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Name:
Reverse Shoulder - Deltoid Split Trauma
Description:
Reverse Shoulder - Deltoid Split Trauma
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Duration:
T00H21M19S
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https://cadmoreoriginalmedia.blob.core.windows.net/7865d15b-e4c2-46ed-8852-8f2ee7f6ec2c/Reverse Shoulder - Deltoid Split Trauma.mp4?sv=2019-02-02&sr=c&sig=OsgmLekLZF7uncNJhW4C2mOtePJ7HGWIRElZt58QYXg%3D&st=2024-12-04T19%3A09%3A14Z&se=2024-12-04T21%3A14%3A14Z&sp=r
Upload Date:
2024-03-12T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. I'm presenting on a 75-year-old chap with a four part fracture, proximal humerus, which showed fairly comminuted fracture, which was non reconstructible and in not good alignment. The CT scan confirmed this and hence we decided to proceed with reverse polarity shoulder replacement. He's active, still part time works and enjoys playing golf and swimming. Today I'm going to show a deltoid split or a McKenzie type approach.
BIJAYENDRA SINGH: Patient in a beach chair. I routinely inject the plane of injection with xylocaine adrenaline mixture, a general anesthetic and a block, and I draw a line about 7 centimeters from the acromion roughly to see where the axillary nerve is likely to be. Obviously this will vary based on the height and the morphology of the patient. This just gives an idea where to look for thick skin
BIJAYENDRA SINGH: flaps with the fat is raised and you can see the bleeding is not as bad as you would expect. Once I have done and raised enough flaps around, I would then go on to identify the interval between the entry and the mid part of the deltoid.
BIJAYENDRA SINGH: Often there is a rafay, I go a few millimeters behind the anterior edge of the acromion and incise the superficial fascia and some of the muscle layers. After this I use a scissors to split and do a blunt dissection and fresh fractures. You should usually see a hematoma that appears as you open the deltoid. I peel the deltoid from top of the acromion lifting a little flap. Here,
BIJAYENDRA SINGH: I'm going to not go beyond the axillary nerve by putting a stay stitch just proximal to where I drew the line. This is to avoid any further splits in the deltoid causing damage to the axillary nerve. Once I've done that, I use an osteotome to take a small slither of the acromion. The idea being that the healing is better bone to bone rather than soft tissue to bone.
BIJAYENDRA SINGH: Once I've done that, I remove the bursa. I often will take a bit of a acromion out to do an acromioplasty at the same time. Here, I'm just trying to separate the bony fragment of the GT. Sometimes you may need an osteotome to lift it up.
BIJAYENDRA SINGH: And using a scissors, I split in the rotator interval. I'm trying to manipulate the head fragment, but you can see I can only get a small comminuted fragment from the metaphysis. Once I get a bit more play, then I'll put a stay suture through the rotator cuff to hold that greater tuberosity fragment.
BIJAYENDRA SINGH: The head is delivered and you can see it's quite a small size fragment, although it does have a little bit of attachment posteriorly. You can either use an osteotome to release this, leaving a small fragment of bone, which facilitates repair to the upper humerus when coming to the closure.
BIJAYENDRA SINGH: Often you will find that the humeral head already has lost some of the cartilage, as in this case and you can see I'm using a saw blade to reduce that now to remove that fragment. Now, once you've removed the head fragment, the next step is to get the guidewire in.
BIJAYENDRA SINGH: I've marked my space and using a guide to introduce the guidewire for the baseplate of the glenoid. Once the guidewire is in, then you perform the reaming for the base plate. This is a Zimmer comprehensive system which utilizes a mini base plate of 25 millimeter diameter. Care must be taken not to over ream the glenoid especially in the older age group patient as it can be easily done.
BIJAYENDRA SINGH: All you need to see is a smiley face at the bottom of the glenoid and you do not need to see a whole bleeding cancellous bone like preparing the acetabulum. Make sure any excess bone and soft tissue has been removed, particularly around the inferior part of the glenoid.
BIJAYENDRA SINGH: Once this is done, then you use the base plate. This is the 25 millimeter with four holes and has got HA coating and when tapping the base plate, must be careful, carefully listen to the sound as any change and one must stop otherwise you can crack the glenoid. The guidewire is then removed and the depth of the central screw measured.
BIJAYENDRA SINGH: This is a compression screw and in vast majority of the cases can achieve a good primary and stable fix with this group. Then the peripheral locking screws are drilled. I normally tend to use two, one superiorly and one inferiorly, which provides enough fixation. The anterior and posterior screws may be used, but so far, I have not needed to use them.
BIJAYENDRA SINGH: Can measure the length of the drill guide and I find that if the central screw is in good position, the peripheral screws are about 5 millimeter within that range.
BIJAYENDRA SINGH: And now inserting the peripheral locking screws. Once this is done, then you do a trial glenosphere. This allows to check for the exact position. Use this torque device to rotate it around and get the best position of the glenoid sphere.
BIJAYENDRA SINGH: Once I'm happy, I leave the trial sphere in place and then lock the screw and once that has done, the glenoid sphere can then be removed and checked on the back for the exact position that I wish to put the line the base place in.
BIJAYENDRA SINGH: Following the trial, you get the definitive implant and lining up, line it up in the exact position I want it to be. Double check the orientation of the offset and then using the grabber, the glenoid sphere is inserted and then tapped into place. One thing I'm very particular about is making sure that the trunnion is dry
BIJAYENDRA SINGH: so that the Morse taper engages in the best possible fashion. Once this is done, the humerus is gently brought down. Now, when using the deltoid split approach, the rotation can be a bit limited, so care must be taken that you position your retractors in such a way that you can access the humerus and the serial reaming.
BIJAYENDRA SINGH: We're going to use a mini stem, so we're going to be using accordingly. This goes up in millimeter size. It does not need to be a cortical fix, but enough that it catches. And once this, we're happy with the size, then put a broach starting two sizes lesser to create the upper end.
BIJAYENDRA SINGH: This is quite an important repair step. I'm preparing the upper end of humerus to get the tuberosities in place. This is what my registrars named it as the Singh Sling. So I've made four holes on the upper end of the humerus all around, and I'm passing this non-absorbable suture. A one to two, two to three, and three to four holes. So there will be three loops of this nonabsorbable suture.
BIJAYENDRA SINGH: I then collect the three loops of the sutures, keep it at length, and then I will insert the humeral stem through this loop. The advantage of using this technique is that I'm not relying on the strength of the bone to hold the sutures, but in fact relying on the strength of the metal of the humeral components, which is certainly significantly more than the
BIJAYENDRA SINGH: bone quality. So this is the stem going through the loops. You can see here and then I pull on the sutures to tighten it around the stem. Now I put it to the area where there is no HA coating, so it's unlikely to cause any issues with the bonding of the proximal end of the humerus.
BIJAYENDRA SINGH: The stem is then inserted. At this stage, I do a trial reduction holding the or inserting the glenoid sphere upside down as it's easy to dislocate once I have reduced it. This is where the reverse shoulder comes of its own compared to a hemi, where you can adjust the height as required. And also it's a more constrained prosthesis than the hemi, and hence it works better than a hemiarthroplasty.
BIJAYENDRA SINGH: So I'm now putting the humeral component, the tray and the poly insert going, lining up the notch appropriately, and then with a gentle push, this should lock into place. Sometimes if it doesn't, then you may have to tap it in. Once it's in, you check but as you can see here, it's just taking a bit more persuasion for this to go in.
BIJAYENDRA SINGH: Once that is in, make sure it's inserted in the correct orientation and it has got written on its superior side so it's very easy. Tap that in place, making sure that the Morse taper is dry and then the prosthesis is reduced.
BIJAYENDRA SINGH: Now, this is quite an important step to repair the tuberosities. I'm taking the sutures that I passed through the humerus and putting it in the middle one through the superior cuff, greater tuberosity. It's important that these sutures are passed through the cuff tissue rather than the bone, as that is the stronger material.
BIJAYENDRA SINGH: I passed from the second suture to the posterior part of the cuff and one must make sure that you have put all the sutures through before starting to tighten them.
BIJAYENDRA SINGH: This can appear to be quite daunting, but once you've done it a few times, it does become easier. Some surgeons have the luxury of using different colored or different stripes, but it does increase the cost of the procedure. Here I'm using an Ethibond suture, which is commonly available in most theaters.
BIJAYENDRA SINGH: Once all the sutures have been parsed, then I start to tying them serially. If required, I will change the position of the shoulder to facilitate bringing the tuberosities on onto the stem. Once I've repaired all of these, if there is any visible gaps, then I will use the bone removed from the humeral head to bone graft it to improve the healing of the tuberosities.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Finally, you can tie the front to the back sutures to provide more stability of the whole repair. Following this repair of the rotator cuff, I repair the top of the deltoid and the acromion using non-absorbable suture, doing an osteo fascial repair followed by a continuous suture.
BIJAYENDRA SINGH: I put the sutures longitudinally rather than criss-cross, and in my practice I've noticed this reduces the puckering of the skin followed by fatty layer and then I normally use an absorbable monocryl subcuticular for the skin closure. These are the immediate post-operative radiographs from this patient and you can see how well the tuberosity has come both on the AP and the lateral view.
BIJAYENDRA SINGH: The patient is started on pendular exercises from the following day. For the vast majority of my reverses be for trauma elective, I do get them to do active assisted at two weeks and completely out of the sling at four weeks. If you have any professional or patient related queries, then please do not hesitate to contact the team.
BIJAYENDRA SINGH: There are more videos to be watched on my YouTube and my VuMedi channel. If you feel like, please go to prof bijaysingh. Thank you for watching. [VIDEO ENDS]
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. I'm presenting on a 75-year-old chap with a four part fracture, proximal humerus, which showed fairly comminuted fracture, which was non reconstructible and in not good alignment. The CT scan confirmed this and hence we decided to proceed with reverse polarity shoulder replacement. He's active, still part time works and enjoys playing golf and swimming. Today I'm going to show a deltoid split or a McKenzie type approach.
BIJAYENDRA SINGH: Patient in a beach chair. I routinely inject the plane of injection with xylocaine adrenaline mixture, a general anesthetic and a block, and I draw a line about 7 centimeters from the acromion roughly to see where the axillary nerve is likely to be. Obviously this will vary based on the height and the morphology of the patient. This just gives an idea where to look for thick skin
BIJAYENDRA SINGH: flaps with the fat is raised and you can see the bleeding is not as bad as you would expect. Once I have done and raised enough flaps around, I would then go on to identify the interval between the entry and the mid part of the deltoid.
BIJAYENDRA SINGH: Often there is a rafay, I go a few millimeters behind the anterior edge of the acromion and incise the superficial fascia and some of the muscle layers. After this I use a scissors to split and do a blunt dissection and fresh fractures. You should usually see a hematoma that appears as you open the deltoid. I peel the deltoid from top of the acromion lifting a little flap. Here,
BIJAYENDRA SINGH: I'm going to not go beyond the axillary nerve by putting a stay stitch just proximal to where I drew the line. This is to avoid any further splits in the deltoid causing damage to the axillary nerve. Once I've done that, I use an osteotome to take a small slither of the acromion. The idea being that the healing is better bone to bone rather than soft tissue to bone.
BIJAYENDRA SINGH: Once I've done that, I remove the bursa. I often will take a bit of a acromion out to do an acromioplasty at the same time. Here, I'm just trying to separate the bony fragment of the GT. Sometimes you may need an osteotome to lift it up.
BIJAYENDRA SINGH: And using a scissors, I split in the rotator interval. I'm trying to manipulate the head fragment, but you can see I can only get a small comminuted fragment from the metaphysis. Once I get a bit more play, then I'll put a stay suture through the rotator cuff to hold that greater tuberosity fragment.
BIJAYENDRA SINGH: The head is delivered and you can see it's quite a small size fragment, although it does have a little bit of attachment posteriorly. You can either use an osteotome to release this, leaving a small fragment of bone, which facilitates repair to the upper humerus when coming to the closure.
BIJAYENDRA SINGH: Often you will find that the humeral head already has lost some of the cartilage, as in this case and you can see I'm using a saw blade to reduce that now to remove that fragment. Now, once you've removed the head fragment, the next step is to get the guidewire in.
BIJAYENDRA SINGH: I've marked my space and using a guide to introduce the guidewire for the baseplate of the glenoid. Once the guidewire is in, then you perform the reaming for the base plate. This is a Zimmer comprehensive system which utilizes a mini base plate of 25 millimeter diameter. Care must be taken not to over ream the glenoid especially in the older age group patient as it can be easily done.
BIJAYENDRA SINGH: All you need to see is a smiley face at the bottom of the glenoid and you do not need to see a whole bleeding cancellous bone like preparing the acetabulum. Make sure any excess bone and soft tissue has been removed, particularly around the inferior part of the glenoid.
BIJAYENDRA SINGH: Once this is done, then you use the base plate. This is the 25 millimeter with four holes and has got HA coating and when tapping the base plate, must be careful, carefully listen to the sound as any change and one must stop otherwise you can crack the glenoid. The guidewire is then removed and the depth of the central screw measured.
BIJAYENDRA SINGH: This is a compression screw and in vast majority of the cases can achieve a good primary and stable fix with this group. Then the peripheral locking screws are drilled. I normally tend to use two, one superiorly and one inferiorly, which provides enough fixation. The anterior and posterior screws may be used, but so far, I have not needed to use them.
BIJAYENDRA SINGH: Can measure the length of the drill guide and I find that if the central screw is in good position, the peripheral screws are about 5 millimeter within that range.
BIJAYENDRA SINGH: And now inserting the peripheral locking screws. Once this is done, then you do a trial glenosphere. This allows to check for the exact position. Use this torque device to rotate it around and get the best position of the glenoid sphere.
BIJAYENDRA SINGH: Once I'm happy, I leave the trial sphere in place and then lock the screw and once that has done, the glenoid sphere can then be removed and checked on the back for the exact position that I wish to put the line the base place in.
BIJAYENDRA SINGH: Following the trial, you get the definitive implant and lining up, line it up in the exact position I want it to be. Double check the orientation of the offset and then using the grabber, the glenoid sphere is inserted and then tapped into place. One thing I'm very particular about is making sure that the trunnion is dry
BIJAYENDRA SINGH: so that the Morse taper engages in the best possible fashion. Once this is done, the humerus is gently brought down. Now, when using the deltoid split approach, the rotation can be a bit limited, so care must be taken that you position your retractors in such a way that you can access the humerus and the serial reaming.
BIJAYENDRA SINGH: We're going to use a mini stem, so we're going to be using accordingly. This goes up in millimeter size. It does not need to be a cortical fix, but enough that it catches. And once this, we're happy with the size, then put a broach starting two sizes lesser to create the upper end.
BIJAYENDRA SINGH: This is quite an important repair step. I'm preparing the upper end of humerus to get the tuberosities in place. This is what my registrars named it as the Singh Sling. So I've made four holes on the upper end of the humerus all around, and I'm passing this non-absorbable suture. A one to two, two to three, and three to four holes. So there will be three loops of this nonabsorbable suture.
BIJAYENDRA SINGH: I then collect the three loops of the sutures, keep it at length, and then I will insert the humeral stem through this loop. The advantage of using this technique is that I'm not relying on the strength of the bone to hold the sutures, but in fact relying on the strength of the metal of the humeral components, which is certainly significantly more than the
BIJAYENDRA SINGH: bone quality. So this is the stem going through the loops. You can see here and then I pull on the sutures to tighten it around the stem. Now I put it to the area where there is no HA coating, so it's unlikely to cause any issues with the bonding of the proximal end of the humerus.
BIJAYENDRA SINGH: The stem is then inserted. At this stage, I do a trial reduction holding the or inserting the glenoid sphere upside down as it's easy to dislocate once I have reduced it. This is where the reverse shoulder comes of its own compared to a hemi, where you can adjust the height as required. And also it's a more constrained prosthesis than the hemi, and hence it works better than a hemiarthroplasty.
BIJAYENDRA SINGH: So I'm now putting the humeral component, the tray and the poly insert going, lining up the notch appropriately, and then with a gentle push, this should lock into place. Sometimes if it doesn't, then you may have to tap it in. Once it's in, you check but as you can see here, it's just taking a bit more persuasion for this to go in.
BIJAYENDRA SINGH: Once that is in, make sure it's inserted in the correct orientation and it has got written on its superior side so it's very easy. Tap that in place, making sure that the Morse taper is dry and then the prosthesis is reduced.
BIJAYENDRA SINGH: Now, this is quite an important step to repair the tuberosities. I'm taking the sutures that I passed through the humerus and putting it in the middle one through the superior cuff, greater tuberosity. It's important that these sutures are passed through the cuff tissue rather than the bone, as that is the stronger material.
BIJAYENDRA SINGH: I passed from the second suture to the posterior part of the cuff and one must make sure that you have put all the sutures through before starting to tighten them.
BIJAYENDRA SINGH: This can appear to be quite daunting, but once you've done it a few times, it does become easier. Some surgeons have the luxury of using different colored or different stripes, but it does increase the cost of the procedure. Here I'm using an Ethibond suture, which is commonly available in most theaters.
BIJAYENDRA SINGH: Once all the sutures have been parsed, then I start to tying them serially. If required, I will change the position of the shoulder to facilitate bringing the tuberosities on onto the stem. Once I've repaired all of these, if there is any visible gaps, then I will use the bone removed from the humeral head to bone graft it to improve the healing of the tuberosities.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Finally, you can tie the front to the back sutures to provide more stability of the whole repair. Following this repair of the rotator cuff, I repair the top of the deltoid and the acromion using non-absorbable suture, doing an osteo fascial repair followed by a continuous suture.
BIJAYENDRA SINGH: I put the sutures longitudinally rather than criss-cross, and in my practice I've noticed this reduces the puckering of the skin followed by fatty layer and then I normally use an absorbable monocryl subcuticular for the skin closure. These are the immediate post-operative radiographs from this patient and you can see how well the tuberosity has come both on the AP and the lateral view.
BIJAYENDRA SINGH: The patient is started on pendular exercises from the following day. For the vast majority of my reverses be for trauma elective, I do get them to do active assisted at two weeks and completely out of the sling at four weeks. If you have any professional or patient related queries, then please do not hesitate to contact the team.
BIJAYENDRA SINGH: There are more videos to be watched on my YouTube and my VuMedi channel. If you feel like, please go to prof bijaysingh. Thank you for watching. [VIDEO ENDS]
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