Secret shoulder secrets Dominik Meyer
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1 Secret shoulder secrets Dominik Meyer
2 Head of the prostheses better too big or too small? In case of stiffness: smaller (loosening of capsule) In case of hyperlaxity / instability or strong correction of a glenoid retro/anteversion: bigger (stuffing) In case of doubt: smaller PROTHETIC
3 PROSTHETIC Combination head / glenoid: good: small head / big glenoid bad: big head / small glenoid because of loosening of the glenoid
4 Retrotorsion of the head (i.e. torsion of humerus)? PROSTHETIC normal: 18-25, (average approx 60 ) Anatomical Prosthesis: 20 Inverse Prosthesis approx. 0
5 Orientation of inverse prosthesis: If antetorsion: If retrotorsion: Position of dislocation: PROSTHETIC difficult to reduce, posterior impingement risk of dislocation Internal rotation, adduction or abduction
6 Flexion movement: PROSTHETIC
7 PROSTHETIC
8 PROSTHETIC Anteversion glenoid, antetorsion head: retrotorsion head:
9 If glenoid in anteversion: antetorsion of the shaft PROSTHETIC If glenoid in retroversion: retrotorsion of the shaft
10 PROSTHETIC Shaft too long, cannot reduce inverse prosthesis: 1. Use smalles inlay possible 2. Relax patient 3. you may consider metaphyseal component with no offset or correct for torsion (if stable) 4. If still in trouble: Consider distraction clamp (from rotator cuff repair or arthrodesis distractor). Danger of later acromion fracture (!)
11 PROSTHETIC Fix the subscapularis?
12 INSTABILITY If there is an unstable hyperlax patient: Do not correct laxity, only the defect causing instability Otherwise, you may create osteoarthritis
13 Stabilization: open versus arthroscopic bony versus soft tissue INSTABILITY -> repair the pathology In case of doubt: bony more reliable than soft tissue
14 Portals: posterior: soft spot 2cm medial, 2cm inferior: Can be easier in IR, more medial, better piercing of muscle. ARTHROSCOPY look for the acromion and feel the head
15 ARTHROSCOPY 2cm medial, 2cm inferior of acromion more lateral: problems with posterior cuff, problem to pierce the cuff, less mobility but: better for subacromial, easier to find the bursa
16 ARTHROSCOPY Where is it safe to place the posterior portal?
17 Portals anterior and lateral: ARTHROSCOPY
18 CUFF REPAIR First repair side to side (close buttonhole) then repair tendon to bone
19 CUFF REPAIR If closing the interval is not possible, partial repair may be an option, but there is a risk that the head pushes through the buttonhole
20 CUFF REPAIR If you cannot bring the cuff to the footprint after extensive release: 1. consider debridement particularly if there was good function 2. consider partial repair try to bring the posterior to the anterior edge 3. consider augmentation of the cuff difficult, expensive 4. consider medialization of the cuff maximal 1.5cm
21 CUFF REPAIR If you cannot bring the cuff to the footprint after extensive release: 1. consider debridement particularly if there was good function 2. consider partial repair try to bring the posterior to the anterior edge 3. consider augmentation of the cuff difficult, expensive 4. consider medialization of the cuff maximal 1.5cm
22 CUFF REPAIR repairif you cannot bring the cuff to the footprint after extensive release: 1. consider debridement particularly if there was good function 2. consider partial try to bring the posterior to the anterior edge 3. consider augmentation of the cuff difficult, expensive 4. consider medialization of the cuff maximal 1.5cm
23 CUFF REPAIR If you cannot bring the cuff to the footprint after extensive release: 1. consider debridement particularly if there was good function 2. consider partial repair try to bring the posterior to the anterior edge 3. consider augmentation of the cuff difficult, expensive 4. consider medialization of the cuff maximal 1.5cm
24 Pseudoparalysis is treated with rotator cuff repair CUFF REPAIR but Pseudoparalysis is a contraindication for rotator cuff repair???
25 CUFF REPAIR 1. Painful pseudoparalysis? If yes, inject with 10cc Lidocain and see. Exclude stiffness. 2. When painfree: Bad for cuff repair: Dynamic anterosuperior subluxation Cranialization <7mm Patient cannot hold the arm at 90 Abduction. Chronic situation Good cuff for repair: Patient can hold the arm in 90 Abduction (moderate) Patient can bring the arm to 90 Abduction Acute injury, previous good function
26 untangling of sutures: A ARTHROSCOPY C B D
27 untangling of sutures: A ARTHROSCOPY C B D
28 ARTHROSCOPY on which one to pull?
29 ARTHROSCOPY which one as post? mobile vs non-mobile suture
30
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