Dr Michell Ruiz
Cirugía de hombro y del Manguito rotador
sábado, 12 de julio de 2014
miércoles, 9 de julio de 2014
A complex revision of an infected reverse total shoulder
http://shoulderarthritis.blogspot.mx/2014/07/a-complex-revision-of-infected-reverse.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed:+ShoulderArthritis+(Shoulder+Arthritis)
At surgery he was found to have massive humeral and glenoid deformity with severe posterior glenoid erosion and malformation of the humeral head with posterior capsular laxity and anterior capsular contracture. His surgery was a humeral hemiarthroplasty with subscapularis lengthening. His post operative film is shown here.
However, the humeral head again became posteriorly unstable. A year later he had an open reduction of the posteriorly dislocated shoulder with anterior release, prosthetic head removal, posterior cortical iliac autograft of the glenoid with screw fixation, posterior soft tissue reconstruction, and reinsertion of hemiarthroplasty head. However, on testing the range of motion of the shoulder at surgery, the securely fixed bone graft fragmented requiring removal of the graft and screws and insertion of a reverse total shoulder. His postoperative film is shown here.
Three years later he represented with pain in his shoulder that started with golfing. He had no clinical evidence of infection. His x-rays showed humeral osteolysis and subsidence
He then had a primary exchange revision of reverse total shoulder arthroplasty to a long stemmed humeral component and a new glenoid component at which time six cultures were obtained before antibiotics were administered. At this procedure there was a substantial amount of membrane and granulomatous tissue from the glenoid and from the humeral medullary canal. There was no cloudy fluid and no purulence.
His histology showed gram-positive rods and up to 40 white blood cells per high power field on frozen section. The patient’s final pathology eventually returned “synovial tissue with multiple foci of dense neutrophilic infiltrates (greater than five neutrophils per high power microscopic field using a 40 X objective in at least five separate microscopic fields) in a background of prominent plasmacytic inflammation and hemosiderin-laden macrophages.” He was placed on a six-week course of IV vancomycin and rifampin, which was changed to ceftriaxone to better cover Propionibacterium after the culture results were final at 3 weeks.
His culture results were as follows:
Glenoid Membrane No. 1: 2+ Propionibacterium
Glenoid Membrane No. 2: 1+ Propionibacterium
Fluid Right Glenoid: 1+ Propionibacterium
Humeral Membrane No.1: 1 colony Propionibacterium
Humeral Membrane No. 2: 1+ Propionibacterium
Humeral Membrane No. 3 One colony Propionibacterium
He remained on oral Augmentin for a year.
Today six years after his most recent revision he plays tennis (tossing the ball with his right hand serving with his left), skis gentle slopes, and runs for fitness. His Simple Shoulder Test responses are 8/12:
1: Is your shoulder comfortable with your arm at rest by your side?: Yes
2: Does your shoulder allow you to sleep comfortably?: Yes
3: Can you reach the small of your back to tuck in your shirt with your hand?: Yes
4: Can you place your hand behind your head with the elbow straight out to the side?: Yes
5: Can you place a coin on a shelf at the level of your shoulder without bending your elbow?: Yes Yes
6: Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow?: Yes
7: Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow?: No
8: Can you carry twenty pounds at your side with this extremity?: Yes
9: Do you think you can toss a softball under-hand twenty yards with this extremity?: No
10: Do you think you can toss a softball over-hand twenty yards with this extremity?: No
11: Can you wash the back of your opposite shoulder with this extremity?: No
12: Would your shoulder allow you to work full-time at your regular job?: Yes
His x-rays today continue to show stable component fixation.
Comment: This case reveals the challenges of severe capsulorrhaphy arthropathy with posterior instability as well as the substantially delayed insidious presentation of osteolysis associated with Propionibacterium.
Monday, July 7, 2014
A complex revision of an infected reverse total shoulder
A 45 year old right handed active man had a Simple Shoulder Test score of 4/12. His x-rays revealed severe capsulorrhaphy arthropathy with posterior dislocation of right shoulder after a Putti Platt procedure for shoulder instability performed many years earlier.
At surgery he was found to have massive humeral and glenoid deformity with severe posterior glenoid erosion and malformation of the humeral head with posterior capsular laxity and anterior capsular contracture. His surgery was a humeral hemiarthroplasty with subscapularis lengthening. His post operative film is shown here.
However, the humeral head again became posteriorly unstable. A year later he had an open reduction of the posteriorly dislocated shoulder with anterior release, prosthetic head removal, posterior cortical iliac autograft of the glenoid with screw fixation, posterior soft tissue reconstruction, and reinsertion of hemiarthroplasty head. However, on testing the range of motion of the shoulder at surgery, the securely fixed bone graft fragmented requiring removal of the graft and screws and insertion of a reverse total shoulder. His postoperative film is shown here.
Three years later he represented with pain in his shoulder that started with golfing. He had no clinical evidence of infection. His x-rays showed humeral osteolysis and subsidence
He then had a primary exchange revision of reverse total shoulder arthroplasty to a long stemmed humeral component and a new glenoid component at which time six cultures were obtained before antibiotics were administered. At this procedure there was a substantial amount of membrane and granulomatous tissue from the glenoid and from the humeral medullary canal. There was no cloudy fluid and no purulence.
His histology showed gram-positive rods and up to 40 white blood cells per high power field on frozen section. The patient’s final pathology eventually returned “synovial tissue with multiple foci of dense neutrophilic infiltrates (greater than five neutrophils per high power microscopic field using a 40 X objective in at least five separate microscopic fields) in a background of prominent plasmacytic inflammation and hemosiderin-laden macrophages.” He was placed on a six-week course of IV vancomycin and rifampin, which was changed to ceftriaxone to better cover Propionibacterium after the culture results were final at 3 weeks.
His culture results were as follows:
Glenoid Membrane No. 1: 2+ Propionibacterium
Glenoid Membrane No. 2: 1+ Propionibacterium
Fluid Right Glenoid: 1+ Propionibacterium
Humeral Membrane No.1: 1 colony Propionibacterium
Humeral Membrane No. 2: 1+ Propionibacterium
Humeral Membrane No. 3 One colony Propionibacterium
He remained on oral Augmentin for a year.
Today six years after his most recent revision he plays tennis (tossing the ball with his right hand serving with his left), skis gentle slopes, and runs for fitness. His Simple Shoulder Test responses are 8/12:
1: Is your shoulder comfortable with your arm at rest by your side?: Yes
2: Does your shoulder allow you to sleep comfortably?: Yes
3: Can you reach the small of your back to tuck in your shirt with your hand?: Yes
4: Can you place your hand behind your head with the elbow straight out to the side?: Yes
5: Can you place a coin on a shelf at the level of your shoulder without bending your elbow?: Yes Yes
6: Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow?: Yes
7: Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow?: No
8: Can you carry twenty pounds at your side with this extremity?: Yes
9: Do you think you can toss a softball under-hand twenty yards with this extremity?: No
10: Do you think you can toss a softball over-hand twenty yards with this extremity?: No
11: Can you wash the back of your opposite shoulder with this extremity?: No
12: Would your shoulder allow you to work full-time at your regular job?: Yes
His x-rays today continue to show stable component fixation.
Comment: This case reveals the challenges of severe capsulorrhaphy arthropathy with posterior instability as well as the substantially delayed insidious presentation of osteolysis associated with Propionibacterium.
lunes, 7 de julio de 2014
Posterior Approach - Spinal Accessory to Suprascapular Nerve Transfer - Standard
Publicado el 3/7/2014
Posterior Approach - Spinal Accessory to Suprascapular Nerve Transfer
Standard Edition (130422.120309)
Reconstructing shoulder function following a nerve injury is a challenge due to its dynamic movement originating from several muscles. The supra/infraspinatus muscles are critical for shoulder function in that they initiate abduction of the arm, external rotation, and stabilization of the shoulder joint. In upper brachial plexus injuries, it is common to find a deficit in the suprascapular nerve associated with the axillary and musculocutaneous nerves due to their C5,6 root origins. These patients present with no shoulder function or elbow flexion. Reconstruction includes nerve transfers to innervate the axillary and suprascapular nerves for shoulder function. An available donor nerve for restoring the suprascapular nerve includes the spinal accessory nerve from a posterior or anterior approach. The posterior approach utilizes the distal branches of the accessory nerve that innervates the inferior segments of the trapezius. This video portrays that posterior approach. In this case, a 49-year-old male presented post-Schwannoma resection from the upper brachial plexus with a shoulder and elbow flexion deficit. To reconstruct shoulder function, a spinal accessory to suprascapular nerve transfer was elected with a medial triceps to axillary nerve transfer. To reconstruct elbow flexion, a double fascicular nerve transfer was elected. This video details the posterior approach to reconstructing the suprascapular nerve using the spinal accessory nerve.
Table of Contents (Standard)
00:25 Pre-operative Discussion on Anatomical Landmarks
00:54 Incision / Exposure
01:36 Developing a Superficial Plane to the Trapezius
02:34 Dissection through the Trapezius
03:05 Identifying the Fascial Plane and Fat Deep to the Trapezius
03:50 Identifying and Exposing the Spinal Accessory Nerve
05:04 Dissection through the Trapezius towards the Suprascapular Notch
05:32 Palpating the Suprascapular Notch for Orientation
06:01 Identifying and Exposing the Suprascapular Ligament
06:44 Releasing the Suprascapular Ligament
07:26 Identifying the Suprascapular Nerve
08:17 Proximal Dissection of the Suprascapular Nerve
08:40 Dividing the Suprascapular Nerve Proximally
09:16 Distal Dissection of the Spinal Accessory Nerve
11:37 Dividing the Spinal Accessory Nerve Distally
12:20 Spinal Accessory to Suprascapular Nerve Transfer
Authors: Susan E. Mackinnon, Andrew Yee
Terms of Use and Private Policy: nervesurgery.wustl.edu/pages/termsofuse.
Standard Edition (130422.120309)
Reconstructing shoulder function following a nerve injury is a challenge due to its dynamic movement originating from several muscles. The supra/infraspinatus muscles are critical for shoulder function in that they initiate abduction of the arm, external rotation, and stabilization of the shoulder joint. In upper brachial plexus injuries, it is common to find a deficit in the suprascapular nerve associated with the axillary and musculocutaneous nerves due to their C5,6 root origins. These patients present with no shoulder function or elbow flexion. Reconstruction includes nerve transfers to innervate the axillary and suprascapular nerves for shoulder function. An available donor nerve for restoring the suprascapular nerve includes the spinal accessory nerve from a posterior or anterior approach. The posterior approach utilizes the distal branches of the accessory nerve that innervates the inferior segments of the trapezius. This video portrays that posterior approach. In this case, a 49-year-old male presented post-Schwannoma resection from the upper brachial plexus with a shoulder and elbow flexion deficit. To reconstruct shoulder function, a spinal accessory to suprascapular nerve transfer was elected with a medial triceps to axillary nerve transfer. To reconstruct elbow flexion, a double fascicular nerve transfer was elected. This video details the posterior approach to reconstructing the suprascapular nerve using the spinal accessory nerve.
Table of Contents (Standard)
00:25 Pre-operative Discussion on Anatomical Landmarks
00:54 Incision / Exposure
01:36 Developing a Superficial Plane to the Trapezius
02:34 Dissection through the Trapezius
03:05 Identifying the Fascial Plane and Fat Deep to the Trapezius
03:50 Identifying and Exposing the Spinal Accessory Nerve
05:04 Dissection through the Trapezius towards the Suprascapular Notch
05:32 Palpating the Suprascapular Notch for Orientation
06:01 Identifying and Exposing the Suprascapular Ligament
06:44 Releasing the Suprascapular Ligament
07:26 Identifying the Suprascapular Nerve
08:17 Proximal Dissection of the Suprascapular Nerve
08:40 Dividing the Suprascapular Nerve Proximally
09:16 Distal Dissection of the Spinal Accessory Nerve
11:37 Dividing the Spinal Accessory Nerve Distally
12:20 Spinal Accessory to Suprascapular Nerve Transfer
Authors: Susan E. Mackinnon, Andrew Yee
Terms of Use and Private Policy: nervesurgery.wustl.edu/pages/termsofuse.
viernes, 4 de julio de 2014
Ream and run with RIP and eccentric head for a B1 glenoid recognized on a standardized axillary view
http://shoulderarthritis.blogspot.mx/2014/07/ream-and-run-with-rip-and-eccentric.html
Ream and run with RIP and eccentric head for a B1 glenoid recognized on a standardized axillary view
The arthritis shown on this anteroposterior x-ray doesn't look that bad, but the patient reported that he could perform only 2 of the 12 functions of the Simple Shoulder Test.
However, the axillary view (or 'truth view') shows the glenoid retroversion and the large amount of posterior subluxation of the humeral head on the glenoid a B1 anatomy.
At surgery today we found the humeral head and the posterior glenoid were denuded of cartilage. We performed a ream and run with a 52+2 glenoid reamer, a 52 21 anteriorly eccentric humeral head and a rotator interval plication. Here are the postoperative films.
Note the centering of the humeral head in the new glenoid concavity and that there was not a substantial change in glenoid version.
Comment: This option for managing the arthritic triad eliminates the risk of wear or loosening of a plastic glenoid component or failure of a posterior bone graft.
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