CLINICAL HISTORY AND EXAMINATION

The same type of clinical history and physical examination is used for candidates for reverse shoulder arthroplasty as for candidates for unconstrained shoulder arthroplasty (see Chapter 7). Because most candidates for reverse shoulder arthroplasty have a compromised rotator cuff, it is important to obtain a detailed history of the patient’s complaints (pain only; weakness only; pain and weakness; pain, weakness, and stiffness).

Any previous surgery, especially attempts at rotator cuff repair and fracture surgery, merits special consideration. The type of surgical approach (arthroscopic or open) should be noted. Previous open surgery may compromise deltoid function to a degree that contraindicates use of a reverse prosthesis.

As with unconstrained shoulder arthroplasty, any symptoms of previous infection, especially in patients who have undergone surgery or injections, should be investigated further. If patients have a history of infection after shoulder surgery or have had symp-toms suggestive of infection (systemic fevers; shoulder warmth, redness), a preoperative infection workup is indicated. The workup includes hematologic evaluation with a complete blood cell count and differential, a sedimentation rate, and C-reactive protein. Additionally, fluoroscopically guided shoulder aspiration is performed and the specimen submitted for aerobic, anaerobic, fungal, and mycobacterial culture. If the findings are suggestive or diagnostic of infection, shoulder arthroplasty is postponed or canceled until infectious disease consultation is obtained and the infection is appropriately treated.

Any medical history of systemic illness (diabetes mellitus, cardiac problems) should be considered in the preoperative planning. Although these factors may not affect the actual surgical procedure, they may necessitate special considerations in the patient’s postoperative care. 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 reverse shoulder arthroplasty. The presence and location of surgical scars are noted (Fig. 25-1). In thin patients, anterosuperior escape of the humeral head caused by anterior superior rotator cuff deficiency may be obvious (Fig. 25-2) or may be noted only when the patient attempts arm elevation or abduction. Special attention should be paid to the condition of the deltoid, especially if it has previously been surgically violated (Fig. 25-3). The condition of the deltoid is best evaluated by asking the patient to push against your hand to observe an isometric contraction. Any areas of deltoid origin that may not have healed to the acromion after a previous operation should be noted. Atrophy of the supraspinatus and infraspinatus should be noted as well (Fig. 25-4).

Figure 25-1 Scar from a previous open rotator cuff repair (arrows) in a candidate for implantation of a reverse prosthesis.

Figure 25-2 Obvious anterior superior escape of the humeral head.

Figure 25-3 Patient with previous surgery involving detachment of the deltoid (arrows).

Figure 25-4 Patient with supraspinatus and infraspinatus atrophy.

Both active and passive mobility is recorded, as detailed in Chapter 7. The presence of glenohumeral crepitus with motion is recorded, as is any discrepancy in active and passive mobility. Special attention should be paid to evaluation of the deltoid muscle. If deltoid contractility appears to be compromised, additional evaluation with electromyography and nerve conduction studies should be performed before further consideration for implantation of a reverse prosthesis.

Rotator cuff examination consists of testing each tendon of the rotator cuff by isolating it as much as possible. Jobe’s test is used to test supraspinatus integrity.¹ The infraspinatus is tested by the external rotation lag sign and external rotation strength with the arm at the side.² The horn blower’s sign is used to test the teres minor.³ The subscapularis is tested with the belly press test and, when mobility allows, the lift-off test.⁴ Performance of the various rotator cuff tests is depicted in Chapter 7.

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. Findings are discussed with the patient in terms of postoperative outcome and patient expectations. For example, it is important for patients without posterior rotator cuff function (no infraspinatus or teres minor) to understand that the operation will not restore their ability to actively externally rotate the arm.