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Name:
Reverse Shoulder Arthroplasty for Fracture Using Delto-Pectoral Approach
Description:
Reverse Shoulder Arthroplasty for Fracture Using Delto-Pectoral Approach
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https://cadmoreoriginalmedia.blob.core.windows.net/2d1adf2e-d809-4ad8-a3ac-7a154239e427/Reverse Shoulder Arthroplasty for fracture using delto-pecto.mp4?sv=2019-02-02&sr=c&sig=4FzDcyqz%2BBlItoLRbEMARCehuRgSkKD1Pc1hXXBese4%3D&st=2024-11-21T14%3A43%3A35Z&se=2024-11-21T16%3A48%3A35Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Hello, everyone. Welcome back to a new video. This is Bijay Singh. Today I'm going to demonstrate a reverse polarity shoulder replacement for trauma using an anatomic reverse stem from the Zimmer family with the comprehensive glenoid using an astranom adapter.
This patient is a 74-year-old fit, and active lady who still goes to the gym enjoying doing sports who was initially treated with non operative management. These are the initial radiographs that show some connection possible likely that this may inch back and realign itself into place.
Unfortunately, two weeks later, the repeated radiograph appears to show that these are completely displaced. There was no contact between the two ends, and in fact the distal fragment was just lying under the deltoid with some soft tissue into position. She was in a lot of pain and discomfort. So this patient had a general anesthetic acquisition in beach chair with her arm holder.
I normally use tranexamic acid 1 gram IV pre-operatively, as well as infiltrate the approach with a mixture of local anesthetic and adrenaline. I've found this helps reduce the initial bleeding. I normally have started doing deltoid split approach for the fracture reverses as I find it's much more easier to get hold of the tuberosity,
act at the tuberosity, then suture them. But this time I decided to go back to using the delta pectoral, which I use for my elective shoulder replacements. So here marking the incision first along the deltopectoral. A groove. This is quite an easy, straightforward approach.
Unfortunately, here it looks like there was a small webbing [?] which I went through, which had an initial bleed, but they settled down quite quickly. The advantage of this approach is that it's inter-nervous and also playing strong quite nicely in a native shoulder or a virgin shoulder. There's always this fat pad which is present along where the cephalic vein is, and that guides the approach.
So anybody who's starting off to do this needs to look out for that. Also at the top of the delta pectoral groove, it's quiet and um. Space for that can be used as another landmark to approach this. Now, although the textbooks say that when the vein, the cephalic vein needs to go laterally, I found it easier in my hands for it to go medially the left as there is less tension on the nerve, on the vessel.
Once I've done that, I've then released a bit of the deltoid distally using a finger sweep and do a subdeltoid release as well. As you will see in a second, so this is the deltoid release, distally the anterior part as it allows bit more rotation. Following this, you identify the pectoralis insertion.
And although more important in elective site where there is a stiff shoulder. Find if you release the upper centimeter or so. It allows better rotation and better access to the upper end of the humerus. And I've so far not seen any issues. It heals up well. So you've done that, identified the coronoid process, the coracoclavicular ligament, which is released.
And that, again, frees up the humeral head and allows to isolate the conjoined tendon where you can put that in front. So now we're going to put some soft retractors around the upper end of the incision. These are soft and causes less damage to the delta and the pectoral muscle
when it opens also, it swivels around to employ full coverage. The next step is to identify the long head of biceps. Generally, it's felt fairly easily if it's present or certainly the groove can be felt easily unless there is significant osteophytes. Once I've identified the biceps and its groove trace that it's repeatedly into the rotator interval and even in this fracture case can put a homer around the back of the humeral head.
You need to make sure you have decent sharp scissors to open up the rotator interval. Do a tenotomy of the biceps at this stage in subsequent. Subsequently can reach into the rotator interval. In a fractious situation,
I generally tend to use an osteotomy saw to lift off the lesser tuberosity as its already fractured it employs a better repair. And on the open end of the prostheses, once you've removed this, once you want to osteomise rather than being a subperiosteum pain.
It's once that some release has been done and start to see the humeral head peeping through that window as this is a couple of weeks old, already starting to wear some callus can gently manuveure the hemoral head out.
But here the gluteal tuberosity or the GT is attached to the humeral head fragment and hence have to optimize using a saw. And then the head is delivered. The head is then removed and you can see it's quite a small size head. And in this older age group patient. They're not re-salvageable.
Sometimes you have to use a heavy scissors to perform the soft tissue releases around the tuberosity making sure that you will not cause any further damage. Also make sure that you release the rotator interval adequately. You remove any excess bone.
Too much bone can be a bit of a problem as well. Trying to get the repair can be tricky and putting the tuberosity to work would be tricky. Getting the perfect amount is critical. Then place a retractor at the back of the glenoid and another retractor at the front of the glenoid providing me with that exposure required. The biceps down for a scene provides a landmark to place the glenoid check in the right place.
When putting this end to your retractor, be careful not to push it too medially as it can irritate or catch the musculocutaneous nerve. Causing numbness in the fingers. At this stage you can remove the biceps longer to Bicep tendon from it.
INAUDIBLE well as mark the axis of the glenoid removing the excess lavarum. Clearly this is a traumatic case and hence glenoid is generally not degenerate. It has a fairly thick articular cartilage. It needs to be removed. So here I've got a good exposure of the glenoid.
I'm now going to draw the axis for demonstration purposes. Generally, even in real life, I would mark it out. Here we're going to spend a bit of time getting the placement correct. My registrar is ready to put the die pin in.
This is a forked head protractor which can come in handy to put it under the around the medial spine of the scapula acts as a inferior retractor for the humeral head. If not any other retractor may be useful. I like the Bhattman Retractor. Check and make sure that you've got the orientation correct of the jig.
Sometimes I find it's easier and quicker to do a free hand technique. The other way to check the guide pin is to put the finger in front of the glenoid. And as long as it's about 3 centimeters before it perforates, that seems to be adequate. Then perform the reaming.
I'm getting my registrar to put his hand On the reamer shaft to avoid too much taut. What we are aiming to see is some cancellous bone particularly like a smiley face at the bottom, which means there's angle of the inclination is correct.
Be careful not to over ream, unlike something like the hip. That is small quantity of the glenoid bones.
Once that's done, give it a good wash, remove any excess bone. In arthritic it will be the osteophytes in a trauma situation when the cartilage is removed, it does need a bit of lip. Insert the base plate, which is a chain coated in case of comprehensive. Generally, he had a change in the tone. And a firm grip of the glenoid sphere into the bone stock.
At this stage, remove the guide pin. The guide pin on the comprehensive system is the same size as the drill diameter.
So as long as you perforated the shoulder blade, the scapula, you do not need to drill it again. I have not needed to. At this stage, I'll just use the depth gauge to measure the length of the screw. The center screws the compression screw, to 6.5 millimeters and it bottoms out so it could hold.
Then I use a jig to put two peri-lock locking screws. Generally, I prefer the superior and the imperial one as they've got the best bone store can put compression screws or a variable angle screws anteriorly and posteriorly.
But I can't remember the last time I had to use it for a traumatic case. It certainly may be useful if the bone stock is lacking the superior inferior part.
Of the two locking screws, top and bottom have generally found that if they are within 5 millimeters of the central screw, that suggests that they adequately aim for both the central screw and the peripheral screws.
I'm now using this gadget to check the seating of the central screw as this is vital to assess the depth. But disengages the morse taper of the glenoid sphere. This is followed by a trial deduction. Again, this is being performed by my registrar. Once the trial glenoid sphere is in, use a spatula type device to rotate the crown to assess the positioning which generally should be inferior and slightly anterior.
Once you are happy with the position, so he is demonstrating the twisting of the glenoid sphere to achieve the right offset.
Once happy with the position, the screw is tightened. True lock to trial, components in place. The glenoid sphere is removed. And then the position checked. This is the same position where our actual prosthesis is going to go. If this off centered all positions, the actual prosthesis is then put together the glenoid sphere and the modular taper.
Matching the retro, the offset that we decided to trial and once this has been inserted, flip it over. And that gives the orientation of the offset which was decided by the trials. Client, this is the best device to hold this in place as it gives me a bit more maneuverability to position {to} accurately.
Make sure that the INAUDIBLE of the Morse Taper is dry. Required wash it again? Detritis we do not want any debris in here. Glenoid sphere is then inserted. And the clamp removed with a thumb or a finger holding it in place.
This can be a bit tricky at times. Once that's in place, use the tap to tap the glenoid sphere into position. Before removing the retractors, check to make sure that the base plate and the glenoid sphere are stable.
Now we'll move on to doing the humerus. It's quite vital that this maneuver is performed by the surgeon removing the arm from the clamp holder and making sure to a bimanual maneuver so as to avoid the upper end of the humerus catching into the glenoid sphere. Generally in the fractures, it can start with the size that appears appropriate.
This one is showing the use of the anatomic stem for the reverse from the Zimmer family. It appears to be quite bulky. The reason for choosing this here was to, you get some pins in place to be able to provide better suturing of the tuberosity. And I tell the verdict at the end of the procedure.
The brooches that introduced at the appropriate, the retroversion. In this case, it's 20 degrees. And then stamped. Position you got to see these brooches to get the size that is correct for the patient. [?]
Being open. I'm going to prepare for doing the repair of the tuberosity. In the practice situation, I make two holes on the left side of the humerus as wide as I can. Generally, about 2 and 1/2 to 3 centimeters gap between the two.
And then I'll pass non-absorbable sutures through this. Making a loop on the medial side of the medullary canal outside. You can use up to three or four sutures as required to repair the that tuberosity in seconds which are going in now.
In the meantime, the prosthesis is being made ready. Put this on the inserter. What we've forgotten here is the Ashcrom Adapter, which is uh, the in-between device between the comprehensive humeral tray
and the anatomic reverse stem. And I put the sutures through the stem between the suture surface. So a loop is formed around the stem, which provides increased strength. This is then tamped in place to the appropriate height.
The advantage of reverse shoulder prostheses over hemming, however, is that it is more constrained, significantly more constrained, and also allows the surgeon to build up the height and the lateralization to a certain degree. This is the Ashcrom Adaptor that has gone in that will allow for trial. So taking the tray first, starting with the standard tray.
And I can see the reduction. Often I'll assess just the reduction rather than doing the actual reduction. Now inserting the volley into the humeral tray and the ring lock and this is the best technique I've learned and evolved over the last few years.
In a small arthro clip to split the spring lock spring open, and then the pole is inserted and then tapped to place. Quite cleverly shows which way to put in this inscribed superior. Where the superior side of the prostheses should go. This is what I call as an orthopedic surgeon proven right. In gentle terms to gauge the Morse Taper, then hopefully we should be able to use this fairly easily.
Sometimes I have to remove the retractors as they may cause pull and tension onto the muscles around the shoulder. So now you can see that this probe prosthesis is nicely in position, a reduction is fairly stable and now begins the step of preparing the tuberosity.
So the sutures have come from inside out as it's a loop. And I do the same on the cuffs. It goes outside in a crisscross. So the one that has got anteriorly goes into the posterior cuff and vice versa. Sometimes the tuberosity have to be gently persuaded to come into the warm.
Now, I still find sometimes it can be tricky to get the adequate amount of bone attached to the tuberosity: too less the repair may be less effective. Too much, it could cause impingement or even encourage microscopic calcification.
Often past multiple times, as long as it's not being locked, then going across to the other side of the cup. I'm breaking out outside to in, so hopefully one can pull the tuberosity back in place.
Once I've crossed over to the other side of the cuff and under constant tension tie the knots down. The key thing is not to pull on the sutures too hard as it can snag if it's caught on the edge of a bone or the prosthesis. If required, pull on the tuberosity and the cuff to bring them down rather than pulling on the suture that had been put through the cuff.
You can see it's covering the prosthesis quite well. Repeat the sequence with the next suture starting from outside in. Going across. From the inferior parts.
From the inside. And as you can see, doing a little bit of abduction always helps the tuberosity to relax. Being pulled down. I can see there's some open. But displacement between the two tuberosity once I've tied suturing, this can put another non absorbable suture.
It requires multiple passes through all the parts of the cuff to be able to repair the tuberosity. I do pay a fair amount of attention to repair this back in place.
Then the remainder of the suture is used to put a running stitch through the rest of the cuff.
That is the complete repair of the tuberosity. With about four different non absorbable sutures. At this stage if required, you can suture the biceps, long biceps tendon, incorporated into tenodesis. Generally in my elective arthroplasty, I would repair this with the pect or around with the subscapularis anatomic replacement to provide more stability or robustness to the repair.
Then close the delta pectoral interval. Place the arm in a sling. These are the post-op radiographs, as you can see, there is slightly chunkiness of the upper end of the prosthesis. The tuberosity also appeared to be slightly bigger than what I would have ideally liked to and slightly more proximal.
Uh, but this should not cause any problems. I hope you enjoy it. Learn something from this video. For more videos, please visit my YouTube channel. Leave a comment, please. Thank you.
Segment:0 .
Hello, everyone. Welcome back to a new video. This is Bijay Singh. Today I'm going to demonstrate a reverse polarity shoulder replacement for trauma using an anatomic reverse stem from the Zimmer family with the comprehensive glenoid using an astranom adapter.
This patient is a 74-year-old fit, and active lady who still goes to the gym enjoying doing sports who was initially treated with non operative management. These are the initial radiographs that show some connection possible likely that this may inch back and realign itself into place.
Unfortunately, two weeks later, the repeated radiograph appears to show that these are completely displaced. There was no contact between the two ends, and in fact the distal fragment was just lying under the deltoid with some soft tissue into position. She was in a lot of pain and discomfort. So this patient had a general anesthetic acquisition in beach chair with her arm holder.
I normally use tranexamic acid 1 gram IV pre-operatively, as well as infiltrate the approach with a mixture of local anesthetic and adrenaline. I've found this helps reduce the initial bleeding. I normally have started doing deltoid split approach for the fracture reverses as I find it's much more easier to get hold of the tuberosity,
act at the tuberosity, then suture them. But this time I decided to go back to using the delta pectoral, which I use for my elective shoulder replacements. So here marking the incision first along the deltopectoral. A groove. This is quite an easy, straightforward approach.
Unfortunately, here it looks like there was a small webbing [?] which I went through, which had an initial bleed, but they settled down quite quickly. The advantage of this approach is that it's inter-nervous and also playing strong quite nicely in a native shoulder or a virgin shoulder. There's always this fat pad which is present along where the cephalic vein is, and that guides the approach.
So anybody who's starting off to do this needs to look out for that. Also at the top of the delta pectoral groove, it's quiet and um. Space for that can be used as another landmark to approach this. Now, although the textbooks say that when the vein, the cephalic vein needs to go laterally, I found it easier in my hands for it to go medially the left as there is less tension on the nerve, on the vessel.
Once I've done that, I've then released a bit of the deltoid distally using a finger sweep and do a subdeltoid release as well. As you will see in a second, so this is the deltoid release, distally the anterior part as it allows bit more rotation. Following this, you identify the pectoralis insertion.
And although more important in elective site where there is a stiff shoulder. Find if you release the upper centimeter or so. It allows better rotation and better access to the upper end of the humerus. And I've so far not seen any issues. It heals up well. So you've done that, identified the coronoid process, the coracoclavicular ligament, which is released.
And that, again, frees up the humeral head and allows to isolate the conjoined tendon where you can put that in front. So now we're going to put some soft retractors around the upper end of the incision. These are soft and causes less damage to the delta and the pectoral muscle
when it opens also, it swivels around to employ full coverage. The next step is to identify the long head of biceps. Generally, it's felt fairly easily if it's present or certainly the groove can be felt easily unless there is significant osteophytes. Once I've identified the biceps and its groove trace that it's repeatedly into the rotator interval and even in this fracture case can put a homer around the back of the humeral head.
You need to make sure you have decent sharp scissors to open up the rotator interval. Do a tenotomy of the biceps at this stage in subsequent. Subsequently can reach into the rotator interval. In a fractious situation,
I generally tend to use an osteotomy saw to lift off the lesser tuberosity as its already fractured it employs a better repair. And on the open end of the prostheses, once you've removed this, once you want to osteomise rather than being a subperiosteum pain.
It's once that some release has been done and start to see the humeral head peeping through that window as this is a couple of weeks old, already starting to wear some callus can gently manuveure the hemoral head out.
But here the gluteal tuberosity or the GT is attached to the humeral head fragment and hence have to optimize using a saw. And then the head is delivered. The head is then removed and you can see it's quite a small size head. And in this older age group patient. They're not re-salvageable.
Sometimes you have to use a heavy scissors to perform the soft tissue releases around the tuberosity making sure that you will not cause any further damage. Also make sure that you release the rotator interval adequately. You remove any excess bone.
Too much bone can be a bit of a problem as well. Trying to get the repair can be tricky and putting the tuberosity to work would be tricky. Getting the perfect amount is critical. Then place a retractor at the back of the glenoid and another retractor at the front of the glenoid providing me with that exposure required. The biceps down for a scene provides a landmark to place the glenoid check in the right place.
When putting this end to your retractor, be careful not to push it too medially as it can irritate or catch the musculocutaneous nerve. Causing numbness in the fingers. At this stage you can remove the biceps longer to Bicep tendon from it.
INAUDIBLE well as mark the axis of the glenoid removing the excess lavarum. Clearly this is a traumatic case and hence glenoid is generally not degenerate. It has a fairly thick articular cartilage. It needs to be removed. So here I've got a good exposure of the glenoid.
I'm now going to draw the axis for demonstration purposes. Generally, even in real life, I would mark it out. Here we're going to spend a bit of time getting the placement correct. My registrar is ready to put the die pin in.
This is a forked head protractor which can come in handy to put it under the around the medial spine of the scapula acts as a inferior retractor for the humeral head. If not any other retractor may be useful. I like the Bhattman Retractor. Check and make sure that you've got the orientation correct of the jig.
Sometimes I find it's easier and quicker to do a free hand technique. The other way to check the guide pin is to put the finger in front of the glenoid. And as long as it's about 3 centimeters before it perforates, that seems to be adequate. Then perform the reaming.
I'm getting my registrar to put his hand On the reamer shaft to avoid too much taut. What we are aiming to see is some cancellous bone particularly like a smiley face at the bottom, which means there's angle of the inclination is correct.
Be careful not to over ream, unlike something like the hip. That is small quantity of the glenoid bones.
Once that's done, give it a good wash, remove any excess bone. In arthritic it will be the osteophytes in a trauma situation when the cartilage is removed, it does need a bit of lip. Insert the base plate, which is a chain coated in case of comprehensive. Generally, he had a change in the tone. And a firm grip of the glenoid sphere into the bone stock.
At this stage, remove the guide pin. The guide pin on the comprehensive system is the same size as the drill diameter.
So as long as you perforated the shoulder blade, the scapula, you do not need to drill it again. I have not needed to. At this stage, I'll just use the depth gauge to measure the length of the screw. The center screws the compression screw, to 6.5 millimeters and it bottoms out so it could hold.
Then I use a jig to put two peri-lock locking screws. Generally, I prefer the superior and the imperial one as they've got the best bone store can put compression screws or a variable angle screws anteriorly and posteriorly.
But I can't remember the last time I had to use it for a traumatic case. It certainly may be useful if the bone stock is lacking the superior inferior part.
Of the two locking screws, top and bottom have generally found that if they are within 5 millimeters of the central screw, that suggests that they adequately aim for both the central screw and the peripheral screws.
I'm now using this gadget to check the seating of the central screw as this is vital to assess the depth. But disengages the morse taper of the glenoid sphere. This is followed by a trial deduction. Again, this is being performed by my registrar. Once the trial glenoid sphere is in, use a spatula type device to rotate the crown to assess the positioning which generally should be inferior and slightly anterior.
Once you are happy with the position, so he is demonstrating the twisting of the glenoid sphere to achieve the right offset.
Once happy with the position, the screw is tightened. True lock to trial, components in place. The glenoid sphere is removed. And then the position checked. This is the same position where our actual prosthesis is going to go. If this off centered all positions, the actual prosthesis is then put together the glenoid sphere and the modular taper.
Matching the retro, the offset that we decided to trial and once this has been inserted, flip it over. And that gives the orientation of the offset which was decided by the trials. Client, this is the best device to hold this in place as it gives me a bit more maneuverability to position {to} accurately.
Make sure that the INAUDIBLE of the Morse Taper is dry. Required wash it again? Detritis we do not want any debris in here. Glenoid sphere is then inserted. And the clamp removed with a thumb or a finger holding it in place.
This can be a bit tricky at times. Once that's in place, use the tap to tap the glenoid sphere into position. Before removing the retractors, check to make sure that the base plate and the glenoid sphere are stable.
Now we'll move on to doing the humerus. It's quite vital that this maneuver is performed by the surgeon removing the arm from the clamp holder and making sure to a bimanual maneuver so as to avoid the upper end of the humerus catching into the glenoid sphere. Generally in the fractures, it can start with the size that appears appropriate.
This one is showing the use of the anatomic stem for the reverse from the Zimmer family. It appears to be quite bulky. The reason for choosing this here was to, you get some pins in place to be able to provide better suturing of the tuberosity. And I tell the verdict at the end of the procedure.
The brooches that introduced at the appropriate, the retroversion. In this case, it's 20 degrees. And then stamped. Position you got to see these brooches to get the size that is correct for the patient. [?]
Being open. I'm going to prepare for doing the repair of the tuberosity. In the practice situation, I make two holes on the left side of the humerus as wide as I can. Generally, about 2 and 1/2 to 3 centimeters gap between the two.
And then I'll pass non-absorbable sutures through this. Making a loop on the medial side of the medullary canal outside. You can use up to three or four sutures as required to repair the that tuberosity in seconds which are going in now.
In the meantime, the prosthesis is being made ready. Put this on the inserter. What we've forgotten here is the Ashcrom Adapter, which is uh, the in-between device between the comprehensive humeral tray
and the anatomic reverse stem. And I put the sutures through the stem between the suture surface. So a loop is formed around the stem, which provides increased strength. This is then tamped in place to the appropriate height.
The advantage of reverse shoulder prostheses over hemming, however, is that it is more constrained, significantly more constrained, and also allows the surgeon to build up the height and the lateralization to a certain degree. This is the Ashcrom Adaptor that has gone in that will allow for trial. So taking the tray first, starting with the standard tray.
And I can see the reduction. Often I'll assess just the reduction rather than doing the actual reduction. Now inserting the volley into the humeral tray and the ring lock and this is the best technique I've learned and evolved over the last few years.
In a small arthro clip to split the spring lock spring open, and then the pole is inserted and then tapped to place. Quite cleverly shows which way to put in this inscribed superior. Where the superior side of the prostheses should go. This is what I call as an orthopedic surgeon proven right. In gentle terms to gauge the Morse Taper, then hopefully we should be able to use this fairly easily.
Sometimes I have to remove the retractors as they may cause pull and tension onto the muscles around the shoulder. So now you can see that this probe prosthesis is nicely in position, a reduction is fairly stable and now begins the step of preparing the tuberosity.
So the sutures have come from inside out as it's a loop. And I do the same on the cuffs. It goes outside in a crisscross. So the one that has got anteriorly goes into the posterior cuff and vice versa. Sometimes the tuberosity have to be gently persuaded to come into the warm.
Now, I still find sometimes it can be tricky to get the adequate amount of bone attached to the tuberosity: too less the repair may be less effective. Too much, it could cause impingement or even encourage microscopic calcification.
Often past multiple times, as long as it's not being locked, then going across to the other side of the cup. I'm breaking out outside to in, so hopefully one can pull the tuberosity back in place.
Once I've crossed over to the other side of the cuff and under constant tension tie the knots down. The key thing is not to pull on the sutures too hard as it can snag if it's caught on the edge of a bone or the prosthesis. If required, pull on the tuberosity and the cuff to bring them down rather than pulling on the suture that had been put through the cuff.
You can see it's covering the prosthesis quite well. Repeat the sequence with the next suture starting from outside in. Going across. From the inferior parts.
From the inside. And as you can see, doing a little bit of abduction always helps the tuberosity to relax. Being pulled down. I can see there's some open. But displacement between the two tuberosity once I've tied suturing, this can put another non absorbable suture.
It requires multiple passes through all the parts of the cuff to be able to repair the tuberosity. I do pay a fair amount of attention to repair this back in place.
Then the remainder of the suture is used to put a running stitch through the rest of the cuff.
That is the complete repair of the tuberosity. With about four different non absorbable sutures. At this stage if required, you can suture the biceps, long biceps tendon, incorporated into tenodesis. Generally in my elective arthroplasty, I would repair this with the pect or around with the subscapularis anatomic replacement to provide more stability or robustness to the repair.
Then close the delta pectoral interval. Place the arm in a sling. These are the post-op radiographs, as you can see, there is slightly chunkiness of the upper end of the prosthesis. The tuberosity also appeared to be slightly bigger than what I would have ideally liked to and slightly more proximal.
Uh, but this should not cause any problems. I hope you enjoy it. Learn something from this video. For more videos, please visit my YouTube channel. Leave a comment, please. Thank you.
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