ZIMMER®

BIGLIANI/FLATOW®

THE COMPLETESHOULDERSOLUTION

TotalShoulderArthroplastySurgicalTechnique

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CONTENTSBIGLIANI/FLATOW®

THE COMPLETESHOULDER SOLUTIONSURGICAL TECHNIQUE

Instruments and surgical technique

developed in conjunction with:

Louis Bigliani, M.D.

Chairman, Department of Orthopaedics

Director, The Shoulder Service

New York Presbyterian Hospital

Columbia-Presbyterian Center

New York, New York

Evan Flatow, M.D.

Chief of Shoulder Surgery

Mount Sinai Medical Center

New York, New York

SURGICAL TECHNIQUE FOR BIGLIANI/FLATOWSHOULDER SYSTEM

Patient Positioning ......................................................... 2

Incision and Exposure ................................................... 2

Humeral Preparation ...................................................... 3

Glenoid Preparation ....................................................... 9

Humeral Head Selection .............................................. 15

Expanded Glenoid Options .......................................... 16

Implantation ................................................................. 18

Humeral Head Removal ............................................... 25

Closure .......................................................................... 25

Postoperative Management ......................................... 25

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expose the deltoid and pectoralis major muscles.Retract the skin by placing Gelpi retractors about one-third of the way down, and one-third of the way up.Develop the deltopectoral interval, retracting thepectoralis major medially and the deltoid laterally.Identify and dissect the interval between the pectoralismajor muscle and the cephalic vein. Retract the ceph-alic vein either medially or, preferably, laterally as thiswill minimize bleeding from the deltoid muscle orcephalic vein. Release the upper 1cm-2cm of theinsertion of the pectoralis major tendon, being carefulto avoid the long head of the biceps tendon. In verytight shoulders, the pectoralis may need to be com-pletely released. Tag the pectoralis major muscle witha suture so it can be easily identified for later reattach-ment. Reposition the distal medial retractor under thepectoralis major muscle.

Release any adhesions between the deltoid and strapmuscles (coracobrachialis and short head of biceps)and develop a plane between the strap muscles andthe humerus. Reposition the proximal medial retractorunder the strap muscles (Fig. 3).

Sweep the bursa off the humeral head and the greatertuberosity. Then expose the superior portion of thesubacromial space by resecting the leading edge ofthe coracoacromial ligament. Identify the superior andinferior margins of the subscapularis tendon. Dividethe tendon just medial to the bicipital groove andremove it from the lesser tuberosity. Being carefulinferiorly to avoid the axillary nerve, retract the sub-scapularis medially, exposing the articular surface ofthe humeral head.

PATIENT POSITIONINGPatient positioning is especially important in totalshoulder surgery (Fig. 1). Place the patient in a semi-beach-chair position. Use a head rest that allows forthe superior part of the table to be removed. Place twotowels under the spine and the medial border of thescapula to raise the affected side. Raise the head ofthe table approximately 25-30 degrees to reducevenous pressure. Attach a short arm board to thetable, or use another arm support method that willallow the arm to be raised or lowered as necessarythroughout the procedure.

INCISION AND EXPOSUREFirst, mark the coracoid process. Then mark the lineof the incision, beginning at the clavicle just lateral tothe coracoid process. Extend the line along the del-topectoral groove to the area of the mid-humerus (Fig.2). Then make the incision following the line. Under-mine the skin flaps to improve exposure. Dissectsubcutaneous tissue from the deltoid fascia, and

Fig. 1

Fig. 2

Fig. 3

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It is very important to maintain as much length of thesubscapularis muscle as possible. Remove the cap-sule and subscapularis tendon as a unit laterally fromthe humerus. Do this as close as possible to the hu-meral neck to avoid injury to the axillary nerve. Exter-nal rotation of the humerus is helpful. In cases wherethere is a large inferior osteophyte on the humeralhead, it is especially important to dissect the capsuleoff the neck of the humerus laterally as the axillarynerve is on the medial and inferior aspect of the os-teophyte. Medially, at the glenoid rim, the capsule andlabrum can be separated from the subscapularistendon. This will facilitate lateral mobilization.

HUMERAL PREPARATIONThe goal in replacing the humeral head is to place aprosthetic articular surface precisely on the proximalhumerus as it would have been before the destructivearthritic process began. The relationship among bonyanatomy, rotator cuff insertions, and soft tissue ten-sion must all be considered.

Technique Tip: To facilitate access to the humeral canal,the shoulder should be off the table. To accomplish this,push the elbow back and externally rotate the arm.

Fig. 4

Short Reamer

RatchetingT-Handle

REAM HUMERAL CANALDislocate the humeral head by externally rotating andextending the humerus. If necessary, place a metalfinger inferiorly between the humerus and the glenoid.Removal of capsule from the inferior aspect of thehumeral neck may be needed to achieve dislocation.Before reaming the canal, it is important to remove allanterior or inferior osteophytes so that the true ana-tomical neck (junction of the articular cartilage andcortical bone) can be determined.

Attach a Short Intramedullary Reamer with a trocarpoint to the Ratchet T-handle. There are three posi-tions marked on the collar of the T-handle: FORWARD,LOCKED, and REVERSE. To ream the starter hole, usethe FORWARD position. Short Intramedullary Reamersare available in diameters of 6mm, 7mm, and 8mm,and the appropriate size should be chosen for thepatient’s humeral canal. Place the trocar tip of thereamer just posterior to the bicipital groove (Fig. 4)and ream a starter hole. A mallet may be used to startthe hole in hard bone.

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Attach the T-handle to the longer, blunt-tipped In-tramedullary Tapered Reamer of the same diameterand begin manually reaming the humeral canal. Useprogressively larger reamers in 1mm increments untilresistance is felt from cortical contact in the canal(Fig. 5). Continue reaming to the appropriate depth asindicated on the reamer shaft. The depth correspondsto the implant length chosen. Do not remove corticalbone. These reamers have blunt tips to help guidethem down the canal and prevent obtrusion intocortical bone. Remove the T-handle, but leave the lastreamer in the canal to interface with the HumeralHead Cutting Guide (Fig. 6).

Fig. 5

Fig. 6

Note: If using a 60mm length stem, use only theShort Intramedullary Reamers. Use theIntramedullary Tapered Reamers for 110mmmonoblock stems. Ream until the flutes areburied in the bone.

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Fig. 9

Fig. 8

Fig. 7

until the point is approximately in line with the bicipi-tal groove (Fig. 8). Then tighten the first thumb screw,which is located on the end of the boom. Advance theboom stem and cutting block along the boom until theblock contacts the bone (Fig. 9). Tighten the secondthumb screw, which is located at the junction of theboom and boom stem.

Boom Sleeve

Cutting Block

Boom Stem

Boom

Sleeve

Bicipital Groove

RESECT HUMERAL HEADAssemble the Humeral Head Cutting Guide for either aright or left configuration. (See “How to Assemble theHumeral Head Cutting Guide” on next page.) Slide theboom sleeve over the reamer shaft (Fig. 7). Adjust thedepth of cut by moving the sleeve up or down on thereamer shaft. Rotate the sleeve on the reamer shaft

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To gauge the retroversion of the cut, insert AlignmentPins into the holes marked 20 degrees and 40 degreeson either the cutting block or boom sleeve (Fig. 10a).Then line up the pins with the forearm to assess theretroversion (Fig. 10b). Retroversion can be adjustedby loosening both thumb screws and rotating thecutting guide about the axis of the IntramedullaryReamer. The forearm should be between the 20 de-gree and 40 degree pins (Fig. 10c). Then retighten thethumb screws, being sure that the cutting block isagain touching the bone (Fig. 10d).

HOW TO ASSEMBLE THE

HUMERAL HEAD CUTTING GUIDE

Step A

Step B

Step C

Step D

Step E

Step F

Fig. 10b

AlignmentPins

Alignment Pins usedwith sleeve.

Alignment Pins used withCutting Block.

Fig. 10a

Align the groove on theboom stem with thegroove on the cuttingblock. Push the compo-nents together until theysnap into place (Step A).

With the thumb screw atthe end of the boompointed toward you, ob-serve the various “R” or“L” etchings that indicatea right or left configura-tion. All the etchings thatare facing you nowshould be the same, ei-ther “R” or “L” (Step B).

To change the right/leftorientation, remove thethumb screw at the end ofthe boom (Step C). Thenloosen the second thumbscrew on the box at thetop of the boom stem.Slide the boom stem offthe end of the boom. Ro-tate the sleeve towardyou, top to bottom, andreinsert it from the oppo-site side into the box atthe top of the boom stem(Step D). Retighten thethumb screw on the boxat the top of the boomstem. Then reinsert andtighten the thumb screwat the end of the boom(Step E). Finally, verifythat all the appropriateright or left etch marksare visible when theboom thumb screw is fac-ing you (Step F).

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Make sure the Cutting Blocktouches the bone.

Insert the Humeral Head Cutting Guide Fingers intothe cutting slots to visualize the path of the saw bladethrough the bone (Fig. 11). If necessary, loosen thethumb screw at the end of the boom, and move thesleeve up or down to adjust the depth of cut. In somecases, the shoulder capsule may be too tight to ac-commodate the fingers.

Partially insert a Cutting Guide Pin (5977-56-01)through one of the lateral holes in the cutting block.Fully insert a second pin through one of the medialholes (Fig. 12). If the cortex is very hard, predrill theseholes using a drill with a diameter between 2.0mmand 2.7mm.

Loosen both thumb screws on the guide and removethe boom, leaving the cutting block in place. Set the T-handle to the REVERSE position. Attach the T-handleto the reamer and remove the reamer from the humer-al canal. Then finish impacting the first pin.

Before making the cut, remove the Alignment Pins. Itis important to make the cut along the articular sur-face as this will ensure the correct retroversion on themajority of cases. Care must be taken to avoid cuttinginto the rotator cuff posteriorly. Use an oscillating sawto resect the humeral head (Fig. 13). Then remove thecutting block.

Fig. 11

Fig. 12

Fig. 13

Humeral HeadCutting GuideFingers

Cutting Guide Pin

Cutting GuidePin Puller

20 degree and 40 degree holesare used to check retroversion.

Fig. 10c

Fig. 10d

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STEM PROVISIONAL INSERTIONUse the Wrench handle through one of the holes totighten the white plastic cap on the Humeral StemInserter/Extractor. Attach the appropriate HumeralStem Provisional to the inserter/extractor. (The Hu-meral Stem Provisional is typically the same size asthe largest reamer used.) There are also 20-degreeand 40-degree holes on the inserter/extractor to allowfor verification of the stem retroversion using theAlignment Pins (Fig. 14).

Technique Tip: To facilitate access to the humeral canal,the shoulder should be off the table. To accomplish this,push the elbow back and externally rotate the arm.

Remove the Alignment Pins before impacting theHumeral Stem Provisional. Insert and impact theHumeral Stem Provisional into the humeral canal until

Fig. 14

20-degree and 40-degreeholes on the HumeralInserter/Extractor areanother way to assessretroversion.

Attach Stem Provisionalto the Humeral Inserter/Extractor.

Fig. 15

Collar is Flush withthe cut.

the collar is flush with the cut surface (Fig. 15). Thefins on the Humeral Stem Provisional are self-cuttingto prepare a path for the fins on the stem implant. Thisshould place the humeral component in the correctdegree of retroversion for that patient.

If the anatomy places the collar of the Humeral StemProvisional eccentrically, the humeral head will over-hang the bony margins on one side and place asym-metric tension on the rotator cuff. This may suggestthe use of an offset head for more complete bonecoverage. Ideal placement of the humeral head will beachieved when the head is centered relative to therotator cuff (Fig. 16). The margin of the humeral head

Fig. 16

Alignment Pins

StemProvisional

Tighten Holes withPin Wrench

Mallet

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should rest immediately adjacent to the rotator cuffinsertion superiorly on the greater tuberosity, andslightly overhang the calcar medially.

If the humeral component is placed too low, the great-er tuberosity will be relatively prominent and impingeunder the acromion. This condition can limit the rangeof motion. In addition, the resulting vector forces willdrive the humeral head down against the inferior marginof the glenoid and can contribute to rocking and possi-ble loosening. Therefore, it is important to always checkthat the superior aspect of the humeral head is abovethe superior aspect of the greater tuberosity.

If the humeral component is placed too high, the su-praspinatus muscle will be under too much tensionaround the prominent lateral margin of the humeralhead. In addition, the uncovered calcar can abut underthe inferior margin of the glenoid component and canlead to glenoid rocking and possible loosening.

It is important to keep in mind the very precise rela-tionship of the glenoid articular surface to the tuber-osities and rotator cuff insertions so that contractureof the rotator cuff muscles and capsule do not eccen-trically load the glenoid. The relationship of this entirecomplex to the acromion is also critical. The subacro-mial space should just accommodate the functionalrotator cuff and tuberosities.

Use a curette to remove any bone from the center holeof the Humeral Stem Provisional. This will allow forlater placement of the Humeral Head Provisional (Fig.17). Leave the Humeral Stem Provisional in place tohelp minimize bleeding and protect soft tissue duringthe glenoid preparation.

For a hemiarthroplasty, advance to page 15.

GLENOID PREPARATIONPrecise placement of the glenoid component* is moretechnically demanding than placement of the humeralcomponent. Before implanting the glenoid compo-nent, it is essential to thoroughly evaluate the bonyarchitecture of the glenoid vault. Therefore, it is im-portant to have an axillary radiograph of the glenoidto assess for anterior or posterior wear. If a glenoidradiograph is not possible, a CT or MRI should beobtained. It is important to identify the center of theglenoid vault. To accomplish this, retract the softtissues both anteriorly and posteriorly to expose theglenoid. A Fukuda Retractor, or a bent glenoid retrac-tor should be placed posteriorly. This will subluxatethe humerus posteriorly and inferiorly. A special point-ed Darrach-type Retractor should be placed anteriorly.Strip the capsule from the articular margin of theglenoid. Then place a finger along the anterior glenoidneck to palpate the anteversion of the glenoid face. Inmost tight shoulders, it may be necessary to releasethe capsule along the inferior margin of the glenoid,taking care to avoid injury to the axillary nerve. Releaseof the posterior capsule, which is often already stretchedout from chronic posterior humeral subluxation, is notroutinely performed to avoid posterior prosthetic insta-bility. In rare cases of extremely tight shoulders someposterior release may be helpful, but this must be indi-vidualized and performed with caution.

Osteophytes may disguise the center of the glenoidvault. The surgeon may choose to trim any marginalosteophytes so the glenoid vault can be clearly de-fined. Sometimes, osteophytes are more pronouncedon one side of the glenoid surface than on the other.In such cases, the center of the articular surface,including osteophytes, is not the center of the glenoidvault. It is not necessary to remove all the osteophytesto establish the true center of the glenoid vault; how-ever, if any osteophytes are removed, they should beremoved carefully. In particular, removal of posteriorosteophytes should be done with caution as the cap-sular attachments may be more proximal resulting ininstability. After removing osteophytes, the center ofthe humerus can then be centered over the glenoidand the soft tissues balanced.

An inadequate or deformed glenoid vault can create anumber of technical problems when implanting aglenoid component. Several bone grafting techniquescan be used to enhance the bone stock of an inade-quate glenoid vault; however, these procedures arevery difficult and each one is unique. If a glenoidreplacement is not possible, it is recommended that ahemiarthroplasty be used instead of a total shoulderreplacement.

Fig. 17

*U.S. Patent 5,928,285

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GLENOID SIZINGUse the Glenoid Scraper and Glenoid Planer to removeany remaining cartilage and soft tissue from the gle-noid (Fig. 18a). Then use the Glenoid Centering Guidesto determine if the glenoid size (black=40mm,white=46mm, and blue=52mm) will fit well on theglenoid face. The outer dimensions of the guide matchthe articular profile of the glenoid implant.

Fig. 18b

Fig. 19

Centering Hole

Fig. 20

Glenoid Circular Reamer

GlenoidCenteringGuide

Straight Driver

GlenoidCircularReamer Straight

Driver

Glenoid Scraper

Fig. 18a

DRILL CENTERING HOLEWhen the glenoid size has been selected, apply theappropriately sized Glenoid Centering Guide over theglenoid (Fig. 18b). Glenoid instruments are colorcoded by glenoid size (black=40mm, white=46mm,and blue=52mm). If there is greatly increased glenoidretroversion noted on preoperative radiographs or CTscans, a burr may be used to lower the front of theglenoid slightly. Then use the Glenoid Planer tosmooth the area. This will help to avoid perforatingthe anterior glenoid wall when drilling perpendicularto a retroverted glenoid face. Then apply the appropri-ate Glenoid Centering Guide. Attach the Glenoid Drillwith Stop to the Straight or Angled Driver. TheStraight Driver is useful when the glenoid is fullyexposed. With limited glenoid exposure, the AngledDriver is recommended. Using power, drill a centeringhole through the subchondral bone of the articularsurface (Fig. 19).

REAMAttach the Angled Driver or Straight Driver to theRatchet T-handle. Then attach the appropriate GlenoidCircular Reamer to driver. Insert the nose of the ream-er into the centering hole, and ream the glenoid (Fig.20). To help minimize soft tissue damage, do not usepower for reaming. Glenoid reaming is performed toachieve intimate contact between the bone and thespherical undersurface of the glenoid implant.

Reaming may also be performed to compensate forposterior glenoid wear by reaming slightly more ante-riorly. In this case, a shallow centering hole is drilledinitially, and used to seat the reamer. After reaming,the centering hole may be redrilled to the full depthallowed by the Glenoid Centering Guide.

Overreaming will reduce the depth of the glenoid vaultand should be avoided. It is important not to removetoo much subcortical bone as this may affect glenoidstability.

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FOR KEELED GLENOID COMPONENT

CREATE SLOTApply the appropriate size Keeled Glenoid Drill Guideby inserting the tip into the centering hole (Fig. 21).Use the Glenoid Drill with Stop to drill the secondhole. An Antirotation Pin or additional Glenoid Drillwith Stop may be used to maintain alignment of theguide while the third hole is drilled (Fig. 22). Removethe Keeled Glenoid Drill Guide and apply the appropri-ate size Keeled Glenoid Slot Guide to the articular

Fig. 21

Keeled GlenoidDrill Guide

Fig. 22

Use the Antirotation Pinto maintain alignment.

surface (Fig. 23). Use a 5mm high-speed burr to createa vertical slot in the subchondral bone of the articularsurface (Fig. 24). Palpate the glenoid vault with theindex finger to determine its limits. Then underminethe subchondral bone adjacent to the slot. Use acurette rather than a burr to deepen the slot to theapex of the vault because it is much less likely topenetrate the anterior or posterior cortical wall. Donot attempt to remove the remaining cancellous bonein the vault.

Fig. 23

Fig. 24

Keeled GlenoidSlot Guide

Fig. 25Keeled Glenoid Sizer/Pressurizer

Keeled GlenoidSizer/Pressurizer

Use a Keeled Glenoid Sizer/Pressurizer to impact theremaining bone in the slot (Fig. 25). This will helpensure an appropriate internal depth and diameter toaccept the keel of the glenoid component. This stepshould be implemented with caution if the bone is softor deficient.

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KEELED GLENOID COMPONENT CONT’D.

If additional glenoid reaming is necessary to improvethe glenoid fit or adjust anteversion, attach the appro-priate Glenoid Circular Reamer with Keel Locator toeither the Angled Driver or Straight Driver. Insert thekeel locator into the slot, and use the T-handle toream the glenoid (Fig. 26).

Fig. 26

Glenoid Circular Reamer withKeel Locator

Glenoid CircularReamer

GlenoidInserter

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Fig. 27

Pegged GlenoidDrill Guide

Fig. 28

Antirotation Pin

FOR PEGGED GLENOID COMPONENT

CREATE PEG HOLESApply the appropriate size gold Pegged Glenoid DrillGuide to the articular surface by inserting the tip intothe centering hole (Fig. 27). Use the Glenoid Drill withStop to drill the second hole. An Antirotation Pin oradditional Glenoid Drill with Stop may be used tomaintain alignment of the guide while the third hole isdrilled (Fig. 28). Use the Pegged Glenoid Sizer/Pres-surizer and mallet to impact the remaining bone in theholes (Fig. 29). If additional glenoid reaming is neces-sary, insert the Glenoid Circular Reamer into thecentral hole and manually ream. Additional reamingmay lower the articular surface and necessitate re-drilling of the peg holes.

Fig. 29

Pegged Glenoid Sizer/Pressurizer

Pegged GlenoidSizer/Pressurizer

Glenoid Circular Reamer

GlenoidInserter

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GLENOID TRIAL FITInsert the appropriate size Pegged or Keeled GlenoidProvisional. These are solid colored provisional com-ponents. The undersurface of the component shouldseat flush with the articular surface of the bone. Donot trim the pegs or keel of a glenoid component tocompensate for an inadequate glenoid vault thatcannot accommodate full-size pegs or keel. This cancompromise fixation and lead to premature loosening.If the fit of the glenoid component is not appropriate,it may be necessary to reassess reaming and the depthof the peg holes or keel slot.

Position the glenoid component for optimal bonysupport (Fig. 30). The base of the glenoid componentshould not overhang the perimeter of the glenoid.Loosening or excessive wear may occur if the glenoidcomponent lacks sufficient bony support.

Fig. 30

GlenoidProvisional

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Fig. 31

HUMERAL HEAD SELECTIONChoose a Humeral Head Provisional that best coversthe prepared surface of the proximal humerus and fillsthe rotator cuff circumferentially. Standard or offsetheads are available. Insert a metallic Capture Pin intothe Humeral Head Provisional (Fig. 31). The resectedhumeral head can be used as an initial reference forchoosing the humeral head size.

Place the Humeral Head Provisional on the HumeralStem Provisional to the point where the head is at thelevel of the supraspinatus insertion. The humeral headmust at least reach or slightly overhang the calcarmedially (Fig. 32). If using an offset head, rotate thehead into the proper anatomical position and markthe position on the bone at the etched line labeled“MAX” (Fig. 33), or use the lateral fin as a point ofreference (Fig.34).

Offset HeadProvisional

Capture Pin

Fig. 32

Fig. 33

Fig. 34

OffsetProvisionalHead

Standard HeadProvisional

Capture Pin

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EXPANDED GLENOID OPTIONSAs detailed elsewhere in this technique, glenoid andhumeral preparation are accomplished separately.Therefore, there may be times when the preparedarticular surface of the glenoid does not match thearticular surface of the desired humeral head. Whenthis occurs, the bi-colored provisionals must be used.This is necessary to match the articular surfaces of theselected components.

The color of the center bar (Fig. 35 ) of the GlenoidProvisional must always match the color of the Hu-meral Head Provisional. The following chart illustratesthe range of glenoid sizes.

Fig. 35

Peripheral color corresponds to prepared glenoid size. Center bar color, of bi-colored provisional, corresponds to humeral head size.

40mm 46mm 52mm 56mm

BLACK

WHITE

BLUE

INS

TR

UM

EN

TAT

ION

CO

LO

RS

GLENOID IMPLANTS/PROVISIONALS SIZING CHART

HUMERAL HEAD SIZES

BK/40 BK/46

WH/40 WH/46 WH/52

BL/46 BL/52 BL/564301-95-50

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For example, if white (46mm) instrumentation wasused to size/prepare the glenoid, either a black(40mm), white (46mm) or blue (52mm) Humeral Headmay be used. If a blue Humeral Head is selected (Fig.36), remove the white WH46 Glenoid Provisional (Fig.37) and replace it with the WH52 white with bluecenter bar Glenoid Provisional (Fig. 38).

The solid color glenoid provisional should be replacedwith the appropriate bi-colored provisional for jointreduction and trial range of motion. Then remove theProvisional Head, but leave the Stem Provisional in placeto help decrease bleeding while cementing the glenoidcomponent.

Fig. 37

Fig. 38

GlenoidProvisional

OffsetProvisionalHead

Bi-coloredGlenoidProvisional

Fig. 36

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Keel Sponge

Fig. 39b

Keeled Pegged

Fig. 39a

Keeled GlenoidSizer/Pressurizer

IMPLANTATION

GLENOID COMPONENTRemove the Glenoid Provisional and use pulsatilelavage, such as the Pulsavac® Wound DebridementSystem, to irrigate the glenoid vault. Coagulate anyactive bleeding, and dry the glenoid vault. If implant-ing a keeled glenoid component, insert a thrombin-soaked Keel Sponge to dry the vault (Fig. 39a).

Remove the Keel Sponge. Introduce cement into thekeel slot or peg holes using a 60cc syringe, beingcareful that no cement is applied to the articularsurface of the glenoid bone. Cement should be intro-duced early in the working time to facilitate pressur-ization into the cancellous bone bed. Then attach aPressurizer Sponge to the appropriate Glenoid Sizer/Pressurizer (Fig. 39b) and pressurize the cement.When the Glenoid Sizer/Pressurizer is removed, someof the cement may adhere to the instrument and thesponge; however, most of the cement remains in theglenoid having been pressurized into the cancellousbone. Apply additional cement and repressurize.Finally, apply more cement before inserting the gle-noid component. If desired, you may apply cement tothe keel or pegs. Do not apply cement to the under-side of the glenoid component.

Pegged GlenoidSizer/Pressurizer

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Prior to opening the glenoid implant, confirm that thecomponenet matches the glenoid provisional used inthe trial reduction. Use the Glenoid Inserter to insertthe component (Fig. 40). Then use the Glenoid Pusherto impact the component until there is completecontact with the perimeter of the glenoid (Fig. 41).Maintain pressure on the glenoid with the pusher orthumb until the cement has hardened. Be sure that thepressure remains centralized within the glenoid sothat eccentric pressure is not applied during cementhardening. Remove excess cement with care.

Fig. 40

Fig. 41

Glenoid Inserter

Glenoid Pusher

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of the proximal humerus. The counterbore depth ofcut is limited, and the Stem Collar Counterbore willbottom out (Fig. 42d). When removing the counter-bore, do not pull up in line with the shaft of the driver.Instead, pull up in line with the axis of the humeralshaft.

Attach the Humeral Stem Provisional to the HumeralInserter/Extractor and reinsert the provisional toensure that the collar is completely countersunk (Fig.43). Snap on the appropriate size Humeral Head Provi-sional. Then reduce the joint and check the fit on boththe superficial and deep surfaces. Choose a humeralhead so that, when in position, applied pressure willsublux the head about 50 percent of its diameterposteriorly and inferiorly, falling back into place whenthe pressure is released. A head that does not fill thecapsule will dislocate over the glenoid rim, and onethat overstuffs the joint will not allow this “50-50”laxity assessment. Pull the subscapularis muscle overthe joint. If the fit is too tight, release the tendon asnecessary. Often, releasing the subscapularis from theanterior labrum and capsule will provide sufficientmobilization to the neck of the humerus. Remove theprovisional components and perform any necessarysoft tissue releases.

Before inserting the final humeral component, drillfour to five suture holes through the anterior neck ofthe proximal humerus. The drill holes should startsuperior just anterior to the bicipital groove and pro-ceed inferiorly to the inferior aspect of the neck just infront of the midline. Place heavy number 2 braidednylon sutures with wedged-on needles prior to ce-ment fixation. Each needle should progress from theoutside cortex to the inside so that the same needle isused to place the sutures through the subscapularistendon. By placing the subscapularis tendon more

Fig. 43

ProvisionalStem

HUMERAL COMPONENTUse the Wrench handle through one of the holes totighten the white plastic cap on the Humeral StemInserter/Extractor. Attach the inserter/extractor to theHumeral Stem Provisional and tighten the thumbscrew. Apply the Slaphammer Weight to the inserter/extractor, and remove the Humeral Stem Provisionalfrom the canal.

If countersinking of the humeral component is de-sired, assemble the Stem Collar Counterbore using theappropriate size stem extension to match the stemdiameter chosen (Fig. 42a). Attach the Straight Driverto the counterbore (Fig. 42b) and insert the stemextension of the counterbore into the humeral canal(Fig. 42c). (Do not use the Angled Driver.) Using theRatcheting T-handle, counterbore the resected surface

Fig. 42a

StemExtension

Stem CollarCounterbore

Countersink depth of cut islimited. Counterbore willbottom out.

Insert StemExtension ofcounterboreassembly into humeral canal.

Attach Straight Driver tocounterbore using the PinWrench. Note: Make sure the slots on the Straight Driver and the counterbore line up.

Fig. 42b

Fig. 42c

Fig. 42d

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Fig. 44

HumeralInserter/Extractor

medially against the neck of the humerus, the tendonis effectively lengthened because it does not have tobe placed lateral to the lesser tuberosity. After the finalhumeral head prosthesis has been securely implanted,suture the subscapularis tendon inferiorly and repair itprogressively to the superior sutures with the armplaced comfortably in 20 degrees to 30 degrees ofexternal rotation. Place heavy nylon sutures into theanterior edge of the humerus for reattachment of thesubscapularis tendon and muscle.

Cemented Technique Intraoperative AssemblyInsert canal sizers to determine the appropriate sizecement restrictor plug. Then insert a plug one centi-meter distal to the tip of the humeral stem.

Thoroughly clean and dry the canal. Inject cement intothe humeral canal. Use a finger to thoroughly pack thecement. Use the Wrench handle through one of theholes to tighten the white plastic cap on the HumeralInserter/Extractor. Attach the humeral component tothe inserter/extractor, and insert the distal tip of thecomponent into the canal (Fig. 44). Insert the two

Fig. 46

Humeral component seatedflush on the cut surface of

the humerus.

Alignment Pins into the 20-degree and 40-degreeholes of the inserter/extractor and check retroversion(Fig. 45). When properly aligned, fully insert the steminto the canal. Remove the Alignment Pins and impactthe component with a few light taps of the mallet. Besure that the collar of the component is seated flushon the cut surface of the humerus (Fig. 46).

Fig. 45

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Cemented Technique Back-table AssemblyWith the offset implant “clock face” visible, place thehumeral stem component so that the lateral fin is atthe previously determined reference point. Place theassembled components into the Impaction Stand.Apply the Humeral Head Pusher to the head andimpact it with a mallet (Fig. 49). Make sure that thehead is firmly attached.

Insert canal sizers into the humeral canal to deter-mine the appropriate size cement restrictor plug. Theninsert a plug one centimeter distal to the tip of thehumeral stem.

Fig. 49

Assembled components

ImpactionStand

HumeralHeadPusher

The humeral head may be assembled to the implantedstem only after the cement has been allowed to fullycure. Remove the Capture Pin and place the HumeralHead Provisional on the humeral stem taper andperform a trial reduction to check subscapularis ten-sion. The subscapularis, when reinserted, shouldallow for 30 to 45 degrees of external rotation, butsometimes with a chronically contracted rotator cuff,this is not possible. If the closure is too tight, a lowerprofile head may be used. Once the final head size hasbeen selected, remove the Humeral Head Provisional.

Thoroughly clean the humeral stem taper. Attach theoffset humeral head component to the Offset HumeralHead Inserter so the single prong is positioned at the“MAX” or previously marked indication (Fig. 47). Makesure protective sleeves are properly in place on theprongs of the Offset Humeral Head Inserter. Insert thefinal humeral head component so the single prong isat the mark made earlier (Fig. 48). Apply the HumeralHead Impactor to the head and impact it with a mallet.Make sure that the head is firmly attached. Thenreduce the joint and assess stability.

Fig. 47

Fig. 48

Offset HumeralHead Inserter

ProtectiveSleeves

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Fig. 50

Fig. 51

Humeral component seatedflush on the cut surface of

the humerus.

Thoroughly clean and dry the humeral canal. Injectcement into the canal. Use a finger to thoroughly packthe cement. Insert the assembled humeral componentinto the canal (Fig. 50). The final selection of stem sizeis a matter of surgeon judgement based on the pre-ferred cementing technique. Be sure that the collar ofthe component is seated flush on the cut surface of thehumerus (Fig. 51). Then reduce the joint and assessstability.

Press-fit TechniqueThe humeral stem can be press-fit and sized to thereamed diameter. Attach the humeral component tothe Humeral Stem Inserter/Extractor and insert thestem into the canal (Fig. 52). Insert the two AlignmentPins into the 20-degree and 40-degree holes of theinserter/extractor and check retroversion (Fig. 53).Impact the component with a few light taps of themallet. Be sure that the collar of the component isseated flush on the cut surface of the humerus (Fig. 54).

Fig. 52

Fig. 53

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Fig. 56a

Apply the HumeralHead Pusher to the headand impact it with a Mallet

Fig. 56b

Remove the Capture Pin and place the Humeral HeadProvisional on the humeral stem taper and perform atrial reduction to check subscapularis tension. Thesubscapularis, when reinserted, should allow for 30 to45 degrees of external rotation, but sometimes with achronically contracted rotator cuff, this is not possible.If the closure is too tight, a lower profile head may beused. Once the final head size has been selected,remove the Humeral Head Provisional.

Fig. 54

Humeral component seatedflush on the cut surface of

the humerus.

Fig. 55

Thoroughly clean the humeral stem taper. Attach theoffset humeral head component to the Offset HumeralHead Inserter so the single prong is positioned at the“MAX” or previously marked indication (Fig. 55). Insertthe final humeral head component so the single prongis at the mark made earlier (Fig. 56a). Apply the Hu-meral Head Pusher to the head and impact it with amallet (Fig. 56b). Make sure that the head is firmlyattached. Then reduce the joint and assess stability.

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Fig. 57

HeadDistractor

HUMERAL HEAD REMOVALShould a humeral head ever have to be removed, slidethe Head Distractor between the collar of the humeralstem and the undersurface of the humeral head (Fig.57). Firmly tap the end of the instrument to loosen thehead. This instrument can be used to remove eitherprovisional heads or implants.

CLOSUREIrrigate the wound and, beginning inferiorly, reattachthe subscapularis muscle to the sutures at the rim ofthe proximal humerus. Insert a Hemovac WoundDrainage Device, being careful to avoid the axillarynerve. Close the deltoid and the subcutaneous layers.Then close the skin.

POSTOPERATIVE MANAGEMENTOn the first postoperative day, the patient typicallybegins passive, assisted range of motion. This shouldinclude pendulum exercises in the erect position,assisted forward elevation exercises in the erect andsupine positions, and external rotation exercises witha stick in the supine position with the arm slightlyabducted. The patient is typically discharged at two tofour days postoperative, but should continue exercisesas an outpatient with goals of 140-degrees forwardelevation and 40-degrees external rotation within twoto three weeks. Further range of motion is progres-sively achieved with stretching exercises.

Active exercises are typically started after one to twoweeks depending on the pathology. Active internalrotation should be avoided, however, as the subscap-ularis muscle has been repaired. After six weeks,more resistant strengthening exercises should bestarted. These exercises should emphasize stretchingand balancing the range of motion. Strengthening is asecondary concern that need not be achieved untilseveral months postoperatively.

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