Clinical Pathway for TSA/HHR Patients
Shane K. Woolf, MD
James R. Demarco, MD
H. Del Schutte, MD
Objective:
I.
To create an evidence-based clinical pathway for the evaluation and care
of patients who present with degenerative disease of the gleno-humeral
joint and are candidates for surgical reconstruction.
Preoperative evaluation
a. Imaging
i. Plain radiographs
1. Grashey AP view
2. Axillary lateral view
3. Supraspinatous outlet view
4. External/Internal rotation AP views, possibly
ii. CT scan
1. If any concern for posterior glenoid wear or gleno-humeral
deformity
iii. MRI
1. If need to evaluate status of rotator cuff tendons or muscle
belly
2. Aids in decision for HHR vs TSA
b. Outcomes Assessment
i. SANE
ii. VAS pain scale
iii. Simple Shoulder Test
iv. ASES??
c. Lab Studies
i. EKG if over 50
ii. CXR if indicated
iii. BMP
iv. CBC
II.
v. Coags, if indicated
vi. Urinalysis, culture + sensitivity
1. Must be done within 5 days of surgery, if possible
2. Call in Cipro 250 mg po bid x 5 days or Bactrim DS I po
bid x 5 days if positive cultures, leuk esterase or nitrites
vii. Type and screen in holding
viii. If revision case:
1. Infection labs (ESR, CRP, CBC with manual diff)
2. Nutrition labs (transferrin, prealbumin, absolute
lymphocyte count)
3. Joint aspirate if indicated
a. Cell count, gram stain
b. Aerobic/anaerobic cultures
d. Medical Evaluation and Preoperative Optimization
i. Notify Hospitalist when scheduled
1. Decision for preop anesthesia and ortho workup
ii. PCP letter of medical clearance (in chart before surgery)
iii. No preop workup if otherwise healthy???
iv. Stop ASA, NSAIAs, Plavix by 7 days preop
v. Stop coumadin by 5 days preop, INR < 1.5 for surgery, preop
heparinization on case-by-case basis
e. Dental Evaluation
i. Indicated in those with poor dentition, loose teeth, caries
ii. Treat oral pathology before implants in shoulder
Perioperative Management
a. Holding room
i. Confirm labwork and studies are complete and satisfactory
ii. ISB or paravertebral block by anesthesia in all eligible candidates
1. Indwelling pump OK, if paravertrebral block
2. Placement within 1 hour of OR
iii. Cefazolin 2 gm IV (or Vancomycin 1 gm IV OCTOR if
PCN/cephalosporin allergy more than rash/hives)
iv. TED stockings and SCDs placed in holding
v. Wash operative extremity/site with chlorhexidine and rinse with
alcohol in holding
vi. Initial operative site, confirmed by consent form and verbally
b. Operating room
i. Beachchair position
ii. Foley catheter on request only
iii. Surgeon preference for setup
iv. Surgeon preference and indications for implants, technique
v. Simple sling + ABDs in axilla when finished
c. PACU
i. May raise head of bed to tolerance
ii. Remain in sling
iii. Neurovascular checks q 30 min x 2 hours to operative extremity
1. Capillary refill
2. Grip, finger abduction, thumb extension, gentle elbow
flexion and extension
3. Forearm, index and small finger sensation to light touch
iv. Shoulder precautions
1. No external rotation > neutral
2. No active or resisted internal rotation
3. May forward flex to 90 degrees
v. Postoperative imaging
1. Neutral and internally rotated AP views
d. Pain management
i. Regional block +/- indwelling catheter
ii. Morphine PCA pump
iii. May change to oral pain meds (oxycodone or Percocet, NOT
oxycontin) with IV breakthough once taking po well
e. Arrival to JRU bed and HD #1
i. General patient care
1. MIVF until taking >300 cc fluids without nausea
2. Pain control as above
3. Reinforce dressing as needed
4. Must have assistance 1st 24 hrs whenever getting out of bed
5. Foley removed once able to get out of bed to commode or
toilet
6. SCDS or Foot pumps whenever in bed prior to d/c
7. TEDs until mobilized
8. Shoulder precautions as above
9. Drain removed on POD#1 unless > 30 cc/shift
ii. Patient positioning
1. Elevate HOB as needed for comfort
2. Keep hand above elbow
3. Pillow under forearm to support hand and slightly flex
shoulder forward
iii. Physical Therapy
1. Begin POD #1
a. Mobilization and transfers
i. Assess safety
ii. Fall precautions
b. Reinforce shoulder precautions
c. Initiate protected (‘helper hand’) pendulums
d. Protected supine forward flexion (overhead
elevation) and rotation from chest wall to neutral
position
2. TSA/HHR rehab protocol
a. See Appendix A
b. Modify as indicated
iv. Occupational Therapy
III.
1. Begin POD #1
a. ADL assistance
b. Don/doff clothing safely
c. Assess home status
v. Perioperative Medications
1. Antibiotics
a. 1st 24 hrs
b. Cefazolin or Vancomycin
2. DVT prophylaxis
a. LMWH
i. Begin by 12-18 hours postop
ii. Continue until mobilized/ambulatory
b. Continue LMWH in high risk patients
i. Previous DVT/PE
ii. Previous extremity surgery or trauma
iii. Age > 70
iv. Protein C/S or Antithrombin III deficiency
v. Hx of Cancer
vi. HX PVD or phlebitis
vii. Slow to mobilize
viii. If smoker and on HRT
ix. > 2 risk factors
Lyman et al, CORR 2006
3. General
a. MVI + iron
b. Stool softener  7 West Bowel protocol
vi. Labwork
1. POD #1
a. BMP
b. Hemoglobin/hematocrit
2. POD #2
a. Only if indicated
Postoperative Management
a. Discharge from hospital
i. Criteria
1. Transfer and ambulate with minimal to no assistance
2. Taking po and voiding
3. Pain control adequate
4. No apparent postop issues/complications
ii. Copy of patient instructions to be placed in folder
1. See Appendix B
iii. Medications
1. Pain meds (oxycodone)
2. MVI + iron
3. stool softener
4. LMWH x 10 days (if indicated)
iv. Physical therapy
1. outpatient vs HHPT
a. Prescription in folder
b. TSA/HHR protocol
2. sling x 4-6 weeks, MD directed
3. Shoulder precautions
v. Will need antibiotics for future dental and surgical procedures
b. Follow-up
i. Routine follow-up schedule
1. ~ 2 weeks - 1st visit
a. No radiographs unless an issue arises
b. Sutures/staples removed, wide steri-strips applied
(no benzoin)
c. May drive at 4-6 weeks only if no pain off pain
meds
i. Explain liability risk to patient if accident
occurs
ii. Risk of disrupting repair
2. 6 weeks – 2nd visit
a. Plain radiographs
i. Grashey AP
ii. Axillary lateral
iii. External rotation/internal rotation views
b. d/c sling
c. continue PT
3. 3-4 months – 3rd visit
a. No radiographs unless indicated
b. PT only as needed
4. 6 months
a. Radiographs
i. Grashey AP
ii. Axillary lateral
iii. External rotation/internal rotation views
b. Activity as tolerated
5. 12 months and every year thereafter
a. Radiographs as above
ii. Outcomes Measures
1. Administer at 4, 6, 12 months
2. Administer annually after 12 month anniversary
Appendix A.
Total Shoulder Arthroplasty/ Humeral Head Replacement
Rehabilitation Protocol
Goals:
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Pain control
Edema control
Protect subscapularis, rotator interval, and/or rotator cuff repairs
Gradual restoration of motion
Return to effective use of limb for ADLs
Restore shoulder strength and function
Phase I (0-4 weeks postop)
Sling immobilization except for washing and clothing changes x 4-6 weeks
Exercises 5-6 times/day for 10-15 minutes each session
 Codmans/Pendulum exercises using ‘helper hand’ for support
 Wrist, Hand AROM
 Elbow AROM (***wait 2-3 weeks if biceps tenotomy/tenodesis)
 Gripping exercises
Limits:
 FF-AAROM (supine)-limited to 90o
 ER to 0o only
 IR to chest wall
 Sub-maximal, pain-free deltoid, trapezius isometrics in neutral
Modalities as needed
Phase II (4-6 weeks)
Continue sling whenever out of home in public to protect repairs
Continue FF-AAROM (wand/pulleys)
ER - AAROM to 30º only
FF – begin supine AROM
Manual scapular stabilization exercises
Begin pain-free ER isometrics in modified neutral
Modalities as needed
Phase III (6-8 weeks)
D/C sling
Begin use of the limb for ADLs as tolerated except no lifting/carrying
6 weeks - begin Biceps/Triceps strengthening
Progress scapular strengthening in protective arcs
Begin limited isotonic IR/ER strengthening in modified neutral
Begin seated FF in plane of scapula
Begin AROM for ER
Continue to increase FF AROM/PROM/AAROM
Phase IV (8-10 weeks)
Continue scapular strengthening
Advance isotonic strengthening for deltoid, trapezius, biceps, triceps and
latissimus as tolerated
Begin general flexibility exercises at 10 weeks
Phase V (10-16 weeks)
Begin gentle progressive resistive exercises of deltoid and rotator cuff
Restore shoulder flexibility
Continue full upper extremity strengthening
Appendix B.
Patient Instructions After Shoulder Replacement Surgery
1.
2.
3.
4.
5.
6.
7.
Apply ice for 20-30 minutes every 2 hours while awake for the
first 48 hours after surgery.
Pain medicine will be prescribed prior to discharge. Use the
medicine, as directed, over the first 48 hours, then begin to taper
your use.
Remove the dressing on the 3rd day after surgery. If the sites are
still moist, place a Band-Aid over the site until dry. If drainage
continues contact your physician.
Keep incisions dry for at least 5 days. After 5 days you may
shower, but do not submerge incisions until discussed with your
physician. When you shower do not rub the incision. Simply allow
the water to wash over the site, and then pat it dry.
A sling will be provided prior to discharge. Remove the sling 5
times each day to perform motion exercises. The sling should only
be removed for exercises or while showering. Continue to use the
sling for as long as your surgeon instructs, including during
sleep. Keep a clean pad in your armpit while wearing the sling to
prevent excessive sweating.
Active motion of the elbow, wrist, and hand are permitted
immediately. Active shoulder overhead reaching and lifting
are NOT permitted yet! You may use the operated arm after
surgery only for activities of daily living that do not require it to
leave the side of the body (eg eating, drinking, bathing, writing,
computer use, etc.)
Five times each day you should perform Passive and ActiveAssisted Range of Motion exercises. For example, forward
elevation and external rotation exercises should be performed with
the non-operated arm used as the “therapist arm” controlling the
motion of the operated arm. The operated arm should remain
relaxed at all times. Twenty of each exercise should be performed
five times per day.
8.
Overhead Reach is helping
to lift your stiff arm up as
high as it will go. Stretching
is the GOAL! To perform
overhead reach, lie flat on
your back, RELAX, grasp the
wrist of your operated
shoulder with the opposite
hand. Using the power of
your well arm, bring the other
arm up as far as comfortable. Start by holding it for 10 seconds and
then work up to where you can hold it for 30 seconds. Breathe
slowly and deeply while the arm is moved. Repeat this stretch
20 times, trying to move the arm up a little higher each time.
9.
Special Instructions:
***You must always take antibiotics before any major dental work (more than
routine cleanings) or surgical procedures. Please notify your dentist, surgeon,
or your orthopaedic surgeon if you need a prescription.
10.
Please Call (843) 792-0404 for:
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Any Urgent Questions or Concerns
o For medical emergencies call 911
Excessive redness of the incision
Drainage of more than 4 days
Fever of more than 101.5°
Call to confirm a follow up appointment with your surgeon 7-10
days after surgery if not already scheduled