Can anyone identify the type of prosthesis seen in this radiograph?

Can anyone identify the type of prosthesis seen in this radiograph?

Reverse Total Shoulder Arthroplasty
Kate Dunn DPT 751 July 12, 2010

Objectives - To understand the surgical procedure of a rTSA
-To apply current evidence in the development of an POC for rTSA -To describe the overall physical therapy management of a patient who underwent a rTSA -To incorporate complex impairments of an individual with a rTSA that has PD By the end of this presentation: everyone will….. 1- understand the surgical procedure of a reverse total shoulder arthroplasty 2- be able to apply current evidence to develop a POC and describe the overall PT management 3- to incorporate the neurological condition of PD to a pt with a rTSA

What do we already know? -TSA: for patients with advanced GH joint pathology (OA, RA, RCA) -persistent pain and loss of function despite conservative management1 -Hemiarthroplasty: for patients with either severe cuff pathology or irreparable cuff1 -replacement of humeral head So, what do we already know about shoulder arthroplasty? Traditional total shoulder arthroplasty is for patients w/ GH jt pathology, that continue to have persistent pain & LOF despite PT conservative management Hemiarthroplasty is for pts with severe RC pathology or an irreparable cuff consists of replacement of the humeral head TSA:-normal shoulder jt mechanics in this prosthesis are never restored because the rotator cuff musculature is not repaired -center of rotation of the GH jt is still shifted superiorly and the RC is not able to oppose this motion Hemi: -high functional return in this population is not realistic

What is a rTSA? -Reverses the orientation of the shoulder girdle
-Approved by the FDA in 20041 -Reverses the orientation of the shoulder girdle -Glenoid fossa > glenoid base plate & glenosphere -Humeral head > humeral shaft & concave cup - Increases deltoid moment arm to enhance the torque - Enhanced mechanical advantage of deltoid compensates for deficient RC So, what exactly is a rTSA? It was approved by the FDA in 2004 for use in the US and it reverses the orientation & components of the shoulder girdle -the glenoid fossa becomes the base plate & glenosphere -humeral head becomes the concave cup -resulting in an increased deltoid moment arm Which enhances the mechanical advantage of the deltoid muscle so that it can compensate for the absent or minimally functional RC This prosthesis moves the center of rotation medial & inferior, improved torque

Here is a picture that demonstrates the differences
Superior migration of the humeral head associated with RC failure results in loss of deltoid function -because the contraction of the deltoid produces superior translation of the humeral head rather than humeral elevation. (B) The reverse prosthesis restores deltoid function & creates an appropriate fulcrum for the deltoid to produce humeral elevation. Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010;468:

Why choose a rTSA? Indications1,3
-GH joint arthritis associated with irreparable RCT -Complex humeral fracture -Revision of failed traditional TSA -Absent RC -Over the age of 70yrs Contraindications3 -Advanced glenoid destruction -Severe lesions of deltoid -Axillary nerve palsy -Patient with expectation of high functional return Who is a appropriate for a rTSA? -pts w/ GH jt arthritis associated with an irreparable RCT -pts w/ complex humeral head or shaft fractures -pts in need of a revision for a failed TSA -in the presence of an absent RC -and in a pt over the age of 70yrs Who is not a candidate? - advanced glenoid damage -severe lesions of the deltoid muscle -axillary nerve palsy from previous surgery or injury -pt w/ expectation or need for high functional return

Surgical Outcomes -Post-op complications3
-Hardware instability or dislocation (abd with ER) -Nerve damage -Infection -Hematoma -Intra-operative fracture -Complication rates are 2-68%1 Here are some surgical outcomes that have been reported. Post-op complications include: -the most common is hardware instability or dislocation as seen in the picture at right -nerve damage -infection or hematoma -intra-op fracture Complication rates are 2-68% (Bondreau) -and the primary complication is what is described as scapular notching -wearing away of the inferior scapular neck caused by humeral cup impingment

Review -Glenoid destruction -What are some indications for a rTSA?
-GH joint arthritis with irreparable RC -Revision of failed TSA or hemiarthroplasty -Over the age of 70 years -Who is not appropriate for a rTSA procedure? -Glenoid destruction -Deltoid that is not intact -Patient wanting high functional return -What is the most common surgical complication? -hardware instability or dislocation Let’s review What are some indications for rTSA? -GH jt arthritis w/ irreparable RC -revision of TSA or hemi -over the age of 70 Who is not appropriate for a rTSA procedure -glenoid destruction -deltoid not intact -high functional return What is the most common surgical outcome? -hardware instability or dislocation

CASE DESCRIPTION So now that we have reviewed what a rTSA is, now I will relate the information to a specific patient case.

Patient Description -76y/o female -Referred to PT s/p right rTSA (05/14/10) -Previous injury: fall 07/16/09 -Previous sx: RCR Sept PMHx: Parkinson’s Disease (1997), CVA (1996), PAD, breast cancer (R mastectomy), memory loss -Social hx: retired, does not drive The patient I have chosen is a 76y/o female referred to PT s/p right rTSA 2.5 weeks Her medical history shows a previous fall in July 2009 resulting in a RCR in Sept 2009 Her history is also remarkable for a CVA in 1996, PAD, breast cancer resulting in a right mastectomy, memory loss and most notable PD that was dx in 1997 Her social history states that she is retired and does not drive

Past Medical History -Parkinson’s Disease: progressive degeneration of dopamine cells & imbalance of neurotransmitters in basal ganglia -Body impairments: tremors, rigidity, akinesia, postural instability -FORCE CONTROL (impaired amplitude of movement) -Rotator Cuff Repair -Sept Repaired supraspinatus & infraspinatus -Repair sites failed A more in-depth review of her medical history about PD & the previous RCR First, a review of PD from our neuro manag courses, PD is a progressive degeneration of dopamine cells & an imbalance of NT in the BG -one of the major concerns in individuals with PD is force control, more specifically initiation & amplitude of mvm PD has a worse prognosis when dementia involvement -Mean survival 15y/o post diagnosis -Movement patterns: slow gait, tremors during rest/ under stress, increased rigidity, akinesia (defined as a delayed initiation of movement), postural instability -Activity limitations: limited trunk rotation, difficulty rising from chair, decreased stride length & cadence, diff with UE function -most common cause of death is pulmonary infection/aspiration, UTI, pulm embolism Secondly, the previous RCR in 2009 resulted in failure of repair sites > there was no return of previous LOF, decreased ROM & strength, and inability to perform functional tasks

Surgical Report -Arthritic changes of the humeral head -Significant retraction of cuff musculature Impression: irreparable pathology without replacement -General anesthesia with an interscalene block -Subscapularis released -No supraspinatus, biceps tendon, infraspinatus attachments found -Capsule released, labrum debrided circumferentially These are the highlights from the surgical report Pre-operative imaging showed: arthritic changes in the humeral head & significant retraction of the cuff musculature -The final impression was an irreparable cuff pathology w/o a joint replacement Operative report included a general anesthesia w/ interscalene block -the subscapularis was released & there was no attachment of the supraspinatus, biceps tendon, or infraspinatus found -the capsule was released and the labrum was debrided circumferentially

Examination -Completed 2.5wks post-op
-Subjective: right shoulder, elbow & hand pain (5/10), N & T into fingers -PIP’s: difficulty washing & combing hair, difficulty with household chores, shoulder pain -Patient goals: get back to doing basic household chores, be able to move arm without pain *On 1L of O2 at night So, the initial examination occurred 2.5 weeks post-op Subjective information from the patient included right shoulder/elbow/hand pain (rated 5/10) andN & T into right fingers The pt identified problems were difficulty washing & combing hair, diff w/ household chores, and shoulder pain The pt’s goals for therapy were to get back to doing basic household chores, and be able to move arm w/o pain It was noted that the pt had been placed on 1L of O2 at night following surgery

Examination -Observation -Rounded shoulders -FHP -Increased thoracic kyphosis -Reverse scapular rhythm -Scar mildly adhered -Neuro Screen -Intact to LT bilaterally -Postural instability -B UE “pill rolling tremor” -Jaw tremor -Decreased facial expressions -PROM 90° flex 60 ° abd 11° ER -5° elbow ext -Palpation -Tender over anterolateral incision & mid belly of biceps -Quick DASH: 72% (0-100%, higher score indicates more disability) Further examination: including 1- general observation showed posture of rounded shoulders, forward head, & increased thoracic kyphosis when out of abduction sling -with initiation of movement, she displayed reverse scapular rhythm 2- neuro screen revealed her sensation was intact to light touch and symmetrical -there was moderate postural instability with walking and sitting -she had a bilateral UE pill rolling tremor & decreased facial expressions 3- PROM: 90deg shoulder flexion, 60 abd, 11 ER, and -5deg elbow extension 4- tender to palpation over anterolateral incision & mid belly of biceps The functional outcome tool that we used was the Quick-DASH: initial score was 72%

Here are some pictures of the patient at 4 weeks post-op
-on the left, passive shoulder flexion in supine -on the right, shoulder flexion with pulleys

Evaluation -Initial Hypothesis: Patient presents with decreased ability to perform ADL’s and functional activities secondary to decreased right shoulder ROM & strength, increased shoulder pain, postural instability, and bilateral UE rigidity & tone. -APTA Guide Patterns -4H: impaired joint mobility, motor function, muscle performance, and ROM associated with joint arthroplasty -5E: impaired motor function & sensory integrity associated with progressive disorders of the CNS Our initial hypothesis was that the pt presents with decreased ability to perform ADL’s and functional activities secondary to decreased right shoulder ROM & strength, increased shoulder pain, postural instability, and bilateral UE rigidity & tone. -APTA Guide Patterns -4H: impaired joint mobility, motor function, muscle performance, and ROM associated with joint arthroplasty -5E: impaired motor function & sensory integrity associated with progressive disorders of the CNS

Prognosis -Good to fair prognosis for return to (I) functioning
-Progress may be limited by: -Severity of PD (rigidity, tremors, postural instability, akinesia) -Previous shoulder surgery -Age of time of current surgery -Cognitive functioning -Compliance with POC/ HEP I set her prognosis for a good to fair outcome for return to (I) functioning -I believe that her progress may be limited due to -the severity of her PD (she has a 4 major signs of the disease: rigidity, tone, akinesia & postural instability), & was dx 13yrs ago) -she has had previous shoulder surgery that resulted in no return to previous LOF -the advanced age of the pt -the pt has some cognitive impairments that may alter the compliance with the POC & HEP

Intervention -Frequency: 3x/wk for 6 weeks to date (3x/wk for 10wks)
1- Pt education: precautions, sling use 2- Transfer & gait training 3- Joint/ soft tissue mobilizations 4- Ther-ex for ROM 5- Ther-ex for strengthening 6- Modalities for pain & edema management -Things to remember: -Only deltoid & teres minor are intact -High risk for anterior/inferior subluxation -Patient has difficulty with movement initiation & amplitude of movement -Avoid dual tasks (BG controls one, attention on the other) The suggested tx frequency of 3x/wk for 10wks, as of today, the pt has been seen for 4 wks, for a total of 6wks post-op The priorities that we set for our POC included: 1- Pt education about precautions & sling use 2- Transfer & gait training 3- Joint/ soft tissue mobilizations 4- ROM & strengthening 6- Modalities for pain & edema management Things to remember about this patient for management are 1- that only the deltoid & teres minor are still intact, therefore the teres minor becomes the primary ER, and the posterior deltoid assists with ER only when coupled w/ abd 2- there is a high risk for anterior/inferior subluxation 3- This patient may have difficulty with movement initiation & grading the amplitude of movement *Avoid dual tasks: the faulty BG will control one, while attention is focused on the other

Joint Kinematics -TSA: convex humeral head moving on concave glenoid fossa (opposite direction) *superior rotation, inferior glide -rTSA: concave humeral cup moving on convex glenosphere (same direction) *superior rotation, superior glide The major difference in the POC between a TSA & a rTSA is the joint kinematics of the GH joint -TSA: the convex humeral head is moving on a concave glenoid fossa, therefore the components move in opposite directions -for example: for shoulder flexion, there is superior rotation with an inferior glide of the humeral head -with a rTSA: the concave humeral cup is moving on a convex glenosphere, the components will move in the same direction -for example: for shoulder flexion, there is superior rotation with superior glide of the humeral head Boudreau S, et al. JOSPT 2007;37:

Patient Education - Shoulder mechanics & function will have some limitations when compared to unaffected shoulder - Establish appropriate functional & ROM expectations For the POC, the most important component will be patient education -the shoulder mechanics & function will have some limitations when compared to unaffected shoulder -and it will be necessary to establish appropriate functional & ROM expectations

Precautions -Sling 4 weeks -Potential for instability due to design
-No active IR or extension for 6 weeks1 -Pt must be able to visualize elbow while lying supine (no hyperextension) -No resisted IR or extension for 12 weeks -No IR, adduction, extension (tucking in shirt) for 12 weeks Precautions with the rTSA….. -sling is recommended for 4 weeks -there is a potential for dislocation & GH instability due to the design of prosthesis -no active IR or extension for 6wks -the pt must be able to visualize their elbow when lying supine -no resisted IR or extension for 12 weeks, no IR/add/ext (tucking in shirt) for 12 wks

Goals -STG: 5 weeks 1-MinA with established HEP 2- Decrease in pain by 50% -LTG: 10 weeks 1- Able to wash & comb hair with R UE independently 2- R UE AROM within 75% of L UE AROM 3- Decreased Quick-DASH by 50% We established these ST & LT goals The ST goals were to be met in 5weeks -minA w/ HEP -decrease in pain by 50% LT goals to be met in 10weeks -able to wash & comb hair w/ R UE indep -R UE AROM within 75% of L UE AROM -decreased DASH by 50%

JOSPT 2007: rTSA Protocol -no combined add/IR/ext (tucking in shirt)
-Dislocation precautions for 12 weeks post-op -no combined add/IR/ext (tucking in shirt) -no GH joint extension beyond neutral -Phase 1: Joint Protection (day 1 to week 6) -joint protection, PROM, edema/pain management -PROM: flex 120°, ER to tolerance, IR <50° -AROM & resisted exercises of involved elbow/wrist/hand -Criteria to move to next phase: -Pt tolerate PROM of shoulder -Pt is able to isometrically activate each component of the deltoid & scapular muscles The intervention/POC that we are following is based off of the surgeon’s protocol & the research performed by Boudreau, et al in JOSPT in 2007 -You have a copy of the protocol -What I am going to do is highlight the pertinent information in each phase Dislocation precautions should be followed for 12 weeks post-op -no combined add/IR/ext (tucking -no GH joint extension beyond neutral Phase 1: focus on joint protection & encompasses day 1-week6 post-op -goals are joint protection, increasing PROM of the shoulder, and edema/pain management -PROM: flexion 120deg, ER to tolerance, begin IR at week 6, should not exceed 50deg -can do AROM & gentle resisted exercises of elbow, wrist & hand Criteria to move to phase 2: is when the pt can tolerate PROM of the shoulder, and is able to isometrically activate all sections of the deltoid & scapular mm

JOSPT 2007: rTSA Protocol -Phase 2: AROM, Early Strength (weeks 6-12) -Gradual AROM, control pain & inflammation, re-establish dynamic stability -Begin AROM when gleno-humeral rhythm is restored -Flex, abd, ER isotonic strengthening -Criteria to move to next phase: -Improving functional ability -Pt is able to isotonically activate each component of the deltoid & scapular muscles Phase 2: includes week 6-12 with the focus of AROM & early strength -goals are to increase AROM, control pain & inflammation, re-establish dynamic stability -can begin AROM when gleno-humeral rhythm is restored -can begin flex/abd/IR/ER strengthening (<5lbs) Criteria to move to phase 3 is when the functional use of the shoulder is improving & the pt is able to isotonically activate all components of the deltoid & scapular muscles

JOSPT 2007: rTSA Protocol -Phase 3: Moderate Strengthening (weeks 12-16) -Enhance functional use, increase strength/power/ endurance -Begin gentle resisted flexion/abduction (5+lbs) in standing -Phase 4: Independent HEP (months 4+) -3-4x/wk -strength gains, return to functional/recreational activities -Criteria for discharge: -Pt is able to maintain pain-free AROM with proper shoulder mechanics -ROM: ° of flexion, 30° of ER Phase 3: includes week with the focus of moderate strengthening -goals are to increase functional use, increase strength/power/endurance -can begin gentle resisted flexion & abduction in standing (>5lbs) Phase 4: transition into independent HEP (16 weeks) -exercises should be performed 3-4x/wk with the focus on strength gains & return to functional activities Criteria for discharge from therapy is when the pt is able to maintain pain-free AROM with proper shoulder mechanics -and has reached the minimal ROM of deg of flexion and 30deg of ER

Outcomes: ROM & pain Here are this specific patient’s outcomes of ROM & pain from initial visit to 6 weeks post-op -You can see that she had a sharp increase in passive shoulder flexion after 4weeks of therapy, with a plateau of about 140deg -There has been a steady increase in passive abduction -increase in passive ER after 4 weeks, with a plateau of 40deg -Her pain has gone from 5/10 at initial visit, to a report of 1/10 with movement & 0/10 at rest

Progress at 6 weeks -PIP’s 1- Difficulty washing & combing hair
2- Difficulty with household chores 3- Shoulder pain -Non- PIP’s 1- Swinging arms during gait MET 2- Right arm strength -STG: 5 weeks 1-MinA with established HEP MET 2- Decrease in pain by 50% MET -LTG: 10 weeks 1- Able to wash & comb hair with R UE independently ? 2- R UE AROM within 75% of L UE AROM ? 3- Decreased Quick-DASH by 50% % > 52% (MCID=15pts)5 So, here is a review of the goals we set for therapy and her progress at 6 weeks -The patient has met the STG of a 50% decrease in pain -she needs only supervision with occasional guidance for her HEP - and she has decreased her Quick-DASH score from a 72-52% The goals she has not met yet are -being able to wash & comb hair with R UE -and R UE AROM within 75% of L UE AROM

Here are some pictures to demonstrate her progress at 6 weeks
-at left, you can see that she is using an arm ladder for shoulder flexion -at right, demonstrates her shoulder flexion with AAROM on the pulleys -at bottom, you can see her active ER seated R compared to L

Discussion -Improvement in passive range of motion, pain scores, and functional outcome scores -Pt has met all STG, progressing towards LTG -Pt is progressing consistently, but may reach plateau due to comorbidities -Primary focus needs to be on patient education and precautions, high functional return is unlikely -No setbacks in POC, compliance with HEP is questionable To review what we what we have learned so far….. -there has been improvement in PROM, pain & functional outcome scores -the pt has met all STG, progressing towards LTG -pt is progressing consistently, but may reach plateau due to comorbidities -primary focus needs to be on patient education and precautions, stressing that a high functional return is unlikely -There have been no setbacks in our current POC, but compliance with HEP is questionable

Frankle M, Siegal S, Pupello D, et al. J Bone Joint Surg. 2005.
-60 pts (mean age 70yrs) with glenohumeral arthritis associated with severe RC deficiency treated with rTSA, followed for minimum of 2 yrs -2 groups: previous RC repair, no previous surgery -Intervention: PROM started day 2, sling worn for 4 weeks, AAROM 4wks, AROM 8wks, resisted 12wks -All measures improved significantly (p<0.001) -ASES increased 33.9pts -VAS decreased 4.1pts -ROM: flexion increased 50°, abduction 60°, ER 29° -No significant difference between 2 groups in terms of demographic data, preoperative scores, post-op VAS scores, ROM -Device failed in 7 pts, requiring average of 21.4 months (insuffient bone density, glenoid loosening) -Results suggest that arthroplasty with rTSA may be a viable treatment for pts w/ GH arthritis & a massive RC tear, future studies need to determine the longevity of the implant A study by Frankle et al in 2005 followed 60pts w/ GH arthritis associated with severe RC deficiency that were treated w/ a rTSA for 2 yrs post-op -the subjects were divided into 2 groups: those w/ previous RC repair and those w/ no previous shoulder sx -PT began day 2, rest of protocol was similar to previous POC that was discussed -all outcomes improved significantly including, pain and ROM -there was no significant difference b/w the 2 groups in demographic data, pre-op score, post-op pain scores or ROM -results suggest that arthroplasty with rTSA may be a successful treatment for pts w/ GH arthritis & a massive RC tear but, future studies need to determine the longevity of the implant

Boileau P, et al. J Shoulder Elbow Surg. 2006
-45 pts w/ rTSA -21 massive & irreparable RCT associated with arthritis treated -5 complex humeral fracture with arthritis -19 failure of revision arthroplasty -Mean follow-up was 40 months -Outcomes: ROM , VAS pain scale, Constant functional score -Intervention: sling for 6 weeks, pendulum exercises started day 2, physical wk 3, no 90° with ER -Results: all groups showed significant increase in flexion by 66°, no significant change in ER or IR -rTSA can improve function and restore active flexion in patients with cuff-deficient shoulders -rTSA should not be offered to a young individual who wants a normal shoulder or who will demand more out of the prosthesis that it was designed to do Another study by Boileau et al in 2006 followed 45 pts with severe GH pathology for 40months -PT was began at week 3 with pendulum exercises started day 2 -Results showed a significant increase in active flexion, but no significant change in active ER or IR -Study concluded that a rTSA can improve function & restore active flexion in pts w/ RC deficient shoulders -it should not be used in pts <70y/o that will demand more out of the prosthesis that it was designed to do

Koch et al. J Shoulder Elbow Surg. 1997
-15 TSA in patient’s with PD -Mean follow-up: 5.3yrs -Results: significant improvement -Pain -Poor functional results -Duration of PD, rigidity, arm swing & rapid alternating movement scores were not found to be significant predictive factors -Increased failure rates of TSA in PD- increased muscle tone, severity of tremor, increased mortality rate of 1.6 to 3x that of general population -Increase in subluxation rates & associated complication- result of increased tone of shoulder girdle musculature, difficulties w/ rehab, stretching of RC-capsule arthrotomy site -Similar results found by Kryzak, et al in 2009 A study by Koch et al in 1997 examined 15 pts treated with a TSA that had PD, mean follow-up was 5yrs -results showed a significant improvement in pain, but poor functional results -found that the duration of PD, rigidity, arm swing & rapid alternating movement scores were not a significant predictor of successful outcome for TSA -concluded that there was an increased failure rate in this popul compared to normal popul, possibly due to increased mm tone, the severity of the tremors, & increased mortality rate -similar results found by Kryzak et al in 2009 that would be more current

How does evidence affect my intervention?
-Enhance deltoid function in absence of RC -Biofeedback: to assist pts in learning recruitment strategies1 -PT day 2 or 3rd week, no significant difference in LT outcome -LTG may be limited by severity of PD (tone, rigidity, akinesia, dementia) -Use rhythmic cues to increase cadence of activity -Amplitude of movements: think BIG concept9 -HEP compliance issue: suggest 5x/wk for 20min1 Therefore, how does this evidence affect my intervention? The most important concept is to enhance the deltoid function where the RC is absent -can use biofeedback machine to activate the 3 portions of the deltoid separately, can assist pts in learning the recruitment patterns & strategies PT started on day 2 or week 3, has no significant difference in LT outcome LTG may be limited based on severity of comorbidities -the amplitude of movements may be altered, strategy is to train using BIG movements that over-excentuate the motion that is desired -use rhythmic cues to increase cadence of activity Finally, there may be a HEP compliance issue: suggest increased frequency, decreased duration of sessions in the clinic -for example: 5x/week for 15-20min

Questions? THANK YOU! Thank you very much for listening. Are there any questions?

References 1. Boudreau S, Boudreau E, Higgins LD, Wilcox RG. Rehabilitation following reverse total shoulder arthroplasty. JOSPT 2007;37: Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010;468: Volpe S, Craig JA. Postoperative physical therapy management of a reverse total shoulder arthroplasty (rTSA). Ortho Practice. 2007;21: Boileau P, Watkinson D, Hatz AM, Hovorka I. Neer Award 2005: The Grammont reverse shoulder prosthesis: Results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006;15: Beaton DE, Katz JN, Fossell AH, et al. Measuring the whole or the parts? Validity, reliability and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in difference regions of the upper extremity. J Hand Ther. 2001;14: Frankle M, Siegal S, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone Joint Surg. 2005;87: Koch LD, Cofield RH, Ahlskog JE. Total shoulder arthroplasty in patients with Parkinson’s Disease. J Shoulder Elbow Surg. 1997;6: Kryzak TJ, Sperling JW, Schleck CD, Cofield RH. Total shoulder arthroplasty in patients with Parkinson’s Disease. J Shoulder Elbow Surg. 2009;18: Farley BG, Koshland GF. Training BIG to move faster: the application of the speed- amplitude relation as a rehabilitation strategy for people with Parkinson’s Disease. Exp Br Res 2005;167:

Can anyone identify the type of prosthesis seen in this radiograph?

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Can anyone identify the type of prosthesis seen in this radiograph?

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