Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 23 - Upper and Lower Extremities Medical Treatment Guidelines › Subchapter B - Shoulder Injury Medical Treatment Guidelines › Section I-2327 - Therapeutic Procedures - Operative

Current through Register Vol. 50, No. 6, June 20, 2024
A. All operative interventions must be based
					 upon positive correlation of clinical findings, clinical course and diagnostic
					 tests. A comprehensive assimilation of these factors must lead to a specific
					 diagnosis with positive identification of pathologic condition(s). It is
					 imperative to rule out non-physiologic modifiers of pain presentation or
					 non-operative conditions mimicking operative conditions (e.g., peripheral
					 neuropathy, myofascial pain, scleratogenous or sympathetically mediated pain
					 syndromes, psychological), prior to consideration of elective surgical
					 intervention.
B. In addition,
					 operative treatment is indicated when the natural history of surgically treated
					 lesions is better than the natural history for non-operatively treated lesions.
					 All patients being considered for surgical intervention should first undergo a
					 comprehensive neuro-musculoskeletal examination to identify mechanical pain
					 generators that may respond to non-surgical techniques or may be refractory to
					 surgical intervention.
C.
					 Structured rehabilitation interventions should be strongly considered
					 post-operative in any patient not making expected functional progress within
					 three weeks post-operative.
D.
					 Post-operative therapy will frequently require a repeat of the therapy provided
					 pre-operatively. Refer to Therapeutic Procedures, Non-operative, and consider
					 the first post-operative visit as visit number one, for the time frame
					 parameters provided.
E.
					 Return-to-work restrictions should be specific according to the recommendation
					 in Therapeutic Procedures - Non-Operative.
1.
					 Shoulder Replacement (Arthroplasty)
a.
					 Description/Definition. Prosthetic replacement of the articulating surfaces of
					 the shoulder joint. There are three types of procedures commonly performed. The
					 total shoulder component in which the glenoid and humeral head are replaced
					 anatomically. The hemiarthroplasty which involves replacement of the humeral
					 head only. The reverse arthroplasty where the head of the humerus is replaced
					 by a prosthesis forming a socket and the glenoid is replaced with a ball
					 prosthesis.
b. Occupational
					 Relationship. Usually from post-traumatic arthritis, or from trauma resulting
					 in severe humeral head fractures.
c. Specific Physical Exam Findings. Stiff,
					 painful shoulder with limited function.
d. Diagnostic Testing Procedures: Radiographs
					 or CTs demonstrating humeral head fracture. CTs or diagnostic arthroscopy to
					 explore the status of rotator cuff and associated muscles and tendons, the
					 presence of arthritis or subluxation, or superior migration of the humeral
					 head. For revision procedures, a non-MRI arthrography or sonogram may be
					 important to better visualize associated pathology.
e. Surgical Indications. The decision of
					 whether a patient receives a total arthroplasty or a hemiarthroplasty depends
					 on the surgeon's discretion. Factors to consider are the presence of glenoid
					 erosions, humeral head subluxation and rotator cuff strength. There is good
					 evidence that total arthroplasties compared to hemi-arthroplasties results in
					 improved function in primary osteoarthritis of the shoulder, and relief of pain
					 two years post-operatively. Longer-term results are unknown.
i. Hemiarthroplasty may utilize a long stem
					 humeral head replacement or a resurfacing device. It may also be performed for
					 humeral head fractures. It has been used for severe arthritis unresponsive to
					 other treatments; however, there is some evidence that total shoulder
					 arthroplasty may yield a better functional outcome. In younger active patients
					 the eventual wear on the glenoid cartilage may cause decreased function over
					 time. Total arthroplasty may therefore be preferred in many cases. Partial
					 humeral head prosthesis may be useful in some cases. Cementless surface humeral
					 head replacement may be indicated in young patients with glenohumeral arthritis
					 and retained glenoid cartilage.
ii.
					 Total shoulder arthroplasty is usually performed in cases of severe arthritis
					 when all reasonable conservative measures have been exhausted without
					 sufficient return to activities of daily living. Arthroscopic surgery may be
					 considered in selected patients with a milder degree of arthritis. Arthroscopic
					 SLAP repair is usually not recommended in cases of severe arthritis. The
					 rotator cuff should generally be intact or repairable.
iii. Reverse arthroplasty is generally
					 considered a salvage procedure for patients over 70 with severe osteoarthritis,
					 massive rotator cuff tears and pseudo paralysis with integrity of the deltoid.
					 Complications rates may be in the vicinity of 10 percent of patients within the
					 first year following surgery. The long-term success of the prosthesis is not
					 known at this time.
iv. Reverse
					 prosthesis may also be the treatment for failed hemiarthroplasty with extensive
					 cuff tears and/or instability. Most literature confirms that the complication
					 rate is higher and the success rate lower when reverse arthroplasty is
					 performed on a previously operated joint, however, many patients demonstrate
					 good improvement with elevation, but not necessarily rotation. Bone loss may
					 increase the complication rate.
v.
					 Procedural complications may include humeral head subluxation or dislocation,
					 humeral and/or glenoid loosening, rotator cuff tear, fractures, stiffness,
					 painful glenoid erosion, transient nerve palsies, heterotopic ossification,
					 bone loss, and component mal-positioning.
vi. Revision surgery may be performed by an
					 orthopedic surgeon in cases with chronic pain and stiffness, painful glenoid
					 erosion, or difficulty with activities of daily living. Prior authorization is
					 required and a second opinion by a surgeon with special expertise in shoulder
					 surgery should usually be performed. In the case of a total failure of the
					 prosthesis, arthrodesis is the salvage procedure.
f. Operative Treatment: Prosthetic
					 replacement of the articular surfaces of the shoulder.
g. Post-operative Treatment:
i. Individualized rehabilitation program
					 based on communication between the surgeon and the therapist. Timing of passive
					 motion and active rehabilitation is dependent on the type of procedures
					 performed.
(a). Pool exercise initially under
					 therapists or surgeon's direction then progressed to independent pool
					 program.
(b). Progression to a home
					 exercise is essential. Therapy should continue for at least 10 weeks with
					 transition to home exercises at the beginning of each new phase of
					 therapy.
(c). Gradual resistive
					 exercise from 3 to 12 months, with gradual return to full activity at 6 to 12
					 months.
(i). Time frames for therapy
					 (excluding pool therapy).
(ii).
					 Optimum: 12 to 24 sessions.
(iii).
					 Maximum: 36 sessions. If functional gains are being achieved additional visits
					 may be authorized for the patient to achieve their functional goal.
ii. Reverse
					 arthroplasty patients may have a more rapid rehabilitation in some cases. Per
					 the recommendation of the surgeon the following therapies may take place: Sling
					 use for the first three weeks, ADLs at three to six weeks, and then gentle
					 strengthening.
iii. Should progress
					 plateau the provider should reevaluate the patient's condition and make
					 appropriate adjustments to the treatment plan. Other therapies may be employed
					 in individual cases.
iv. Gradual
					 return to full activity can occur between 6 to 12 months, depending on the
					 procedure.
v. Return to work and
					 restrictions after surgery may be made by an experienced primary occupational
					 medicine physician in consultation with the surgeon or by the
					 surgeon.