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Pre-Op Planning for the TSA Patient Peter D. McCann, MD Director, Orthopaedic Surgery Lenox Health Greenwich Village Northwell Health Professor, Orthopaedic Surgery Zucker School of Medicine at Hofstra/Northwell. Disclosures. No Industry Relations. Pre-Op Planning for the TSA Patient. Surgery

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  1. Pre-Op Planning for the TSA PatientPeter D. McCann, MDDirector, Orthopaedic SurgeryLenox Health Greenwich VillageNorthwell HealthProfessor, Orthopaedic SurgeryZucker School of Medicineat Hofstra/Northwell

  2. Disclosures • No Industry Relations

  3. Pre-Op Planning for the TSA Patient • Surgery • Anesthesia • Discharge Planning

  4. Pre-Op Planning: History • Failed non-op treatment, disabling pain • PMHx: medical comorbidities, ASA class • Social Hx: home support • Candidate for Ambulatory TSA

  5. Pre-Op Planning: Physical Exam • Red Flags: “Atypical” OA findings • Sever stiffness: < 90° FE, < 0° ER • Strength: pseudo-paralysis, weak ER • Advanced glenoid deformity • Incompetent rotator cuff • Influence surgical technique, prosthetic design

  6. Pre-Op Planning: Imaging • Radiographs: Shoulder series, scapular plane • AP, lateral, axillary • Adequate for 90% patients with OA • Correctable glenoid deformity • No weakness, cuff intact • Anatomic TSA

  7. Radiographs- Scapular plane AP, Axillary

  8. Pre-Op Planning: Imaging • Computerized Tomography • Poor quality radiographs • “Advanced” glenoid deformity • “Bad” B2, B3, C (Walsh) • All revision cases

  9. Radiographs: B3, Medial and Posterior wear

  10. CT: B3, Medial and Posterior wear

  11. Pre-Op Planning: Imaging • MRI- -Pseudo-paralysis • Full passive, active < 90° -Weak ER -History of rotator cuff repair

  12. Pre-Op Planning: Imaging, MRI

  13. Pre-Op Planning: Imaging, MRI

  14. Pre-Op Planning: Imaging • 3D Computer Planning Software • Patient Specific Instrumentation • Industry Products • Match Point System (DJO) • Blueprint (Wright) • Signature System (Zimmer-Biomet)

  15. 3D Computer Planning Goals • Severe glenoid deformity: > 25° • Preserve host bone • Retroversion < 10° • Superior inclination < 10° • 80% glenoid implant support • Maximize implant survival • Enhance joint stability

  16. 3D Computer Planning, PSI • Current use- Shoulder Centers • More reliable glenoid placement? • Indicated for complex deformity • Will become more common? • Less severe deformity • Improve glenoid positioning

  17. Pre-Op Planning: Anesthesia • Multimodal 48 hour pain plan • Cortisone scalene block • Liposomal bupivacaine wound • Scheduled NSAID and ACMH • Cryotherapy • Boddu et al., JSES Feb, 2018

  18. Pre-Op Planning: Anesthesia • Cortisone scalene block • 18-36 hour duration • Must discuss pre-op • “Odd sensation,” but… • “Preferable to pain” • Accepted > 95%

  19. Pre-Op Planning: Discharge • Ambulatory: 10%, hospital • ASA 1,2 • Home support • Pain managed with prolonged block, multimodal program • Preferred in selected patients

  20. Pre-Op Planning: Discharge • Overnight stay- 80% • LOS > 2 days- 10% • Some ASA 3,4 • Live alone: arrange VNS • SNF: home health pre-op

  21. Pre-Op Planning: Discharge • Independent in ADL’s POD 1 • Instructed pre-op • Sling management • Active use: side pocket-nose • Wash, dress, eat independently

  22. Pre-Op Planning: Summary • Physical exam “Red Flags” • Severe stiffness, weakness • Glenoid deformity • Incompetent rotator cuff • Not routine TSA

  23. Pre-Op Planning: Summary • Imaging • Radiographs sufficient 90% • CT: severe glenoid deformity • MRI: pseudoparalysis, weak ER • PSI: complex glenoid deformity • More common, less deformity

  24. Pre-Op Planning: Summary • Anesthesia: 48 hour program • Multimodal management • Cortisone enhanced block • 0-24 hours analgesia • Lysosomal bupivacaine • 18-36 hours analgesia • “Minimal” narcotics

  25. Pre-Op Planning: Summary • Consent for Anatomic/Reverse • Equivocal findings pre-op • Intra-operative decision • “Correctable” glenoid deformity • Rotator cuff: “functional?”

  26. Pre-Op Planning: Summary • Discharge • Ambulatory TSA: 10% • ASA 1, 2 • Home support • Overnight stay: 80% • Independent in ADL’s POD 1 • Instructed pre-op

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