case presentation

1. Sept 21 2022
Shoulder cases
conference

2. Case 2

3. ID: 71 male
CC: Worsening R>L shoulder pain, weakness X 3- 4 years
All:
• NKDA
PMHx:
• Ulcerative Colitis
• OA
SoHx:
• RHD, non-smoker, retired, 1 EtOH/ weeks

4. Inspection
• Supraspinatus atrophy, infraspinatus atrophy
Active Range of Motion:
• forward flexion (130 deg.), external rotation at 0 deg. of abduction (50
deg.), internal rotation (L1 deg.)
Strength:
• Forward flexion, external rotation 4/5
Special Tests: Neg drop arm sign. Neg external lag sign. Negative
hornblower
Deltoid contractile

7. • What is your diagnosis and what would you like next?

8. • Explain your surgical steps
• Surgical considerations specific to this case

10. • Findings:
• Massive (greater than 5 cm), non-repairable complete, full thickness tear of the supraspinatus and
infraspinatus tendons
• Implants used
• Depuy-Synthes INHANCE
• 24mm baseplate
• 36 mm standard centric glenosphere
• Short humeral stem
• Metal humeral shell with a 36 mm + 0 mm standard humeral cup

11. Case 1

12. ID: 78 female
CC: Worsening R shoulder pain, weakness X 10+ years.
•All:
•Advil
•Bicillin C-R
•Keflex
•Penicillins
•Sulfa (Sulfonamide Antibiotics)
PMHx:
• Crohn’s
• GERD
• Gout
• HTN
• Hypercalcemia

13. Meds:
•budesonide
•fluticasone
•Levofloxacin
•Losartan
•Pantoprazole
•Prednisone
•Trazodone
SoHx:
• 1 glass wine / week
• Non-smoker
• RHD
• Surgical history
• R shoulder arthroscopic rotator cuff repair + biceps tenotomy
• Treatments to date
• PT X2 / week
• NSAIDs
• Cortisone

14. • Describe your full physical exam

15. Physical examination:
No swelling , Surgical incisions healed without erythema or warmth
Deltoid contractile
AROM 80/30/L1
Elevation MP 3+
External Rotation MP 4
Internal Rotation MP 5
Negative External Rotation Lag Sign
Negative Drop Arm Sign
Impingement Positive
Painful arc of motion
Positive Acromioclavicular joint tenderness
Positive Cross-body Adduction Test
Positive O'Brien's test
Positive Neer's test, Positive Hawkin's test
Positive Speed's test

16. • What is your provisional diagnosis and what would you like next?

19. • What is your diagnosis and what would you like next?

23. • Favard classification of glenoid morphology

24. • What are your treatment options

25. • Explain your surgical steps
• Surgical considerations specific to this case
• Goals of surgery

26. Procedure: right reverse total shoulder arthroplasty
Position: Beach chair, semi-sitting (45 degrees)
C spine neutral
Pad prominences
Anesthesia: Brachial plexus block + general anesthesia
Approach: Deltopectoral approach
OR equipment: Spider, reverse total shoulder arthroplasty trays
Specific considerations:
• 3D plan?
• Exposure
• Humerus can be difficult with posterior subluxation of humeral head
• Glenoid airplane bed to visualize better
• Posterior humeral head subluxation: Careful soft tissue balancing and implant sizing
• Severe glenoid retroversion: augment, bone graft, eccentric reaming?
• Severe glenoid superior inclination: augment, bone graft?
• Glenoid medialization
• Bone quality: Cemented humeral component?
• ER lag?

27. Goals:
• Stability (you want at least 50% bone support for baseplate)
• Well fixed components
• Impingement free ROM
• Correct pre-morbid deformity
• At least neutral RSA
• Correct some retroversion, rTSA more forgiving than anatomic
• Avoiding complications: axillary nerve neuropraxia, peri-prosthetic fractures

28. • Post-operative x-rays

29. • Findings:
• Large (3-5 cm), non-repairable complete, full thickness tear of
the supraspinatus and infraspinatus tendons
• Implants used
• Depuy-Synthes INHANCE
• 24mm baseplate
• 32 mm standard centric glenosphere
• Short humeral stem
• Metal humeral shell with a 32 mm + 4 mm retentive humeral cup

30. • What are some ways of improving stabilization
• Larger glenosphere
• Lateralized glenosphere
• Increase eccentricity
• Thicker poly
• Rententive/ constrained cup
• Capsular plication
• Augmented components to ensure correction of post-morbid deformity

31. • Post-operative protocol
• Abx X 24 hour coverage
• DVT: ASA X 28 days
• Home POD 0-1
• Sling X 3 weeks
• X-ray at 3 weeks

32. Case 3

33. ID: 45 male
CC: Remote history of dislocation (15 years ago), worsening left shoulder pain and stiffness
•All:
•NKDA
PMHx:
• HTN
SoHx:
• RHD
• Works in IT
• Ex-smoker (quit 10 years ago)

34. Meds:
•Lisinopril
•Meloxicam
•Carvedilol
• Surgical history
• None

35. Physical examination:
Left shoulder:
• No swelling
• Deltoid contracts
• AROM 160/50/L1
• Elevation MP 5
• External Rotation MP 5
• Internal Rotation MP 5
• Positive Painful arc of motion
• Negative O’Briens test
• Positive Hawkin's test
• Positive Jerk test
• Negative Speed's test

36. What investigations would you like?

38. • What is your differential diagnosis and what would you like next?

41. • GH degeneration
• Subchondral cyst posterior glenoid
• Paralabral cyst

42. • What are your treatment options

43. Treatments to date
• PT
• Cortisone - 4 months ago

44. Procedure: Left anatomic vs. reverse total shoulder arthroplasty
Position: Beach chair, semi-sitting (45 degrees)
C spine neutral
Pad prominences
Anesthesia: Brachial plexus block + general anesthesia
Approach: Deltopectoral approach
OR equipment: Spider, Total shoulder arthroplasty trays
Specific considerations:
• 3D plan?
• Assess glenoid implant contact and seating %
• Aiming for >50% seating for glenoid baseplate, ideally 80%+ in anatomic
• Exposure
• Young, muscular – may need extensive releases (anterior deltoid/ pec major/ CH)
• Humerus can be difficult with posterior subluxation of humeral head
• Posterior humeral head subluxation: Careful soft tissue balancing and implant sizing

45. • A 36 mm + 4mm anterior eccentric glenosphere
• L short humeral stem 40 mm + 0 mm standard metal humeral shell
• Retentive humeral cup

46. Case 4

47. ID: 58 female
CC: R shoulder pain, 2 years post op from aTSA
All: Pen G
PMHx:
• Asthma
• Carpal tunnel syndrome
• GERD
• OSA
SoHx:
• Non-smoker
• RHD
• Operator at automobile company

48. Physical examination:
Well healed deltopectoral incision without erythema or swelling, no drainage
No apparent swelling of shoulder
Shoulder active ROM FF 45, ER 30, IR to GT
Shoulder passive ROM FF 130
Rotator cuff strength 3/5 supraspinatus, 4/5 infraspinatus, 3/5 subscapularis
Sensation intact to light touch in Ax/R/U/M distributions.
Deltoid contractile
Palpable radial pulse.

51. • What is your differential diagnosis for failed anatomic total shoulder arthroplasty?

52. • What further investigations would you like?

53. • CRP 42
• ESR 98
• R shoulder aspirate:
• Negative after 14 days of growth
• 9,740 WBCs (97% neutrophils)

54. Risk factors for PJI in shoulder arthroplasty
• Young
• Male
Most common pathogen
• Cutibacterium acnes (31 – 70%) > s. aureus
• Gram +ve
• Aerotolerant anaerobe
•Synnovial cell count of more than
•2000/μl and/or more than 70% of polymorph nuclear leucocytes is indicative of a late
PJI of the shoulder
•Synovial WBC >1,100 cells/uL and PMN >64% in knees
•Synovial WBC>3,000 cells/ uL and PMN >80% for hips

56. • What is your treatment plan

57. Procedure: Right shoulder 1st stage revision with antibiotic beads
Position: Beach chair, semi-sitting (45 degrees)
C spine neutral
Pad prominences
Anesthesia: Brachial plexus block + general anesthesia
Approach: Deltopectoral approach
OR equipment: Spider, Total shoulder arthroplasty trays, antibiotics (Tobra/ vanco), cement, VAC, drains
Specific considerations:
• Intra-operative samples
• >14 days of growth
• Anaerobes/ aerobes/ TB/ fungal
• Odd number (>3) of cultures/ pathology/ cell count
• Irrigation material (bactisure/ triple wash)
• Static vs. dynamic
• Wound management
• Regular vs. VAC

59. Post operatively
• ID consult
• PICC
• CT scan for 2nd stage planning