Patient Education and Consent

Patient education is a critical part of the preoperative evaluation, as well as of the postoperative rehabilitation period. A multidisciplinary approach involving the surgeon, primary care physician, physician extenders, nurses, physical therapists, and occupational therapists provides the patient with the resources necessary for optimal outcomes.

Educating the patient about reasonable goals, expectations, and outcomes as well as potential complications ensures that the patient can make an informed decision and be sufficiently motivated. The physical therapist plays a critical role in educating the patient as to ongoing home exercises that will optimize and maintain the health of the shoulder replacement.

Preprocedural Planning

Preoperative laboratory tests are ordered on the basis of the patient’s age and medical history. Studies such as urinalysis, electrocardiography (ECG), and complete blood count (CBC) with differential are ordered for all patients older than 50 years. Patients with a medical history are counseled by primary care providers or specialists to obtain medical clearance in advance of surgery, and laboratory tests are performed at the discretion of the referred provider.

Equipment

An important innovation in shoulder arthroplasty is the use of three-dimensional (3D) virtual planning programs by surgeons.^[11]After computed tomography (CT) scans of the patient are uploaded, the software creates an anatomically correct, patient-specific computerized model of the shoulder joint. This allows surgeons to plan the surgery virtually and estimate the patient’s postoperative function on the basis of both their training and the suggestions made by the program.

Overall, this software helps improve outcomes, precision, efficiency, and component placement and sizing. Furthermore, it helps surgeons anticipate possible issues (eg, bony cysts or equipment needs).

After planning is complete, a customized drill guide can be ordered for use in the actual surgical procedure; this customized guide enables optimal placement of the glenoid component. Walch et al demonstrated the precision of the 3D planning software and the guides for glenoid placement.^[40]This virtual planning software poses no known risks to patients and has been shown to aid surgeons in making informed operative decisions.^[41]It has been used by Dr Warner at the Boston Shoulder Institute.

Various humeral components are available for hemiarthroplasty, depending on patient-specific anatomy, bone quality, and surgical indication, as follows (see the images below):

Humeral resurfacing caps without a stem
Fluted stem prostheses for cementing
Press-fit cementless stemmed prostheses
Long-stem prostheses for fracture or revision
Stemless prosthesis
Cobalt chrome or titanium alloy components

Tornier Aequalis resurfacing cap.

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Tornier Aequalis cemented primary shoulder.

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Tornier Aequalis press-fit primary shoulder.

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$Tornier Aequalis fracture shoulder.$ Tornier Aequalis fracture shoulder.

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Tornier AEQUALIS ASCEND™ FLEX Convertible Shoulder System. For more information visit www.wright.com. Used with permission.

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Levy and Copeland reported excellent results using cementless resurfacing caps for osteoarthritis of the shoulder.^[42]By avoiding the use of a stemmed component, complications involving periprosthetic fracture and humeral insertion were avoided.

Modular systems offer multiple component choices to match patient-specific inclination and retroversion to restore proper anatomy. Modular systems have also revolutionized the revision of hemiarthroplasty to reverse total shoulder arthroplasty. In a revision surgery using previously implanted modular components, the humeral head can be removed from the stem and replaced with a reverse total shoulder cup component. This change-out bypasses the necessity for removing the humeral stem during the revision.

Anesthesia

Patients receive a preoperative interscalene before being taken back to the operating room to anesthetize the upper roots of the brachial plexus. This provides excellent pain control in the immediate postoperative period and permits minimization of general anesthetic during the procedure. The anesthesiologist administers general anesthesia with neuromuscular paralysis for the duration of the surgical procedure.

Positioning

The patient is placed in the modified beach-chair/semi-Fowler position with knees flexed. A McConnell headrest allows proper positioning with the patient toward the top portion of table and with the affected shoulder's arm hanging off the table edge nearest the primary surgeon. The entire arm should then be draped and prepped in meticulous sterile fashion.^[43]

Monitoring & Follow-up

After hemiarthroplasty, long-term monitoring is left to the discretion of the surgeon on the basis of the stability of results after the initial 6 months of rehabilitation. Annual examinations with plain films can be scheduled to determine potential implant loosening, assess progressive glenoid wear, and clinically examine shoulder function. Any loss of function, interference with previously normal activities of daily living, or progressive shoulder pain should prompt a visit to the surgeon; these symptoms may be indicative of implant wear or failure.

Technique

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Media Gallery

Tornier Aequalis resurfacing cap.
Tornier Aequalis cemented primary shoulder.
Tornier Aequalis press-fit primary shoulder.
Tornier Aequalis fracture shoulder.
Tornier AEQUALIS ASCEND™ FLEX Convertible Shoulder System. For more information visit www.wright.com. Used with permission.