Kolbel and Friedebold, 1975; Kolbel, Rohlmann and Bergmann, 1982; Lettin,
Copeland and Scales, 1982; Post, 1987; Post, 1988; Post and Haskell, 1978; Post,
Haskell and Jablon, 1980; Post, Jablon, Miller, et al., 1979; Reeves, Jobbins,
Dowson, et al., 1974; Wheble and Skorecki, 1977; Zippel, 1975) Of these, many
included complex and extensive attachments to the scapula by cementing within the
glenoid, and by stems, wedges, a screw, and bolted flanges. Some designs reversed
the ball and socket configuration--attaching the ball part of the implant to the glenoid.
(Reeves, Jobbins, Dowson, et al., 1974) Others incorporated two ball-in-socket units.
(Buechel, Pappas and DePalma, 1978; Gristina and Webb, 1982) Engelbrecht et al
suggested a hemiarthroplasty with modification of the glenoid by osteotomy and bone
graft to buttress the humeral prosthesis. (Engelbrecht and Heinert, 1987) Burkhead
and Hutton(Burkhead and Hutton, 1995) performed biological resurfacing of the
glenoid in association with humeral hemiarthroplasty.

Some designs had a hood on the glenoid component, in an attempt to prevent

upward humeral subluxation associated with rotator cuff weakness or absence.
(Amstutz, 1982; Amstutz, Sew Hoy and Clarke, 1981; Amstutz, Thomas, Kabo, et al.,
1988; Engelbrecht and Stellbrink, 1976; Mazas and de la Caffiniere, 1982; McElwain
and English, 1987; Neer, Watson and Stanton, 1982) Implants could be classified as
anatomical, semiconstrained (hooded glenoid), or constrained (ball in socket).

The nonretentive prosthesis of Mazas and Caffinire also included a superiorly placed
hood on the glenoid component. Of 38 shoulders operated, 9 developed instability,
and 14 shoulders remained stiff after surgery. (Mazas and de la Caffiniere, 1982) A
third early system including a hooded component was the English-Macnab. This
system also has a nonhooded glenoid implant and incorporates porous ingrowth

2
surfaces on the glenoid component and the humeral stem. (Faludi and Weiland,
1983; McElwain and English, 1987)

The Neer system originally included 200 per cent and 600 per cent enlarged glenoids.
These components were used in only 12 of 273 shoulders reported, (Neer, Watson
and Stanton, 1982) suggesting that the need for them was quite uncommon. The
Dana total shoulder arthroplasty includes a semiconstrained, hooded component
designed to enhance stability in shoulders with irreparable rotator cuff tears.
(Amstutz, 1982) The Monospherical total shoulder also incorporated a slight hood on
the glenoid component, imparting somewhat greater stability to the articulation.
(Fukuda, Chen, Cofield, et al., 1988; Gristina, Romano, Kammire, et al., 1987)
Laurence (Laurence, 1991) has described a snap fit prosthesis for arthroplasty in the
cuff deficient shoulder; the cup is secured to the glenoid and acromion.

Neer defined many of the challenges of shoulder reconstruction, including the

management of malversion of the glenoid, cementing the glenoid and proximal
humeral deficiency. (Neer, Watson and Stanton, 1982) He expanded the diagnoses
that could be managed by prosthetic shoulder reconstruction. Cofield also pioneered
the extended application of shoulder arthroplasty with an expanded implant system.
(Cofield, 1990) Pearl and Lippitt(Pearl and Lippitt, 1994) and Collins et al (Collins,
Harryman, Lippitt, et al., 1991) have recently outlined many of the elements of
modern arthroplasty technique.

The 1980's saw the advent of a number of modular humeral component designs,
trying to accommodate the variations in humeral anatomy and space available for the
joint and humeral medullary canal diameters. On the glenoid side, some designs
offered cementless fixation using screws and porous coatings on metal backing to the
polyethylene. In the 1990's, increased emphasis is being placed on restoring normal
kinematics with anatomical location and orientation of the humeral and glenoid joint
surfaces, advanced soft tissue balancing methods, and physiological stabilization of
the joint. Zuckerman and Cuomo have recently provided a review of the indications
and preoperative planning for glenohumeral arthroplasty. (Zuckerman and Cuomo,
1993) Brems has conducted a review of the evolution of the glenoid component.
(Brems, 1993) Rodosky and Bigliani have reviewed the indications for glenoid
resurfacing. (Rodosky and Bigliani, 1996)

Unfortunately, the results of most of the tens of thousands of surgeries performed for
glenohumeral arthritis are not available. This is due in large part to the fact that most
outcome systems are too burdensome for most of the surgeons carrying out
shoulder reconstructions. Over the 20 years since the advent of shoulder arthroplasty,
the results of the procedure have been published for less than 2000 cases performed
in this country, an estimated 5% of the total. In that most of the published reports
come from centers where relatively large numbers of these procedures are
performed, it would be of immense interest to know to what degree the results of the
other 95% were similar.

An important recent advance is that simple and practical systems are now available
by which surgeons can easily document the status of their patients before and
sequentially after shoulder arthroplasty. (Lippitt, Harryman and Matsen, 1993;
Matsen, 1996; Matsen, Smith, DeBartolo, et al., 1996; Richards, An, Bigliani, et al.,
1994; Ziegler, DeBartolo and Matsen, 1995) This documentation of treatment
effectiveness will permit the comparison of different management approaches for
defined groups of patients. If data on over 6000 shoulder arthroplasties being
performed each year can be gathered, analyzed and compared, shoulder surgeons
will be in a powerful position to understand and to progressively improve the
effectiveness of the care they offer their patients.

3
Milne and Gartsman (Milne and Gartsman, 1994) recently reviewed the costs of
arthroplasty in 1992-3 in a Houston, Texas private practice setting. They found the
average for hemiarthroplasty was $15,656 and for total shoulder arthroplasty
$16,606. Of this Fig.ure, 20% was for the surgeon, 75% for the hospital, 3% for the
anesthesia, and 2% for consultations. 4% of the patients were on workers
compensation, 43% were private pay, and 53% were on Medicare. The length of stay
averaged 5 days with a range from 3-14 days.

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5
 Figure 4

Figure 2

Figure 5

Figure 6

Figure 3

6
 Figure 7

Management of Glenohumeral Arthritis

Edited by Frederick A. Matsen, III, M.D.
Last updated August 27, 2001

Special considerations in arthroplasty

Degenerative joint disease

In this condition, the glenoid face is typically flattened and often

eroded posteriorly from chronic posterior subluxation (see figure Figure 54
54). The glenoid may be distorted by peripheral osteophytes masking the location of the anatomic
fossa. The humeral head may be flattened in a corresponding manner and effectively enlarged by the
proliferation of "goat's beard" osteophytes from the anterior, inferior and posterior articular rim.
Intraarticular loose bodies may lie hidden in the subcoracoid or axillary recesses. Anterior capsular
and subscapularis contractures are common in degenerative joint disease and require release.
Figure 8
However, posterior capsular release is not performed if there is posterior humeral subluxation
preoperatively.

Rheumatoid arthritis

The basic principles of shoulder arthroplasty in rheumatoid arthritis are similar to those in degenerative
arthritis, but some important differences exist. Rheumatoid tissues are much more fragile. The bone is
more prone to fracture, and the muscle and tendons are more prone to tear. Thus, from the outset,
extreme care must be taken to preserve bone and soft tissue integrity. We refer to these requirements
for extraordinary gentleness as "rheumatoid rules."

Because rheumatoid arthritis is an erosive and destructive disease, tissue deficiencies of the bone and
rotator cuff are more likely than in degenerative joint disease. Thus, the soft tissues anteriorly may be
insufficient to allow for a subscapularis lengthening. The glenoid bone may be so eroded that there is
Figure 9
insufficient stock to support a glenoid component. The rotator cuff may be partially or totally deficient.
Thus, in the preoperative evaluation and in discussion with the patient concerning the possible
outcomes of surgery, all of these factors need to be considered.

The standard preoperative scapular anteroposterior and axillary radiographs are required to evaluate
the humeral and glenoid bone stock. In rheumatoid arthritis the glenoid erosion is usually medial
(rather than posterior as in degenerative joint disease). For this reason, only minimal glenoid reaming
may be necessary to achieve an excellent quality fit to the back of the glenoid component. The
potential fragility of the bone and soft tissues makes it particularly important that the joint not be

7
Figure 10
overstuffed, and that adequate soft tissue laxity be present for immediate postoperative motion. This is
particularly a challenge in diminutive patients with juvenile rheumatoid arthritis who may also have a
tiny humeral medullary canal. In some cases there may be insufficient joint volume to permit the
insertion of a glenoid component in spite of complete soft tissue releases.

Secondary degenerative joint disease

In posttraumatic arthritis, the challenges may be even greater. The anatomy is likely to be distorted by
previous fracture and surgery. The nonarticular humeroscapular motion interface is likely to be
scarred, obscuring important neurologic structures, such as the axillary nerve. The tuberosities, the
humeral shaft, and the glenoid may be ununited or malunited.

As a first step, the motion interface must be carefully freed, and the axillary nerve identified both as it
crosses the subscapularis and as it courses laterally on the deep surface of the deltoid. Case by case
Figure 11
judgments must be made concerning the need for osteotomy to try to restore more normal anatomic
relationships, recognizing that additional healing and postoperative protection may be required. Again,
the goal is restoration of anatomic relationships, firm fixation of components, soft tissue balance,
stability, and smooth gliding in the humeroscapular motion interface.

Capsulorrhaphy arthropathy

Shoulders affected by capsulorrhaphy

arthropathy present additional Figure 55
challenges, such as neurovascular
scarring from previous surgery, soft tissue contractures, bone
deficiencies, implants from previous surgery, changes
of glenoid version, and an increased potential for
glenohumeral instability after the arthroplasty (see
figure 55).

Cuff tear arthropathy

In this condition there are several unique challenges for

regaining glenohumeral smoothness. The Figure
Figure 1256 humeral head is
subluxated in a superior position so that it is articulating with
the coracoacromial arch. The rotator cuff is almost never amenable to a strong repair, and the glenoid
is eroded superiorly, so that an acetabular-like structure is formed in continuity with the coracoacromial
arch. Under these circumstances, normal glenohumeral relationships are very difficult to normalize
and maintain by a durable cuff reconstruction. More often it is preferable to accept the altered joint
relationship which uses the "acetabulum" for secondary stability in the absence of primary stability
from the rotator cuff. In this "special hemiarthroplasty," the articular surface of the proximal humerus is
resurfaced with a component matching the preoperative humeral joint surface size and position. The
tuberosities are smoothed so that they are congruous with the humeral articular surface. This allows
for the proximal humerus to match the "acetabulum," and to articulate smoothly within it. It is very
important to avoid using "oversized" humeral components, because they overstuff the joint, do not
match the concavity of the "acetabulum" and restrict joint motion. In a special hemiarthroplasty, the
patient is spared the necessity of protecting a rotator cuff repair, so that immediate passive and active
exercises can be instituted after surgery. The patient is also spared the risk of glenoid loosening from
the rocking horse mechanism (see figure 56).

8
 Figure 13

The ideal patient for this procedure has a normal deltoid muscle, a concentric coracoacromial
"acetabulum" stabilizing the proximal humerus, which is superiorly displaced with respect to the
glenoid, concentric erosion of the upper glenoid fossa, a "femoralized" upper humerus with rounding
off of the greater tuberosity, an irreparable rotator cuff defect, no previous surgical compromise of the
acromion or coracoacromial ligament, good patient motivation, and realistic expectations.

In a series of ten patients having special hemiarthroplasty for rotator cuff tear arthropathy, the range of
active motion and function were substantially improved by this procedure (Table 16-20). These results
are not be as good as those for total glenohumeral arthroplasty because the patient lacks the benefit
of both prosthetic glenoid smoothness as well as the function of the rotator cuff.

Management of Glenohumeral Arthritis

Edited by Frederick A. Matsen, III, M.D.
Last updated August 27, 2001

Postoperative rehabilitation Figure 14

Figure 57
Continuous passive motion

Rehabilitation is started immediately following surgery in the recovery

room with the initiation of slow and gentle continuous passive motion
(see figure 57).

For patients who have had an interscalene block prior to surgery this
early motion is pain free. Continuous passive motion (CPM) should
be stopped and the wrist brace removed every two to three hours for
approximately 15 - 20 minutes to relieve any skin and nerve
compression. A sling is worn between exercise sessions until active
muscle control is regained. Figure 58

The patient-conducted rehabilitation program is started the day of surgery under the instruction of the
surgeon or therapist. While the program may vary with the details of the surgery performed (see
footnote 1), the following is a description of the basic program for shoulder arthroplasty. The stretching
exercises include

1. elevation
2. external rotation limited to 40 degrees
3. internal rotation
Figure 15
4. cross body adduction
5. grip strengthening
6. elbow range of motion
7. external rotator isometrics, and
8. anterior, middle and posterior deltoid isometrics.

The patient is instructed to perform a total of five exercise sessions spread evenly throughout the day
both while in the hospital as well as at home following discharge.

9
Charts are placed on the wall in full view from the patient's bed to graph the progress of external
rotation and elevation (see figure 58) as measured by the surgeon or therapist. This provides positive
feedback for rehabilitative progress.

Figure 16

Figure 17

10
Figure 18
11
For the routine arthroplasty, the range of
motion Figure 59 goals to be achieved before discharge
are 140 degrees of elevation, 40 degrees of
external rotation, and functional internal
rotation and cross body adduction. These
goals may be modified according to the specific
surgical procedure. Because the desired
range has been achieved on the operating
table, the patients' task is simplified, they have
only to maintain this range during the post
operative period.

Figure 60

Exercises

Elevation (overhead reach) is performed

in the supine position (lying flat on the back),
grasping the wrist or elbow of the
operative shoulder with the hand of the
unoperated arm, pulling up toward the
ceiling and reaching overhead as high as
possible to the goal of 140 degrees with
the arm relaxed (see figure 59). A pulley or
the forward lean (see figure 60) may also be
useful in achieving elevation, especially if the
opposite shoulder is involved.

External Rotation (rotation away from the

body) is performed in the supine position (see
figure 61), the operative side elbow held against
or close to the side and flexed to 90
degrees. A stick is held in both hands so
that the unaffected extremity pushes on the
Figure 61 operative arm to externally rotate it to the
goal of 40 degrees. Holding on to a door and
turning away is another useful way to stretch
external rotation (see figure 62).

Figure 62 Internal Rotation is performed by

grasping the wrist of the relaxed involved
arm with the non-operative side hand, the
hands are lifted up the back as high as possible.
A towel can also be used to assist with
pulling the involved arm into internal rotation
behind the back (see figure 63).

Cross Body Adduction is performed sitting or

standing, grasping the elbow of the
involved arm with the other hand. The

12
involved arm is relaxed with the elbow extended and pulled across the body until a stretch is felt (see
figure 64).

Active Elbow Motion is performed standing in order to allow unimpeded or unrestricted

flexion/extension and supination/pronation.

Grip Strengthening is performed to maintain forearm tone and can be accomplished using a foam pad
or tennis ball.

External Rotator Isometrics are performed with the forearm at neutral rotation. An attempt is made to
move the wrist out to the side against the resistance of the other hand or a fixed object (see figure 65).

Deltoid Isometrics are also performed standing or sitting. The arm is held in a neutral position and
pushed forward, to the side and to the back to exercise the anterior, middle, and posterior deltoid
respectively.

Supine Presses are performed initially holding a cloth or stick between both hands with the hands held
close together (see figure 66). From a starting position with the elbows bent and hands lying across
the chest, the stick is pushed straight to the ceiling with both hands in a slow and controlled manner
and then slowly lowered back to the resting position at the chest. The space between the two hands is
progressively increased. As the shoulder becomes stronger, the hands are pushed to the ceiling in a
slow and controlled manner independent of each other. With increasing strength, the exercise is
conducted with a one pound weight which is held in the involved hand as it is pressed to the ceiling.
When that is comfortable the incline is gradually increased to eventually reach the upright position. All
presses should be performed in a slow and controlledmanner; they are progressed to the next level
only when 20 repetitions can be performed comfortably.

The patient is instructed in all these exercises on three occasions:

1. Prior to surgery,
2. Immediately after surgery, and
3. Prior to leaving the hospital. Before discharge, the goals of assisted external rotation to
40 degrees and assisted elevation to 140 degrees must be accomplished.

The patient is placed in charge of their own rehabilitation and taught to progressively return to normal
use of the shoulder. Typically, keyboarding and driving are achieved at two weeks, swimming is started
at six weeks, golf or tennis are started at three-six month and chopping wood is precluded.

Footnotes

Footnote 1: For example if tuberosity or cuff fixation has been part of the procedure, external rotation
isometrics and active elevation may be delayed.

13
Figure 66

14
 Management of Glenohumeral Arthritis
Edited by Frederick A. Matsen, III, M.D.
Last updated August 27, 2001

Results

Hemiarthroplasty results

The results for the Neer design of hemiarthroplasty have been reported for osteonecrosis,
osteoarthritis, rheumatoid arthritis, and the residuals of trauma. When this procedure is applied to the
treatment of proximal humeral osteonecrosis, the pain relief has been quite good, ranging from 91 to
100 per cent, and the range of motion of the shoulder approaches normal. When this operation is
applied to patients with rheumatoid arthritis, osteoarthritis, or the residuals of trauma, satisfactory pain
relief is less consistently achieved but, with the exception of 3 of the 11 reported series, is still quite
acceptable. Range of motion in these latter patients tends to be less and is variable from series to
series; average active abduction ranged from one-third to three-quarters normal.

Total shoulder arthroplasty results

The most commonly used total shoulder arthroplasty has been the Neer design. Most patient series
contain a mixed diagnostic grouping, including patients with rheumatoid arthritis, osteoarthritis, old
trauma, and a variety of less common diagnostic categories. As can be seen from the table, the
percentage of patients achieving satisfactory pain relief is quite high, and, quite typically, slightly
greater than 90% of patients report no or only slight pain following surgery. Motion data following
surgery have not been as consistently reported as one might desire, but the amount of motion
regained seems variable and dependent on diagnostic category. For example, in the series reported
by Cofield, the mean active abduction following surgery for the entire group of patients reported was
120 degrees. (Cofield, 1984) The average return of active abduction varied greatly according to
diagnosis: 141 degrees for osteoarthritis, 109 degrees for those with post-traumatic arthritis, and 103
degrees for patients with rheumatoid arthritis. The return of movement in Cofield's series was not only
dependent on diagnosis but was also highly dependent on the condition of the rotator cuff and
shoulder capsule and on the avoidance of complications. (Cofield, 1984)

The largest series of total shoulder arthroplasties of this category has been reported by Neer. (Neer,
Watson and Stanton, 1982) He has suggested two systems for grading results. Patients who received
a full rehabilitation program were graded as excellent, satisfactory, or unsatisfactory. To achieve an
excellent result, the patient was enthusiastic about the operation, had no significant pain, could use
the arm without limitations, strength approached normal, active elevation of the arm was within 35
degrees of the opposite normal side and external rotation was 90 per cent of the normal side. In
patients with a satisfactory result, there was no more than occasional pain or aching with weather
changes, good use of the shoulder for daily activities, elevation of at least 90 degrees, and rotation to
50% of the normal side. Muscle strength was at least 30% of the normal side, and the patients
expressed satisfaction with the operation. In an unsatisfactory result, the above criteria were not
achieved. Neer has suggested a separate evaluation category for patients who have total shoulder
replacement but whose muscles could be classified as detached and not capable of recovering
function after repair because of fixed contracture or denervation. Patients with substantial bone loss,
particularly bone loss in the proximal humerus, might also be included within this evaluative category.
In this setting, rehabilitation is aimed at achieving limited goals, the purpose being to gain a lesser
range of motion but maintain stability. Neer has suggested that this limited-goals rehabilitation is
successful when patients with these muscle or bone deficiencies achieve 90 degrees of elevation and
20 degrees of external rotation, maintain reasonable stability, and achieve satisfactory pain relief.
Other series of results with this type of prosthesis have been reported. (Weiss, Adams, Moore, et al.,
1990)

All series report lucent lines or lucent zones at the glenoid-bone cement junction. These vary
considerably in frequency among the different series, ranging from 30% to 93% of shoulders reported.
The keel portion of this implant serves as the significant means of attachment to the scapula, and the

15
lucent zones seen at the cement-bone junction surrounding the keel are of great concern. The median
percentage of the number of shoulders analyzed in which a lucent line was identified at the bone-
cement junction of the keel part of the component is 36. The argument has been presented that when
these lucent lines or zones are seen in patients they are almost always present immediately
postoperatively and clearly represent an error in surgical technique. (Neer, Watson and Stanton, 1982)
This may be the most common sequence of events associated with roentgenographic lucent zones at
the glenoid bone-cement junction and speaks for the need for meticulous preparation of the bony bed
and cementing at the time of surgery. However, it has also been reported that these lucent zones have
not been present immediately after surgery but rather have developed over time. (Cofield, 1984)
Green and Norris(Green and Norris, 1994b) and Slawson et al (Slawson, Everson and Craig, 1995)
have recently provided a review of imaging techniques for evaluating glenohumeral arthroplasty.

Franklin and co-authors have suggested a classification system for describing the radiographic
appearance of the glenoid component. (Franklin, Barrett, Jackins, et al., 1988) In Class 0, there is no
lucency. In Class 1, there is lucency at the superior or inferior flange only. In Class 2, there is
incomplete lucency at the keel. In Class 3, there is complete lucency up to 2 mm around the
component. In Class 4, there is complete lucency greater than 2 mm around the component. In Class
5A, the component has translated, tipped, or shifted in position. And in Class 5B, the component has
become dislocated from the bone.

In the series by Barrett (Barrett, Franklin, Jackins, et al., 1987) and Cofield, (Cofield, 1984) analyses
have also included a shift in glenoid component position relative to the position achieved immediately
following surgery. Analysis of component movement relative to the bone requires the viewing of
sequential x-rays over time because often a lucent zone is not seen. This finding implies component
loosening, but it can easily be overlooked if serial x-rays are not studied.

Management of Glenohumeral Arthritis

Edited by Frederick A. Matsen, III, M.D.
Last updated January 9, 2002

Methods of assessing functional outcome

Ernest A. Codman will be remembered in the annals of orthopaedic history as a pioneer in the study of
shoulder disorders but few except the most ardent of his followers are familiar with the role he played
as a visionary and champion of what is currently described as outcomes research. (Codman, 1934)

Evaluating success and failure

Central to what Codman described in the early 1900's as an "end-result" system was the admonition
that every patient should be followed to determine if the treatment was a success and if not to
determine the reasons for failure so that such occurrences could be prevented in the future. Despite
Codman's admonition nearly 100 years ago, there continues to exist a lack of standardized methods
for measuring results and reporting complications associated with total shoulder implants.
Unfortunately, the lack of a universally accepted outcome measurement system for shoulder
arthroplasty increases methodologic flaws in structured literature reviews and often precludes
meaningful retrospective or prospective comparisons between various arthroplasty series. The
desirability of research methodologies which will improve the quality and comparability of multicenter
studies is underscored by our review of nearly fifty total shoulder replacement series. (Boyd, Thomas,
Scott, et al., 1990; Brenner, Ferlic, Clayton, et al., 1989; Brostrom, Kronberg and Wallensten, 1992;
Brumfield, Schilz and Flinders, 1981; Clayton, Ferlic and Jeffers, 1982; Cofield and Daly, 1992; Cofield
and Stauffer, 1977; Coughlin, Morris and West, 1979; Cruess, 1980; Engelbrecht, Siegel, Rottger, et
al., 1980; Faludi and Weiland, 1983; Fenlin, 1975; Fig.gie, Inglis, Fig.gie, et al., 1989; Frich, Moller and
Sneppen, 1988; Gristina, Romano, Kammire, et al., 1987; Gristina and Webb, 1982; Hawkins, Bell and
Jallay, 1989; Kelly, Foster and Fischer, 1987; Kolbel, Rohlmann and Bergmann, 1982; Laurence,
1991; Lettin, Copeland and Scales, 1982; Linscheid and Cofield, 1976; Martin, Sledge, Thomas, et al.,
1995; Mazas and de la Caffiniere, 1981; McCoy, Warren, Bade, et al., 1989; McElwain and English,

16
1987; McKeeand Watson-Farrar, 1966; Neer and Morrison, 1988; Neer and Kirby, 1982; Pahle and
Kvarnes, 1985a; Pollock, Deliz, McIlveen, et al., 1992; Post, 1987; Post, Haskell and Jablon, 1980;
Post and Jablon, 1983; Post, Jablon, Miller, et al., 1979; Roper, Paterson and Day, 1990; Torchia,
Cofield and Settergren, 1994-1995; Warren, Ranawat and Inglis, 1982; Wilde, Borden and Brems,
1984) The results of this review revealed that only thirty-three of these reports assessed the outcome
of treatment by applying a specific grading system. Moreover there was a great lack of unanimity in
regards to these evaluation schemes as twenty-two different grading systems were utilized. Also
disconcerting was the variability in reported data, variations in terminology, and ill-defined standards of
assessing complications which made it difficult to systematically analyze many of these studies.

The necessity for improving study design, defining the important constituents of outcome
measurement, and increasing the validity of orthopaedic clinical research has been emphasized by
several authors. (Cowell and Curtiss, 1985; Cutler and Ederer, 1958; Gartland, 1988; Rudicel and
Esdiale, 1985) It has been suggested that the current emphasis of orthopaedic clinical studies should
be directed toward outcome research which documents the effect of treatment on the health of those
treated and the subsequent quality of their lives. (Gartland, 1988) Recently, the American Shoulder
and Elbow Surgeons proposed a standardized form for assessment of the shoulder which is applicable
to all patients regardless of diagnosis. (Richards, An, Bigliani, et al., 1994) Such standardized forms
represent assessment tools which will facilitate the analysis of multi-center studies, permit validity
testing of measurement tools and provide documentation of patient outcome in terms of economics
and improved quality of life.

Survivorship analysis

The validity of survivorship analysis in the evaluation of long-term clinical studies involving total hip
replacements is well established. (Cornell and Ranawat, 1986; Dobbs, 1980; Dorey and Amstutz,
1986; Jinnah, Amstutz, Tooke, et al., 1986; Pavlov, 1987) Although non-parametric estimates of
survivorship based upon life tables and the Kaplan-Meier curve have proven useful in predicting the
longevity of hip arthroplasties, the application of these instruments to total shoulder arthroplasty
studies is limited to two series. (Brenner, Ferlic, Clayton, et al., 1989; Cofield, 1993)

In 1983, Cofield performed a non-parametric estimation of survivorship in 176 unconstrained total

shoulder arthroplasties and predicated a 9.6 percent cumulative probability of failure at five years.
(Cofield, 1993) The criteria for failure was defined as the need for a major reoperation which occurred
in eight (4.5 percent) cases. The indication for reoperation included early dislocation in three
shoulders, glenoid component loosening in three shoulders, and muscle transfer for axillary nerve
paralysis and resectional arthroplasty for sepsis in one shoulder each. In a more recent article by the
same author, this Fig.ure did not significantly change at an eleven year end point. (Torchia, Cofield and
Settergren, 1994-1995) In 1989, Brenner and colleagues (Brenner, Ferlic, Clayton, et al., 1989)
analyzed the results of fifty-three unconstrained total shoulder arthroplasties using the Kaplan-Meier
survivorship curve. Employing a more rigid definition that considered failure as not only the need for
reoperation, but also patient dissatisfaction with the degree of pain relief, the authors reported an
eleven year survival of only 73 percent.

In a large multi-center prospective study involving more than 470 unconstrained total shoulder
arthroplasties, the five year survival was estimated at 97 percent (95 percent confidence interval).
(Rockwood, 1990) A more rigid definition of failure, similar to the criteria proposed by Brenner et al,
(Brenner, Ferlic, Clayton, et al., 1989) was applied to a subset of these patients whose diagnosis was
restricted to osteoarthritis. For these patients, failure was defined by one of two parameters. The first
parameter, as with the two previous studies, simply involved the need for reoperation following the
index procedure. The second parameter was based upon a patient self-assessment visual analog
scale for pain. For this analysis, failure was defined as the point in time at which the patient reported
shoulder pain which was equal or worse than the preoperative condition. For the osteoarthritis
subgroup, the probability of five year survival was 92 percent using the more stringent criteria.

17
Patient self-assessment

As a practical approach to effectiveness measurement which can easily be applied in an active

practice, one of us (FAM) has used patient self-assessment methods. Since January 1992, all new
shoulder patients have been asked to complete the Simple Shoulder Test (SST) (Lippitt, Harryman
and Matsen, 1993; Matsen, Lippitt, Sidles, et al., 1994) to define their pretreatment shoulder function
and the SF 36 to characterize there overall health status. The results from these pre treatment
questionnaires serve as the baseline on "INGO" for evaluating treatment effectiveness from the
perspective of the patient. Followup questions questionnaires reveal the "outcome" of treatment from
the patients' perspective. The difference between the outcome and the ingo is the effectiveness of the
treatment. Table 16-25 indicates some of these early data for the effectiveness of total or hemi
arthroplasty for each of the indicated diagnoses. The preoperative scores are shown to the left of each
arrow and the followup score to the right. The data include the SF 36 parameters for total body
physical role function and comfort as well as the 12 SST parameters which are specific to the
shoulder. The SF 36 scores are the average of the scores of the patients. The SST scores are the
percent of the patients answering yes to the indicated question. While some of these numbers are too
small for rigorous comparison, in the future, data such as these will indicate the absolute and relative
effectiveness of different treatments for different types of glenohumeral arthritis. Dividing the
effectiveness by the cost of treatment will reveal the cost effectiveness for different diagnoses by
different programs.

Surgery for Traumatic Instability of the Shoulder

Edited by Frederick A. Matsen, III, M.D.
Last updated August 27, 2001

About surgery for traumatic instability

Here is some patient information typically given to a patient before a repair for traumatic instability.
However, this will vary with the surgeon, the patient and the repair. If you have are going to have such
a repair, only your surgeon can give you specific information relative to your procedure.

Traumatic instability

When a major force is applied to the arm, the supporting ligaments of the shoulder joint may be torn.
Sometimes these ligaments heal spontaneously in the proper location so that the stability of the
shoulder is regained. On other occasions, strong healing to the appropriate location does not occur,
leaving the shoulder unstable when it is put in certain specific positions. We refer to this as traumatic
instability of the shoulder.

These injuries most commonly arise from situations in which the elevated arm is forced violently
backward such as in a fall while skiing. If this is the situation, one may elect to avoid the positions in
which the shoulder feels unstable, recognizing that this may require giving up certain activities.
Alternatively, one may seek a surgical repair of the torn structures with a goal to regain some of the
functional abilities that were lost.

Who should consider this surgery

We consider surgical treatment for informed patients who are unwilling to accept the functional
limitations imposed by recurrent traumatic instability.

18
Goals of surgery

The ligaments are almost always torn from the front bottom part of the socket of the shoulder. We can
often repair this injury by sewing the ligaments back to the bone from which they were torn. We make
an incision in the lower front skin creases of the shoulder and gain access to the joint between two of
its major muscles: the deltoid and the pectoralis major. The ligaments are reattached by roughening up
the edge of the bony socket and placing small drill holes in the lip of this socket. Sutures are passed
through these drill holes and through the ligaments so that when the sutures are tied the ligaments are
held in the appropriate place for healing.

Risks of surgery

The risks of this surgery include, but are not limited, to:

infection,
injury to nerves and blood vessels around the shoulder,
unwanted shoulder stiffness,
persistent instability of the shoulder,
pain,
complications of anesthesia,
and the need for revision surgery.

Post-surgery limitations

For three to four weeks after the surgery one must protect the shoulder from elevation above the
horizontal and from rotation away from the body. It is important to carry out isometric strengthening
exercises which are done with the arm in a sling. After this first period of protection, gentle range of
motion and additional strengthening exercises are added.

During the second six weeks we emphasize shoulder range of motion, strength, endurance, and
coordination. Usually patients can resume rigorous physical activities three months after the operation
provided they have regained excellent strength, coordination, endurance, and a near-normal range of
motion of the shoulder.

Details of the surgery

About the surgery

Here are some details regarding surgery for the management of traumatic anterior glenohumeral
instability.

This section on surgical treatment concerns the management only of patients who have traumatic
anterior inferior glenohumeral instability that has been established preoperatively by careful history
and physical examination. The indications for surgical treatment of this lesion are persistent significant
functional deficits (apprehension, subluxation, dislocation) in abduction, external rotation, and
extension resulting from an initial episode which was sufficiently traumatic to tear part of the major
capsuloligamentous supporting structures of the glenohumeral joint. For patients not meeting these
strict criteria, we use the methods of treatment for atraumatic instability.

The goals of treating traumatic anterior inferior glenohumeral instability are to repair the traumatic
lesion safely, restoring the attachment of the glenohumeral ligaments, capsule, and labrum to the rim
of the glenoid. By assuring that reattachment occurs to the rim, the effective depth of the glenoid is
restored. By definition these patients do not have a functional problem with capsular laxity, thus,
capsular reefing is not a part of this procedure.

19
Surgical
technique

The goal of the surgical

treatment for traumatic
anterior glenohumeral
instability is the safe
and secure
reattachment of the
detached glenohumeral
ligaments to the lip of
the glenoid from which
they were avulsed. No
attempt is made to
modify the normal laxity
of the anterior capsule.
This anatomic
reattachment should
reestablish not only the
capsuloligamentous
check rein but also the Figure 1 - Glenohumeral ligaments
fossa-deepening effect
of the glenoid labrum. A
repair that is secure
from the time of surgery
is highly desirable in
that it allows patients to
resume many of their
activities of daily living
while the repair is
healing. A repair that is
secure from the time of
surgery also allows
controlled mobilization,
thereby minimizing the
possibility of unwanted
stiffness.

In traumatic anterior
instability, the absence
of the normal anterior
glenoid lip can often be
demonstrated by the
lack of resistance to
anterior glenohumeral
translation on the sheer
test.

The patient is
positioned in a 30
degree inclined beach
chair position with the
arm free over the edge
of the table. No sand Figure 2 - Bankart lesion
bag is used underneath
the shoulder blade.

20
Prepping and draping allow the arm to be freely moveable and allows generous exposure to the
anterior aspect of the shoulder.

The skin incision is marked in the dominant anterior axillary crease which is revealed when the arm is
adducted. After the incision is marked, an adhesive drape is applied and the incision is made. The
deltopectoral groove is entered, retracting the cephalic vein laterally with the deltoid. The clavipectoral
fossa is incised just lateral to the short head of the biceps, up to but not through the coracoacromial
ligament. We routinely palpate the axillary nerve as it crosses the anteroinferior border of the
subscapularis. A Balfour retractor is useful in the exposure. The anterior humeral circumflex vessels
can usually be protected by bluntly dissecting them off of the subscapularis muscle at its inferior
border. The subscapularis tendon and the subjacent capsule are incised 5 mm medial to their insertion
at the lesser tuberosity. This incision starts superiorly at the upper rolled edge of the subscapularis and
extends inferiorly to the bottom of the lesser tuberosity. It is important that the incision through the
subscapularis tendon leaves strong tendinous material on both sides of the incision to facilitate a
secure repair at the conclusion of the procedure. We examine the joint for loose bodies, for displaced
fragments of glenoid labrum and particularly in older patients for evidence of rotator cuff tears. We can
usually palpate a posterior lateral humeral head defect. The capsule and subscapularis are then
retracted medially as a unit and a humeral head retractor is placed in the joint. An angled retractor is
used to expose the glenoid lip and to identify the capsuloligamentous avulsion know as the Bankart
defect. Occasionally flimsy attempts to heal the lesion will temporarily obliterate the defect. However,
in these cases a blunt elevator will easily reveal the typical lesion in the anterior-inferior quadrant of
the glenoid. A spiked retractor is then placed through the ligamentous avulsion to expose the defect at
the glenoid lip.

We roughen the anterior, non-articular aspect of the glenoid lip with a curette or a motorized burr,
taking care not to compromise the bony strength of the glenoid lip. We mark the intended sites for
holes in the glenoid lip with cautery. A i.7 mm drill is then used to make holes on the articular aspect of
the glenoid 3 to 4 mm back from the edge of the lip to ensure a sufficiently strong bony bridge. We
place these holes 5 to 6 mm apart; thus the size of the defect dictates the number of holes used for
reattachment of the avulsed capsule. Corresponding slots are placed on the anterior non-articular
aspect of the glenoid. Using a 000 angled curette, we establish continuity between the corresponding
slots and holes.

We then pass a strong number 2 absorbable braided suture through the holes in the glenoid lip using
a trocar needle and an angled needle holder. After each suture is placed through the glenoid lip, the
integrity of the bony bridge is checked by a firm pull on the suture. At this point in the procedure it is
again useful to verify the location of the axillary nerve.

The spiked retractor is then removed from the lesion and an angled retractor is used to expose the
trailing medial edge of the avulsed capsule. Next, using the trocar needle, we pass the end of the
suture, exiting the anterior non-articular aspect of the glenoid lip through the trailing medial edge of the
capsule, taking care to include the glenoid labrum, if present. We avoid including any more capsule
than necessary to obtain a firm purchase; this prevents unwanted tightening of the anteroinferior
capsule. In larger glenohumeral ligament avulsions, the detached medial edge of the capsule tends to
sag inferiorly; thus, in these larger lesions an effort needs to be made to pass the needle through the
capsule slightly inferior to the bony holes in the glenoid. At the time of closure the inferiorly sagging
medial capsule will be repositioned anatomically.

Once the sutures have been passed through the capsule, they are tied so that the labrum and medial
edge of the capsule are positioned on the glenoid lip. The knots are tied so that they come to rest over
the capsule, rather than on the articular surface of the glenoid.

Once these sutures are tied, the smooth continuity between the articular surface of the glenoid fossa
and the capsule should be reestablished. No stepoff or discontinuity in the capsule should be present.
If such a discontinuity is noted, the sutures are replaced so that they obliterate the defect.

At the conclusion of the surgical repair the capsule and subscapularis tendon are repaired
anatomically to their mates at the lesser tuberosity. The integrity of the axillary nerve, which has been
monitored through the case, is again verified on closure.

21
Movies
Goal of surgery (0.61 MB)
Glenoid labrum (0.37 MB)
Sheer test (0.14 MB)
Arm is freely movable (0.05 MB)
Skin incision marked in the dominant anterior axillary crease (0.09 MB)
Incision (0.09 MB)
Entering the deltopectoral groove (0.31 MB)
Incising the clavipectoral fossa (0.28 MB)
Palpating the axillary nerve (0.10 MB)
Anteroinferior border of the subscapularis (0.09 MB)
Balfour retractor (0.12 MB)
Incising the subscapularis tendon and the subjacent capsule (0.46 MB)
Incision starts superiorly (0.10 MB)
Upper rolled edge of the subscapularis (0.09 MB)
Examining the joint for loose bodies (0.11 MB)
Palpating a posterior lateral humeral head defect (0.15 MB)
Bankart defect (0.06 MB)
Exposing the defect at the glenoid lip (0.23 MB)
Roughening the anterior, non-articular aspect of the glenoid lip (0.41 MB)
Motorized burr (0.05 MB)
Marking the intended sites for holes in the glenoid lip with cautery (0.10 MB)
Drilling holes on the articular aspect of the glenoid (0.12 MB)
Corresponding slots placed on the anterior non-articular aspect of the glenoid (0.21
MB)
000 angled curette (0.27 MB)
Establishing continuity between the corresponding slots and holes (0.11 MB)
Angled needle holder (0.17 MB)
Each suture is placed through the glenoid lip (0.16 MB)
Verifying the location of the axillary nerve (0.07 MB)
Passing the end of the suture, exiting the anterior non-articular aspect of the glenoid
lip through the trailing medial edge of the capsule (0.17 MB)
Sutures are positioned on the glenoid lip (0.15 MB)
Smooth continuity (0.19 MB)
The capsule and subscapularis tendon are repaired anatomically (0.36 MB)
Positioned on the glenoid lip (0.15 MB)

After the surgery

The sheer test is checked again after the repair.

The shoulder should have at least 30 degrees of external rotation at the side after the
subscapularis/capsular repair. A standard wound closure is carried out, using a subcuticular suture,
which is removed at three days.

Within the first few days after surgery, reliable patients are encouraged to use the arm up to 90
degrees of elevation in the anterior plane and out to zero degrees of external rotation. This allows
sufficient range of motion to perform most activities of daily living, such as eating and personal
hygiene, as well as certain vocational activities, such as writing and typing. Gripping, isometric
external rotation, and isometric abduction exercises are started immediately after surgery to minimize

22
effects of disuse. If a patient does not appear able to comply with this restricted use program, we
require that the arm be kept in a sling for three weeks.

At three weeks the patient should return for an examination and should have at least 90 degrees of
elevation and external rotation to zero degrees. From three weeks to six weeks postoperatively, the
patient is instructed to increase the range of motion to 140 degrees of elevation and 40 degrees of
external rotation. At six weeks after surgery, if there is good evidence of active control of the shoulder,
gentle repetitive activities such as swimming and using a rowing machine may be instituted to help
with coordination, strength, and endurance of the shoulder. More vigorous activities such as
basketball, volleyball, throwing, and serving in tennis should not be started until three months and only
then if there is excellent strength, endurance, range of motion, and coordination of the shoulder.

Movies
Sheer test (0.21 MB)
30 degrees of external rotation (0.06 MB)
Reliable patients are encouraged to use the arm (0.21 MB)
At three weeks the patient should return for an examination (0.34 MB)

Surgery for Traumatic Instability of the Shoulder

Edited by Frederick A. Matsen, III, M.D.
Last updated April 2, 2002

Rehabilitation

Avoid stiffness

Patients are usually able to conduct their own postoperative rehabilitation program with instructions
from a physical therapist or a physician.

Vigilance must be exercised for patients over 35 years of age to be sure that they do not develop
unwanted postoperative stiffness. Thus, particularly for these patients, the three-week and six-week
checks are very important to make sure that the ranges of elevation and external rotation are
respectively 90 and 0 degrees at three weeks, and 140 and 40 degrees at six weeks.

Instructions for rehabilitation

These are typical instructions given to a patient after a repair for traumatic instability. However, the
program will vary with the surgeon, the patient, and the repair. If you have had such a repair, only your
surgeon can give you instructions on the postoperative management. Do not do any exercises after
surgery except after consultation with your physician.

After your surgical repair, your arm is in a sling to assure that it heals properly. If this sling is not
comfortable, be sure to let your doctor know immediately.

You may remove your arm from the sling to perform your exercises. These include lying down on your
back and lifting your arm so that the elbow points straight up. In the second exercise, also performed
lying on your back, you rotate your forearm away from your stomach until it points straight ahead.

You need to start exercises in your sling right away. First you need to maintain the strength of your grip
by squeezing a ball, sponge, or putty several hundred times a day. Second you should perform three
minutes of gentle isometric exercises at least three times a day against some fixed object - pushing

23
your wrist outward, pushing your hand forward, pushing your elbow outward, and pushing the elbow
back. These exercises are designed to maintain your muscle tone. The shoulder is not moved during
these exercises. They should be comfortable.

You will return to the office three weeks after surgery. If everything is healing properly, you will begin
weaning yourself from the sling at that time.

At three weeks after surgery, you can increase your overhead reach until your arm is close to your ear
and until your forearm can be externally rotated 40 degrees from the straight ahead position. You need
to continue your previous isometric exercises and can add internal and external rotation strengthening
using rubber tubing.

You then progress by using your arm for light activities of daily living, avoiding the positions that used
to be unstable. Always avoid "checking" your shoulder to see if it is stable. You must not lift over 10
pounds for the first six months after your surgery.

After six weeks you can begin gentle, well-controlled, repetitive activities with your shoulder such as
swimming or using a rowing machine, provided that these activities are comfortable for you.

At three months it is often appropriate to implement the full home exercise program. You cannot return
to contact sports or heavy work for at least three months after this surgery, and then only if you have
excellent strength and coordinated control of your shoulder.

24