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

Universal Citation: LA Admin Code I-2327

Current through Register Vol. 50, No. 12, December 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.

2. Oats Procedure Osteoarticular allograft transplantation is a procedure which places a plug of cadaveric bone tissue into a chondral defect at the articular surface of an injured bone. Its use has been described in case reports in the treatment of recurrent shoulder instability when large humeral head defects (Hill-Sachs lesions) are thought to be responsible for repeated episodes of subluxation. At this time, there is limited information concerning its effectiveness and appropriate application. For this reason, it requires prior authorization as an isolated procedure with a second opinion by a surgeon with special expertise in shoulder surgery. The procedure may be used for isolated chondral/bony deficits involving the humeral head, including avascular necrosis. Partial humeral head prosthesis may be useful in some cases. (Refer to Hemi-arthroplasty)

3. Arthrodesis

a. Description/Definition:

i. Fusion of the shoulder. Used as a salvage procedure.

b. Occupational Relationship:

i. Secondary to severe trauma and failure of other procedures.

c. Specific Physical Exam Findings:

i. Shoulder function is minimal and is usually associated with severe rotator cuff pathology.

d. Diagnostic Testing Procedures:

i. See Specific Diagnostic sections.

e. Surgical Indications:

i. Inability to perform activities of daily living, failed previous procedures.

f. Operative Treatment:

i. Fusion.

g. Post-operative Treatment. An individualized rehabilitation program based upon communication between the surgeon and the therapist. Therapy may begin 6 weeks to 3 months depending on recovery. Occupational therapy is critical to improve function in activities of daily living. Assistive devices may be necessary.

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.

4. Manipulation Under Anesthesia (Refer to Adhesive Capsulitis/Frozen Shoulder Disorder)

5. Hardware Removal

a. Description/Definition:

i. Surgical removal of internal or external fixation device, commonly related to fracture repairs.

b. Occupational Relationship:

i. Following healing of a post-traumatic injury that required fixation or reconstruction using instrumentation.

c. Specific Physical Exam Findings:

i. Local pain to palpation, swelling, erythema.

d. Diagnostic Testing Procedures:

i. Radiographs, tomography, CT scan, MRI.

e. Non-operative Treatment:

i. Active and/or passive therapy for local modalities, activity modification. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs).

f. Surgical Indications:

i. Persistent local pain, irritation around hardware.

g. Operative Treatment:

i. Removal of instrumentation may be accompanied by scar release/resection, capsular release, and/or manipulation. Some instrumentation may be removed in the course of standard treatment without local irritation.

h. Post-operative Treatment:

i. Include an individualized rehabilitation program based upon communication between the surgeon and the therapist.

ii. Early rehabilitation interventions are recommended to maintain range-of-motion and progressive strengthening.

(a). Frequency Three to five times per week for the first two weeks, three times per week for the following two weeks, then one to two times per week.

(b). Optimum Duration for six to eight weeks with progression to home exercise and or pool therapy.

(c). Maximum Duration 12 weeks. Occasional follow-up visits may be justified to reinforce exercise patterns, or to reach final functional goals if the therapy to date has demonstrated objective functional gains.

(d). 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.

5. Human Bone Morphogenetic Protein (RhBMP) is a member of a family of proteins which are involved in the growth, remodeling, and regeneration of bone tissue. It has become available as a recombinant biomaterial with osteo-inductive potential for application in long bone fracture non-union and other situations in which the promotion of bone formation is desired. In the treatment of non-union of fractures of the humerus and clavicle, no controlled clinical trials have been conducted as of this date, though small case series have resulted in union of some fractures. Ectopic ossification into adjacent muscle has been reported to restrict motion in periarticular fractures. Due to lack of information on the incidence of complications and overall success rate, its use requires prior authorization. It should be used principally for non-union of fractures that have not healed with conventional surgical management or peri-prosthetic fractures.

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1203.1.

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