TECHNIQUE FOR WOUND CLOSURE

After closure of the subscapularis and rotator interval, the wound is irrigated with 800 mL of antibiotic-impregnated sterile saline (50,000 units bacitracin per liter sterile normal saline) via a bulb syringe. The wound is checked to ensure that adequate hemostasis has been achieved. The electrocautery is used as necessary to minimize any residual hemorrhage. No drain is used because it has been shown to be unnecessary during unconstrained shoulder arthroplasty.¹ We do not close the deltopectoral interval but initiate our closure with the overlying fascial layer. This layer is reapproximated with no. 0 braided absorbable suture via an interrupted figure-of-eight technique (Fig. 15-1). The subcutaneous fascia is reapproximated with 2-0 braided absorbable suture via an interrupted figure-of-eight technique (Fig. 15-2). The skin is reapproximated with 3-0 undyed absorbable monofilament suture in a subcuticular running closure (Fig. 15-3).

Figure 15-1 A and B, Closure of the deep fascial layer.

Figure 15-2 A and B, Closure of the subcutaneous fascia.

Figure 15-3 A and B, Subcuticular skin closure.

The occlusive draping is removed adjacent to the incision, and the skin is cleansed of blood with a saline-soaked sponge and then dried. Half-inch Steri-Strips are placed over the incision (Fig. 15-4). Sterile gauze is placed over the incision and a sterile absorbent pad is placed over the gauze (Fig. 15-5). The dressing is secured with 3-inch foam tape (Fig. 15-6). The remaining surgical drapes are then removed.

Figure 15-4 A and B, Steri-Strips covering the incision.

Figure 15-5 Sterile dressings used after shoulder arthroplasty.

Figure 15-6 Completed postoperative dressing.

The dressing is maintained in place until postoperative day 3, at which time it is removed and not replaced. After removal of the dressing, the patient is allowed to shower, but submerging the incision in a bathtub is prohibited until 2 weeks postoperatively. The patient removes the Steri-Strips progressively as they lose their adhesion to the skin.

POSTOPERATIVE ORTHOSIS

The postoperative orthosis is placed in the operating room immediately after the dressing is applied. The type of orthosis used is determined by the procedures performed. We use two types of postoperative orthoses. For unconstrained shoulder arthroplasty without an associated posterior capsulorrhaphy, we use a simple sling (Fig. 15-7). This is used for the patient’s comfort and protection and is discontinued whenever the patient decides that it is no longer required, usually between 2 and 4 weeks postoperatively. We ask patients to avoid externally rotating beyond neutral for 4 weeks (6 weeks for inflammatory arthropathy) and to avoid pushing or pulling their body weight with the operated extremity for 8 weeks to protect the subscapularis repair.

Figure 15-7 Simple sling used in most cases of unconstrained shoulder arthroplasty.

In patients who have undergone an associated posterior capsulorrhaphy, we use a neutral-rotation sling (Fig. 15-8). This sling is maintained for 4 weeks to protect the posterior capsulorrhaphy. Patients are allowed to remove the sling only for hygiene and rehabilitative exercises. Additionally, patients who have undergone posterior capsulorrhaphy are cautioned against cross-body adduction and internal rotation behind the back for the first 4 postoperative weeks.

Figure 15-8 Application of a neutral rotation sling in patients who have undergone an associated posterior capsulorrhaphy.