Monday, July 18, 2011

Revision surgery for failed total shoulder replacement arthroplasty - our approach, Part 2


General Principles of Revision Surgery

Before the anesthetic, the patient’s consent is checked to make sure it is complete.  The instrument and implant inventory are verified for possible variations on the preoperative plan, including the need to modify a prosthesis or to possibly use a special implant (e.g., a long stemmed humeral implant in case of shaft fracture).

The patient is anesthetized, positioned, prepped and draped in a manner that anticipates all possible variations on the surgical plan.  The entire forequarter is prepped so that incisions can be made anteriorly, posteriorly or distally as needed.  The arm is draped so that it can be moved freely.  Ipsilateral iliac crest and hamstring autograft donor sites are prepped if their possible need is anticipated.

Preoperative antibiotics are not administered.  Prophylactic antibiotics are administered only after specimens are collected for culture and sensitivity testing.

The incision is made in a manner that provides optimal access to the mechanical problem and, if possible, incorporates or respects previous skin incisions.  The possible need for extending the incision is anticipated. As shown below, the coracoid is an important landmark when the normal anatomy of the deltopectoral interval is scarred from previous surgery through the anterior approach.

The surgical approach is conducted carefully to protect and preserve the deltoid, the rotator cuff, and the neurovascular structures about the shoulder – each of which may have been altered by previous surgery. The coracoid process serves as a lighthouse for proper orientation in a scarred shoulder. It divides the lateral (safe side) from the medical side (suicide), where the brachial plexus and vascular structures are located.

The humeroscapular motion interface is entered and all adhesions lysed. The axillary nerve is identified and protected.

Specimens are collected for aerobic, anaerobic, and fungal culture, sensitivity, and gram stains.  Frozen and permanent sections are obtained of any tissue suspicious for inflammation, infection, or neoplasm.  Prophylactic antibiotics are given intravenously at this point.


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