oceania
New
PREOPERATIVE DIAGNOSIS: Right anatomic total shoulder instability.
POSTOPERATIVE DIAGNOSIS: Right anatomic total shoulder instability.
OPERATIONS:
1. Right anatomic total shoulder arthroplasty revision to a reverse total
shoulder arthroplasty construct. This revision included exchange of both the
glenoid and humeral components.
2. Right shoulder open rotator cuff reconstruction of the subscapularis
tendon with Achilles allograft.
BLOOD LOSS: Approximately 500 mL.
BLOOD REPLACEMENT: None.
IV FLUIDS: Lactated Ringer's.
WOUND: Clean.
COMPLICATIONS: None.
DRAINS AND PACKING: JP x 1.
IMPLANTS: Please see the hospital record for exact implant specifications,
but again, the previously placed anatomic total shoulder system was completely
exchanged to a DJO RSP reverse system.
INDICATIONS FOR SURGERY: Please see my extensive past medical record for the
patient's extensive history, but he underwent an uneventful right anatomic
total shoulder arthroplasty in 1/2014. Unfortunately, he had a tooth abscess
unrelated to the shoulder surgery, that subsequently provided some level of
septicemia, and he had a secondary lumbar spine diskitis. Again, the shoulder
was not directly involved, but because of the patient's debilitating pain and
dysfunction, he admittedly required upper extremity strength for any movement
because he was essentially bedridden because of the back pain. He admits to
removing the sling just less than 2 weeks following the surgery and not only
removing the sling, but using the right upper extremity for weightbearing and
power because he had limited use of his back and lower extremities. Following
this, instability of the right shoulder had developed, but because the patient
had an active lumbar infection, we delayed surgery today until that active
infection was resolved.
Risks and benefits of operative intervention of this complex procedure were
described at length with the patient and his wife. I explained risks of the
procedure including infection, neurovascular injury, neuropraxia, the failure
to completely eliminate his pain, limited range of motion and strength
following the procedure, periprosthetic fracture and dislocation and medical
and cardiac complications of anesthesia. All these concepts were reviewed and
all questions were answered. Informed consent was obtained and I marked the
right shoulder as the operative site in the preoperative holding area.
DESCRIPTION OF PROCEDURE: Regional anesthesia was achieved by the anesthesia
team in the preoperative holding area and the patient was transported from
there to the operating room where he was laid in a supine position on the
operative room table. Supplemental general anesthesia was achieved by the
anesthesia team and Ancef antibiotic was administered to the patient prior to
any operative incision. The patient was placed in a well-padded beach chair
position and the right shoulder was prepped and draped in standard sterile
fashion for his shoulder surgery. A timeout was called and confirmed.
At this point, the previous incision over the right deltopectoral interval was
opened and meticulous hemostasis was maintained throughout the case using
Bovie electrocautery. Scar tissue was removed and dissection ensued to the
deltopectoral interval, which was identified because in primary routine cases,
I use green Ethibond suture to close the deltopectoral interval. These green
Ethibond sutures were easily identified and the deltopectoral interval was
opened and scar tissue was removed.
Dissection ensued to the clavipectoral interval, where this was opened as well
and standard retractors were placed. Adhesions in the subacromial space were
divided and the right humerus was analyzed. The previous biceps tenodesis was
found to be stable and the previous anterior supraspinatus rotator cuff repair
was also found to be stable and healed. Interestingly, the subscapularis was
also found to be intact with scar tissue around the previous Ethibond sutures
placed at the lesser tuberosity. Although grossly intact, the subscapularis
was found to have some tearing in the superior portion, and the tissue itself
was quite flimsy and redundant likely as evidenced by his clinical picture.
Thus, the remainder of the subscapularis was taken down using a tenotomy peel
technique and heavy stay sutures were placed for later repair and
reconstruction, which was obviously necessary. The shoulder was adducted,
extended and externally rotated, presenting the proximal humerus. The
previous implants were found to be in anatomic alignment and stable with
appropriate retroversion, but because of the patient's instability, revision
to a reverse construct was necessary. The previously placed humeral head was
first removed and the previous stem was removed because conversion to a first
system was not going to be appropriate because of stability concerns. Thus,
the previous stem was removed and the wound was thoroughly irrigated with
normal saline under pulsatile lavage. The proximal humerus was found to be
grossly intact and scar tissue was debrided and standard glenoid retractors
were placed as attention turned to the glenoid.
Again, the polyethylene component was found to be grossly stable without
distraction, but we proceeded with the revision and osteotomes were used to
remove the glenoid polyethylene component in its entirety and meticulous care
was made to remove all aspects of cement in the glenoid. The wound was again
thoroughly irrigated and standard releases were performed of previous scar
tissue from the previous constructs.
The glenoid was then prepared in standard fashion for the RSP DJO system with
first tapping of the metaglene component and the glenoid was reamed
appropriately down to a stable bleeding base. Appropriate retroversion was
again confirmed and the center hole was tapped and the final component was
placed. Locking screws were used to secure the baseplate to the glenoid and
scapula in standard AO fashion and excellent purchase was noted of the
constructs. A trial reduction was performed and following the trial
reduction, the shoulder was found to be stable and able to be taken through a
full range of motion. Please again see the hospital record for exact implant
details.
The trial implants were removed and the wound was thoroughly irrigated once
again with normal saline and pulsatile lavage and the final implants were
placed and third generation cementing technique with tobramycin infused cement
was used for the humeral stem. The shoulder was reduced after the cement was
allowed to cure. Again, the shoulder was found to be grossly stable in all
planes and excellent range of motion was achieved. The wound was again
thoroughly irrigated and attention turned to the subscapularis reconstruction.
Again, because of the patient's history of anterior superior instability, a
reconstruction of the subscapularis was certainly necessary. Using a
previously obtained Achilles allograft tissue, the tissue was fashioned to
anatomically be placed over the subscapularis, and it was secured in all
planes using a #2 FiberWire suture. The lateral end of the subscapularis was
tied down in standard fashion using a previously placed FiberWire through
drill holes in the lesser tuberosity. The sutures were tied down in a
Mason-Allen construct and the subscapularis repair and reconstruction was
found to be anatomic and added to stability of the overall construct. The
rotator cuff interval was then also closed with a #2 FiberWire suture.
The wound was thoroughly irrigated with normal saline, and again, the
construct was found to be stable through a full range of motion. The
deltopectoral interval was again closed with a 3-0 Ethibond suture, and a JP
drain was placed deep to this and brought out through a lateral punch hole in
the deltoid. The wound was again thoroughly irrigated and the subdermal layer
was closed with a 3-0 Vicryl suture and the skin was closed with a 3-0
Monocryl suture in a subcuticular stitch. A standard sterile dressing was
applied and the patient was placed in a shoulder immobilizer. Anesthesia was
discontinued from the anesthesia team, and the patient was transported from
the operating room to the recovery room where he arrived in a hemodynamically
stable condition having tolerated the procedure well.
POSTOPERATIVE DIAGNOSIS: Right anatomic total shoulder instability.
OPERATIONS:
1. Right anatomic total shoulder arthroplasty revision to a reverse total
shoulder arthroplasty construct. This revision included exchange of both the
glenoid and humeral components.
2. Right shoulder open rotator cuff reconstruction of the subscapularis
tendon with Achilles allograft.
BLOOD LOSS: Approximately 500 mL.
BLOOD REPLACEMENT: None.
IV FLUIDS: Lactated Ringer's.
WOUND: Clean.
COMPLICATIONS: None.
DRAINS AND PACKING: JP x 1.
IMPLANTS: Please see the hospital record for exact implant specifications,
but again, the previously placed anatomic total shoulder system was completely
exchanged to a DJO RSP reverse system.
INDICATIONS FOR SURGERY: Please see my extensive past medical record for the
patient's extensive history, but he underwent an uneventful right anatomic
total shoulder arthroplasty in 1/2014. Unfortunately, he had a tooth abscess
unrelated to the shoulder surgery, that subsequently provided some level of
septicemia, and he had a secondary lumbar spine diskitis. Again, the shoulder
was not directly involved, but because of the patient's debilitating pain and
dysfunction, he admittedly required upper extremity strength for any movement
because he was essentially bedridden because of the back pain. He admits to
removing the sling just less than 2 weeks following the surgery and not only
removing the sling, but using the right upper extremity for weightbearing and
power because he had limited use of his back and lower extremities. Following
this, instability of the right shoulder had developed, but because the patient
had an active lumbar infection, we delayed surgery today until that active
infection was resolved.
Risks and benefits of operative intervention of this complex procedure were
described at length with the patient and his wife. I explained risks of the
procedure including infection, neurovascular injury, neuropraxia, the failure
to completely eliminate his pain, limited range of motion and strength
following the procedure, periprosthetic fracture and dislocation and medical
and cardiac complications of anesthesia. All these concepts were reviewed and
all questions were answered. Informed consent was obtained and I marked the
right shoulder as the operative site in the preoperative holding area.
DESCRIPTION OF PROCEDURE: Regional anesthesia was achieved by the anesthesia
team in the preoperative holding area and the patient was transported from
there to the operating room where he was laid in a supine position on the
operative room table. Supplemental general anesthesia was achieved by the
anesthesia team and Ancef antibiotic was administered to the patient prior to
any operative incision. The patient was placed in a well-padded beach chair
position and the right shoulder was prepped and draped in standard sterile
fashion for his shoulder surgery. A timeout was called and confirmed.
At this point, the previous incision over the right deltopectoral interval was
opened and meticulous hemostasis was maintained throughout the case using
Bovie electrocautery. Scar tissue was removed and dissection ensued to the
deltopectoral interval, which was identified because in primary routine cases,
I use green Ethibond suture to close the deltopectoral interval. These green
Ethibond sutures were easily identified and the deltopectoral interval was
opened and scar tissue was removed.
Dissection ensued to the clavipectoral interval, where this was opened as well
and standard retractors were placed. Adhesions in the subacromial space were
divided and the right humerus was analyzed. The previous biceps tenodesis was
found to be stable and the previous anterior supraspinatus rotator cuff repair
was also found to be stable and healed. Interestingly, the subscapularis was
also found to be intact with scar tissue around the previous Ethibond sutures
placed at the lesser tuberosity. Although grossly intact, the subscapularis
was found to have some tearing in the superior portion, and the tissue itself
was quite flimsy and redundant likely as evidenced by his clinical picture.
Thus, the remainder of the subscapularis was taken down using a tenotomy peel
technique and heavy stay sutures were placed for later repair and
reconstruction, which was obviously necessary. The shoulder was adducted,
extended and externally rotated, presenting the proximal humerus. The
previous implants were found to be in anatomic alignment and stable with
appropriate retroversion, but because of the patient's instability, revision
to a reverse construct was necessary. The previously placed humeral head was
first removed and the previous stem was removed because conversion to a first
system was not going to be appropriate because of stability concerns. Thus,
the previous stem was removed and the wound was thoroughly irrigated with
normal saline under pulsatile lavage. The proximal humerus was found to be
grossly intact and scar tissue was debrided and standard glenoid retractors
were placed as attention turned to the glenoid.
Again, the polyethylene component was found to be grossly stable without
distraction, but we proceeded with the revision and osteotomes were used to
remove the glenoid polyethylene component in its entirety and meticulous care
was made to remove all aspects of cement in the glenoid. The wound was again
thoroughly irrigated and standard releases were performed of previous scar
tissue from the previous constructs.
The glenoid was then prepared in standard fashion for the RSP DJO system with
first tapping of the metaglene component and the glenoid was reamed
appropriately down to a stable bleeding base. Appropriate retroversion was
again confirmed and the center hole was tapped and the final component was
placed. Locking screws were used to secure the baseplate to the glenoid and
scapula in standard AO fashion and excellent purchase was noted of the
constructs. A trial reduction was performed and following the trial
reduction, the shoulder was found to be stable and able to be taken through a
full range of motion. Please again see the hospital record for exact implant
details.
The trial implants were removed and the wound was thoroughly irrigated once
again with normal saline and pulsatile lavage and the final implants were
placed and third generation cementing technique with tobramycin infused cement
was used for the humeral stem. The shoulder was reduced after the cement was
allowed to cure. Again, the shoulder was found to be grossly stable in all
planes and excellent range of motion was achieved. The wound was again
thoroughly irrigated and attention turned to the subscapularis reconstruction.
Again, because of the patient's history of anterior superior instability, a
reconstruction of the subscapularis was certainly necessary. Using a
previously obtained Achilles allograft tissue, the tissue was fashioned to
anatomically be placed over the subscapularis, and it was secured in all
planes using a #2 FiberWire suture. The lateral end of the subscapularis was
tied down in standard fashion using a previously placed FiberWire through
drill holes in the lesser tuberosity. The sutures were tied down in a
Mason-Allen construct and the subscapularis repair and reconstruction was
found to be anatomic and added to stability of the overall construct. The
rotator cuff interval was then also closed with a #2 FiberWire suture.
The wound was thoroughly irrigated with normal saline, and again, the
construct was found to be stable through a full range of motion. The
deltopectoral interval was again closed with a 3-0 Ethibond suture, and a JP
drain was placed deep to this and brought out through a lateral punch hole in
the deltoid. The wound was again thoroughly irrigated and the subdermal layer
was closed with a 3-0 Vicryl suture and the skin was closed with a 3-0
Monocryl suture in a subcuticular stitch. A standard sterile dressing was
applied and the patient was placed in a shoulder immobilizer. Anesthesia was
discontinued from the anesthesia team, and the patient was transported from
the operating room to the recovery room where he arrived in a hemodynamically
stable condition having tolerated the procedure well.