Op report Open McLaughlin
Yes, thank you!
I dissected sharply through the subcutaneous tissue and identified the deltopectoral fascia and the cephalic vein. I dissected the vein and retracted it medially, protecting it throughout the case. I identified the coracoid and the conjoined tendon and elevated the clavipectoral fascia to the lateral border of the conjoined tendon, placed a retractor. This exposed the proximal humerus. There was a large amount of scarred, thickened bursa, which I excised sharply. I was able to visualize hematoma on the lateral aspect of the proximal humerus consistent with his fracture. I entered this sharply and exposed the fracture site. Using an osteotome, was able to elevate his lesser tuberosity fracture and sharply excise any adhesions. I was able to then access the joint. The biceps tendon was associated with the fracture fragment. I opened the rotator interval and cut the biceps at its base using #1 Vicryl suture to tenodese it to the subscapularis. I then externally rotated the arm and released the inferior capsule to allow me access to the humeral head. There was a large reverse Hill-Sachs lesion consistent with his x-rays. I irrigated the joint and removed a large amount of fibrinous material. The Hill-Sachs was inspected, and there were 2 small pieces of intact articular cartilage. I elevated these with an elevator, and this still left approximately a 1 cm wide strip of humerus without articular cartilage. There was a defect between the 2 pieces as well, and at this point I felt that elevating the cartilage and disimpacting was not going to give us adequate bone stock. At this point, I removed these pieces of articular cartilage and planned for transfer of the lesser tuberosity at the fracture site. I drilled and placed four 3.0 SutureTak, 2 toward the articular margin medially of the reverse Hill-Sachs lesion and 2 more laterally. I then passed the medial row anchors in a horizontal mattress fashion through the subscapularis and the lateral row through the lesser tuberosity fracture fragment. Beginning medially, I tied these and reduced the subscapularis into the medial portion of the defect in the lesser tuberosity into the lateral portion. This securely reduced the lesser tuberosity fracture into the reverse Hill-Sachs lesion. I was able to externally rotate his arm 60 degrees and forward elevate to 140 degrees without undue tension on the repair. His internal rotation was blocked at the buttock. At this point, I cut the lateral sutures and I brought the medial tendinous sutures to two 4.5 self-punching SwiveLock at the superior and inferior aspects of the lesser tuberosity fracture creating a speed bridge over the lesser tuberosity. Once this was complete, I again
inspected the repair and it was securely adhered into the reverse Hill-Sachs lesion. I irrigated the wound with copious amounts of sterile saline with bacitracin. Orthogonal fluoroscopic views confirmed reduction of the glenohumeral joint with reduction of the fracture fragment into the defect. I then closed the skin and subcutaneous tissue in a layered fashion with 2-0 Vicryl, 3-0 Vicryl, and a running 3-0 Monocryl suture.