Shoulder Arthroplasty Protocol Sheet

This sheet sets the perioperative pathway for primary anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). It parallels the hip/knee Arthroplasty Quick Reference — shared domains (optimization, decolonization, antibiotics, dexamethasone, TXA, post-op medications) are identical unless noted, and only shoulder-specific differences are spelled out. Rehabilitation detail lives in the Shoulder Arthroplasty Rehab Protocol.

1 · Selection & Optimization (same targets as hip/knee)

• HbA1c < 7 outpatient / < 7.5 inpatient · albumin ≥ 3.5 · Hb ≥ 12 (11–11.9 acceptable inpatient after IV-iron attempt) · nicotine cessation ≥ 4 weeks · empiric vitamin D · no steroid injection into the operative shoulder within 3 months · no active infection (including dental).
• Site of surgery follows the same three tiers: outpatient (< 75, BMI < 36, ASA I–II/optimized III) · rural inpatient (75–82, BMI 36–39) · tertiary referral (> 82, BMI ≥ 40, or organ-failure comorbidity).
• Protein 120/150 g/day and the vitamin bundle (C 1,000 · D 5,000 · Mg glycinate 400) from 2 weeks before through 8 weeks after; Ensure Pre-Surgery carbohydrate protocol identical to hip/knee.

2 · Decolonization — two washes for 5 days

Shoulders get the standard bundle plus benzoyl peroxide. The two agents do different jobs and both cover the operative shoulder — benzoyl peroxide is not a substitute for CHG there. CHG lowers the broad bacterial load; benzoyl peroxide targets Cutibacterium acnes, the dominant shoulder-PJI organism, which lives in the oil glands of the skin where CHG reaches poorly. In the shower they go on the shoulder one after the other: benzoyl peroxide first (rinsed off), then the CHG whole-body wash covers the shoulder last. This mirrors the standard published protocol — benzoyl peroxide × 5 days plus CHG — where both agents are applied to the surgical shoulder, and matches published shoulder-surgery patient guides.

• Benzoyl peroxide 5% wash — operative shoulder, armpit, and upper chest, once a day × 5 days. Over-the-counter (acne-wash aisle); no prescription needed.
• CHG (chlorhexidine 4%) wash — whole body from the neck down (including the operative shoulder), once a day × 5 days and the morning of surgery, exactly as for hip/knee, applied last so CHG is the final agent left on the skin.
• Nasal povidone-iodine/mupirocin BID × 5 days. No shaving of the chest, shoulder, or armpit.

Patient instructions — the two washes (goes in the pre-op packet)

For the 5 days before surgery — and the morning of surgery — wash with these two soaps once a day, in this order. Doing them back-to-back in one shower is easiest. Your surgery shoulder gets both soaps.

1. Shower normally first with your own shampoo and soap, then rinse.
2. Benzoyl peroxide on the surgery shoulder. Put a small amount on a clean washcloth and gently wash the shoulder, the armpit, and the upper chest on the surgery side. Let it sit about a minute, then rinse it off. It may bleach towels, washcloths, and colored clothing — use white ones, and keep it out of your eyes.
3. Chlorhexidine (CHG) wash — your whole body from the neck down, surgery shoulder included. This goes on last. Keep it away from your face, eyes, ears, and private areas. Rinse well, and do not use your regular soap again afterward.
4. Pat dry with a clean towel and put on clean clothes. No lotion, deodorant, or powder afterward.
5. Do not shave the shoulder, chest, or armpit during these 5 days. If your skin gets red or irritated, stop and call the clinic.

3 · Anesthesia & Intraoperative

• Interscalene brachial plexus block + general anesthesia (beach-chair positioning) is the shoulder default — the block is the analgesic workhorse; counsel patients that the arm will be numb and flail-weak until it wears off, and plan the first night's oral meds before it does. Confirm interscalene-block availability with anesthesia at each operating site.
• Dexamethasone 10 mg IV at induction; TXA 1 g before incision (same contraindications as hip/knee); cefazolin 2 g (3 g > 120 kg), single dose; maintain normothermia with active warming.
• Intraosseous (IO) vancomycin — 500 mg in ~100 mL injectable saline, into the proximal humerus, in addition to IV cefazolin (same regimen we use for TKA/THA). Contraindicated for vancomycin allergy or local infection/fracture at the site. Evidence note: the IO-vancomycin data specific to shoulder arthroplasty are sparse — the clinical outcome and pharmacokinetic work is overwhelmingly in TKA (and, by extrapolation, THA). We are adopting it for the shoulder anyway: the pharmacologic rationale (high local tissue levels of a drug active against Cutibacterium acnes, the dominant shoulder-PJI organism, with low systemic exposure) is compelling and the safety profile is favorable. Applied as a standing element of the pathway, not case-by-case.
• No drains. Sling applied in the OR for comfort.

4 · VTE Prophylaxis

• VTE risk after shoulder arthroplasty is substantially lower than after hip/knee; ambulation begins the day of surgery.
• Standard-risk: aspirin 81 mg BID × 2 weeks + early mobilization and hourly walks.
• Elevated-risk (prior VTE, clotting disorder, active cancer treatment): not aspirin — a stronger anticoagulant (Eliquis, Xarelto, or Pradaxa) per the VTE protocol, arranged before discharge.

5 · Post-Operative Medications (shared backbone)

• Dexamethasone 16 mg PO on POD 1 (sent home with same-day discharges) · celecoxib 200 mg BID scheduled — OTC naproxen or ibuprofen may substitute by patient preference (add GI protection; separate from aspirin) · acetaminophen 1,000 mg q8h scheduled × 2 weeks · opioids rescue only (≈10–20 tabs) · senna-docusate while on opioids.

6 · Wound Care (unified to the silver-dressing standard)

• Waterproof antimicrobial (silver) dressing, same as hip/knee: shower from POD 1 with the dressing on, leave it undisturbed 5–7 days, off at the 2-week visit or when instructed; no soaking (baths, pools, hot tubs) until the incision is fully healed. This replaces the older Steri-Strip/Band-Aid routine — one wound story across all arthroplasty.

7 · Sling & Rehabilitation (summary — full detail in the PT protocol)

• Accelerated, criterion-based: sling for comfort only, weaned as pain allows (not strict immobilization); PT begins within ~1 week; early gentle active motion as comfort allows. Nothing heavier than a pencil in the operative hand at first.
• Anatomic TSA — protect the subscapularis × 6 weeks: no active or resisted internal rotation, limit end-range passive ER, no behind-the-back.
• Reverse TSA — avoid the dislocation position: no combined internal rotation + adduction + extension; no hand-behind-back × 12 weeks; ER limited ~30–45° × 6–8 weeks. Early deltoid activation.
• Fracture cases or tuberosity repair: protected, delayed-motion course — surgeon-directed exception.
• Return: criterion-based, ~4–6 months; long-term lifting commonly ≤ ~25 lb at or below shoulder level; heavy overhead work discouraged, especially after RTSA.

8 · Discharge & Follow-Up

• Milestone-based discharge; most shoulder arthroplasty patients are same-day or one night. Sleep coaching: semi-reclined (recliner or wedge) with a pillow under the elbow is the comfortable early position.
• Nurse call POD 1–2; clinic visit at 2 weeks; then per surgeon (6 weeks, 3 months, criterion-based thereafter).
• Red flags identical to hip/knee (fever > 101.5°F unified across all arthroplasty), plus block-specific counseling (expected numbness < 24 h; call for numbness or weakness that persists beyond it).

9 · Do Not

• No drains · no strict 6-week immobilization for standard cases (accelerated motion is the protocol) · no systemic antibiotics beyond 24 h (IO vancomycin is a single intraoperative dose, not continued) · no routine post-op labs/imaging beyond the baseline film · no routine dental antibiotic prophylaxis afterward.