Archery after reverse total shoulder arthroplasty

Andrew Lachance; Brandon O'Brien; Margaret E. Jonas; Jesse Constantino; Mira Patel; Anna Moravec; Antonina Calcavecchio; Joseph Y. Choi

doi:10.1016/j.jorep.2023.100304

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Research Article

2024

:3;

100304

doi:

10.1016/j.jorep.2023.100304

Archery after reverse total shoulder arthroplasty

Andrew Lachance^a, Brandon O'Brien^b, Margaret E. Jonas^a, Jesse Constantino^b, Mira Patel^c, Anna Moravec^a, Antonina Calcavecchio^d, Joseph Y. Choi^a,c,

a Department of Orthopaedics, Guthrie Clinic, 1 Guthrie Square, Sayre, PA, 18840, USA

b Department of Emergency Medicine, University at Buffalo, 77 Goodell Street, Buffalo, NY, 142031, USA

c Geisinger Commonwealth School of Medicine, 525 Pine St., Scranton, PA, 18501, USA

d Department of Family Medicine, Guthrie Clinic, 1 Guthrie Square, Sayre, PA, 18840, USA

∗Corresponding author: Joseph Y. Choi. joseph.choi@guthrie.org

Received: 2023-12-15, Accepted: 2023-12-28, Published: 2023-12-29

The Authors

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Archery, a popular recreational activity, puts strain on the shoulder girdle. rTSA indications are expanding, thus it is necessary to further understand return to sports such as archery.

A retrospective chart review was performed on patients undergoing primary rTSA with a minimum of 6-month follow-up. Demographic and surgical data was collected. Return to archery metrics included utilization of vertical vs. crossbow, ability to return to archery, presence of pain and instability during archery, modification of archery technique, and reason for lack of return to sport. VAS and ASES scores were obtained.

13 patients self-reported routinely participating in archery before undergoing rTSA. Seven participants (53.8 %) with a mean age of 69.7 years ( ± 6.32 years), returned to sport postoperatively. Four of these seven participants indicated that they switched to using a crossbow to return to the sport. Average VAS score was 1.85 ( ± 0.34, range 0–6). Only one participant returning to the sport had surgery on their dominant arm.

Return to archery following rTSA is possible and more likely if the surgery is performed on the bow arm. Switching from a vertical to a crossbow alongside targeted physical therapy to strengthen the deltoid may help facilitate return to archery postoperatively.

III.

Keywords

rTSA

Archery

Return to sport

Activity

Stability

Show Related Articles from PubMed

1 Introduction

Further indications for reverse total shoulder arthroplasty (rTSA) include rotator cuff tear with arthritis, fracture, tumor, instability or revision arthroplasty.¹ rTSA has been used for glenohumeral arthritis in patients with rotator cuff tears and puts tension on the deltoid.² With high rates of return to golf, swimming and tennis following shoulder arthroplasty, understanding of return to archery is required.³

Only 40 % of patients were able to return to archery in a smaller series of patients undergoing rTSA.⁴ Within the native shoulder, several studies have demonstrated acute and chronic injuries due to the strain put on the shoulder joint.⁵ Considering that a little over 9 % of the United States population participates in archery annually,⁶ appreciating if patients can return to activity is important in preoperative and postoperative counseling. Furthermore, functional status and stability is essential for patient safety participating in hunting in austere or isolated environments. With these low rates of return to sport in previous studies of anatomic total shoulder arthroplasty (aTSA), we hypothesize that patients will similarly have low levels of return to archery after rTSA.

2 Methods

2.1

2.1 Patient population

Institutional Review Board (IRB) at a single academic institution was obtained. Patients who underwent rTSA by a single fellowship trained surgeon and were 18 years old or older were included in a retrospective manner. Patients with revision rTSA or fracture were excluded from this study.

2.2Data collection

Data from our EMR included patients that underwent rTSA by one surgeon within a minimum of 6 months and a maximum of 5 years from the data collection period. Demographic and surgical were obtained. Return to archery metrics included if they utilized vertical vs. crossbow, if they were able to return to archery, if they experienced pain and instability during the activity, if they modified their archery technique and the reason for what inhibited them from returning to sport. Satisfaction and pain scores were also recorded.

2.3

2.3 Surgical technique and postoperative rehabilitation protocol

A deltopectoral approach was used in all cases. Careful attention was paid to the glenoid exposure, the critical step, in order to accurately place the glenosphere. We used Lima rTSA implants (Lima SMR, LimaCorporate, Italy) which have a neck shaft angle of 150° and a 40 mm eccentric glenosphere to decrease the risk of scapular notching. A diaphyseal fitting stem was utilized in all patients. The subscapularis was repaired if there was viable tissue. Postoperatively patients are in a sling for 6 weeks, only performing elbow and wrist range of motion. Passive range of motion (PROM) exercises are started after 6 weeks. Once PROM is tolerable, we advance to strengthening. Generally by 3–4 months, patients are allowed to actively strengthen their shoulder overhead.

3 Results

Thirteen patients were identified that self-reported as routinely participating in vertical bow archery before undergoing rTSA. Overall, 54 % of patients were able to return to archery. Within our patient population, 84.6 % (11) were male with a mean age of 70.77 years ( ± 7.11 years). 53.8 % (7) had rTSA on their non-dominant arm, 30.7 % (4) had rTSA on their dominant arm, and 15.4 % (2) indicated that they had rTSA surgery bilaterally. Demographic data of the cohort is provided (Table 1). 7 participants (53.8 %) participated in archery postoperatively. Of those who endorsed returning to the sport, 4 participants indicated that they had switched to using a crossbow to return to the sport. The mean age of the participants who returned to sport was 69.7 years ( ± 6.32 years). Average VAS pain score of the return to sport group was 1.85 ( ± 0.34, range 0–6). Only one participant out of the 7 who endorsed returning to the sport had surgery on their dominant arm (Table 1). Of the six patients not returning to sport, two patients did not return due to pain and function, two due to functional limitations, one due to fear of injury and one due to another medical problem that inhibited participation.

Table 1 Patient demographics surgery side, return to sport, and pain scale.

Patient	Age	Gender	Dominant/Non-dominant	Returner	Pain Scale
1	81	Male	bilateral	YES^a	0
2	67	Male	N	YES	0
3	64	Male	N	NO	–
4	71	Male	D	NO	–
5	62	Female	D	NO	–
6	71	Male	N	YES^a	0
7	70	Male	D	YES^a	1
8	80	Male	N	NO	–
9	64	Male	N	YES^a	6
10	62	Female	bilateral	YES	4
11	73	Male	N	YES	2
12	72	Male	N	NO	–
13^a	83	Male	D	–	–
Mean	70.77				1.86
SD	7.11				2.34

a Indicates return by switching to crossbow.

a Indicates new archery participant.

4 Discussion

Overall, 54 % of patients were able to return to archery. This percentage is slightly higher than a smaller series finding only 2 out of 5 patients returned to archery after undergoing rTSA.⁴ These numbers are still below the average return to sport of a systematic review by Davey et al. that found 79.1 % of patients were able to return to sport after rTSA.⁷ Of the patients in our cohort, only three were able to return to vertical bows while four transitioned to crossbows. Drawback of a vertical bow requires 90° of shoulder abduction that is held until full drawback,⁸ which likely puts stress on the shoulder implant alongside the rotator cuff muscles. Utilizing a crossbow, putting the shoulder in a vulnerable and potentially painful position of abduction is not necessary and likely helps return to activity. Furthermore, return to sport was likely facilitated through improvements in patient pain and functional capacities. Postoperative pain in returning to sport was low with VAS averaging 1.85, ranging from 0 to 6. Four of the patients reported improvement in function postoperatively while two found worse function. Similarly, Garcia et al.⁹ found the average VAS pain scores to be 0.63 postoperatively for patients returning to sport following rTSA. However, fitness sports, such as running, were more likely to return than sports like golf or tennis. Return to golf and tennis are around 66.7 % and 50 % respectfully following rTSA, similar to the results found in this study.⁹ These sports stress the implants similarly to archery, likely limiting return to sport.⁷

Modified equipment may be helpful in facilitating return to archery after rTSA. Four patients switched to utilizing crossbows while one patient utilized a crank mechanism to facilitate pulling their crossbow. Patients did not report other modifications such as switching draw arms or changing the tension on their bows. Alongside equipment modifications, technical modifications may assist patients in return to archery. Lin et al.¹⁰ found that in unstable patients with a tremor, 90° of elevation in the full draw position was optimal to maximize muscle performance. Furthermore, scapular muscle amplitude was important for stability during drawing¹⁰ which may provide another mechanism to improve technical return to sport following rTSA. Thus, changes in technique, as well as equipment modifications, likely augments return to archery following rTSA.

Only one patient was able to return to archery after surgery on their dominant shoulder. This is likely due to the strain on the implant and surrounding musculature put on the draw arm in which the surgery occurred. During different stages of archery, changes in position of the humerus and scapula alter the stress experienced by the rotator cuff muscles.¹¹ Peak muscle activation is significantly higher in the biceps muscle of the draw arm while the lateral deltoid and triceps have significantly higher peak muscle activation in the bow arm.¹² The teres minor is under greater stress during release while the subscapularis can be damaged during prolonged abduction during the draw phase. Mann et al.⁸ found supraspinatus, infraspinatus and teres minor tendonitis among elite archers in the drawing arm, suggesting extra stress along the rotator cuff muscles. Alternatively, You et al.¹³ found biceps long head tendinopathy, more so than subscapularis or supraspinatus tendinopathy, of the draw arm in wheelchair athletes performing archery. These authors hypothesized that an eccentric contraction of the biceps is important to maintain a constant force in the draw arm during the draw phase. While bicep tenodesis doesn't alter flexion or supination strength in the native shoulder,¹⁴ we would hypothesize it may affect the patients ability to maintain this force during the draw phase. Additionally, strengthening the lower trapezius muscles improves function and decreases shoulder pain in archers.¹⁵ Razmjou et al.¹⁶ proposed exercises in the scapular plane and higher abduction angles to activate the deltoid, which may benefit patients seeking to return to archery after rTSA. Therefore, strengthening shoulder girdle muscles, including the deltoid as primary muscle for shoulder abduction in rTSA, may provide biomechanical advantages in returning to archery following rTSA.

For patients not returning to archery, two patients did not return due to pain and function, two due to functional limitations, one due to fear of injury and one due to another medical problem that inhibited participation. Previous studies have found restricted motion, fear of injury and weakness as the most common reasons preventing return to sport.⁴ Surgical factors may include medializing the center of rotation in rTSA,¹⁷ stabilizing the shoulder via subscapularis repair¹⁸ and improving range of motion,¹⁹ and larger glenospheres to limit impingement²⁰). Surgical considerations may assure patients they have a solid construct in return to archery.

4.1

4.1 Limitations

Our patient population was mostly men and was a small sample size, limiting generalizability of our findings. With only one surgeon, the results may not reflect that of another practice. The study was performed retrospectively and was a survey, which introduces some bias.

5 Conclusion

Return to archery following rTSA is possible and is more likely if the surgery is performed on the bow arm than the draw arm. Modulating technique and equipment may benefit patients wishing to return to sport including switching from a vertical to a crossbow. Furthermore, targeted physical therapy to strengthen the deltoid as well as the trapezius may better facilitate ability to bow drawing capabilities. Preoperative surgical considerations could include a medialized prosthesis or subscapularis repair to improve biomechanical strength and stability.

Author contributions

Andrew Lachance, MD: writing, editing.

Margaret E. Jonas, MS: data collection, editing.

Brandon O'Brien, D.O.: data collection, writing.

Mira Patel: data collection.

Antonina Calcavecchio, D.O.: data collection.

Jesse Constantino: data collection.

Anna Moravec, M.D. 1: data collection.

Joseph Choi, MD PhD MH: editing, creation of project.

Financial/material support statement

None.

Consent

Human subjects research was deemed not applicable by IRB.

Ethics

There are no reported ethical conflicts of interest within this study.

Funding

There was no funding for this project.

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