Jonathan C. Levy, MD

Transcription

1 Jonathan C. Levy, MD Chief of Orthopedics Program Director, ASES Fellowship Holy Cross Hospital Fort Lauderdale, Florida USA Disclosure: Consultant, Royalties, & Research Support from DJO

2

3 72 year old male 4 years s/p RSA for Massive Cuff Tear No prior surgery Minimal Pain Notes drainage from shoulder for past 6 months ESR 7; CRP 3.6 [NORMAL]

4

5

6 1. Suppressive Antibiotics 2. 2-Stage Revision 3. Single Stage Complete Revision 4. Single Stage Partial Revision (only modular components)

7 2/6 positive for p.acnes at 10 days >10 WBC per HPF on 5 different fields Gross Purulence Well Fixed Implants

8 Definite PJI: The presence of one or more of the following criteria is diagnostic of definite shoulder PJI: Sinus tract communicating with prosthesis is present. Gross intra-articular purulence is present. Two positive cultures with phenotypicallyidentical virulent organism present.

9 Scoring System: If criteria for Definite PJI are not met, a summative scoring system is used to classify likelihood of PJI: Score 6 with an identified organism = probable PJI Score 6 without an identified organism = possible PJI Score <6 with: Single positive culture of a virulent organism = possible PJI Two positive cultures of a low-virulence organism = possible PJI Negative cultures or single positive culture of a low-virulence organism = unlikely PJI If no draining sinus, then score for case: 1- Single Positive Intraop Culture low virulent organism 1- Second Positive Intraop Culture low virulent organism 3 Positive frozen section Total Score 5 with 2 positive cultures of low-virulent organism POSSIBLE PJI

10

11

12 86 yo active male Underwent Left TSA in 2014 At 6 month follow-up Doing great, no pain ROM FF 130, Abd 120, ER 50, IR T12

13

14 Falls riding a bicycle 7 months post-op Sustains periprosthetic humerus fracture

15 Bone quality? Stem well-fixed or loose? Rotator cuff integrity? Options: Non-op ORIF Revision to long stem TSA Revision to long stem RSA Use of Cortical Strut Graft

16 Skive Screws Skive Screws 1 year

17

18 70 year old male s/p TSA Falls off chair within first 6 weeks postop Has revision humeral head exchange Presents c/o pain Exam: dynamic posterior instability and pseudoparesis

19 Options: Revision with posterior plication? Revision to RSP Revise stem and glenoid -- ie convert to new RSA Revise glenoid and convert stem ie convert to Stryker RSP Hybrid (off-label) DJO Baseplate/Glenosphere Stryker convertible shell

20 3 years post-op 3 years post-op

21 80 year old male presents after RSA for Fracture Tuberosities Excised Primary Surgeon performed single revision to larger humeral tray after dislocation

22 Revised to Hybrid RSA 36 Neutral DJO Glenosphere Zimmer 36 Humeral Shell Humeral Augment Well Balanced Intra-op

23 First Post-op Visit

24 Compared Humeral Length Symmetric (~33cm) Felt to be Soft-tissue Tension Problem OPTIONS DISCUSSED: 1. Prox Humeral Allograft 2. Larger Glenosphere 1. Lateral Offset 2. Larger Diameter 3. Occupy More Volume 3. Leave Dislocated PLAN: 1. Remove Zimmer stem 2. Revise with long stem Monoblock 3. Cement to Restore Proximal Humeral Bone Loss Glenosphere 1. Lateral Offset 1. 6mm from COR 2. 22mm from Diameter 2. Larger Jump Distance 3. Occupy more volume

25 Immediate Post-op

26 1 Year Follow-up

27

28 71 year old with failed cemented Hemi

29 Press fit at Metaphyseal Shell Bone graft window Distal fit

30

31 55 year old with TM Humeral Zimmer Stem and well fixed glenoid

32 Metaphyseal press-fit at shell & diapyseal press fit within cortical shell reaction of previous stem

33 64 yo female with painful TSA with subscap failure

34

35 10 days 3 months Repaired using racking hitch sutures through the lateral fins on the stem Fractured Tuberosity may have healed to the P2 on the Shell rather than to the humerus Despite Tuberosity Fracture, Press-Fit obtained using: bone graft window diaphseal fit

36 71 year old small female with failed Turon TSA with massive cuff tear

37 Metaphyseal press fit obtained at shell and side-burns

38 65 year old with failed TSA and dislocated glenoid with severe bone loss with medialization

39 Press-Fit obtained using: Shell/Fin Fit Bone graft window diaphseal fit

40 Subscap/Supraspinatus Tear

41