Stemless Shoulder Replacement Surgery

Stemless Shoulder Replacement Surgery


Hello, I’m Anand Murthi here at MedStar
Union Memorial Hospital. Today we will be viewing a video of a stemless shoulder
replacement, a relatively new technology in shoulder replacement. This will be a
50-year-old male who has had long-standing osteoarthritis of his
right shoulder, has failed conservative treatment cortisone injections and
therapy, and he’s ready to move on to improve his range of motion, get pain
relief with the new shoulder replacement. Today we’ll be utilizing the stemless
shoulder replacement. Here is a traditional stemmed shoulder replacement
that we’ve used for many years. You can see it has an approximately six to seven
inch stem and traditionally we would place this after coring out the inside
of the humerus bone, removing a significant amount of bone inside the
humerus. Today we will be using what’s called a stemless replacement. You can
see there’s a small cage which is placed inside a receptacle created on the
humerus bone requiring very little bone removal. Patients have much less pain
after surgery and a quicker recovery while having an anatomic shoulder
replacement. This is the metallic ball that is placed on top of the cage and
then the polyethylene socket or glenoid is placed on the inside. And when we put
these two together, the patients routinely have improved motion and pain
relief. They usually stay one day. Sometimes they go on the same day as an
outpatient and begin their rehabilitation the next morning. Forceps. Today we’ll be performing a case
of a right stemless total shoulder replacement on a 50-year-old male with
end-stage osteoarthritis. Here we’re performing a standard deltopectoral
approach. We isolate the bicipital tendon and we routinely either tenodese or
tenotomize the bicipital tendon. At this point we will be isolating the subscapularis tendon to perform a
tenotomy. The patient has relatively good preserved rotation. We’ve detached the
subscapularis from top to bottom. We’ll be releasing the subscapularis tendon here
inferiorly around the large osteophytes to allow us to dislocate this arthritic
shoulder and allow us to prepare the humeral head or resection. Here we are
protecting the axillary nerve and continuing to release the inferior part
of the subscapularis tendon and the capsule. With general rotation you can
see we will then dislocate this very arthritic shoulder and into the open
operative field which will then allow us to prepare the humerus. So we’re going to
make our resection anatomically. You can see the entire humeral head,
here very arthritic, devoid of any cartilage. The rotator cuff is superiorly.
And this is the area that we will be resecting in order to perform an
anatomic stemless replacement. That’s the rotator cuff posterior. We use a sagittal saw to remove the
entire arthritic humerus, but we continue to protect the rotator cuff in the back,
so the patient will continue to have great function after the surgery. So we’ve resected as much humerus as possible, maintaining the insertion point
of the rotator cuff. At this point in the surgery, we will now address the glenoid
or the socket. We have specialized retractors that allow us to push or
retract the humerus out of the way so we can then visualize the glenoid or the
socket to implant our polyethylene socket. We are releasing all the
adhesions around one of the major rotator cuff tendons called the
subscapularis tendon to allow us to gain better motion after the surgical
procedure and this also allows us to have better exposure to the socket which
is the most difficult part of the procedure and can give many people
difficulty. Here we are slowly implanting or placing our retractors in the
front on the top and in the back, once again releasing scar tissue, remnants of
capsule and labrum, allowing us to visualize the entire socket. This socket
was relatively deformed and had been eroded from the many years of arthritis
and in an arthritic ball, articulating or rotating with the socket. But you can see
here we’re slowly gaining access. This is old labrum where excising. These are the
things that cause a rough surface and pain when the patients are rotating or
raising their arms overhead. This patient actually had a relatively large, loose
osteophyte in the posterior aspect of his glenoid which is relatively rare.
And so we removed that as well. Here we are trialing the plastic or polyethylene
sockets to find the proper size for this patient. He was a relatively large male.
And we’re finding or and marking our starting point. And now we will create
the holes for placement of the socket, as well as preparing the socket to a smooth
surface to allow it to be fully supported by our polyethylene glenoid.
The small drill that creates the insertion point for our reamer. This
reaming device creates a nice smooth surface as currently we have a very
irregular surface and deformed surface of the glenoid. This reamer will be
positioned properly and then when we turn it on, it will remove just the
correct amount of bone as we angle the socket to a nice smooth surface. Upon completion of the reaming we will
then create a larger, central hole which will accommodate a special finned portion of the prosthesis. We will now create the three separate peg holes,
which will once again support our socket or glenoid and prevent rotation of the
socket. These are small drill holes made in the periphery of the socket, which
will then be cemented in place with our real prosthesis. Once again the glenoid has to be
prepared very carefully as in long-term studies the glenoid or socket is the
portion of the shoulder replacement that potentially can wear out or loosen in
time. So we’d like to prepare the socket very carefully to make sure it’s fully
supported and very stable. Upon completion of the preparation, we will
then trial our socket, these are trial plastic sockets, to make sure that we
have a nice fit. It’s fully supported. It’s not rocking. And we know that this
will last the patient for a very long time and hopefully his lifetime. So you
can see here, the socket fits nicely. It’s fully supported. We cement the glenoid in
place using cement in the periphery of the peripheral peg holes. Once again, we
want to maintain as dry a surface and as dry as peg hole as possible. Any type of
blood will prevent great fixation, so we continue to impact the cement and will
pressurize the cement a few times, and get a nice, solid cement mantle. You can
see we’re pressurizing the cement holes while maintaining suction in the central
hole. After completion of our cement placement, we’ll dry the glenoid one more
time and then take our real glenoid, our real, plastic polyethylene glenoid, place
it in the proper rotation, and then we will impact this to get a nice solid
fixation. And the excess cement that excludes from the back we will remove
with a small device. Once again, we’re checking to make sure we have solid
fixation, no extra cement, and then we can move on back to the humerus. All right.
Perfect. Here we will dislocate the humerus again.
We’re visualizing that prepared cut surface. We will trial different head
sizes to make sure we have a perfect anatomic replacement of the bone that
we’ve removed and that fits each individualized patient. Here you can see
we’re trialing a humerus and then we will make sure we have the right
thickness, the right width, and using the new stemless design, we will place a
small pin in the center of the humeral cut to prepare it for the remaining
portion of the humeral preparation. There are various size cages that will
fit into the humerus. This is a size 2, which is the majority of patients will
accommodate for most men. We’ll place this center peg, and that allows us to prepare
the rest of the humerus. We’ll smooth out the surface that we’ve cut. This is
called a planer, which will be attached to the central pin. Creates a nice smooth
surface. We will then use a small device that creates the impression, or the
cutout, for the small, stemless cage that we will use. So this is the trial. We’ll
impact it into position with a nice fixation from the spines of the cage
trial. This patient is very good bone. This will
last a long time. We’ll remove the inserter and then we’ll remove the
central pin that we also utilized at the beginning of this preparation. And now
we’ll be able to trial our head sizes to make sure we have a nice, stable shoulder
replacement with good motion. So this is a trial humeral head. We’ll then remove
our retractors and will allow us to reduce the shoulder joint again. We’ve
reduced the shoulder joint, you can see our socket in place. We have nice
stability, nice translation of the shoulder joint. It’s not too unstable, has
great rotation on the field. And this is the prosthesis that we’ll choose for
this patient. Here we are placing heavy, non-absorbable sutures through the
surface of the humerus and this will be used to reattach the subscapularis
rotator cuff tendon, which is a crucial portion of this procedure. And it
actually will be a crucial part of those rehabilitation and recovery as we
protect this tendon repair during the time period for the first six weeks
after surgery. The sutures have been placed. We will now impact the cage of
the stemless device. This has a surface on it that allows bone to actually grow
into the prosthesis. We will dry the surface and then implant
the true prosthesis that was the size of the trial. We unpacked this firmly with a
nice mallet and impactor. And you can see here we have a perfect anatomic stemless
shoulder replacement. Once again we’ll reduce the shoulder replacement, remove
all our retractors, check our nice stability and the translation of the
joint. That completes our stemless shoulder
replacement. This patient will now be, after closure and awakening, admitted to
the hospital for either an outpatient discharge the same day or an overnight
stay where he will do is rehabilitation and learn his physical therapy and
occupational therapy the next morning. And then we’ll see him in one week.


7 thoughts on “Stemless Shoulder Replacement Surgery

  1. I am contemplting the Equinox Stemless Shoulder, any thoughts or opinions as it's fairly new I can't locate anyone who's had this procedure.

  2. I have AVN and had my left shoulder done. They only repllaced the ball. They used a TESS stemless ball. I feel fine and it works good no more pain

  3. Very interesting and so updated the replacement is..Was told today 8/22/2019,that I need shoulder replacement,not looking forward to the after pain,but down the road,no shoulder pain at all

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