These are the postop and preop X-rays from the previous post (Jay the ab roller extraordinaire). He had severe rotator cuff tear arthropathy with significant pain and limitations in his daily activities because of the pain. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The first two images show the reverse total arthroplasty (AP and scapular Y X-rays). The third image shows his shoulder preoperatively with proximal migration of the humeral head and a very narrow humeral acromial interval (orange arrow and orange line). Another way to determine if these changes are present is to look at the inferior Gothic arch of the shoulder and see if it is broken (in this case it is, see the white curved lines). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ When these changes are present on an X-ray, we know that the rotator cuff is torn and has been for a long time. An excellent surgical solution for this problem in most cases is a reverse total shoulder arthroplasty. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀
Guess what surgery Jay had?!? 💪🏽🤩
These images are the intraoperative X-rays of the patient with the left hip fracture from the previous post. This 95 year-old patient shattered her left hip in a fall. The treatment for this injury is surgical stabilization and I chose to perform a procedure called “cephalomedullary nailing” where I make an incision on the outside of the patient’s hip, manipulate the fracture back into an anatomic position (reduce the fracture) and insert a rod into the patient’s femur, a large screw into the femoral head (blue arrow), a metallic cable (red arrow) around the fracture fragments not adequately secured by the rod and large screw, and smaller screws through the rod at the distal end near the knee (images 4 and 5). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The orange arrows point to the various fracture fragments also highlighted in the previous post. The purple arrow in image 3 points to the femoral head (indicating that the large screw is well inside the bone). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This surgery allowed the patient to mobilize right away; the day after surgery, the physical therapists worked with the patient to sit up and she was working on walking with a walker right away.
This 95 year-old patient fell, shattering her left hip. The first image is an AP pelvis X-ray and the second image is a lateral X-ray of the hip. The orange arrows point to the multiple fracture fragments. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This is a very severe injury. In general, hip fractures are almost always treated surgically. There really isn’t a viable nonoperative treatment option for hip fractures. Patients need their hips stabilized so that they can sit up and, optimally, walk around otherwise pneumonia and other complications leading to death are quite likely. The issue for this specific fracture is how best to treat this fracture and how best to stabilize this injury with the minimal amount of surgery performed. This patient is very frail and we want to fix her hip and get her out of the operating room as efficiently as possible. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀
This is the final postoperative X-ray of the right shoulder of the patient from the previous two posts. I utilized an extended humeral osteotomy to safely remove the previous humeral stem and cement. This allowed revision to a reverse total shoulder arthroplasty without worrying about an unplanned intraoperative proximal humerus fracture. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The distal orange arrow points to the distal aspect of the osteotomy and the proximal orange arrow points to the very thin shell of bone that was the greater tuberosity. The red arrows point to the cables encircling the osteotomy; these were applied to secure the bone in place. The blue arrow points to the articulation of the glenosphere and the humeral tray. This is the new shoulder joint in a reverse total shoulder arthroplasty. When the patient raises or moves her arm, the tray rotates and glides around the glenosphere.
⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ *Warning: if you are bothered by blood or squeamish about surgical images, don’t look at the second image ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ These two photos are intraoperative images of the same shoulder from the previous post. In order to safely remove the well-cemented humeral stem and cement, I performed an extended humeral osteotomy. This involves intentionally creating a controlled fracture of the proximal humerus, creating a large piece of bone l could then hinge open to safely remove the implant and the cement. The bone was so thin that if I simply tried to overpower the cement and hammer it out, I would have likely shattered the proximal humerus, making the revision to a reverse total shoulder arthroplasty much more difficult. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The red arrows point to cerclage cables used to secure the osteotomy back in place. The orange arrow points to the distal aspect of the osteotomy. It looks like a fracture created with a saw blade (which is exactly what it is). The blue arrow points to the shoulder which now has a reverse in place. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ In the second picture, the shoulder is to the left (this is the blue arrow in the X-ray), the metal instrument, a freer, points to the front of the humerus over the osteotomy. The cerclage cables are visible, as are cerclage sutures that I also used. The elbow is to the right of the image. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀
These X-rays are identical and show a right shoulder treated over twenty years ago for a proximal humerus fracture with a cemented hemiarthroplasty. The patient has had severe right shoulder pain for over 1 year without an injury. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The blue arrow points to the distal tip of the cement and the orange arrow points to the junction of cement distally and the very thin greater tuberosity more proximally. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ This patient needs a revision surgery to 1) remove the existing implant and cement and then 2) implant a reverse total shoulder arthroplasty. This will be a very difficult procedure due to the extremely thin cortex of the proximal humerus. There is a high risk of breaking the proximal humerus intraoperatively while trying to remove the implant and the cement. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀
⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ These are intraoperative videos and photos of the patient’s shoulder from the previous two posts. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The first video shows the anterior glenoid rim fracture before it was fixed. The camera is in the front of the shoulder, positioned at the top, looking down. The intact glenoid is to the left and the fracture fragment with associated traumatic debris is to the right. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ In the second video, the camera is in the back of the shoulder and the probe is in the front. Initially the probe tugs on labrum and biceps tendon. The camera then moves to show the fracture fragment of the anterior inferior glenoid rim which is medially and anteriorly displaced. There is a large step-off in terms of where the fracture used to be attached to the glenoid. There is a needle present in the anterior shoulder which was used to localize the correct positioning of an accessory portal. The labrum superior and inferior to the fracture fragment was traumatized but still attached to the glenoid. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ The third image shows a “before” picture of the glenoid, prior to fixing the anterior glenoid rim fracture fragment back in place. The fourth image shows the “after” picture where the fracture is back in its anatomic location. Look at the previous two posts for additional imaging preop and postop. ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀
These are the postoperative X-rays of the patient from the previous post. The large, displaced anterior glenoid rim fracture fragment (orange arrow) is now reduced back to its anatomic, pre-injury location. A screw was utilized to help hold the fracture in position (purple arrow). ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ ⠀⠀⠀⠀⠀⠀⠀⠀⠀ I was able to fix this fracture arthroscopically (using a small camera to visualize inside the joint and instruments that work within the shoulder through small poke-hole incisions). In addition to the screw, I used multiple suture anchors to reattach the fracture fragment indirectly by securing the labrum back anatomically.