Total Shoulder Replacement (TSR): Types, Indications & Rehab MCQs

Total Shoulder Replacement (Arthroplasty)

Total Shoulder Replacement (TSR) involves replacing the damaged humeral head and glenoid socket with artificial components. It is the treatment of choice for end-stage arthritis.

[Image of Total Shoulder vs Reverse Shoulder Replacement]

1. Types of Replacement

• Anatomical TSR: Normal anatomy (Ball on humerus, socket on glenoid). Requires an intact Rotator Cuff.
• Reverse TSR: Ball on glenoid, socket on humerus. Used for Cuff Tear Arthropathy (when cuff is torn, Deltoid powers the arm).
• Hemiarthroplasty: Replacing only the humeral head.

2. Indications

• Osteoarthritis (OA) or Rheumatoid Arthritis (RA).
• Avascular Necrosis (AVN).
• Complex Fractures (4-part).

3. Physiotherapy Rehabilitation

Precautions (Anatomical TSR):
- Protect the Subscapularis (which is cut and repaired during surgery).
- No Active Internal Rotation or Extension for 4-6 weeks.
- No External Rotation > 30 degrees initially.

4. Complications

• Glenoid loosening (most common long-term issue).
• Instability/Dislocation.
• Infection.

25 Practice MCQs

Q1. Reverse Shoulder Replacement is specifically indicated for:

Answer: A). It changes the mechanics so the Deltoid can lift the arm.

Q2. Which muscle is typically detached and repaired during standard TSR surgery?

Answer: A). To access the joint anteriorly. Protecting it post-op is critical.

Q3. The primary indication for TSR is:

Answer: A). Pain relief is the main goal; ROM improvement is secondary.

Q4. In Reverse TSR, the "Ball" is placed on the:

Answer: A). Reversing the anatomy increases the lever arm for the deltoid.

Q5. Which movement is strictly limited for 4-6 weeks post-op (Anatomical TSR)?

Answer: A). To prevent rupture of the Subscapularis repair.

Q6. Hemiarthroplasty involves replacing:

Answer: A). Used when the glenoid is healthy or bone stock is poor.

Q7. The most common long-term complication of Total Shoulder Arthroplasty is:

Answer: A). The glenoid has less bone stock for fixation.

Q8. Resurfacing Arthroplasty is typically used for:

Answer: A). Preserves more bone than a stemmed implant.

Q9. Which nerve is at risk during the anterior approach for TSR?

Answer: B). Retractors can compress these nerves.

Q10. Expected range of motion after Anatomical TSR is usually:

Answer: A). Depends on soft tissue status.

Q11. For Reverse TSR, avoiding which combined position is crucial to prevent dislocation?

Answer: A). The dislocation mechanism for Reverse shoulder is unique.

Q12. Active immunity (infection) is an:

Answer: A). Do not put metal in an infected joint.

Q13. A "Stemless" humeral component relies on:

Answer: A). Preserves bone stock.

Q14. Driving is usually permitted after:

Answer: B). Once the patient has control and safety.

Q15. Phase 1 Rehab (Weeks 0-4) focuses on:

Answer: A). Protecting the subscapularis repair is priority.

Q16. Deltoid strengthening is MOST critical for:

Answer: B). Because the rotator cuff is absent/non-functional.

Q17. "Notching" of the scapula neck is a complication of:

Answer: A). The humeral cup rubs against the scapula neck.

Q18. Is MRI useful after TSR?

Answer: B). Metal distorts the image; CT is often better for loosening.

Q19. Propionibacterium acnes (Cutibacterium) is a common cause of:

Answer: A). It lives in the shoulder skin pores.

Q20. External Rotation limits in Phase 1 are usually:

Answer: A). To avoid stretching the repaired subscapularis.

Q21. Which activity is generally discouraged permanently after TSR?

Answer: A). Increases wear and loosening risk.

Q22. In RA patients, glenoid bone stock is often:

Answer: A). Making glenoid fixation difficult.

Q23. What is "Rocking Horse" phenomenon?

Answer: A). If the rotator cuff is unbalanced, the head rocks on the glenoid edge.

Q24. Cemented fixation is more common for:

Answer: A). Press-fit (uncemented) needs good bone quality for ingrowth.

Q25. Pre-operative stiffness implies:

Answer: A). Contractures must be released to regain motion.