Dr. Sanchez-Sotelo reviews his techniques for gaining exposure of the glenoid for shoulder arthroplasty surgery by sharing details from skin-incision, to capsular release, to retractors.
Thank you very much to above George and J. For the invitation to participate in this meeting. Fantastic. First year of a meeting. My talk is going to overlap a fair amount with the ones that you are listen before because the title is pretty much the same. And it's about my top five in red. In my top 10 steps to get exposure for generate enough to make sure that passes. I think the mindset when you go to the operating room is trying to get this idea of having the patient and show you the Glenwood, which is particularly difficult in the cases that we discussed before the veto Glenroy. So the question that we get asked many times in meetings is how do you get to the plenary And for me, these are my top 10 steps that I think help you get into the plenary number one. I think it helps to get a more lateral skin incision. I see oftentimes as conditionalities over the delta pectoral interval. And because the glen oid is actually more postural lateral, if you cheat your skin incision more laterally you will have a better access was you do more and more angioplasties, especially for people that are less experienced. I think it will help you secondly, if you want to get to the ground that you cannot think about. M. S. Surgery is really a long multilateral approach from the clavicle to the human will shaft, get the delta it out of the way. I would do the pack. Major Religion only selectively. It's very important to release completely the inferior capsule and available human cat remove all the osteo fights and part of the metamorphosis and then have the adequate set of retractors and use either an arm holding um understand. And in some cases you can do policies but in my practice that is actually rare. So you can see my skin initiation is actually pretty lateral is actually 2cm lateral to the tip of the carotenoid. And the first thing I'm gonna do is I'm gonna release on pretty large pasta. Oh um sorry. Andrew superior flap to find the median age of the deltoid. And as soon as you identify the Corre Coid, I think it's very useful to place a Hohmann retractor over the coral coid that's going to level out both the skin flap and the deltoid. It's also important to find these deeper vessels that are the transfers arch of the truck, cranial artery and vein because this typically are otherwise bleeding through the whole case. And then if you then place a home and just proximal to the inception of the delta and place them in abduction on the major stand. You have a very easy way to mobilize the delta. So we're going to basically open up the versa and use a plant derived retractor to mobilize the delta completely. It is much easier in primary oil than in cultural anthropology. And I like to use a brown retractor to get the delta completely out of the way. Next we will do a selective release of affect major only in very muscular patients Address the Biceps Tendon doing that anatomy and 10 of disease and then find out the space between the condo intendant and the surface capillaries. Make sure that you're safe in terms of the location of the nerve. My preferred our throttle me is eight anatomy so I will find the superior aspect of the superstar apparatus in the soft spot and then divide the tendon approximately 1.5 images medial to the most medial edge of the hospital roof and then target together with the capsule with a couple of switchers. Once you go through the tendon was part of the super scapula trees, then you can do the muscular portion. And then I start to aim more laterally to basically detach the capsule just proximal to the location of the latest mortars. And I'd like to preserve Leticia mortars if at all possible. Once you get to this step, the key is to release all that capsule. And to do that. What's best is to have your assistant get the elbow to the ceiling of the operating room. So you're doing that very large inferior cultural release. If your assistant is moving the elbow up, that's going to place the shoulder into flexion and a standard rotation and then you can release easily passed. This is a club position. And that's important because now you have created a major astronomy which will allow you to translate the humans post clearly when you try to get to the generator, it's also important to in my opinion, get Kolkata as low as possible. And even though many surgeons talk about doing your cut flush with the super committee to stand and I actually like to make it with the investment to stand on and I'm a huge fan of intermediary guys because I think that you get the access of your human rights, it is always possible to get a very accurate cut in every single patient regardless of deformity and what you want to do is use some type of instrument. In my case, I use a C guide to make sure that the exit point of your subject is going to be just at the junction between the particular college and the interest you need to stand on so you can see how in this animation looks a little high. So we're gonna drop down the cutting guide and then we're gonna cut the human head. And by doing it this way you do the cut only once and you get it right all the time. First set your version because an angle cat will potentially violate the posterior capsule auditor calf if you're off by a few degrees and then ensure that the exit point of you're so it's going to be exactly the junction between the human head and the posterior superior auditor calf. I typically do an incomplete cat with the I am guided still in place because that gives you more stability of your cutting guide and then remove the whole um cutting guide. Combined with the um um under direct vision you can guarantee that the economy will not violate the posterior superior of the calf. And in doing so you have the lowest possible human cut. But that is not enough. Once the broaches inside the canal and you have the proximal humerus bones that protect it is important to remove a fair amount of bone immediately. And this is what dr cornfield armento used to call trim the metaphysics. So it's not only removed the also face go a little bit beyond that because as the humans gets narrowed that will make it easier for you to get access to the Glenwood. Next already are going to come out. And my favorite actor is a modified Fukuda retractor that has a larger ring and a pretty large liver arm. As you can see how if you place this retractor posturing inferior early and with your assistant it can translate the humans completely out of the way with minimal excursion. Then we face a common posture to the base of the car occupied. Um And this is important to gain the standard rotation. You have to release the anterior capsule and I agree with dR below that in my opinion, excising the capsule is not a good idea because you will potentially compromise your future holding power of the sword vocabulary so that we will do the release is first starting superior early in the interval region. And we're going to release both the caracal human ligament which is more anterior superficial and the superior human ligament. That's our first capsule artemis. Then we're gonna separate the anterior capsule from the inferior capsule. So you can see how it's very easy to find that plane. Like a presumption showed in her video and then you can divide that all the way to the rim of Illinois and then basically connect those two capsule. Autumn ease the superior one and the inferior one. So that now there is a rectangle of capsule that is still with the super vocabularies. But because you have disconnected from the rest of the capsule it doesn't restrict your exposure and excursion. And then once you're in that position you can place a retractor and remove the labor room completely to have a perfect view of the face of the planet. And at that point I think it's important to stop and look at your planning. You can do either two D. Planning or three D. Playing whatever you prefer. But it's important to realize that in many patients, even if there is no eccentricity. If there are osteo fights they can give you a false sense of the relationship with the face of exonerate and exonerate vault. So once I am in that situation I typically look at the cities. Can look at my planning and then it will mark the axis of the, collaborate with electro quality and then see if the face of the planet is in line with the elaborate vault. And based on that, proceed with the surgery so to summarize in order to get the best possible exposure. My top 10 tips and tricks are a more lateral skin initiation through long delta. To approach from the clavicle to the human shaft mobilized. The deltoid selective release. The pectoral is major. Do a very large human based infrastructure release the lowest possible human cat with ability in the calf, remove all user fights and even more. Some of the metaphysics use the echo detractors and use the major stand. Thank you very much, mm hmm.
