DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left end-stage shoulder arthritis.
POSTOPERATIVE DIAGNOSIS: Left end-stage shoulder arthritis.
OPERATION PERFORMED: Left shoulder hemiarthroplasty with glenoid resurfacing.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General and local.
ANESTHESIOLOGIST: Bradford Doe, MD.
ESTIMATED BLOOD LOSS: 250 mL.
INDICATIONS: This is an (XX)-year-old lady with history of left shoulder pain and radiographic end-stage arthritis of the left shoulder. She has pain with daily activities and overhead activities. She is unable to elevate her shoulder past 90 degrees due to pain. She also has radiographic posterior glenoid wear. She also has large inferior humeral osteophytes. Because of the persistent pain and because she has failed conservative management, she wished for surgical intervention at this time. Risks and benefits of left shoulder hemiarthroplasty with glenoid resurfacing was explained to the patient by Dr. Doe. Consent was obtained. The patient wished to proceed with the left shoulder hemiarthroplasty with glenoid resurfacing as planned.
DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed supine on the operating room table for left shoulder hemiarthroplasty with glenoid resurfacing. She underwent general anesthesia by Dr. Doe. Her head was then supported in a head holder. She was then placed in a beach chair position. Pillows were placed under the knees. She also got a Foley inserted intraoperatively.
The patient’s head was then secured with a head strap. The left shoulder was examined. The patient does have limited forward flexion and external rotation. Forward flexion to about 100 degrees, external rotation to about 30 degrees. The patient’s left shoulder was then prepped and draped in a sterile fashion as usual. A time-out was taken. The patient was correctly identified, consent verified by the surgical team. She received 1 gram of Ancef prior to the skin incision. A marking pen was used to outline the coracoid and the incision for the deltopectoral approach. Ioban drapes were then used to cover the left shoulder.
A 10 cm incision was made just medial to the coracoid extending laterally down the upper arm. Dissection was then carried down bluntly to the deltopectoral fascia. Next, the deltopectoral interval was then identified bluntly with the finger, tracing it up towards the coracoid. This interval was entered and carried down to the deep fascia. Goelet retractor was then used to retract the deltoid, and the conjoined tendon was identified.
Using the tenotomy scissors, the conjoined tendon fascia was exposed and the conjoined tendon was retracted medially. Distally, the pectoralis major insertion released off the humeral site about 1 cm. The long-headed biceps was also identified. Using a 90-degree clamp, the rotator interval was entered with the shoulder externally rotated and a Freer placed intra-articularly behind the subscapularis muscle.
Using Bovie electrocautery, the subscapularis tendon was then released in superior to anterior fashion. Retention sutures were then placed into the subscapularis tendon. After subscapularis tendon was released completely, it was reflected medially. This visualized the humeral head. There was significant arthritis of the humeral head with large osteophyte inferiorly.
By using a template for the humeral cut, the large broad oscillating saw was then used to make the humeral head cut at the anatomic neck. This was cut above 48 degrees. After completion of the cut, the inferior osteophytes were removed with osteotome. Care was taken to cut the neck at about 10-20 degrees of retroversion in order to prevent posterior instability to accommodate for the retrograded glenoid.
Using blunt dissection, the anterior aspect of the subscapularis was freed as well as the capsule, mainly posterior to the subscapularis muscle. Using the Mayo scissors, the capsule was released off the subscapularis. The anterior rotator interval was also released with Mayo scissors and allowed to bring the subscapularis out laterally. Using a Fukuda retractor, the glenoid space was visualized. The patient has a vertical ridge with posterior glenoid erosion. The glenoid itself was eburnated down to the subchondral bone. The anterior and posterior labrum was removed with a Bovie. The glenoid was retroverted about 20 degrees.
Using a hand reamer, the humeral canal was identified. A sequential reamer was taken up to size 10. A size 12 reamer did not get past the diaphysis. Thus, a 10 mm broach punch was used and placed with its fins in about 20 degrees of retroversion. Using a 10 mm broach, trial implant was placed and a 52 mm head was tried. The eccentric portion of the head was placed posteriorly to make up for the glenoid wear. The joint was then reduced and tested for stability. The patient had satisfactory inferior stability and anterior posteriorly translates about 50%.
At this point, the trial head implant was removed and a Fukuda retractor again placed behind the posterior glenoid. Using a glenoid reamer, the anterior half of the glenoid was then reamed to bring the glenoid surface out of retroversion into more neutral and also slightly anteverted position. After satisfactory reaming, a trial head with a +3 mm depth offset was tried with a 52 head. This gave excellent stability as for superior, inferior, anterior, and posterior. With humeral rotation and abduction, there was no impingement noted.
Next, the trial components were then removed. Autogenous bone graft from the humeral head was then placed into the intramedullary canal and the final porous-coated 10 mm prosthesis was then inserted. Prior to completely seating the implant, bone graft was packed around the implant proximally. The implant was seated by press-fit completely. A 52 x 21 mm head was then placed posteriorly to make up for the posterior defect. The shoulder was then reduced again. Range of motion checked and was satisfactory as well as the laxity.
The shoulder was then irrigated with the pulse lavage. The subscapularis tendon was then reapproximated to the lateral aspect with #2 Ethibond sutures in a figure-of-eight interrupted fashion. This brought the subscapularis tendon back nicely. The rotator hole was left unrepaired. Twenty mL of 0.5% ropivacaine was then injected into the skin and also into the shoulder joint. The subcutaneous was then closed with 2-0 Vicryl followed by 4-0 Monocryl for the skin. Steri-Strips were then applied. A sterile dressing was then placed with tape, and the arm was placed in a sling.
The patient was then placed supine, extubated and then transferred to the recovery room in stable condition. Sponge and needle counts were correct. Dr. Doe was present and scrubbed for the entire procedure and performed key portions of the surgery.
