A man in his 50s from another state presented with a grinding and aching pain in his left shoulder after prior arthroscopic surgery and cortisone injections.
On his Simple Shoulder Test he reported the inability to tuck in his shirt behind his back, to place his hand behind his head with his elbow out to the side, to lift a gallon of milk, to toss under hand, to throw overhand, and had difficulty doing his work as a general contractor. He was previously a competitive archer, however he was currently unable to hold his bow properly given the range of motion deficits and pain in his left shoulder.
His examination revealed 140 degrees of humerothoracic motion of which only 80 degrees was humeroscapular. External rotation was limited to 0 degrees at the side and 10 degrees with the arm in abduction. Internal rotation with the arm abducted was 10 degrees. Reach up the back was to the gluteal area.
His preoperative x-rays are shown below. The axillary truth view showed severe posterior decentering of the humeral head on a biconcave glenoid.
After discussion of the options of an anatomic and a reverse total shoulder, the patient elected a ream and run procedure.
The surgical challenge was to manage the posterior instability while loosening this tight shoulder (avoiding overstuffing). Without using a preoperative CT or 3D planning, it was anticipated that the posterior decentering would require the use of an anteriorly eccentric humeral head component with a short stem to provide secure fixation that would resist eccentric loading.
At surgery, the stiffness of the shoulder was confirmed on examination under general anesthesia, no nerve block was used. The shoulder was approached through a deltopectoral incision and a subscapularis peel. The long head of the biceps was preserved.
The humeral head was deformed as anticipated.
Extensive subscapularis and anterior / inferior capsular releases were performed as shown in these diagrams from Steve Lippitt.
The glenoid was conservatively reamed to a single concavity without attempting to "correct" glenoid retroversion.
The sizing of the humeral head component was determined by trialing, paying attention to the 40, 50, 60 rules and assuring that easy flexion to at least 150 degrees could be achieved.
Implant manufacturers typically describe the size of their humeral head components in terms of diameter of curvature and height.
It is useful to recognize that the humeral head component is a spherical cap (shown in blue below) with a height of h and a radius of r (half the diameter of curvature).
Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).
