Difference between revisions of "Shoulder arthroplasty"

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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type = General vs regional
| anesthesia_type = General and/or regional
| airway = ETT vs non-invasive O2
| airway = ETT if GA
| lines_access = PIV x 1-2 (opposite limb, large bore)
| lines_access = PIV in opposite limb
| monitors = Standard, 5-lead EKG, temperature
| monitors = Standard
| considerations_preoperative = Type and screen, airway and neurologic physical examination
5-lead ECG
| considerations_intraoperative = Optimal BP management for cerebral perfusion, VAE
Temperature
| considerations_preoperative = Type and screen
Airway and neurologic physical examination
Note baseline MAPs
| considerations_intraoperative = Maintain cerebral perfusion (MAP ±20% of baseline)
VAE
| considerations_postoperative = Cerebrovascular accident
| considerations_postoperative = Cerebrovascular accident
}}'''Shoulder arthroplasty''' is a surgical procedure which replaces the humeral head with a prosthesis. Indications include pain associated with severe osteoarthritis and restoration of mobility<ref name=":0">{{Cite journal|last=Ding|first=David Y.|last2=Mahure|first2=Siddharth A.|last3=Mollon|first3=Brent|last4=Shamah|first4=Steven D.|last5=Zuckerman|first5=Joseph D.|last6=Kwon|first6=Young W.|date=2017-12-01|title=Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis|url=https://www.sciencedirect.com/science/article/pii/S0972978X17301071|journal=Journal of Orthopaedics|language=en|volume=14|issue=4|pages=417–424|doi=10.1016/j.jor.2017.07.002|issn=0972-978X|pmc=PMC5537444|pmid=28794581}}</ref>, and may be associated with avascular necrosis, rheumatoid arthritis (RA), trauma, or a rotator cuff tear<ref name=":0" /><ref name=":1" />.
}}'''Shoulder arthroplasty''' is a surgical procedure which replaces the humeral head with a prosthesis. Indications include pain associated with severe osteoarthritis and restoration of mobility<ref name=":0">{{Cite journal|last=Ding|first=David Y.|last2=Mahure|first2=Siddharth A.|last3=Mollon|first3=Brent|last4=Shamah|first4=Steven D.|last5=Zuckerman|first5=Joseph D.|last6=Kwon|first6=Young W.|date=2017-12-01|title=Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis|url=https://www.sciencedirect.com/science/article/pii/S0972978X17301071|journal=Journal of Orthopaedics|language=en|volume=14|issue=4|pages=417–424|doi=10.1016/j.jor.2017.07.002|issn=0972-978X|pmc=PMC5537444|pmid=28794581}}</ref>, and may be associated with avascular necrosis, rheumatoid arthritis (RA), trauma, or a rotator cuff tear<ref name=":0" /><ref name=":1" />.


The procedure is typically performed using a deltopectoral incision. The head of the humerus is removed and a prosthesis is placed with or without cement. The glenoid's surface is smoothed and the glenoid prosthesis is placed. The humeral prothesis is fitted onto the glenoid prosthesis. After surgery, the patient is placed in a shoulder sling or immobilizer.<ref name=":1">{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>
The procedure is typically performed using a deltopectoral incision. The head of the humerus is removed and a prosthesis is placed with or without cement. The glenoid's surface is smoothed and the glenoid prosthesis is placed. The humeral prothesis is fitted onto the glenoid prosthesis. After surgery, the patient is placed in a shoulder sling or immobilizer.<ref name=":1">{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=6|location=Philadelphia|oclc=1117874404}}</ref>


==Preoperative management==
==Preoperative management==
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*Interscalene block as primary anesthetic or supplement to general anesthesia
*Interscalene block as primary anesthetic or supplement to general anesthesia
*Can consider nerve catheter for intraop and postop pain management


==Intraoperative management==
==Intraoperative management==
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==References==
==References==
 
<references />
[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
<references />
[[Category:Orthopedic surgery]]
[[Category:Orthopedic surgery]]
[[Category:Joint replacement surgery]]
[[Category:Joint replacement surgery]]
[[Category:Shoulder surgery]]

Latest revision as of 14:21, 13 June 2022

Shoulder arthroplasty
Anesthesia type

General and/or regional

Airway

ETT if GA

Lines and access

PIV in opposite limb

Monitors

Standard 5-lead ECG Temperature

Primary anesthetic considerations
Preoperative

Type and screen Airway and neurologic physical examination Note baseline MAPs

Intraoperative

Maintain cerebral perfusion (MAP ±20% of baseline) VAE

Postoperative

Cerebrovascular accident

Article quality
Editor rating
Comprehensive
User likes
0

Shoulder arthroplasty is a surgical procedure which replaces the humeral head with a prosthesis. Indications include pain associated with severe osteoarthritis and restoration of mobility[1], and may be associated with avascular necrosis, rheumatoid arthritis (RA), trauma, or a rotator cuff tear[1][2].

The procedure is typically performed using a deltopectoral incision. The head of the humerus is removed and a prosthesis is placed with or without cement. The glenoid's surface is smoothed and the glenoid prosthesis is placed. The humeral prothesis is fitted onto the glenoid prosthesis. After surgery, the patient is placed in a shoulder sling or immobilizer.[2]

Preoperative management

Patient evaluation

System Considerations
Neurologic Baseline neurological exam
  • Preexisting neuropathy especially with regional technique
  • Increased risk of CVA if in beach chair position
Cardiovascular Baseline blood pressure especially important to note given upright position
Respiratory Assess for pleural effusions, pulmonary fibrosis, involvement of cricoarytenoids, and TMJ due to RA
Hematologic Assess for chronic anemia
Endocrine If arthritis is autoimmune-mediated, assess for chronic steroid use
Other Assess for cervical neck motion as some patients suffered rheumatoid arthritis or trauma

Labs and studies

  • Type and screen

Patient preparation and premedication

  • Midazolam for anxiety
  • Consider initiating multimodal pain management preoperatively

Regional and neuraxial techniques

  • Interscalene block as primary anesthetic or supplement to general anesthesia
  • Can consider nerve catheter for intraop and postop pain management

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • 5-lead EKG
  • PIV x 1-2 (opposite limb, large bore)
  • +/- arterial line
  • Consider precordial doppler given increased risk of venous air embolism in the upright position

Induction and airway management

  • If using general anesthesia, ETT typically preferable for airway security given patient positioning and surgical manipulation
  • If regional is chosen, moderate to deep sedation is reasonable

Positioning

  • Semi-sitting upright (beach chair)

Maintenance and surgical considerations

  • Maintain MAP within 20% of baseline to ensure adequate cerebral perfusion in upright position
  • Maintenance of neuromuscular blockade may be helpful for surgeons
  • Monitor for venous air embolus, especially during placement of cement

Emergence

  • PONV prophylaxis
  • Consider cerebral infarction if delayed emergence

Postoperative management

Disposition

  • PACU
  • Floor

Pain management

  • Pain is usually moderate to severe
  • Multimodal management
    • Regional anesthesia
    • Acetaminophen
    • NSAIDs (verify with surgeons)
    • Gabapentin
    • Opioids

Potential complications

  • CVA
  • Bleeding
  • Infection
  • Brachial plexus nerve injury

Procedure variants

Total shoulder arthroplasty
Unique considerations
  • Sitting position
  • Methyl methacrylate cement can cause severe hypotension/VAE
Position Semi-sitting/beach chair
Surgical time 2-5 hours
EBL 200-1000 mL
Postoperative disposition Floor
Pain management moderate-severe
Potential complications
  • CVA
  • VAE
  • brachial plexus injury

References

  1. ↑ 1.0 1.1 Ding, David Y.; Mahure, Siddharth A.; Mollon, Brent; Shamah, Steven D.; Zuckerman, Joseph D.; Kwon, Young W. (2017-12-01). "Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis". Journal of Orthopaedics. 14 (4): 417–424. doi:10.1016/j.jor.2017.07.002. ISSN 0972-978X. PMC 5537444. PMID 28794581.CS1 maint: PMC format (link)
  2. ↑ 2.0 2.1 Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (6 ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404.CS1 maint: others (link)

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