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Total Shoulder Arthroplasty (Stemless) – Pitt Technique

  1. Indications for Total Shoulder Arthroplasty

    1. Primary glenohumeral arthritis with intact rotator cuff
    2. Young, with good bone stock to support stemless humeral prosthesis
      1. Example: A patient with avascular necrosis (AVN) secondary to sickle cell in a relatively young patient may benefit from a stemless total shoulder arthroplasty (shoulder replacement)
        1. If limited to humeral side, you could consider a hemi in this patient as well
  2. Preoperative Exam Under Anesthesia

  3.  Positioning

    1. Beach Chair at around 40-45 degrees of inclination
    2. Consider foley cathether depending on complexity/expected duration of the case
    3. Preoperative IV antibiotics
    4. Sequential compression devices
    5. Pad bony prominences to avoid any peripheral nerve compression
    6. Prep and drape in standard sterile fashion
    7. Place arm in Spider arm holder (sterile)
    8. Make sure you can adduct the arm (for humeral dislocation)
      1. May need to remove kidney bean from chair and koban the patient to the chair instead
    9. Surgical time out
  4. Right Open Total Shoulder Replacement with Stemless Humeral Implant

    1. Deltopectoral approach
      1. Skin (coracoid to medial 1/4 of anterior arm)
      2. Bovie through sub-q tissues
      3. Use blunt gelpy superiorly and sharp inferiorly to spread
      4. After fascia identified, elevate flap medially
      5. Find natural plane between pec and deltoid, bluntly spread with mets starting superiorly near the coracoid
        1. Take cephalic vein laterally
      6. Insert homan retractor into deltopec opening just superior to coracoid
      7. Continue to spread bluntly and insert blunt gelpi to help retract and spread the interval
      8. Identify coracoid and conjoint tendon, and release superior 1cm of pec insertion if necessary
      9. Develop subdeltoid interval and insert deltoid Brown retractor
      10. Identify triad of vessels accompanying the axillary nerve on the inferior border of the subscapularis tendon
        1. Tie these off with 0-Vicryl sutures
      11. Identify long head of the biceps
        1. Release sheath with a Bovie into the rotator interval
        2. Tenodese to Pec insertion 
    2. Deep approach
      1. Place sharp Hohmann into the joint to examine subscapularis muscle
      2. If subscapularis is robust, proceed with lesser tuberosity osteotomy (LTO)
    3. Lesser tuberosity Osteotomy (LTO)
      1. Use 3/4 inch curved osteotome to take a bony wafer of the lesser along with the subscapularis insertion
      2. Take care not to go into the metaphysis or the articular surface of the humeral head
      3. Tag subscapularis with several #5 Tycron sutures
      4. Release the subscapularis with the capsule as one layer from the inferior humeral neck
      5. Use a Bovie and protect axillary nerve with finger
    4. Dislocate humeral head
      1. Use external rotation and extension
      2. Dislocate head
    5. Bony preparation (humerus)
      1. Remove osteophytes with a ronjeur
      2. Examine rotator cuff insertions to ensure adequate cuff
      3. Identify anatomic neck and mark with Bovie
      4. Identify rotator cuff insertion, and place a Hohmann retractor either through the rotator cuff or between the cuff and deltoid
        1. This helps with exposure but also helps to delineate the saw cuts
      5. Make humeral head resection with a wide oscillating saw on freehand 
    6. Sizing (humerus) and Implant Preparation
      1. Use the sizing guide and place a guide pin in the center of the metaphysis and dock in or through the far lateral cortex
      2. Use cannulated drill to create hole for the center of the nucelus
      3. Trial the nucleus and then impact into place 
      4. Place metaphyseal protector
    7. Glenoid exposure and preparation
      1. Remove retractors and place a laminar spreader in the joint to put the IGHL (inferior glenohumeral ligament) on stretch
      2. Define the interval between the subscap and the IGHL with a tonsil and a finger
      3. Release the IGHL extensively up to around the 7 o’clock position on the posterior glenoid
        1. Note: In patients with a B2 glenoid, or with posterior subluxation, only release the IGHL to aproximately 5:30 or 6 o’clock to avoid giving them iatrogenic instability
      4. Keep a finger on the axillary nerve at al times to protect it
      5. Release the MGHL from the deep surface of the subscapularis
      6. Place a sharp Hohmann retractor over the superior border of the glenoid right above the biceps tendon stump to help achieve a circumferential view of the glenoid 
      7. Remove the labrum as well as the biceps from the glenoid circumferentially
      8. Size the glenoid and then drill a guidepin in the center of the glenoid
      9. Use a reamer over the guidepin to prepare the surface
      10. Preserve subchonral bone, especially posteriorly, to avoid future subsidence of the glenoid component
      11. Drill for the cortiloc (central hole)
      12. Place a PEG guide and drill the three peripheral holes and confirm that they are within the glenoid vault
      13. Place trial component and ensure that it sits flush
    8. Glenoid Component
      1. Pulse lavage the glenoid and use epinepherine soaked gauzes to help with hemostasis
      2. Place Simplex antibiotic cement into the peripheral peg sides (not the center for the Tornier implant) and pressurize into each hole
      3. Impact the glenoid component into place
      4. Wait for the cement to harden
      5. While waiting for the cement to harden, place the arm back in extension and neutral to take pressure off the brachial plexus
    9. Humeral Component
      1. Place multiple Hohmann retractors medially and a deltoid Brown retractor laterally
      2. Place the arm in external rotation and extension to bring the humerus back into view
      3. Remove the metaphyseal protector
      4. Place trial component head into place and match the native anatomy
      5. Before placing final implant, drill 5 2.0mm holes into the bicipital groove, just lateral to the osteotomy site
        1. Make sure and keep the trial in place while drilling the holes 
        2. Place #5 FiberWire sutures through the 5 holes in transosseous fashion
      6. Impact the final humeral component into place
      7. Check the shuck with the humerus in place to ensure 40-50% translation with spontaneous reduction and no gross posterior instability
        1. “Shuck” is checking posterior translation
        2. If there is no spontaneous resolution, the patient may need a capsulorraphy or a bigger humeral head component
    10. Closure of LTO/Subscapularis
      1. Pass the #5 FiberWire sutures medial to the LTO wafer site through the subscapularis in a Mason Allen configuration
      2. With the LTO sites mated together, tie the FiberWire sutures sequentially, firmly fixing the LTO and subscapularis repair
      3. Close the rotator interval with additional #2 Tycron sutures in simple and figure-of-eight fashion
    11. Closure
      1. Irrigate with copious amounts of saline
      2. Close the deltopectoral interval with a running #2 Tycron suture
      3. Inject 60 mL of TXA deep to the deltopec interval and into the joint for postoperative hemostasis
      4. Close subcutaneous tissues with 2-0 Vicryl sutures in interrupted, buried, fashion
      5. Close the skin with a running subcuticular 3-0 Caprosyn suture
      6. Reinforce skin closure with Dermabond
      7. Place sterile Telfa and Opsite over the wound
      8. Place patient into abduction sling and place Cryocuff
  5. Postoperative Protocol

    1. The patient will remain in a sling for a total of 4 weeks
      1. Can initiate gentle pendulum and range of motion exercises early
    2. External rotation limit to 20 degrees to protect the subscap repair for first 6 weeks
      1. This is actually based on intraoperative assessment after component implantation and subscap repair. Range patient in external rotation until resistance is felt, and then limit external rotation exercises to 10 degrees less than this (to stay conservative)
    3. Active range of motion exercises starting after 4 weeks
    4. No strenthening until the 12 week mark

 

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