Sunday, May 31, 2015

Shoulder joint replacement - preparation

It is helpful if surgical teams can standardize the preoperative, operative and postoperative protocols for shoulder arthroplasty - this standardization improves both patient safety and efficiency. Because so much is common to most shoulder joint replacements, it presents an opportunity for the surgical team to establish ‘the way we always do it’. While the protocol is a matter of individual surgeon choice, the key is standardization to minimize unnecessary uncertainty. The approach described below is one ‘way to do it’.

The patient’s identity, allergies, medical conditions, side of surgery, condition of the skin of the shoulder and axilla, diagnosis, procedure and discharge plan are confirmed with the patient awake. The presence or absence of a pacemaker is verified along with its recommended management.

The requisite x-ray plain films including a template view are displayed to confirm the side of surgery and reviewed to reveal the amount, quality, and orientation of the glenoid bone, as well as the size and configuration of the humerus down to where the tip of the humeral prosthesis will rest. 

The goal is to anticipate the final position of the humeral and glenoid components and to determine whether any particular problems in their placement can be anticipated. Is there significant glenoid erosion or altered version? Are any potentially confusing glenoid osteophytes present? Is enough bone available to support a glenoid component or is there a large glenoid cyst?


What is the diameter of curvature of the humeral joint surface? Is the humeral canal straight? Is it cylindrical or funnel shaped? What size is it? Does the bone appear fragile? What is the position of the tuberosities in relation to the canal and the joint surface? How much humeral bone will need to be excised? Are there other major abnormalities of bone structure that could change the procedure?

Is it likely that an in situ humeral cut will be needed because locking osteophytes will complicate the dislocation of the proximal humerus?

Might a high-speed saw be needed to modify the humeral stem?

Might cancellous allograft be needed to augment the bone available for impaction grafting? Is there a reason to withhold antibiotics until cultures can be obtained?

Patients are not routinely cross-matched unless they are anemic or unless extraordinary blood loss is anticipated, but specimens are sent preoperatively for ‘type and hold’.

An 18 gauge intravenous line is placed in the opposite upper extremity, avoiding the antecubital fossa (to keep from encumbering the postoperative use of the contralateral arm). If this IV line cannot be established, access is established through the external jugular vein. IVs in the foot are avoided so as not to impair ambulation after surgery. Ceftriaxone (2 grams) and Vancomycin (1 gram q 12 h) are administered in normal saline (to prevent precipitation) as the routine preoperative antibiotic prophylaxis against the most common shoulder arthroplasty pathogens: Propionibacterium and coagulase negative staphylococcus.These antibiotics are discontinued after 24 hours.

General anesthesia is used to avoid the cost and potential risks of nerve blocks, to enable immediate postoperative neurologic examination, and to facilitate rapid transition to oral analgesics as the patient is weaned off intravenous narcotics on the evening of surgery.

The preoperative ranges of motion are measured and posted on a white board in full view of the surgical team. A Foley catheter is placed for most male patients and for female patients with voiding or ambulation difficulties; the Foley is discontinued the morning after surgery. Pneumatic compression stockings are used during surgery. Pharmacologic thromboembolic prophylaxis is used only in patients at substantial risk and after consultation with the medicine service.

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