Transcript Video Bone Preserving TSA with SIMPLICITI™ and PERFORM™+ featuring Dr. George Athwal [AP-010556A] Dr. George Athwal performs bone preserving TSA with SIMPLICITI™ and PERFORM™+ SKU: AP-010556A Product Information okay. In this live surgical technique video, I'll be reconstructing the 65 year old gentleman with a B two deformity with an an atomic total shoulder, our capacity utilizing a stainless implant on the human side and an augmented polyethylene implant on the ground inside. As you can see on the image on the right, this patient has quite profound posters. Subluxation additionally, also be using preoperative planning software, as you can see here to construct a patient specific guide as a preoperative planning a selected the large implant with a 25 degree poster wedge. As you can see here reconstructing the B two deformity. Once I'm happy with the positioning, we're gonna plan on reconstructing this patient back to a box Me five to use retro version Rungkat minimal reaming and will obtain approximately and 98% seating. Moving on to the humor's. I've chosen to use a stem lis implant in this particular patient. He's 65 years age of age and quite healthy. It will select a 52 times 19 millimeter head you can see as we obtain the joint you that we've corrected the poster. Glenn. I'd bone loss with this augmented implant. Now we're gonna move along and construct a patient specific guide. This is gonna allow me to place the guide pin and the implant in the best and most optimum position. And that will transition to the operating room. There is a core coId. Here's our Delta Pectoral incision. I'd like to score the skin with a scalpel before using the movie. We're just gonna work our way through the soft tissues down to the deltoid muscle ran. Insert this rake and we're gonna identify Morin Heights Triangle. And this is the fat triangle that's on the upper most medial aspect of Delta insertion. On the distal clavicle. There's just a folic vein, and now I'm exposing the most lateral aspect of more times Triangle. As you can see this, a phallic vein is entering the incision from the medial side media side of mornings Triangle and I will dissect out the so phallic vein in a proximal to distal direction, and as you can see, we will run across these lateral perforations will go ahead and cauterize those right there, and we'll continue work distantly down to the deltoid insertion, undermining the skin incision. And once I've obtained my delta petrol incision. I'm gonna go ahead and place where tracker directly over the sea. A ligament. There's the core Coid and I'm gonna connect a lateral Clavet pick release underneath the conjoined tendon and now released just underneath the sea A ligament and enter into sub colonel space Mobilized tissues and certain my deltoid retractor. Now, once I have a brown delta Procter and I'm gonna identify the long had a biceps by making a transverse incision directly over the peck Major. Now go ahead and release the transverse ligament all the way up into the biceps groove And then into the rotator interval, as you can see here. And I'm gonna release the upper centimeter Centimeter, half a peck major. And then I'll go ahead and conduct a soft tissue. Tina Jesus off the Long had a biceps to the released portion of the Peck major. The reason I choose to Tina decent to the released portion of Major is that in cases of difficult exposures in the Glen owed if I'm required to release the Peck major further, I won't compromise my bicep opportunities. Cisse. No one who secured the biceps to the release portion of Pec major. I'll use the same stitch to go ahead and tag the sub scapular areas. And once I've tagged sub scapular, so go ahead and release the long had a biceps. I'll follow the biceps tendon up into the rotator interval, releasing Interval and also releasing the biceps tendon directly off the Glenroy. And once I've developed a rotator interval, I'll insert the small dare a tractor into the gonna email joint. And this will place, um, tension onto the sub scapular errors and I'll go ahead and use a sub. Scapular is peel approach to expose his shoulder. My preference right now based on a randomized prospective study by laughter at all, is to conduct appeal type approach. A sub Stabler's peel approach will transition into an inferior caps released directly off the humerus. I'm gonna place the arm into abduction, extra rotation and Ford elevation to get access to the in fear portion of the human head to remove these osteo fights. Now, in order to dislocate the humorous, I'm gonna place this large dara into the glue email joint, and this will function as a skid to slide the human head out of the joint and Once I've got the human head dislocated, we'll go ahead and remove Maura. The Osteo fights and identify the head Neck junction. I'll go ahead and marked the head neck junction, then conducting an atomic osteo Tomy. And so we preoperative Lee size this head at 52 times 19. So we'll bring in the trial head just to get an idea of the fit. After conducting the human head osteo to me, I'm gonna transition to Glenwood Exposure and Glenn on implantation. This is a large Dera, a tractor placed along the poster in Fear portion of the Glenroy. Here's the long had a biceps tendon. Go ahead and remove that and remove the poster labor and now placed this medium dara along the anterior aspect of Glenwood, exposing the anti labor as you can see here, and I'll go ahead and excise the anti labor. Once of excise, the majority of the anti labor all conduct an inferior release of the capsule off of the Glen oId. And now this is the neo Glennon, As you can see on preoperative plans and neo Glenn is quite large, and this is the paleo glinted, which still has articular cartilage on it. It's also, in some time removing that college to get a good view of the entire Glenn. I'd. Now, this is one method of inserting your guide pin. This is a fossa reference guide which is inserted along the anterior aspect Glenwood Vault. As you can see here, this is going to slide right along the entire Glenarden bolt. And then, by referencing off the entire Glennon vault, we're gonna start a guide pin through here. Another option is to use the Checker Guide. I pre operatively template this patient a 25 degree large implant wedge. And so I can use this checker guide and send it on to the Glen wide and also plays a guide pin through it. Also, in this particular patient, I chose toe order patient specific guide, as you can see here. And this fits onto this metal reproduction of this patient's Glenroy. This is the counter rotation drill hole, so I'll go ahead and search the guide. We're gonna ensure the guide fits appropriately by removing all the college and ensuring the guide is resting on bone. Once I'm happy with the position of the guide will insert the guide pin Now, before I remove this guide, I'm going to create a rotational orientation drill hole and this allow us to orientate our post cheerier wedge. So I will remove the guide and we'll start off with preparation of the paleo Glenda. So this is the paleo Reamer. And well, we use this to ream the anti air 50% of the Illinois. And so, as you can see, reviewed the anterior hemisphere of the Glen oId. And now we'll transition to the Neo Ream. We'll set this at 25 degrees, as this is what I pre operatively template it. But we have the option of 15 and 35 degree wedge. This pin right here will fit into the rotational alignment. Drill hole. We'll go ahead, insert the Neil Rimer and prepare the neo Illinois. What we're looking for is witness marks on the post year, 50% of the Glenwood. Now we'll go ahead and check the Glenroy Preparation with the Checker Guide. I wanna make sure I have close to 100% seating, so I'm gonna check the periphery to make sure that the Checker Guidice fully seated once I'm happy with the Glenroy preparation will go ahead and insert this guy that allow us to place our peripheral drill holes once again referencing off the orientation drill hole. I typically like to drill the superior peg hole first, followed by the anti air in Fear and last the poster and fear I'll go ahead and remove the entire guide along with the checker. Now we're gonna go ahead and drill the central quarter lock drill. Now we'll check our Glenn. I'd preparation with this trial. And as you can see, the trial has several cutouts to confirm appropriate seating of the implant, especially when it confirmed that the poster portion and planets fully seated. And, as you can see, the poster wedges fully seated in Fairly and Sapir Lee, I'll go ahead and remove the trial implant, and now we'll prepare the Glen oId. I'll go ahead and irrigate the Glen wide. Prepare the peg holes, insert This meant pressurize it, and after I've pressurize it, I'll go ahead and see the true implant will impact it down, remove any redundant Smith and check the fit. Once I've done with the Glenwood portion of Case, we're gonna go back to the humorous. We'll carefully dislocate the humorous and start on human preparation. So I pre operatively size this patient as a size three stem. Most implant. Therefore, I'll go ahead and place the size three sizing disk on the human head. Osteo tomy surface. Ideally, I want it to be central and tear poster and securely. I'll go ahead and search the guide pin by cortical e. Remove the disc and then we'll go ahead and use the surface. Reamer or plainer. And what I'm looking for is witness marks around the entire osteo tomy surface. As you can see here, once the Austin on the surface is prepared, I'll use the core drill, and after the core drill, I'll go ahead and use the fin blaze. Ideally, I want a place to thins immediately to provide the best loading characteristics of the proximal humerus, and we'll seat this Finn blaze. Fully remove the insert er and check that we're flush. I'll go ahead and remove the guide pin insert, are 52 times 19 millimeter head and conduct a trial reduction after reducing the trial implants. The first thing I check is to ensure that my sub scapular Aris will make it to the lesser generosity. So here's our subs, Cap. It's gonna fit nicely right over the lesser to Rosty. We'll go ahead and check our stability and these exact sizes that I preoperative plan was a 52 times 19 millimeter head and the 25 very large Glenn oId implant. Now go ahead and remove the trial human components. And now I'm gonna prepare for my sub scapular peel repair. Prior to inserting my human implant, I'm gonna place four drill tunnels into the biceps crew. And this is gonna be a trans Odysseus repair of the sub Scapular is tied over a plate on the lateral aspect of the greater truth. Rosty. Once I've drilled my four drill tunnels, I'm gonna go ahead and Souter the sub scapular errors. I'll use three number 25 wire suitors in an inverted horizontal mattress technique. So here's the first stitch, which is secure the upper third of the sub scapular iris. And now the second suitor, which will come in just a moment. I'll die purple so I can distinguish the suitors from the others. And this will also be an inverted horizontal mattress which will secure the middle third of the sub scapular errors. And now I'll bring in a third future once again, these air number two high strength fiber type suitors. And this was secured the bottom third of the subs calculators. And now I'll go ahead and pass these transitions. So that first drill tunnel in the bicep screwball single loaded with the first limb for my first suitor, securing the upper third of the sub scapular and the second drill tunnel. I'll double load with the second strand from the first future in the first round from the died future. And we'll just use this stroke are needle to pop this out the lot of aspect of greater to Rossi, and I'll go ahead and pass these over a plate. The third drill tunnel will also be double loaded with the second died stitch in the first strand of the third suitor, and therefore each of the three suitors will be secured over a bone bridge. The fourth, a drill tunnel will be filled with the last strand from the third suitor. So now we'll go ahead and loosen these off and prepare for human component insertion. So back off these futures dislocate the human heading in and now insert our new clueless. I'll typically impact this down about 50% and then get a sense of the stability. Analyses it completely. Once I've done that, I'll remove the insert er and place on our 52 times, 19 millimeter centered human head. And then I'll go ahead and reduce the shoulder and bring over our subs. Calculators repair. As you can see, this is an inverted horizontal mattress types, future configuration and typically the tie. The middle portion sub scapular is first, followed by the inferior third, as you can see here and then I'll finish off with a superior third. Once I've repaired my sub scapular Aris, I'll close the lateral aspect of the rotator interval toe. Augment my sub scapular is repair all typical place one or two absorbable solution along the far lateral margin of the rotator interval. Once I've done that, I typically do do running closure of the Delta picture animal. I typically use braided observable suitor, start along the inferior aspect of the Delta petrol interval, and then I'll run this distantly to really secure and close the Delta Vector interval. Once I've secured the Delta Pectoral interval in fear really or distantly. I'll then work my way approximately. I typically like to close the Delta picture honorable with so phallic vein still superficial, and I'll do it. Interrupted closure off the skin, followed by Staples for the dermal closure. Typically use a two abraded absorbable than the Staples. And now we'll take a look at our postoperative X rays as you can see our stimulus implant on the left, the AP view and then reconstruction of the B two deformity with the perform plus augmented implant. Published November 26, 2018 Created by
