8 Pearls for Predictable Results with Total Shoulder Arthroplasty
With more than 50,000 surgeries performed in the US each year, total shoulder arthroplasty has evolved into a procedure that reliably improves the lives of patients with glenohumeral osteoarthritis, relieving the pain that can interfere with sleep and providing better shoulder function for activities of daily living.
The goal is to get patients back to their normal lives as soon as possible, and at ICJR’s 13th Annual Winter Hip & Knee Course, Leslie B. Vidal, MD, shared her top 8 tips, tricks, and techniques to help surgeons achieve that goal.
Pay attention to the bony anatomy. Patient selection is key, Dr. Vidal said. The surgeon should evaluate not only the patient’s preoperative range of motion, strength, function, and expectations, but also the patient’s unique bony anatomy. Note whether the patient has glenohumeral osteoarthritis, anterior and posterior bone loss, retroversion, medialization, or proximal migration. Some patients with these issues may be better candidates for reverse shoulder arthroplasty, Dr. Vidal said.
Preoperative planning and templating are critical. When planning a procedure, Dr. Vidal starts with the glenoid, using CT scans for a 3-dimensional view of the bony anatomy, as well as templating guides for assistance with optimizing placement of the implant. The templating software allows her to adjust version, inclination, medialization, and rotation, with the goal of achieving less than 10° of retroversion or inclination and at least 80% of good glenoid seating. On the humeral side, she plans version, resection level, and inclination using the templating software, as well as medialization and lateralization of the stem and sizing and rotational position of the humeral head. She can then combine the glenoid and humeral templates to ensure that the overall version is appropriate.
Get the room right. This includes the patient’s position and the setup of instruments. For total shoulder arthroplasty, Dr. Vidal wants the patient to be in a semi-Fowler’s position, with the head in neutral alignment. The scapula should be supported but allow for good excursion of the humerus to prevent impingement on the table and an increased risk of humeral shaft fracture during exposure. She likes to keep the back table consistent and simple, using a limited number of instruments but having others available for more difficult cases.
Ensure good visualization.
Get the implants right: Glenoid.
Get the implants right: Humerus.
In these 3 pearls, Dr. Vidal describes in detail how she obtains visualization of the subscapularis, the humeral head, and the glenoid and how she prepares the shoulder for implanting the glenoid and humeral components. This section is filled with technical tips from Dr. Vidal to help surgeons fit the implants anatomically and avoid overhang on the humeral and glenoid sides of the joint.
Considerations for the soft tissue. At this point in the procedure, considering subscapularis excursion is critical, Dr. Vidal said. A patient who had a significant amount of restricted motion preoperatively may have a contracted and scarred scapularis. Dr. Vidal uses blunt or finger dissection, predominantly on the superior surface and cautiously on the deep surface, as well as release of the rotator interval toward the base of the coracoid to achieve good mobilization. She then repairs the subscapularis to the lesser tuberosity, performs biceps tenodesis, and reapproximates the distal half of the rotator interval.
Ensure meticulous wound closure. The surgeon should be just as meticulous with wound closure at the end of the case as they were with hemostasis at the beginning, Dr. Vidal said. The wound is closed in layers. Absorbable subcuticular sutures are placed in the skin and the wound is covered with surgical tape that stays in place for 2 weeks.
Provide good pain management perioperatively. Dr. Vidal and her colleagues administer a preoperative “cocktail” of celecoxib, acetaminophen, cyclobenzaprine, pregabalin, and oxycodone. Intraoperatively, the patient receives regional anesthesia. They have found that this combination to effectively manage pain with minimal opioid use postoperatively.
Click the image above to watch Dr. Vidal’s presentation and learn more about techniques for predictable outcomes in total shoulder arthroplasty.
Leslie Vidal, MD, is a shoulder, hip, knee, and sports medicine specialist at The Steadman Clinic in Vail, Colorado. Her clinical areas of interest include shoulder arthroplasty and arthroscopy of the shoulder, hip, and knee.
Disclosures: Dr. Vidal has no disclosures relevant to this presentation.