H Upper extremity arthroplasty
Arthroplasty in the upper extremity makes up a low percentage of the number of joint arthroplasties performed each year. Of the two more commonly replaced upper extremity joints (the shoulder and the elbow), shoulder arthroplasty accounts for approximately 5% of the total number of joint replacements performed each year. The primary goal of shoulder arthroplasty is to relieve pain, with the secondary goal being improvement in overall joint functioning. Indications for shoulder arthroplasty include glenohumeral joint destruction as a result of osteoarthritis, complex proximal humerus fractures, rheumatoid arthritis, avascular necrosis of the humeral head, and malunion or nonunion of the proximal humerus.
Shoulder arthroplasty is performed with the patient in either the lateral decubitus or modified Fowler (beach chair) position. Because a pneumatic tourniquet cannot be used, shoulder arthroplasty tends to result in significant intraoperative blood loss.
Elbow arthroplasty is performed less frequently than shoulder arthroplasty. The goals for elbow arthroplasty are much the same as for shoulder arthroplasty: pain relief and improvement in joint function. The indications for elbow arthroplasty include rheumatoid arthritis, traumatic arthritis, and ankylosis of the joint.
2. Preoperative assessment
a) Respiratory
(1) Patients with rheumatoid arthritis may show signs of pleural effusion or pulmonary fibrosis. Hoarseness may result from cricoarytenoid joint involvement. Inflammation and destruction of laryngeal structures may make intubation difficult in these patients.
b) Cardiovascular: Patients with rheumatoid arthritis may have chronic pericardial tamponade, valvular disease, and cardiac conduction defects. If indicated, a consult with cardiologist may be warranted.
c) Neurologic
(1) Because of the modified Fowler position, blood pressure measurements taken on the arm underestimated cerebral artery autoregulation. Cerebral hypoxia has occurred. Maintenance of the preoperative mean arterial pressure may help to decrease the incidence of brain injury.
(2) Patients with arthritis may have cervical or lumbar radiculopathies. Preoperative documentation of these conditions is essential. Head flexion may cause cervical spinal cord compression.
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