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Name:
Reverse Total Shoulder Arthroplasty - Comprehensive Zimmer Biomet
Description:
Reverse Total Shoulder Arthroplasty - Comprehensive Zimmer Biomet
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T00H31M33S
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https://cadmoreoriginalmedia.blob.core.windows.net/d035dd16-b972-4b13-8870-f31d19be7acb/Reverse Total Shoulder Arthroplasty - Comprehensive Zimmer B.mp4?sv=2019-02-02&sr=c&sig=FAwhAZrnwkOy2c9sTeVDKqQVzxORJkbYhvJYaK5zyac%3D&st=2024-11-23T11%3A17%3A05Z&se=2024-11-23T13%3A22%3A05Z&sp=r
Upload Date:
2024-06-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Good day, everyone. This is a short video on reverse shoulder replacement done by Professor Singh. No conflict of interest. What I'm going to demonstrate is a reverse shoulder arthroplasty using Comprehensive Zimmer Biomet. So patients in a beach chair position.
BIJAYENDRA SINGH: This is the left shoulder, as you can see. Going to use a deltopectoral approach. Always mark the incision, which is longer than what I think I'm going to need about 10, 12cm long incision, lateral to the coracoid and going away from the axillary fold, thick flaps. I generally tend to inject the skin and the subcutaneous tissue with
BIJAYENDRA SINGH: [INAUDIBLE] mixture, which gives a clean field of vision, certainly in the early stages it reduces the blood loss. Putting a sub small self-retainer retractor, then you identify the fat pad which leads into the deltopectoral interval. Certainly the virgin within the shoulder.
BIJAYENDRA SINGH: See this? Identify the cephalic vein and more often than not, I do tend to take the vein medially. Occasionally you may have to burse a tributary or so, but I try and preserve the rein using my finger. Some sharp bisection from the plane between the deltoid and the apex
BIJAYENDRA SINGH: and you can see that insertion of the pectoral major just coming into the view there and I've released about a centimeter, to about a centimeter and a half, depending on the stiffness in the shoulder. That gives a better external rotation. Also release the distal insertion, anterior insertion of the deltoid.
BIJAYENDRA SINGH: And see if this is the coracoid process, the conjoined tendon. I'm just releasing the ongoing tendon followed by release of the coracoid from the ligament. Just need to be careful as sometimes there can be a bit of a cool's for a small bleeder. I'm doing a blunt dissection using the finger. Oh, OK. So, as I said, there is a small bleeder there that I can see.
BIJAYENDRA SINGH: Sometimes it can bleed quite a lot so just be careful. Now after that I will put some Buxton special retractors for the shoulder, which are a bit more gentle onto the soft tissues and they also allow the tractor to swivel without causing damage to the deltoid or the pectoralis muscle.
BIJAYENDRA SINGH: Once I've done that, you can see it subtracts nicely put a blunt Hohmann under the messacromion space. Do that, please if it is still there. After this, I
BIJAYENDRA SINGH: the next step is to identify the biceps. If it's present bicipital groove, which will lead me to the rotator interval which allows to then dissect off the subscapularis and see the fluid from the glenohumeral joint. It's usually quite safe to dissect. Now, just resecting the width of the biceps.
BIJAYENDRA SINGH: Then I can see the biceps tendon is partially torn, but the residual stump, which I will do it but this is later. Generally tend to peel off the subscapularis from the bone
BIJAYENDRA SINGH: even if I'm doing an anatomical placement, I find it preserves the subscapularis better and I can do a transversalis repair of the subscapularis tendon if required at the end. So releasing the subscapularis
BIJAYENDRA SINGH: from the bone as a full, thick layer. As I come further down, I just need to be careful with the three sisters, as they are called, the vessels and as I come further into the axilliary area, one just needs to be careful of the nerve, which is quite close by. At this stage, I
BIJAYENDRA SINGH: will externally rotate the arm and sometimes I have to take it out from its holder, dislocate the humeral head. You can see it's come out nicely. But they said, if there is any osteophytes, I would aim to remove the osteophytes. If not, I would take the first reamer, the sharp ended one.
BIJAYENDRA SINGH: Go in the center and depending on what I feel, I may jump two or three reamers at the first instance, we can go from four on to six or seven. And then depending on how I feel, the catch might go at one or two until the desired. Then then once I'm happy, I leave that reamer in situ
BIJAYENDRA SINGH: and then I will apply the cutting jig. Generally tend to use 30 degrees retroversion in vast majority of them. I find that this gives them a better external rotation. If our patient has got kyphosis, then I would tend to hesitate to put it at 40 degrees. A couple of pins to secure this in place.
BIJAYENDRA SINGH: And then the rest of the bits come off except for the cutting jig. It's important to remember to take the reamer out before you use the saw. May have to push the pins back once you remove the reamer. Sometimes if it's soft bone, I might put a third pin in
BIJAYENDRA SINGH: as well. You want a bit more stability. You can see, this is still a bit more bone. At this stage, sometimes you can use an angel ring to see how much I'm going to cut off.
BIJAYENDRA SINGH: I put this sharp Hohmann on the medial side to protect the axillary nerve as well as the glenoid and that will intersect the humeral head using an oscillating saw. On the Zimmer Biomet, it gives 135 degree angle of the mid shaft.
BIJAYENDRA SINGH: To remove the humeral head and if you're doing anatomic, then this can be used to check the approximate diameter and the size of the humeral head it's going to use, but not so relevant in the reverse shoulder arthroplasty.
BIJAYENDRA SINGH: And then generally then broaching two or three size smaller than the last reamer and again, 30 degrees retroversion. Gently tap, remembering that the actual prosthesis is about 1.5mm wider in diameter than the broach. So slight loose fitting, but not too tight fitting is what is desired.
BIJAYENDRA SINGH: And then you can leave the stem in but I generally tend to remove the trial prosthesis. This removes some of the osteophytes again.
BIJAYENDRA SINGH: So the humeral side is now nearly prepped. Grab hold of the subscapularis to then perform some more release around the front. Sometimes I use scissors or a blunt instrument
BIJAYENDRA SINGH: to release the subsequent ortho front of the glenoid, and then I either retract it. OK, now we are going to do the glenoid. I've done some part of the release of the
BIJAYENDRA SINGH: subscapularis right at the start of the surgery when I exposed the shoulder joint. After that, I release the subscapularis either using the scissors nd then I put a sharp Hohmann in front of the glenoid to push the subscapularis away
BIJAYENDRA SINGH: and generally put a small swab which acts as a retractor and stops it I needing one less assistant. So you've done that, you should be able to see the glenoid fairly easily. Remove any remnant of the biceps and also excise the labrum.
BIJAYENDRA SINGH: Be careful of the inferior side that it's not too close to the nerve. This is more important in patients who have very stiff shoulders. The retractor usually the post-triassic of the glenoid one is enough. Sometimes in a very stiff and a large patient, you may have to put a second
BIJAYENDRA SINGH: rectractor on the superior, posterior superior aspect of the glenoid. I'm happy there with the positioning and the exposure at the guide pin is 3.5 and there is a jig to help position the central guide pin, which sometimes I may or may not use.
BIJAYENDRA SINGH: Here you can see I'm using this test providing a 10 degree of inferior tilt of the, of the base plate. I often find it's quite fiddly and just do it freehand. In that situation, I would put the finger in front of the glenoid to see where the wire is coming out, and generally if it is about 5 centimeters
BIJAYENDRA SINGH: medial to the edge of the glenoid, that is generally a good position. So on the finger, about one and a half digits. Gone on to use mini baseplates, so with all their color coded, with the yellow color, with matching golden sleeves is for the mini baseplates, which is 25 millimeters and I've not felt the need for larger base plates ever since.
BIJAYENDRA SINGH: The base plate can remove any excess osteophytes that may be present
BIJAYENDRA SINGH: and what we need to see is the smiley face, the glenoid bottom. This is the base, which is actually coated with four screws, which goes north, south, east, west but you can rotate it as per requirement. And generally, the base plate itself provides a decent fit on to the glenoid unless it's thin. The guide for the central pin is the same as the diameter of the drill bit, which
BIJAYENDRA SINGH: means that I avoid drilling it again, although it will be certain you could use it. I'll then use the peripheral screw inserter and this is a jig to allow for inserting the locking, the non-locking peripheral screws. I generally put two, one superiorly, one inferiorly, and that's what I found to be required in most cases.
BIJAYENDRA SINGH: Occasionally, if it's a soft one and the hold is a bit poor, then maybe a third or a fourth but this is the central screw which provides a good compression of the base plate against the glenoid followed by insertion of the peripheral locking screws, unscrew to the blue colored to make it easier and the non-locking screws are golden colored.
BIJAYENDRA SINGH: And once that is done, I just use this device to make sure that the central screw is sat to an adequate depth, as I've had once or twice where the central screw is bottomed out
BIJAYENDRA SINGH: and this can risk dissociation of the glenosphere. The glenosphere is fairly easy to put in. It's an eccentric model design. It comes in two parts, the shell and the sensor moist taper.
BIJAYENDRA SINGH: And you can adjust this according to a requirement. I've generally found that going non C, i.e. 3 millimeter inferior offset should work well and you can match that up with the line. And once that is done, gently tap into place and then there is a device to check for which way the orientation goes
BIJAYENDRA SINGH: and then there is an inserter. Make sure you're orientated and remember it otherwise you could end up putting it in the wrong orientation. Make sure you caught it otherwise, it can drop on the floor. I've dried it.
BIJAYENDRA SINGH: I insert the glenosphere and I often find that this is the step that decides how long the procedure is going to be. Often, if you haven't done enough release or the shoulder is very tight, this step can be mighty difficult. We've gone in well, and I've made sure that it's sitting tight. Used my finger around it to check it's not loose or falling out and then bring the humeral upper end of humerus into position
BIJAYENDRA SINGH: and clip it in place. We pull the retractor around the humerus. Now I'm going to make my drilled holes for, in preparation of the repair of the subscapularis. Often just the Ethibond needle is strong enough to pass
BIJAYENDRA SINGH: through the bone. If the suture comes off or if you can't pass the needle, then you can use a Houston type suture passing device. Then really, three in number. That provides a decent repair for the subscapularis. Often it can be a bit annoying when you come to pass the needle
BIJAYENDRA SINGH: and the sutures disappeared and we were founded. Once that is all done, then you go back to inserting the Hohmann then. Nurse has kept it ready. That goes in 30 degrees of retroversion as planned. The assistant supports the elbow
BIJAYENDRA SINGH: and it should go pretty easy. It's still a bit proud and I'm going to push it in a bit more. So that's the humeral insertion and now start with the standard trial. And you can see here it says superior to suggest orientated correctly. Often I will not reduce this fully.
BIJAYENDRA SINGH: I've just checked that it will reduce easily, as I often found that once you reduce it, they reduce it, that it can be a bit tricky to. Please look at the trial prosthesis. We are happy there and we will go with that particular size. So we're now coming towards the implantation of the humeral train closure.
BIJAYENDRA SINGH: I generally put the sutures into the humeral head before I put the humeral stem in as it makes it easier to do the subscapularis repair as well as insertion of the tray. I normally have three non-absorbable sutures and then, I would preferably put the sutures into the subscapularis, as you can see here, which is of good quality.
BIJAYENDRA SINGH: Before I put the humeral tray in, I'm going to run this video slightly faster um, and I've put a mattress stitch times 3. Sometimes it can get a bit tricky and this is where your suture management skills come into play.
BIJAYENDRA SINGH: So all the three sutures are passed and making sure that there is no entanglement, because unfortunately, if this happens, then it's a nightmare situation as you have difficulty in passing any of the sutures into the upper end of the humerus. So once that is done, the next step is to put the plastic in the humeral tray
BIJAYENDRA SINGH: and this particular prosthesis has a ring lock mechanism in which the ring on the humeral tray needs to be clicked into a little slot on the plastics. Sometimes it goes easy with the hand push, but at times it can be a bit tricky and in that situation various techniques is used to get it over.
BIJAYENDRA SINGH: Tapping generally helps. Once that is there, you make sure that you try the trunnion as any blood can cause a prosthesis to be pushed out. I then put the humeral tray in gentle tap to engage the taper.
BIJAYENDRA SINGH: And then usually it should be a pretty easy reduction. You need to make sure that the subscapularis has been pulled out of its way otherwise, it can get into softer center position. So here you can see it's nicely reduced and I put the arm back into the holder. Word of caution at this stage is to make sure that you remove the arm out of the holder and do this in the hand, holding the arm and the hand otherwise
BIJAYENDRA SINGH: it's a very long lever arm, which can cause problems. Once that is done, you untangle your sutures one after the other which again, I normally always spend a few minutes so that you need to make sure this is right. Subscapularis repair is very important, especially if you're doing an anatomic as the stability does rely a great deal on this and generally tend to hand tie one after the other.
BIJAYENDRA SINGH: I would cut one end and leave the one with the needle on just in case I had to do some more sutures to pass through, the more passes. The middle one, usually both of them are cut and then the top one again similarly are tied and if required, you can put a few more passes
BIJAYENDRA SINGH: through the tendon. If the supraspinatus is good quality and finding an anatomic replacement then will almost always close the rotator interval. It gives more support to the repair. What helps is to put the arm in a bit of a adduction and internal rotation makes reduces the tension on the sutures
BIJAYENDRA SINGH: and the repair. Once that is done, you can cut that off and then use the one from the bottom to, to run through repair of the whol rotator into and this will provide you with a fairly robust repair. Once that is done, make sure that you remove your soft tissue.
BIJAYENDRA SINGH: So if there's any swabs, at this stage do a soft tissue tenodesis of the sub, long arm biceps with the pecs. Sometimes I incorporate the longer biceps into the subscapularis repair. I mean, this generally tends to work quite well. Once I've done this repair, I would go ahead and put some interactive sutures to close the deltopectoral interval.
BIJAYENDRA SINGH: The suture's aren't tight, very aren't very tightly pulled to avoid a crushing of the muscles and usually three or four interrupted sutures. That makes this closure very good and provides another layer of soft tissue coverage over the uh, prostheses.
BIJAYENDRA SINGH: After this layer I generally use undyed absorbable vicryl suture to close the fat layer and this is followed by use of an undyed monocryl suture, put subcutaneously,
BIJAYENDRA SINGH: subparticularly to close the skin. Continuous suture, I generally always tie the sutures outside. I've had issues with them tying the sutures under the skin as this causes some degree of irritation and some can cause some discharge, which can be taken as an infection to the untrained eye.
BIJAYENDRA SINGH: So what have we done? This, this usually gives quite a nice, watertight repair. I often put some steri-strips on top at the end of this closure and put a pressure dressing on. I've generally not used to drain any of the shoulders unless it's a revision situation or if it's very easy or the last 12 years.
BIJAYENDRA SINGH: That's us done. Give it a nice clean. Thank you. [VIDEO ENDS]
Segment:0 .
BIJAYENDRA SINGH: Good day, everyone. This is a short video on reverse shoulder replacement done by Professor Singh. No conflict of interest. What I'm going to demonstrate is a reverse shoulder arthroplasty using Comprehensive Zimmer Biomet. So patients in a beach chair position.
BIJAYENDRA SINGH: This is the left shoulder, as you can see. Going to use a deltopectoral approach. Always mark the incision, which is longer than what I think I'm going to need about 10, 12cm long incision, lateral to the coracoid and going away from the axillary fold, thick flaps. I generally tend to inject the skin and the subcutaneous tissue with
BIJAYENDRA SINGH: [INAUDIBLE] mixture, which gives a clean field of vision, certainly in the early stages it reduces the blood loss. Putting a sub small self-retainer retractor, then you identify the fat pad which leads into the deltopectoral interval. Certainly the virgin within the shoulder.
BIJAYENDRA SINGH: See this? Identify the cephalic vein and more often than not, I do tend to take the vein medially. Occasionally you may have to burse a tributary or so, but I try and preserve the rein using my finger. Some sharp bisection from the plane between the deltoid and the apex
BIJAYENDRA SINGH: and you can see that insertion of the pectoral major just coming into the view there and I've released about a centimeter, to about a centimeter and a half, depending on the stiffness in the shoulder. That gives a better external rotation. Also release the distal insertion, anterior insertion of the deltoid.
BIJAYENDRA SINGH: And see if this is the coracoid process, the conjoined tendon. I'm just releasing the ongoing tendon followed by release of the coracoid from the ligament. Just need to be careful as sometimes there can be a bit of a cool's for a small bleeder. I'm doing a blunt dissection using the finger. Oh, OK. So, as I said, there is a small bleeder there that I can see.
BIJAYENDRA SINGH: Sometimes it can bleed quite a lot so just be careful. Now after that I will put some Buxton special retractors for the shoulder, which are a bit more gentle onto the soft tissues and they also allow the tractor to swivel without causing damage to the deltoid or the pectoralis muscle.
BIJAYENDRA SINGH: Once I've done that, you can see it subtracts nicely put a blunt Hohmann under the messacromion space. Do that, please if it is still there. After this, I
BIJAYENDRA SINGH: the next step is to identify the biceps. If it's present bicipital groove, which will lead me to the rotator interval which allows to then dissect off the subscapularis and see the fluid from the glenohumeral joint. It's usually quite safe to dissect. Now, just resecting the width of the biceps.
BIJAYENDRA SINGH: Then I can see the biceps tendon is partially torn, but the residual stump, which I will do it but this is later. Generally tend to peel off the subscapularis from the bone
BIJAYENDRA SINGH: even if I'm doing an anatomical placement, I find it preserves the subscapularis better and I can do a transversalis repair of the subscapularis tendon if required at the end. So releasing the subscapularis
BIJAYENDRA SINGH: from the bone as a full, thick layer. As I come further down, I just need to be careful with the three sisters, as they are called, the vessels and as I come further into the axilliary area, one just needs to be careful of the nerve, which is quite close by. At this stage, I
BIJAYENDRA SINGH: will externally rotate the arm and sometimes I have to take it out from its holder, dislocate the humeral head. You can see it's come out nicely. But they said, if there is any osteophytes, I would aim to remove the osteophytes. If not, I would take the first reamer, the sharp ended one.
BIJAYENDRA SINGH: Go in the center and depending on what I feel, I may jump two or three reamers at the first instance, we can go from four on to six or seven. And then depending on how I feel, the catch might go at one or two until the desired. Then then once I'm happy, I leave that reamer in situ
BIJAYENDRA SINGH: and then I will apply the cutting jig. Generally tend to use 30 degrees retroversion in vast majority of them. I find that this gives them a better external rotation. If our patient has got kyphosis, then I would tend to hesitate to put it at 40 degrees. A couple of pins to secure this in place.
BIJAYENDRA SINGH: And then the rest of the bits come off except for the cutting jig. It's important to remember to take the reamer out before you use the saw. May have to push the pins back once you remove the reamer. Sometimes if it's soft bone, I might put a third pin in
BIJAYENDRA SINGH: as well. You want a bit more stability. You can see, this is still a bit more bone. At this stage, sometimes you can use an angel ring to see how much I'm going to cut off.
BIJAYENDRA SINGH: I put this sharp Hohmann on the medial side to protect the axillary nerve as well as the glenoid and that will intersect the humeral head using an oscillating saw. On the Zimmer Biomet, it gives 135 degree angle of the mid shaft.
BIJAYENDRA SINGH: To remove the humeral head and if you're doing anatomic, then this can be used to check the approximate diameter and the size of the humeral head it's going to use, but not so relevant in the reverse shoulder arthroplasty.
BIJAYENDRA SINGH: And then generally then broaching two or three size smaller than the last reamer and again, 30 degrees retroversion. Gently tap, remembering that the actual prosthesis is about 1.5mm wider in diameter than the broach. So slight loose fitting, but not too tight fitting is what is desired.
BIJAYENDRA SINGH: And then you can leave the stem in but I generally tend to remove the trial prosthesis. This removes some of the osteophytes again.
BIJAYENDRA SINGH: So the humeral side is now nearly prepped. Grab hold of the subscapularis to then perform some more release around the front. Sometimes I use scissors or a blunt instrument
BIJAYENDRA SINGH: to release the subsequent ortho front of the glenoid, and then I either retract it. OK, now we are going to do the glenoid. I've done some part of the release of the
BIJAYENDRA SINGH: subscapularis right at the start of the surgery when I exposed the shoulder joint. After that, I release the subscapularis either using the scissors nd then I put a sharp Hohmann in front of the glenoid to push the subscapularis away
BIJAYENDRA SINGH: and generally put a small swab which acts as a retractor and stops it I needing one less assistant. So you've done that, you should be able to see the glenoid fairly easily. Remove any remnant of the biceps and also excise the labrum.
BIJAYENDRA SINGH: Be careful of the inferior side that it's not too close to the nerve. This is more important in patients who have very stiff shoulders. The retractor usually the post-triassic of the glenoid one is enough. Sometimes in a very stiff and a large patient, you may have to put a second
BIJAYENDRA SINGH: rectractor on the superior, posterior superior aspect of the glenoid. I'm happy there with the positioning and the exposure at the guide pin is 3.5 and there is a jig to help position the central guide pin, which sometimes I may or may not use.
BIJAYENDRA SINGH: Here you can see I'm using this test providing a 10 degree of inferior tilt of the, of the base plate. I often find it's quite fiddly and just do it freehand. In that situation, I would put the finger in front of the glenoid to see where the wire is coming out, and generally if it is about 5 centimeters
BIJAYENDRA SINGH: medial to the edge of the glenoid, that is generally a good position. So on the finger, about one and a half digits. Gone on to use mini baseplates, so with all their color coded, with the yellow color, with matching golden sleeves is for the mini baseplates, which is 25 millimeters and I've not felt the need for larger base plates ever since.
BIJAYENDRA SINGH: The base plate can remove any excess osteophytes that may be present
BIJAYENDRA SINGH: and what we need to see is the smiley face, the glenoid bottom. This is the base, which is actually coated with four screws, which goes north, south, east, west but you can rotate it as per requirement. And generally, the base plate itself provides a decent fit on to the glenoid unless it's thin. The guide for the central pin is the same as the diameter of the drill bit, which
BIJAYENDRA SINGH: means that I avoid drilling it again, although it will be certain you could use it. I'll then use the peripheral screw inserter and this is a jig to allow for inserting the locking, the non-locking peripheral screws. I generally put two, one superiorly, one inferiorly, and that's what I found to be required in most cases.
BIJAYENDRA SINGH: Occasionally, if it's a soft one and the hold is a bit poor, then maybe a third or a fourth but this is the central screw which provides a good compression of the base plate against the glenoid followed by insertion of the peripheral locking screws, unscrew to the blue colored to make it easier and the non-locking screws are golden colored.
BIJAYENDRA SINGH: And once that is done, I just use this device to make sure that the central screw is sat to an adequate depth, as I've had once or twice where the central screw is bottomed out
BIJAYENDRA SINGH: and this can risk dissociation of the glenosphere. The glenosphere is fairly easy to put in. It's an eccentric model design. It comes in two parts, the shell and the sensor moist taper.
BIJAYENDRA SINGH: And you can adjust this according to a requirement. I've generally found that going non C, i.e. 3 millimeter inferior offset should work well and you can match that up with the line. And once that is done, gently tap into place and then there is a device to check for which way the orientation goes
BIJAYENDRA SINGH: and then there is an inserter. Make sure you're orientated and remember it otherwise you could end up putting it in the wrong orientation. Make sure you caught it otherwise, it can drop on the floor. I've dried it.
BIJAYENDRA SINGH: I insert the glenosphere and I often find that this is the step that decides how long the procedure is going to be. Often, if you haven't done enough release or the shoulder is very tight, this step can be mighty difficult. We've gone in well, and I've made sure that it's sitting tight. Used my finger around it to check it's not loose or falling out and then bring the humeral upper end of humerus into position
BIJAYENDRA SINGH: and clip it in place. We pull the retractor around the humerus. Now I'm going to make my drilled holes for, in preparation of the repair of the subscapularis. Often just the Ethibond needle is strong enough to pass
BIJAYENDRA SINGH: through the bone. If the suture comes off or if you can't pass the needle, then you can use a Houston type suture passing device. Then really, three in number. That provides a decent repair for the subscapularis. Often it can be a bit annoying when you come to pass the needle
BIJAYENDRA SINGH: and the sutures disappeared and we were founded. Once that is all done, then you go back to inserting the Hohmann then. Nurse has kept it ready. That goes in 30 degrees of retroversion as planned. The assistant supports the elbow
BIJAYENDRA SINGH: and it should go pretty easy. It's still a bit proud and I'm going to push it in a bit more. So that's the humeral insertion and now start with the standard trial. And you can see here it says superior to suggest orientated correctly. Often I will not reduce this fully.
BIJAYENDRA SINGH: I've just checked that it will reduce easily, as I often found that once you reduce it, they reduce it, that it can be a bit tricky to. Please look at the trial prosthesis. We are happy there and we will go with that particular size. So we're now coming towards the implantation of the humeral train closure.
BIJAYENDRA SINGH: I generally put the sutures into the humeral head before I put the humeral stem in as it makes it easier to do the subscapularis repair as well as insertion of the tray. I normally have three non-absorbable sutures and then, I would preferably put the sutures into the subscapularis, as you can see here, which is of good quality.
BIJAYENDRA SINGH: Before I put the humeral tray in, I'm going to run this video slightly faster um, and I've put a mattress stitch times 3. Sometimes it can get a bit tricky and this is where your suture management skills come into play.
BIJAYENDRA SINGH: So all the three sutures are passed and making sure that there is no entanglement, because unfortunately, if this happens, then it's a nightmare situation as you have difficulty in passing any of the sutures into the upper end of the humerus. So once that is done, the next step is to put the plastic in the humeral tray
BIJAYENDRA SINGH: and this particular prosthesis has a ring lock mechanism in which the ring on the humeral tray needs to be clicked into a little slot on the plastics. Sometimes it goes easy with the hand push, but at times it can be a bit tricky and in that situation various techniques is used to get it over.
BIJAYENDRA SINGH: Tapping generally helps. Once that is there, you make sure that you try the trunnion as any blood can cause a prosthesis to be pushed out. I then put the humeral tray in gentle tap to engage the taper.
BIJAYENDRA SINGH: And then usually it should be a pretty easy reduction. You need to make sure that the subscapularis has been pulled out of its way otherwise, it can get into softer center position. So here you can see it's nicely reduced and I put the arm back into the holder. Word of caution at this stage is to make sure that you remove the arm out of the holder and do this in the hand, holding the arm and the hand otherwise
BIJAYENDRA SINGH: it's a very long lever arm, which can cause problems. Once that is done, you untangle your sutures one after the other which again, I normally always spend a few minutes so that you need to make sure this is right. Subscapularis repair is very important, especially if you're doing an anatomic as the stability does rely a great deal on this and generally tend to hand tie one after the other.
BIJAYENDRA SINGH: I would cut one end and leave the one with the needle on just in case I had to do some more sutures to pass through, the more passes. The middle one, usually both of them are cut and then the top one again similarly are tied and if required, you can put a few more passes
BIJAYENDRA SINGH: through the tendon. If the supraspinatus is good quality and finding an anatomic replacement then will almost always close the rotator interval. It gives more support to the repair. What helps is to put the arm in a bit of a adduction and internal rotation makes reduces the tension on the sutures
BIJAYENDRA SINGH: and the repair. Once that is done, you can cut that off and then use the one from the bottom to, to run through repair of the whol rotator into and this will provide you with a fairly robust repair. Once that is done, make sure that you remove your soft tissue.
BIJAYENDRA SINGH: So if there's any swabs, at this stage do a soft tissue tenodesis of the sub, long arm biceps with the pecs. Sometimes I incorporate the longer biceps into the subscapularis repair. I mean, this generally tends to work quite well. Once I've done this repair, I would go ahead and put some interactive sutures to close the deltopectoral interval.
BIJAYENDRA SINGH: The suture's aren't tight, very aren't very tightly pulled to avoid a crushing of the muscles and usually three or four interrupted sutures. That makes this closure very good and provides another layer of soft tissue coverage over the uh, prostheses.
BIJAYENDRA SINGH: After this layer I generally use undyed absorbable vicryl suture to close the fat layer and this is followed by use of an undyed monocryl suture, put subcutaneously,
BIJAYENDRA SINGH: subparticularly to close the skin. Continuous suture, I generally always tie the sutures outside. I've had issues with them tying the sutures under the skin as this causes some degree of irritation and some can cause some discharge, which can be taken as an infection to the untrained eye.
BIJAYENDRA SINGH: So what have we done? This, this usually gives quite a nice, watertight repair. I often put some steri-strips on top at the end of this closure and put a pressure dressing on. I've generally not used to drain any of the shoulders unless it's a revision situation or if it's very easy or the last 12 years.
BIJAYENDRA SINGH: That's us done. Give it a nice clean. Thank you. [VIDEO ENDS]
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