Monday, July 18, 2011

Revision surgery for failed total shoulder replacement arthroplasty - our approach, Part 1

Principles of Revision Surgery


Considering Revision Surgery

Revision shoulder surgery calls on judgment, experience, and technical skills that are an order of magnitude greater than for primary shoulder surgery.  There are ten questions that we ask before taking on a revision case:

(1)         Do we have sufficient past records on this case?

(2)        Is the problem a mechanical one that is clearly identified (as opposed to a problem that is manifest as pain or frustration without a clear mechanical cause)?

(3)        Is there a nonoperative approach to the problem?

(4)        Is the mechanical problem treatable?

(5)        Is the patient of sufficient mental and physical health and strength to undergo a revision surgery – are the patient’s metabolism and the skin over the shoulder ready for another surgery, has the patient ceased smoking, are alcohol consumption and pain medication use under control?

(6)        Are the patient’s expectations reasonable?

(7)        Does the patient fully understand the risks and possible outcomes of surgery, including the anticipated incision and the possibility that infection may be encountered?

(8)        Do we need a consultation to help define the cause and treatment of the problem?

(9)        Are we the best surgeons to carry out the revision surgery?

(10)    Do we have the right tools and team to carry out the surgical revision?

To answer these questions, we seek the following information prior to considering a surgical revision:

(1)         An understanding of the patient’s status prior to the index procedure.

(2)        Previous operative notes, including information on the type, manufacturer, and size of implants.

(3)        An assessment of the legal and insurance aspects of the case.

(4)        Knowledge of the medical status of the patient including:
a.            Health conditions that may affect the patient’s surgery
b.            Current medications including pain medications and dosages
c.             The amount of nicotine and alcohol currently being consumed
d.            The psychological status of the patient
e.             The vocational status of the patient
f.              The social situation and support systems for the patient
g.            Current laboratory values including a CBC, sedimentation rate, and serum albumin.
(5)        High quality anteroposterior and axillary radiographs as well as an anteroposterior radiograph of the entire humerus.

(6)        Completed Simple Shoulder Test and Short Form-36 Questionnaires.

(7)        A physical examination of the neck and shoulder, including the location of skin incisions and the health of the skin in the areas of possible incision.

(8)        An EMG if there is concern about radiculopathy or neuropathy.

(9)        Consent for bone autograft, tendon autograft, or allograft as necessary.

(10)    Medicine, anesthesiology, and pain service consults as necessary.

(11)     Urine analysis to screen for drug, alcohol and nicotine, if indicated.


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