Wednesday, August 20, 2014

Customizing a prosthesis: shoulder arthroplasty after a total elbow

Not infrequently the performance of a shoulder arthroplasty is complicated by a prior procedure on the humerus below. Here is the shoulder film of a patient with severe rheumatoid arthritis and several years of progressively worsening shoulder pain.On preoperative examination he had very little range of motion due to his central medial erosion into the glenoid.

He had prior bilateral hip, knee, elbow and right shoulder arthroplasties. The ipsilateral elbow arthroplasty and two intramedullary cement restrictors are shown in the film below. We recognized that a standard humeral prosthesis would not fit in his canal, so a preoperative plan was made to customize his implant.

A deltopectoral approach was used and the subscapularis was dissected from the lesser tuberosity medial to the biceps tendon. Due to the limited range of motion and severely osteopenic bone we performed an in-situ humeral head cut. Once accomplished, we were able to safely access his medullary canal and to visualize this thin but intact attachment of the supraspinatus. Given the intact cuff we decided to proceed with a  standard hemiarthroplasty rather than a CTA arthroplasty.
The cement restrictors were retrieved with pituitary rongeurs and the canal was reamed conservatively to protect his fragile bone. The distance within the canal to the previously placed cement from the total elbow was measured. A Midas Rex burr was used to remove 3 cm from the stem and to round off the distal end of the prosthesis.

The prominent bone at the inferior margin of the glenoid was removed with a burr and rongeur due to concerns for contact with the medial proximal humerus. Care was taken to protect the axillary nerve.

The humeral component was then cemented into position and the subscapularis repaired. The postoperative film is shown below.
co-authored by Robert Lucas

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