Preoperative planning, imaging, and special tests

Clinical History and Examination

Although description of a detailed shoulder history and examination are beyond the scope of this textbook, certain aspects of the history and physical examination are important in preoperative planning for revision shoulder arthroplasty. The patient's complaints are reviewed, such as the type of symptoms (pain, stiffness, weakness), duration of symptoms (weeks, months, years), indication for the primary arthroplasty, initial results of the primary arthroplasty (relief of all symptoms, relief of some symptoms, no improvement from surgery), and the presence of any symptoms of infection (previous history of infection, fevers, wound redness, wound drainage). These shoulder-specific complaints help the surgeon decide which patients are candidates for revision shoulder arthroplasty. A patient with complaints of only mild pain, mild weakness, or mild stiffness may initially best be treated with nonoperative modalities even if radiographs demonstrate positive findings such as glenoid erosion after hemiarthroplasty. Similarly, a patient with a sudden onset of symptoms of a short duration to date may be experiencing a transient acute rotator cuff tendinitis not directly related to the shoulder replacement. In this situation, a period of nonoperative treatment would certainly be indicated. Special attention is given to factors that could make the operative procedure more difficult. The number and type of all previous shoulder surgeries, arthroplasty and nonarthroplasty, should be recorded in the patient's history. Chronic use of nonsteroidal antiinflammatory medications can result in excessive operative blood loss, so these medications should be discontinued the week before surgery.

Any medical history of systemic illness (diabetes mellitus, cardiac problems) should be considered in preoperative planning. Although these factors may not affect the actual surgical procedure, they may necessitate special considerations in the patient's postoperative care. Appropriate medical consultations should be obtained well in advance of the surgery date. The availability of appropriate care of these systemic illnesses, including the availability of consultants, should be confirmed before surgery.

All of our patients undergo a thorough shoulder examination, much of which is detailed in Chapter 7 . The visual appearance of the shoulder yields useful information in candidates for revision shoulder arthroplasty. The presence and location of surgical scars are noted. The preoperative plan should include whether all or part of a previous skin incision site is to be used or whether a completely new incision is to be created ( Fig. 36.1 ). In thin patients, anterior superior escape of a prosthetic humeral head caused by anterior superior rotator cuff deficiency may be obvious ( Fig. 36.2 ). Special attention should be paid to the condition of the deltoid, especially if it has previously been surgically violated ( Fig. 36.3 ). Atrophy of the supraspinatus and infraspinatus should be noted as well ( Fig. 36.4 ).

Both active and passive mobility is recorded, as detailed in Chapter 7 . Special attention should be paid to evaluation of the deltoid muscle. If deltoid contractility appears to be compromised, further evaluation with electromyography and nerve conduction studies should be performed before revision shoulder arthroplasty.

The integrity of the rotator cuff is tested (see Chapter 7 ). Details of this examination are of paramount importance in preoperative planning for revision surgery. Although a minor rotator cuff deficiency such as an isolated supraspinatus tendon tear may have little influence on preoperative planning, larger rotator cuff tears (two-, three-, and four-tendon tears), especially when coupled with static or dynamic glenohumeral instability, may change the type of revision prosthesis to be inserted (reverse instead of unconstrained).

The results of the clinical history and examination are documented in the patient's chart and reviewed well in advance of surgery as part of preoperative planning.