A Intermediate Evaluation and Management 1 Performs focused history and physical history premorbid level of function occupation and hand dominance concomitant and associated orthopaedic injuries perform neurovascular exam physical exam 2 Orders and interprets required diagnostic studies 3 Understand appropriate surgical indications. 4 Manges patient in early Post operative period. postop: 2-3 week postoperative visit wound check diagnose and management of early complications<br /> postop: ~ 6 week postoperative visit diagnosis and management of late complications<br /> avoid strenuous activity for 3 months 3 month postoperative visit check radiographs 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 axillary view shows the amount of medial glenoid erosion CT scan 2D scans defines the volume of the glenoid and any defects present 3 Perform operative consent describe complications of surgery including infection hematoma dislocation failure of tissue repair pain intraoperative fracture weakness
E Preoperative Plan 1 Radiographic templating template instrumentation 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 RTSA 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 Approach 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 4 Release the capsule incise the subscapularis and the capsule from the insertion to the lesser tuberosity preserve the maximal length of the tendon release the inferior capsule from the humerus identify the axillary nerve perform a 360 degree subscapularis release H Subscapularis Takedown (LT osteotomy described) 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 Transtendinous approach 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 insert the humeral resection guide into the medullary canal resect the humeral head in 0 degrees of retroversion when the arm is pulled distally, the plane of the humeral cut should pass just below the inferior glenoid 6 Prepare the humeral canal with reamers prepare the humeral canal by inserting progressively larger reamers until cortical contact is achieved insert a trial stem with a metaphyseal reamer guide in 0 degrees of rotation ream the metaphysis until bone purchase is achieved I Humeral Preparation and Trial Placement 1 Resect the humeral head insert the humeral resection guide into the medullary canal resect the humeral head in 0-30 degrees of retroversion when the arm is pulled distally, the plane of the humeral cut should pass just below the inferior glenoid 2 Prepare the humeral canal with reamers prepare the humeral canal by inserting progressively larger reamers until cortical contact is achieved insert a trial stem with a metaphyseal reamer guide in 0 degrees of rotation J Glenoid Preparation and Implant Placement 1 Expose the glenoid expose the upper axillary border of the scapula dissect the capsule from the anterior glenoid down to and around the inferior pole release the long head of the biceps as needed 2 Evaluate the glenoid check the glenoid under direct visualization and with radiographs to identify any abnormal glenoid anatomy remove the labrum and cartilage from the glenoid mark the anatomy points mark a point 13 mm anterior to the posterior rim of the glenoid and 19 mm superior to the inferior glenoid rim 3 Place the guidewire drill a guidewire into this designated point 4 Size the metaglene place metaglene of the Delta prosthesis over the guidewire with the peg laterally to verify the center point the inferior aspect of the metaglene should align with a line that is extended from the axillary border of the scapula 5 Drill the central hole remove the metaglene and drill a central hole with the step drill remove the glenoid in a conservative manner as to only remove enough bone to make the surface flat make sure that the reamer is perpendicular to the face of the glenoid 6 Place metaglene 7 Place screws orient the inferior locking screw the inferior locking screw will make a 16 degree angle with the central peg using a drill guide drill a hole for the inferior locking screw use a 2 mm drill bit unless the bone is hard achieve at least 36 mm of intraosseous drilling insert the inferior locking screw drill and insert the superior locking screw using a similar technique drill and insert the anterior nonlocking screw guide the orientation by palpating the anterior glenoid neck drill and insert the posterior nonlocking screw 8 Verify metaglene fixation after all screws have been inserted, check the metaglene fixation and make sure it is secure insert a trial glenosphere onto to the metaglene 9 Inspect the inferior portion of the glenoid K Trial Placement and Reduction 1 Redeliver the humerus into the wound 2 Perform trial reduction perform a trial reduction of the prepared humerus to see if the reamed metaphysis can be reduced to the glenosphere assemble and insert the trial humeral components in 0 degrees of retroversion with a 3 mm trial plastic component 3 Remove any bone that abuts against the humeral polyethylene component 4 Reduce the joint check for medial abutment of plastic against the axillary border of the glenoid stability range of motion <2 mm of distraction on distal traction L Final Component Placement 1 Place the glenosphere insert the glenosphere into the metaglene make sure that alignment is correct to avoid cross threading and that the component is fully seated 2 Assemble the humeral component secure the definitive humeral component with a strong crescent wrench brush and irrigate the humeral medullary canal insert a cement restrictor 13 cm distal to the lateral aspect of the humeral cut 3 Create anchors in the anterior neck cut drill six holes and place nonabsorbable no.2 suture in the anterior neck cut for reattachment of the of the subscapularis 4 If possible repair the posterior cut 5 Place the humeral component cement the assembled humeral component in 0 degrees of retroversion without a polyethylene insert trial different heights of polyethylene liners starting with 3 mm reduce the shoulder to identify the height that allows for reduction but less than 2 mm of distraction 6 Insert polyethylene insert the polyethylene component making sure that it seats fully irrigate the wound reduce the joint N 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 place a sterile dressing and an axillary pad
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 hand gripping and active elbow flexion no motion for 36 hours to help in prevention of hematoma formation no lifting over 1 pound for three months 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