Shoulder arthroplasty operative report

Operative report 1

Preoperative Diagnosis

1. End-stage primary osteoarthritis of the right shoulder.

2. Advanced glenohumeral joint degeneration.

3. Chronic right shoulder pain.

4. Severe restriction of shoulder range of motion.

Postoperative Diagnosis

1. End-stage primary osteoarthritis of the right shoulder.

2. Complete loss of glenohumeral articular cartilage.

3. Large humeral head and glenoid marginal osteophytes.

4. Intact rotator cuff.

5. Successful right total shoulder arthroplasty.

Procedure performed

1. Right total shoulder arthroplasty.

2. Biceps tenodesis.

3. Open proximal humeral osteophyte excision.

Indication

The patient is a 67-year-old male with a long-standing history of progressively worsening right shoulder pain, stiffness, night pain, crepitus, and significant limitation of activities of daily living. The patient had failed extensive conservative treatment including oral anti-inflammatory medications, corticosteroid injections, supervised physical therapy, and activity modification for more than one year. Radiographs and CT scan demonstrated end-stage glenohumeral osteoarthritis with complete joint space loss, large osteophytes, and advanced degenerative changes. The rotator cuff remained intact. Due to persistent disabling symptoms and failure of conservative management, right total shoulder arthroplasty was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications were discussed in detail with the patient, and informed consent was obtained.

Description of the procedure

The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics and tranexamic acid were administered prior to skin incision.

The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all required implants and instrumentation.

A standard deltopectoral incision was made beginning at the coracoid process and extending distally along the deltopectoral interval. Dissection was carried sharply through the subcutaneous tissue. Hemostasis was maintained with electrocautery throughout the procedure.

The cephalic vein was identified and preserved by mobilizing it laterally with the deltoid muscle. The deltopectoral interval was developed, and the clavipectoral fascia was incised. The conjoined tendon was identified and protected. Retractors were carefully positioned to optimize exposure while protecting the surrounding neurovascular structures.

The long head of the biceps tendon demonstrated significant degenerative changes and synovitis within the bicipital groove. The tendon was released from its origin and secured to the proximal humerus using nonabsorbable sutures, completing a biceps tenodesis. The remaining proximal tendon was excised.

The subscapularis tendon was identified and released from the lesser tuberosity using a peel technique while preserving adequate tendon for later repair. Heavy nonabsorbable traction sutures were placed within the tendon to facilitate exposure and subsequent repair.

The anterior capsule was incised and elevated from the humeral neck. Large inferior humeral osteophytes were identified and removed using osteotomes and rongeurs, allowing improved visualization of the glenohumeral joint. Circumferential capsular releases were performed to restore mobility and facilitate humeral head exposure.

The humeral head was dislocated anteriorly. Complete loss of articular cartilage with extensive eburnated bone and peripheral osteophytes was identified. The anatomic neck of the humerus was identified, and the humeral head osteotomy was performed using the appropriate cutting guide while maintaining the native inclination and retroversion.

Sequential canal preparation was performed using starter awls, hand reamers, and broaches until excellent metaphyseal and diaphyseal stability was achieved. Trial humeral stem and head components were inserted, demonstrating excellent fit and restoration of proximal humeral anatomy.

Attention was then directed toward the glenoid. Circumferential capsular release and labral excision were performed to completely expose the glenoid. Residual articular cartilage and soft tissues were removed. The glenoid demonstrated concentric wear without significant bone deficiency.

The central guide pin was inserted in the planned position, and the glenoid was sequentially reamed until a congruent bleeding cancellous surface was obtained. Peripheral peg holes and the central hole were prepared according to the implant system. Bone cement was introduced into the peripheral peg holes, and the polyethylene glenoid component was impacted into position. Excellent seating and fixation of the glenoid component were confirmed after complete removal of excess cement.

The definitive humeral stem was inserted with excellent press-fit fixation. The definitive humeral head component was impacted securely onto the taper. The shoulder was reduced, and stability was assessed throughout a full range of motion. Excellent joint stability, restoration of soft tissue tension, and smooth glenohumeral articulation were achieved without instability or impingement.

The surgical wound was thoroughly irrigated with copious sterile normal saline followed by dilute antiseptic solution. Meticulous hemostasis was achieved.

The subscapularis tendon was anatomically repaired to the lesser tuberosity using multiple high-strength nonabsorbable sutures passed through transosseous drill holes. The repair was stable throughout gentle passive external rotation.

Final assessment demonstrated excellent implant positioning, restoration of shoulder anatomy, stable prosthetic articulation, and satisfactory range of motion without impingement.

The deltopectoral interval was allowed to fall back into its normal anatomic position. The fascia was loosely approximated. The subcutaneous tissue was closed in multiple layers using absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.

Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer.

The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.

Findings

• End-stage glenohumeral osteoarthritis.

• Complete loss of humeral head and glenoid articular cartilage.

• Extensive eburnated subchondral bone.

• Large inferior humeral head osteophytes.

• Circumferential glenoid osteophytes.

• Degenerative long head of the biceps tendon with synovitis.

• Intact supraspinatus tendon.

• Intact infraspinatus tendon.

• Intact subscapularis tendon.

• Successful anatomic total shoulder arthroplasty with excellent implant stability and restoration of joint mechanics.

Implants

• Press-fit humeral stem.

• Cobalt-chromium modular humeral head.

• All-polyethylene pegged glenoid component.

Check your answer

CPT

23472-RT

Operative report 2

Preoperative Diagnosis

1. End-stage osteoarthritis of the right shoulder.

2. Advanced degeneration of the humeral head.

3. Chronic right shoulder pain.

4. Severe limitation of shoulder range of motion.

Postoperative Diagnosis

1. End-stage osteoarthritis of the right shoulder.

2. Complete loss of humeral head articular cartilage.

3. Large humeral head osteophytes.

4. Mild degenerative glenoid cartilage with preserved bone stock.

5. Intact rotator cuff.

6. Successful right shoulder hemiarthroplasty.

Procedure performed

1. Right shoulder hemiarthroplasty.

2. Biceps tenodesis.

3. Open excision of proximal humeral osteophytes.

Indication

The patient is a 68-year-old male with a prolonged history of progressively worsening right shoulder pain, stiffness, weakness, and severe limitation of activities of daily living. The patient had failed extensive conservative treatment including oral anti-inflammatory medications, corticosteroid injections, activity modification, and supervised physical therapy for more than one year. Radiographic evaluation demonstrated end-stage degeneration of the humeral head with preservation of the glenoid articular surface and adequate glenoid bone stock. The rotator cuff remained intact. Because of persistent disabling pain and functional limitation despite exhaustive conservative treatment, right shoulder hemiarthroplasty was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications were discussed in detail with the patient, and informed consent was obtained.

Description of the procedure

The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics and tranexamic acid were administered prior to skin incision.

The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all required implants and instrumentation.

A standard deltopectoral incision was made extending from the coracoid process distally along the deltopectoral groove. Dissection was carried sharply through the subcutaneous tissue. Hemostasis was maintained with electrocautery.

The cephalic vein was identified and preserved by retracting it laterally with the deltoid muscle. The deltopectoral interval was developed, and the clavipectoral fascia was incised. The conjoined tendon was identified and protected throughout the procedure.

The long head of the biceps tendon demonstrated moderate tendinosis and synovitis within the bicipital groove. The tendon was released from its origin and secured to the proximal humerus using multiple high-strength nonabsorbable sutures, completing a biceps tenodesis. The remaining proximal tendon was excised.

The subscapularis tendon was identified and released from the lesser tuberosity using a peel technique while preserving adequate tendon for later repair. Heavy traction sutures were placed into the tendon to facilitate exposure.

The anterior capsule was incised longitudinally and elevated from the proximal humerus. Circumferential capsular release was performed to improve exposure. Large inferior and anterior humeral osteophytes were identified and excised using osteotomes and rongeurs. The humeral head was then dislocated anteriorly.

Inspection demonstrated complete loss of humeral head articular cartilage with extensive eburnated subchondral bone and large circumferential osteophytes. The glenoid articular surface demonstrated only mild degenerative cartilage wear without significant bone loss and was considered suitable for preservation.

The anatomic neck of the humerus was identified, and the humeral head osteotomy was performed using an oscillating saw with the assistance of an anatomic cutting guide while maintaining appropriate inclination and retroversion.

The humeral canal was sequentially prepared using canal finders, hand reamers, and broaches until excellent cortical stability was obtained. Trial humeral stem and modular head components were inserted. Trial reduction demonstrated restoration of humeral length, appropriate soft tissue tension, excellent joint stability, and satisfactory range of motion without instability or overstuffing of the joint.

Following satisfactory trialing, the definitive press-fit humeral stem was implanted into the prepared humeral canal with excellent metaphyseal fixation. The appropriately sized modular cobalt-chromium humeral head was securely impacted onto the stem taper.

The shoulder was reduced, and the prosthesis was assessed through passive forward elevation, abduction, internal rotation, and external rotation. Excellent stability, smooth articulation against the native glenoid, restoration of shoulder biomechanics, and appropriate soft tissue balance were confirmed. No evidence of impingement or instability was observed.

The operative field was thoroughly irrigated with copious sterile normal saline followed by dilute antiseptic solution. Meticulous hemostasis was achieved.

The subscapularis tendon was anatomically repaired back to the lesser tuberosity using multiple high-strength nonabsorbable sutures passed through transosseous drill holes. The repair demonstrated excellent stability throughout gentle passive external rotation.

Final inspection confirmed excellent implant positioning, restoration of proximal humeral anatomy, preservation of the native glenoid, stable shoulder mechanics, and satisfactory soft tissue balance.

The deltopectoral interval was allowed to return to its normal anatomic position. The fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers using absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.

Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer.

The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.

Findings

* End-stage degeneration of the humeral head with complete loss of articular cartilage.

* Extensive eburnated subchondral bone.

* Large circumferential humeral head osteophytes.

* Mild degenerative changes of the native glenoid with preserved cartilage and bone stock.

* Degenerative long head of the biceps tendon with synovitis.

* Intact supraspinatus tendon.

* Intact infraspinatus tendon.

* Intact subscapularis tendon.

* Successful right shoulder hemiarthroplasty with restoration of humeral anatomy and excellent prosthetic stability.

Implants

* Press-fit humeral stem.

* Modular cobalt-chromium humeral head.

Check your answer

CPT -

23470-RT

Operative report 3

Preoperative Diagnosis

1. End-stage osteoarthritis of the right shoulder.

2. Advanced glenohumeral joint degeneration.

3. Partial tear of the long head of the biceps tendon.

4. Chronic right shoulder pain.

5. Severe limitation of shoulder range of motion.

Postoperative Diagnosis

1. End-stage osteoarthritis of the right shoulder.

2. Complete loss of glenohumeral articular cartilage.

3. Large humeral head and glenoid marginal osteophytes.

4. Partial tear of the long head of the biceps tendon.

5. Intact rotator cuff.

6. Successful right total shoulder arthroplasty with biceps tendon repair.

Procedure performed

1. Right total shoulder arthroplasty.

2. Open repair of the long head of the biceps tendon.

3. Open excision of proximal humeral osteophytes.

Indication

The patient is a 66-year-old male with a prolonged history of progressively worsening right shoulder pain, stiffness, weakness, and severe limitation of activities of daily living. Conservative treatment including oral anti-inflammatory medications, corticosteroid injections, activity modification, and supervised physical therapy failed to provide adequate relief over more than one year. Radiographs and CT scan demonstrated end-stage glenohumeral osteoarthritis with complete loss of joint space and large osteophytes. MRI also demonstrated a partial tear of the long head of the biceps tendon near the bicipital groove. The rotator cuff remained intact. Because of persistent disabling pain and functional limitation despite exhaustive conservative treatment, right total shoulder arthroplasty with repair of the long head of the biceps tendon was recommended. The risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications were discussed in detail with the patient, and informed consent was obtained.

Description of the procedure

The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics and tranexamic acid were administered prior to skin incision.

The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all required implants and instrumentation.

A standard deltopectoral incision was made extending from the coracoid process distally along the deltopectoral groove. Sharp dissection was carried through the subcutaneous tissue. Hemostasis was maintained using electrocautery.

The cephalic vein was identified and preserved by mobilizing it laterally with the deltoid muscle. The deltopectoral interval was developed, and the clavipectoral fascia was incised. The conjoined tendon was identified and protected throughout the procedure.

The long head of the biceps tendon was identified within the bicipital groove. Examination demonstrated a partial-thickness longitudinal tear with surrounding synovitis and degenerative tendon fibers. The torn tendon edges were carefully debrided of nonviable tissue while preserving healthy tendon. The tendon was repaired using multiple interrupted high-strength nonabsorbable sutures, restoring its continuity and normal tension. The repair was inspected and demonstrated excellent stability throughout passive shoulder motion.

Attention was then directed to the subscapularis tendon. The tendon was released from the lesser tuberosity using a peel technique while preserving sufficient tissue for later repair. Heavy traction sutures were placed to facilitate exposure.

The anterior capsule was incised longitudinally and elevated from the proximal humerus. Circumferential capsular release was performed. Large inferior and anterior humeral osteophytes were identified and excised using osteotomes and rongeurs to improve visualization and mobility.

The humeral head was dislocated anteriorly. Inspection demonstrated complete loss of articular cartilage with extensive eburnated subchondral bone and circumferential osteophyte formation. The glenoid demonstrated advanced cartilage degeneration with preserved bone stock suitable for total shoulder arthroplasty.

The anatomic neck of the humerus was identified, and the humeral head osteotomy was performed using an oscillating saw with an anatomic cutting guide while maintaining the appropriate inclination and retroversion.

The humeral canal was sequentially prepared using canal finders, reamers, and broaches until excellent metaphyseal fixation was achieved. Trial humeral stem and head components were inserted and demonstrated satisfactory restoration of humeral height, offset, and soft tissue balance.

Attention was directed toward the glenoid. The remaining labrum and residual articular cartilage were excised to expose the glenoid surface. Circumferential capsular releases were completed to optimize exposure.

A central guide pin was inserted into the glenoid, followed by sequential reaming until a congruent bleeding cancellous surface was obtained. Peripheral peg holes and the central hole were prepared according to the implant system.

Bone cement was introduced into the peripheral peg holes, and the polyethylene glenoid component was implanted with excellent seating and fixation. Excess cement was removed after complete component insertion.

The definitive press-fit humeral stem was implanted into the humeral canal with excellent stability. The appropriately sized modular cobalt-chromium humeral head was securely impacted onto the stem taper.

The shoulder was reduced, and stability was assessed through passive forward elevation, abduction, internal rotation, and external rotation. Excellent prosthetic stability, restoration of shoulder biomechanics, appropriate soft tissue tension, and smooth glenohumeral articulation were confirmed without evidence of impingement or instability.

The operative field was thoroughly irrigated with copious sterile normal saline followed by dilute antiseptic solution. Meticulous hemostasis was achieved.

The subscapularis tendon was anatomically repaired to the lesser tuberosity using multiple high-strength nonabsorbable sutures passed through transosseous drill holes. The previously repaired long head of the biceps tendon was again inspected and remained intact with excellent tension and stability.

Final inspection demonstrated excellent implant positioning, restoration of shoulder anatomy, stable prosthetic articulation, secure biceps tendon repair, and satisfactory soft tissue balance.

The deltopectoral interval was allowed to return to its normal anatomic position. The fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers using absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.

Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer.

The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.

Findings

• End-stage glenohumeral osteoarthritis.

• Complete loss of humeral head and glenoid articular cartilage.

• Extensive eburnated subchondral bone.

• Large humeral head and glenoid osteophytes.

• Partial longitudinal tear of the long head of the biceps tendon.

• Degenerative biceps tenosynovitis.

• Intact supraspinatus tendon.

• Intact infraspinatus tendon.

• Intact subscapularis tendon.

• Successful repair of the long head of the biceps tendon.

• Successful anatomic total shoulder arthroplasty with excellent implant stability and restoration of joint biomechanics.

Implants

• Press-fit humeral stem.

• Modular cobalt-chromium humeral head.

• All-polyethylene pegged glenoid component.

Check your answer

CPT -

23472-RT

23430-59-RT

Operative report 4

Preoperative Diagnosis

1. Failed right shoulder hemiarthroplasty.

2. Progressive glenoid arthrosis.

3. Rotator cuff insufficiency.

4. Painful failed shoulder arthroplasty.

5. Chronic right shoulder pain with functional limitation.

Postoperative Diagnosis

1. Failed right shoulder hemiarthroplasty.

2. Severe glenoid cartilage loss with superior glenoid erosion.

3. Massive irreparable posterosuperior rotator cuff tear.

4. Well-fixed humeral stem.

5. Successful conversion to reverse total shoulder arthroplasty.

Procedure performed

1. Revision of right shoulder hemiarthroplasty.

2. Conversion to reverse total shoulder arthroplasty.

3. Removal of modular humeral head component.

4. Glenoid preparation with implantation of reverse glenoid baseplate and glenosphere.

5. Revision of humeral prosthesis with reverse polyethylene liner.

6. Extensive capsular release and scar tissue excision.

Indication

The patient is a 72-year-old male with a history of right shoulder hemiarthroplasty performed several years previously for glenohumeral arthritis. Over time, the patient developed progressively worsening shoulder pain, weakness, pseudoparalysis, and inability to perform overhead activities. Radiographs and CT scan demonstrated advanced glenoid erosion with superior migration of the humeral prosthesis. MRI and intraoperative evaluation were consistent with massive irreparable rotator cuff insufficiency. The humeral stem remained well fixed without evidence of loosening or infection. Due to progressive pain, loss of function, and failure of conservative management, revision hemiarthroplasty with conversion to reverse total shoulder arthroplasty was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications were discussed in detail with the patient, and informed consent was obtained.

Description of the procedure

The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics and tranexamic acid were administered prior to skin incision.

The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all revision implants and specialized instrumentation.

The previous deltopectoral incision was identified and sharply reopened. Dissection was carried through the subcutaneous tissues utilizing meticulous technique because of dense postoperative scar formation. Hemostasis was maintained with electrocautery throughout the procedure.

The cephalic vein was identified and preserved. The deltopectoral interval was carefully developed. Extensive scar tissue and adhesions surrounding the prosthesis, subdeltoid space, and proximal humerus were encountered and meticulously released using sharp dissection and electrocautery. The axillary nerve was identified, protected, and remained intact throughout the procedure.

The subscapularis tendon was found to be markedly attenuated and was released from the lesser tuberosity. Circumferential capsular release was then performed to restore mobility of the proximal humerus and allow adequate exposure of the prosthesis.

The shoulder was carefully dislocated anteriorly. The modular humeral head component of the existing hemiarthroplasty was exposed and removed using the manufacturer's extraction instruments. The humeral stem was thoroughly inspected and demonstrated excellent fixation without evidence of loosening, osteolysis, corrosion, or mechanical failure. Because of its excellent fixation and compatibility with the revision system, the humeral stem was retained.

Attention was then directed toward the glenoid. Dense fibrous tissue, remaining labrum, hypertrophic synovium, and scar tissue were excised circumferentially to completely expose the glenoid. Severe cartilage loss with superior glenoid erosion and subchondral sclerosis were identified.

The central guide pin was inserted into the planned position using appropriate inferior tilt and version. Sequential glenoid reaming was performed until a congruent bleeding cancellous surface was obtained while preserving maximal glenoid bone stock. Peripheral drill holes were prepared according to the implant system.

The reverse glenoid baseplate was impacted into position with excellent press-fit fixation. Multiple locking and nonlocking peripheral screws were inserted sequentially, achieving rigid fixation. A properly sized glenosphere was then impacted and securely locked onto the baseplate. Stability of the glenoid construct was confirmed.

Attention was returned to the humerus. The retained humeral stem was irrigated and inspected. Trial reverse humeral trays and polyethylene liners were sequentially inserted to determine the appropriate implant size, soft tissue tension, and stability. Trial reduction demonstrated excellent deltoid tension, restoration of shoulder length, stable prosthetic articulation, and satisfactory range of motion without impingement or instability.

Following satisfactory trialing, the definitive reverse humeral tray and polyethylene liner were securely impacted onto the retained humeral stem. The shoulder was reduced without difficulty.

The reconstructed shoulder was taken through passive forward elevation, abduction, internal rotation, and external rotation. Excellent stability was demonstrated throughout the full range of motion. No impingement, prosthetic instability, or excessive soft tissue tension was identified. The deltoid muscle demonstrated appropriate tension following conversion to the reverse prosthesis.

The operative field was thoroughly irrigated with copious sterile normal saline followed by dilute antiseptic solution. Meticulous hemostasis was achieved.

The remaining anterior capsule and subscapularis tissue were repaired where tissue quality permitted using multiple high-strength nonabsorbable sutures. Residual scar tissue was excised to optimize postoperative motion while maintaining prosthetic stability.

Final inspection confirmed excellent implant positioning, secure fixation of the glenoid baseplate and glenosphere, stable articulation of the reverse prosthesis, and satisfactory restoration of shoulder biomechanics.

The deltopectoral interval was allowed to return to its normal anatomic position. The fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers using absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.

Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer.

The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.

Findings

* Failed right shoulder hemiarthroplasty.

* Well-fixed humeral stem without loosening.

* Severe glenoid cartilage loss with superior glenoid erosion.

* Massive irreparable supraspinatus and infraspinatus tendon tears.

* Superior migration of the humeral prosthesis.

* Extensive capsular contracture and postoperative scar tissue.

* Intact deltoid muscle.

* No evidence of prosthetic joint infection.

* Successful conversion from hemiarthroplasty to reverse total shoulder arthroplasty with excellent implant stability and restoration of shoulder biomechanics.

Implants

* Reverse glenoid baseplate.

* Glenosphere.

* Modular reverse humeral tray.

* Reverse polyethylene humeral liner.

* Multiple locking and nonlocking glenoid fixation screws.

Check your answer

23474-RT

Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

Operative report 5

Preoperative Diagnosis

1. Right painful reverse total shoulder arthroplasty.

2. Polyethylene wear of the reverse shoulder prosthesis.

3. Mechanical failure of the humeral polyethylene liner.

4. Chronic right shoulder pain.

Postoperative Diagnosis

1. Polyethylene wear of the reverse shoulder arthroplasty.

2. Stable glenoid baseplate and glenosphere.

3. Well-fixed humeral stem.

4. Mild metallosis secondary to polyethylene wear.

5. Successful revision reverse shoulder arthroplasty with polyethylene liner exchange.

Procedure performed

1. Revision of right reverse total shoulder arthroplasty.

2. Exchange of humeral polyethylene liner.

3. Extensive synovectomy and debridement.

4. Irrigation of the prosthetic joint.

Indication

The patient is a 71-year-old male with a history of right reverse total shoulder arthroplasty performed several years previously. The patient developed progressively worsening shoulder pain, intermittent mechanical clicking, decreased range of motion, and declining shoulder function. Radiographic evaluation demonstrated eccentric polyethylene wear without evidence of loosening of the glenoid or humeral components. Infection workup was negative. Because of symptomatic polyethylene wear with otherwise well-fixed prosthetic components, revision surgery consisting of isolated polyethylene liner exchange was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and potential complications were discussed in detail with the patient, and informed consent was obtained.

Description of the procedure

The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics and tranexamic acid were administered prior to skin incision.

The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all revision implants and instrumentation.

The previous deltopectoral incision was sharply reopened. Dissection was carried carefully through the subcutaneous tissues utilizing meticulous technique because of postoperative scar formation. Hemostasis was maintained throughout the procedure with electrocautery.

The cephalic vein was identified and preserved. The deltopectoral interval was developed, and dense scar tissue surrounding the prosthesis was carefully released. The deltoid muscle and surrounding neurovascular structures were protected throughout the procedure.

The joint capsule was identified and opened. A moderate amount of clear synovial fluid was encountered without evidence of purulence. Multiple tissue specimens and synovial fluid samples were obtained for aerobic, anaerobic, fungal, and acid-fast cultures as well as frozen section analysis. There was no gross evidence of prosthetic joint infection.

The shoulder was carefully dislocated, exposing the reverse prosthesis. Inspection demonstrated significant wear of the humeral polyethylene liner with mild metallosis and reactive synovitis. The humeral stem remained well fixed without evidence of loosening, corrosion, or mechanical failure. The glenosphere and glenoid baseplate were carefully inspected and demonstrated excellent fixation with no evidence of loosening, migration, or excessive wear.

The worn polyethylene liner was disengaged from the humeral tray using the manufacturer's extraction instruments and removed without difficulty. The humeral tray locking mechanism was thoroughly inspected and found to be intact.

Extensive synovectomy was performed utilizing sharp dissection and rongeurs to remove hypertrophic reactive synovium and inflammatory tissue. Areas of metallosis and polyethylene wear debris were meticulously excised. The prosthetic articulation and surrounding soft tissues were thoroughly debrided until healthy tissue remained.

The operative field was copiously irrigated with pulsatile lavage utilizing several liters of sterile normal saline followed by dilute antiseptic solution. Meticulous hemostasis was achieved.

Trial polyethylene liners of various thicknesses were inserted sequentially. Trial reduction demonstrated excellent prosthetic stability, restoration of soft tissue tension, satisfactory deltoid tension, and smooth articulation throughout passive forward elevation, abduction, internal rotation, and external rotation. There was no evidence of instability, impingement, or excessive constraint.

Following satisfactory trialing, the appropriately sized definitive highly cross-linked polyethylene humeral liner was securely impacted into the humeral tray according to the manufacturer's recommended technique. Proper seating and locking of the liner were confirmed.

The shoulder was reduced without difficulty. The prosthesis demonstrated excellent stability throughout a full passive range of motion with no evidence of dislocation or impingement. Final inspection confirmed that the humeral stem, humeral tray, glenosphere, and glenoid baseplate remained well fixed and appropriately aligned.

The joint was irrigated once more with sterile normal saline. The capsule was repaired where feasible using interrupted absorbable sutures. The deltopectoral interval was allowed to return to its normal anatomic position. The fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers using absorbable sutures, and the skin was closed with a running subcuticular absorbable suture followed by skin adhesive.

Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer.

The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.

Findings

* Significant wear of the humeral polyethylene liner.

* Mild metallosis with polyethylene wear debris.

* Reactive hypertrophic synovitis.

* Stable humeral stem without loosening.

* Stable humeral tray locking mechanism.

* Stable glenoid baseplate.

* Stable glenosphere without evidence of loosening.

* No evidence of prosthetic joint infection.

* Successful isolated polyethylene liner exchange with restoration of prosthetic stability and shoulder biomechanics.

Implants

* Highly cross-linked reverse shoulder polyethylene humeral liner (revision component).

Check your answer

23473-52-RT

Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

Operative report 6

Preoperative Diagnosis

1. Infected right total shoulder arthroplasty.

2. Chronic periprosthetic joint infection of the right shoulder.

3. Painful failed total shoulder arthroplasty.

4. Right shoulder synovitis with extensive inflammatory tissue.

Postoperative Diagnosis

1. Chronic periprosthetic joint infection of the right total shoulder arthroplasty.

2. Gross purulence involving the glenohumeral joint.

3. Extensive synovitis with infected periprosthetic membrane.

4. Well-fixed humeral and glenoid prosthetic components.

5. Successful explantation of total shoulder arthroplasty with placement of an articulating antibiotic spacer as Stage I revision.

Procedure performed

1. Removal of right total shoulder arthroplasty prosthesis.

2. Extensive irrigation and excisional debridement of the right shoulder involving skin, subcutaneous tissue, fascia, synovium, capsule, muscle, and bone.

3. Complete synovectomy of the glenohumeral joint.

4. Removal of humeral and glenoid prosthetic components.

5. Removal of residual bone cement.

6. Placement of articulating antibiotic-impregnated cement spacer (Stage I revision for periprosthetic joint infection).

7. Multiple deep tissue and fluid cultures obtained.

Indication

The patient is a 69-year-old male with a history of right total shoulder arthroplasty performed approximately three years previously who presented with progressively worsening shoulder pain, swelling, erythema, decreased range of motion, and elevated inflammatory markers. Preoperative aspiration demonstrated findings consistent with chronic periprosthetic joint infection. Advanced imaging demonstrated loosening of the prosthetic components with surrounding osteolysis. Despite antibiotic therapy, the patient continued to have persistent symptoms. After multidisciplinary evaluation, a planned two-stage revision arthroplasty was recommended. Stage I consisted of complete prosthesis removal, extensive debridement, and placement of an antibiotic-impregnated cement spacer, followed by prolonged culture-directed intravenous antibiotic therapy prior to planned Stage II reimplantation. Risks, benefits, alternatives, expected postoperative treatment, and possible complications were discussed in detail with the patient, and informed consent was obtained.

Description of the procedure

The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, intravenous antibiotics were intentionally withheld until all intraoperative cultures had been obtained. The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of revision instrumentation and antibiotic spacer components.

The previous deltopectoral incision was sharply reopened. Dissection was carried carefully through the subcutaneous tissues utilizing meticulous technique because of extensive postoperative scar formation. Hemostasis was maintained with electrocautery throughout the procedure.

The cephalic vein was identified and preserved. The deltopectoral interval was developed, exposing the underlying prosthesis. Dense scar tissue and inflammatory adhesions were encountered throughout the subdeltoid and glenohumeral spaces. Extensive adhesiolysis was performed to restore surgical exposure while protecting the axillary nerve and surrounding neurovascular structures.

Upon entering the glenohumeral joint, a large amount of cloudy purulent fluid was encountered. Synovial fluid was immediately aspirated and submitted for aerobic, anaerobic, fungal, and acid-fast bacilli cultures, Gram stain, cell count, and crystal analysis. Multiple representative tissue specimens from the capsule, synovium, humeral interface, glenoid interface, and surrounding inflammatory membrane were obtained and submitted for microbiological culture and permanent histopathologic examination.

Extensive hypertrophic infected synovium and thick inflammatory pseudomembrane surrounded the prosthetic components. A complete synovectomy was performed utilizing electrocautery, rongeurs, curettes, and sharp dissection. All visibly infected, necrotic, and nonviable soft tissues were meticulously excised.

Attention was directed toward removal of the humeral component. The humeral head was disengaged from the stem. Flexible osteotomes and specialized extraction instruments were utilized to carefully separate the implant from the surrounding bone while preserving maximal humeral bone stock. The humeral stem was successfully extracted without intraoperative fracture.

Attention was then directed toward the glenoid. The polyethylene glenoid component was exposed. Remaining cement surrounding the glenoid pegs was carefully disrupted using fine osteotomes, curettes, and high-speed burrs. The glenoid component was removed in its entirety. All residual cement fragments and fibrous membrane were meticulously removed from both the glenoid and humeral canals.

The humeral canal and glenoid were thoroughly debrided utilizing curettes, flexible reamers, and high-speed burrs until only healthy bleeding bone remained. Any remaining cement, granulomatous tissue, and infected membrane were completely excised.

Extensive excisional debridement was then performed involving the skin, subcutaneous tissue, fascia, muscle, capsule, synovium, and bone. All devitalized tissue was removed until healthy viable tissue margins were encountered. The axillary recess, bicipital groove, subcoracoid space, and subdeltoid recess were carefully inspected and debrided. No retained foreign material remained.

The operative field was irrigated sequentially using pulsatile lavage with several liters of sterile normal saline followed by dilute antiseptic solution. Mechanical brushing of the humeral canal and glenoid was performed during irrigation to further reduce bacterial biofilm. The wound was again inspected, and meticulous hemostasis was achieved.

An articulating antibiotic cement spacer was then prepared on the back table utilizing polymethylmethacrylate bone cement mixed with high-dose vancomycin and gentamicin according to institutional protocol. The spacer was molded to reproduce appropriate humeral length and soft tissue tension.

The antibiotic spacer was inserted into the prepared humeral canal and reduced against the native glenoid. Excellent stability and satisfactory alignment were achieved. Passive shoulder motion demonstrated stable spacer articulation without dislocation.

Following placement of the spacer, intravenous culture-directed broad-spectrum antibiotics were administered after all cultures had been obtained.

The operative field was irrigated one final time. A closed-suction drain was placed within the glenohumeral joint and brought out through a separate stab incision.

The deltopectoral interval was loosely reapproximated. The subcutaneous tissues were closed in multiple layers using absorbable sutures. The skin was closed with interrupted nylon sutures to allow postoperative wound monitoring.

Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer.

The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition. Plans were made for infectious disease consultation, prolonged culture-directed intravenous antibiotic therapy, serial inflammatory marker monitoring, and planned Stage II reverse or anatomic shoulder arthroplasty reimplantation following eradication of infection.

Findings

* Gross purulent fluid within the glenohumeral joint.

* Chronic periprosthetic joint infection involving the total shoulder arthroplasty.

* Extensive hypertrophic infected synovitis.

* Thick inflammatory periprosthetic membrane.

* Well-fixed humeral prosthesis.

* Well-fixed polyethylene glenoid component.

* Mild proximal humeral osteolysis.

* Glenoid osteolysis surrounding the implant.

* Complete removal of all prosthetic components and bone cement.

* Successful extensive excisional debridement with complete synovectomy.

* Successful placement of an articulating antibiotic-impregnated cement spacer as Stage I revision.

Implants

* Articulating polymethylmethacrylate antibiotic cement spacer containing vancomycin and gentamicin.

Check your answer

23335-RT

11981-51

Operative report 7

Preoperative Diagnosis

1. Status post Stage I explantation of infected right total shoulder arthroplasty with placement of an articulating antibiotic spacer.

2. Resolved right shoulder periprosthetic joint infection.

3. Right shoulder arthroplasty deficiency following prosthesis explantation.

4. Chronic right shoulder pain and functional limitation.

Postoperative Diagnosis

1. Resolved right shoulder periprosthetic joint infection.

2. Well-incorporated articulating antibiotic spacer.

3. No gross evidence of persistent infection.

4. Mild proximal humeral and glenoid bone loss.

5. Successful Stage II revision reverse total shoulder arthroplasty.

Procedure performed

1. Removal of articulating antibiotic cement spacer.

2. Revision reverse total shoulder arthroplasty.

3. Revision humeral component implantation.

4. Glenoid preparation with implantation of reverse glenoid baseplate and glenosphere.

5. Extensive irrigation and excisional debridement.

6. Multiple deep tissue cultures obtained.

Indication

The patient is a 70-year-old male with a history of chronic periprosthetic joint infection following a right total shoulder arthroplasty. Approximately three months previously, the patient underwent Stage I revision consisting of complete prosthesis explantation, extensive debridement, and placement of an articulating antibiotic cement spacer. The patient subsequently completed a six-week course of culture-directed intravenous antibiotic therapy under the supervision of the infectious disease service. Follow-up inflammatory markers normalized, and repeat clinical evaluation demonstrated complete resolution of infection without erythema, drainage, or systemic symptoms. The patient continued to experience severe pain, loss of function, and inability to use the extremity because of the temporary spacer. After confirming eradication of infection, Stage II revision reverse total shoulder arthroplasty was recommended. Risks, benefits, alternatives, expected postoperative rehabilitation, and possible complications were discussed in detail with the patient, and informed consent was obtained.

Description of the procedure

The patient was brought to the operative room and placed supine on the operating table. Following induction of satisfactory general anesthesia, an ultrasound-guided interscalene nerve block was confirmed. Intravenous prophylactic antibiotics were withheld until all intraoperative cultures had been obtained.

The patient was positioned in the beach-chair position with the head and neck maintained in neutral alignment. All bony prominences were carefully padded. The right upper extremity was prepared and draped in the usual sterile orthopedic fashion. A final surgical timeout was performed confirming the patient's identity, operative extremity, planned procedure, and availability of all revision implants and instrumentation.

The previous deltopectoral incision was sharply reopened. Dissection was carried carefully through the subcutaneous tissues utilizing meticulous technique because of postoperative scar formation. Hemostasis was maintained with electrocautery throughout the procedure.

The cephalic vein was identified and preserved. The deltopectoral interval was developed. Dense postoperative scar tissue surrounding the proximal humerus and glenohumeral joint was carefully released. Extensive adhesiolysis was performed to restore surgical exposure while protecting the axillary nerve and surrounding neurovascular structures.

The joint capsule was entered. A small amount of clear synovial fluid was encountered without purulence or evidence of active infection. Multiple synovial fluid samples and deep tissue specimens from the humerus, glenoid, capsule, and surrounding membrane were obtained for aerobic, anaerobic, fungal, and acid-fast bacilli cultures as well as frozen section analysis.

The articulating antibiotic cement spacer was carefully exposed. Flexible osteotomes and extraction instruments were utilized to disengage and remove the spacer without difficulty while preserving the remaining humeral bone stock. Residual antibiotic cement fragments were meticulously removed from the humeral canal and glenoid.

The humeral canal and glenoid were thoroughly inspected. There was no gross evidence of persistent infection. Mild fibrous tissue was present and was sharply excised. Extensive excisional debridement of residual scar tissue, inflammatory synovium, capsule, and nonviable tissue was performed until healthy viable tissue was encountered. Pulsatile lavage with several liters of sterile normal saline followed by dilute antiseptic solution was performed.

Attention was directed toward preparation of the glenoid. The glenoid demonstrated mild superior bone loss but adequate remaining bone stock for reverse arthroplasty. The central guide pin was inserted in the planned position with appropriate inferior tilt. Sequential glenoid reaming was performed until a congruent bleeding cancellous surface was obtained while preserving maximal bone stock. Peripheral drill holes were prepared.

A reverse glenoid baseplate was impacted into position with excellent press-fit fixation. Multiple locking and nonlocking screws were inserted sequentially, obtaining rigid fixation. A properly sized glenosphere was then impacted and securely locked onto the baseplate. Excellent stability of the glenoid construct was confirmed.

Attention was then directed toward the humerus. The humeral canal was sequentially prepared using canal reamers and broaches until excellent metaphyseal and diaphyseal stability was achieved. Trial revision humeral stems, trays, and polyethylene liners were sequentially inserted. Trial reduction demonstrated excellent restoration of shoulder length, appropriate deltoid tension, stable prosthetic articulation, and satisfactory range of motion without impingement or instability.

Following satisfactory trialing, the definitive revision humeral stem was implanted into the prepared humeral canal with excellent fixation. The definitive reverse humeral tray and highly cross-linked polyethylene liner were securely impacted onto the stem.

The shoulder was reduced without difficulty. Passive forward elevation, abduction, internal rotation, and external rotation demonstrated excellent prosthetic stability throughout the full range of motion. No evidence of instability, impingement, or excessive soft tissue tension was identified. The deltoid muscle demonstrated appropriate tension, and the prosthesis remained concentrically reduced.

Following completion of the reconstruction, intravenous prophylactic antibiotics were administered after all cultures had been obtained.

The operative field was again irrigated with copious sterile normal saline. Meticulous hemostasis was achieved. A closed-suction drain was placed through a separate stab incision.

Final inspection demonstrated excellent implant positioning, secure fixation of the revision humeral stem, stable glenoid baseplate and glenosphere, restoration of shoulder biomechanics, and no evidence of persistent infection.

The deltopectoral interval was allowed to return to its normal anatomic position. The fascia was loosely approximated. The subcutaneous tissues were closed in multiple layers using absorbable sutures. The skin was closed with a running subcuticular absorbable suture followed by skin adhesive.

Sterile dressings were applied, and the right upper extremity was placed into a padded shoulder immobilizer.

The patient tolerated the procedure well without complications, was awakened from anesthesia, extubated uneventfully, and transferred to the post-anesthesia care unit in stable condition.

Findings

* Well-positioned articulating antibiotic cement spacer.

* No gross evidence of persistent periprosthetic joint infection.

* Clear synovial fluid without purulence.

* Mild residual inflammatory synovium.

* Mild superior glenoid bone loss.

* Mild proximal humeral bone loss.

* Adequate bone stock for revision reverse shoulder arthroplasty.

* Successful removal of antibiotic spacer.

* Successful Stage II revision reverse total shoulder arthroplasty with excellent implant fixation and restoration of shoulder biomechanics.

Implants

* Revision press-fit humeral stem.

* Reverse humeral tray.

* Highly cross-linked polyethylene humeral liner.

* Reverse glenoid baseplate.

* Glenosphere.

* Multiple locking and nonlocking glenoid fixation screws.

Check your answer

23474-RT

Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

Removal of antibiotic spacer is inlcued in revision code here.