A Intermediate Evaluation and Management 1 Performs focused history and physical history premorbid level of function history of malignancy occupation and hand dominance concomitant and associated orthopaedic injuries perform neurovascular exam physical exam 2 Orders and interprets required diagnostic studies 3 Knowledge of surgical indications 4 Post operative management postop: 2-3 week postoperative visit wound check continue maximizing passive range of motion diagnose and management of early complications<br /> postop: ~ 6 week postoperative visit diagnosis and management of late complications<br /> start active elevation above 90 degrees start passive stretching and strengthening exercises start using arm for light daily activities avoid strenuous activity for 6 months 3 month postoperative visit start strength training with rubber bands B Advanced Evaluation and Management 1 Order appropriate imaging studies 2 Provides post-op management and rehabilitation C Preoperative H & P 1 Perform basic history and physical exam check neurovascular status 2 Ensure all studies are required to proceed with surgical intervention radiographs AP view CT scan 2D scans 3 Perform operative consent describe complications of surgery including infection instability rotator cuff tear ectopic ossification glenoid component loosening intraoperative fracture nerve injury
E Preoperative Plan 1 Radiographic templating 2 Execute surgical walkthrough describe the steps of the procedure verbally prior to the start of the case 3 Description of potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation TSA system 2 Room setup and Equipment standard operating table in the beach chair position fluoroscopy 3 Patient Positioning rotate the table 90 degrees so that the operative shoulder is opposite the anesthesia team G Deltopectoral Incision 1 Identify and mark the deltopectoral groove make a 10-15 cm incision following the line of the deltopectoral groove in obese patients, this may be difficult to palpate; the incision starts at the coracoid process, which is usually more easily palpable 2 Identify the deltopectoral fascia the interval can be found by identifying the cephalic vein 3 Develop the interval retract the cephalic vein medially or laterally retract the deltoid laterally and the pectoralis medially identify and protect the axillary and the musculocutaneous nerves H Subscapularis Takedown 1 Start the osteotomy (for Lesser Tuberosity Osteotomy) use a 2 inch curved osteotome to make a 0.5 to 1 cm thick osteotomy start by placing the osteotome at the base of the bicipital groove palpate the most anterior aspect of the tuberosity with the index finger of the other hand once the osteotomy is complete, place a straight osteotome in the osteotomy site and rotate about the long axis to free the osteotomy fragment from the soft tissue attachments 2 Deliver the fragment (for Lesser Tuberosity Osteotomy) place a large Cobb elevator in the osteotomy site to lever the fragment anteriorly 3 Prepare the lesser tuberosity (for Lesser Tuberosity Osteotomy) place 3 nonabsorbable sutures around the lesser tuberosity fragment sutures should be placed in the bone subscapularis junction externally rotate the arm to expose the most inferior portion of the subscapularis muscle incise the muscle belly superficially in line with the fibers about 1 cm superior to the most inferior border 4 Develop interval (for Lesser Tuberosity Osteotomy) use a blunt elevator to dissect the interval between the subscapularis and the underlying capsule once the interval is developed use a scalpel and pass it laterally so that it exits inferior to the fragment continue this from inferior to superior to release the subscapularis and the lesser tuberosity from the underlying anterior and inferior capsule 5 Alternative Approach: Transtendinous release. mark the location of the biceps tendon perform a tenotomy of the subscapularis approximately 1 cm away from the biceps tendon go through the capsule and the subscapularis simultaneously place 1 suture superiorly place 1 suture inferiorly I Humeral Neck Cut and Humeral Preparation 1 Resect the humeral head remove the humeral head with a saw at or near the anatomic neck leave a small amount of bone medial to the supraspinatus tendon 2 Ream the humeral canal ream the humeral canal with sequentially larger reamers until light purchase is obtained use a boxed osteotome that is the same size of the final reamer and pass into the humerus cut the footprint of the humeral implant 3 Sequential broaching and trial stem placement place a broach that corresponds to the size of the box osteotome and final canal reamer to the appropriate depth 4 Place collar (optional depending on prosthesis) screw a collar into the broach that creates a 135 degree neck shaft angle place a calcar over the reamer if the reamer is nearly parallel to the osteotomy surface, it is used to plane the surface to 135 degrees J Glenoid Prepatation and Prosthesis Placement 1 Place retractors place a fukuda ring retractor in the joint and retract the humerus posteriorly place a double pronged bankhart retractor on the scapular neck anteriorly between the anterior capsule and the subscapularis place a blunt hohmann retractor along the anteriorinferior portion of the scapular neck this Is to retract and protect the axillary nerve 2 Remove the capsule excise the anterior and inferior capsule release the posterior capsule unless the preoperative humeral subluxation is greater than 25% 3 Remove the labrum excise the labrum circumferentially 4 Size the glenoid size the glenoid with a sizing disk 5 Drill holes in the glenoid drill a pilot hole in the center of the glenoid use special glenoid reamers to ream concentrically around the center pilot hole create the anchoring holes for the glenoid drill the center hole for the larger fluted central peg drill the holes for the three peripheral pegs 6 Place a trial glenoid component check that the component is seated well and stable 7 Place bone cement irrigate and dry the holes place bone cement into the three peripheral holes 8 Place the final component impact the glenoid component into position hold the glenoid component into position with digital pressure until the cement hardens K Humeral Stem Placement 1 Redeliver the humerus into the wound 2 Place final humeral stem 3 Pass a nonabsorbable suture around the neck of the prosthesis L Humeral Head Trialing and Placement 1 Place a trial humeral head over the collar 2 Verify components 3 Remove trial head 4 Place the final head component rotate into the offset position that gives the most symmetrical coverage of the humeral metaphysis and lock the collar into the broach 5 Impact the head implant onto the humeral stem. N Subscapularis Repair and Wound Closure 1 Pass sutures for repair (for Lesser Tuberosity Osteotomy) pass the sutures that were previously placed in a mattress configuration through the subscapularis tendon from deep to superficial at the bone tendon junction clamp but do not tie the sutures the deep limbs of the sutures that have already been passed around the lesser tuberosity are passed through the cancellous bone of the osteotomy bed as far laterally as possible deep to the bicipital groove and out of the lateral cortex of the humerus use a large, cutting free needle use a fresh needle for each pass 2 Tie sutures (for Lesser Tuberosity Osteotomy) tie sutures beginning with the tuberosity to shaft reapproximation then the tuberosity to tuberosity closure using the previously placed suture limbs pull the clamps on these sutures laterally to hold the lesser tuberosity in a reduced position close the rotator interval with 1 mm nonabsorbable suture tie the three interfragmentary sutures next tie the sutures from the anchors 3 Transtendinous repair place 3 mason allon sutures with non absorbable suture for tendinous repair tie the sutures test external rotation and the integrity of the repair 4 Irrigation copiously irrigate wound 5 Deep closure use 0-vicryl for fascia 6 Superficial closure use 2-0 vicryl for subcutaneous tissue use 3-0 monocryl for skin 7 Immobilization place in sling
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids order AP and lateral views to assess placement of implants DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 inpatient physical therapy start passive ROM exercises on POD 1 passive elevation to 140 degrees passive external rotation to 40 degrees start pendulum exercises appropriate medical management and medical consultation 2 Discharges patient appropriately outpatient pt pain meds schedule follow up appointment in 2 weeks R Complex Patient Care 1 Comprehensive pre-op planning/alternatives. 2 Modify and adjust post-op plan as needed 3 Understand how to avoid and prevent complications 4 Treat simple complications intraoperatively and postoperatively 5 Understand how to avoid /prevent potential complications