Arthroplasty Shoulder

Product

Procedure

The Cage-Screw Difference
<ul>
 <li>13+ years of long-term survivorship data1</li>
 <li>Proprietary cage-screw fixation provides controlled compression at the bone-prosthesis interface and reduces medial calcar osteolysis2</li>
 <li>Single instrument tray allows for streamlined three-step implantation</li>
 <li>Extensive glenoid augment options for treating simple and complex pathologies</li>
 <li>Reproducible SpeedScap™ subscapularis repair system</li>
 <li>Revision-friendly design</li>
</ul>
References
1. Habermeyer P, Lichtenberg S, Magosch P. 9–13 Year results of stemless humeral head replacement. A prospective study. JSES Open Access. 2019;3(4):234. doi:10.1016/j.jses.2019.10.013
2. Alikhah A, Imiolczyk JP, Krukenberg A, Scheibel M. Screw fixation in stemless shoulder arthroplasty for the treatment of primary osteoarthritis leads to less osteolysis when compared to impaction fixation. BMC Musculoskelet Disord. 2020;21(1):295. doi:10.1186/s12891-020-03277-3
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This animation illustrates the features and benefits of the Eclipse™ total shoulder arthroplasty system.

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Eclipse™ Total Shoulder Arthroplasty System: Features and Benefits

Michael Kissenberth, MD (Greenville, SC), demonstrates how to use the instrumentation for sizing and placing the Univers VaultLock® augmented glenoid.&nbsp;

Univers VaultLock® Augmented Glenoid Cadaveric Demonstration

Now we have exposed the glenoid and for this demonstration created a B2 glenoid. So with a B2 glenoid we have two options. We have the 15 degree augment and also the 25 degree augment. In this demonstration we have sized for a 15 degree augment. Typically I would use a VIP plan which really gives the best accurate way to preoperatively template so that you could place a guidewire exactly and know exactly how you should ream. And preoperatively know whether this would be a 15 degree or a 25 degree augment. As you can see in this demonstration, the 15 degree augment fills the defect very nicely. The 2.8mm guide pin is then inserted. After you've drilled the guide pin, which does not have to be placed bicortical to prevent any cement extravasation before you remove the guide, mark superiorly where there's a nice area to easily mark with cautery or with a pen. Posteriorly, anteriorly and can mark the defect also posteriorly. The guide is then removed. After placement of the guide pin. We will begin with our reaming. We will first start using the Nautilus reamer to ream the paleo glenoid. It is important when you're reaming the paleo glenoid to ream slightly just down to subchondral, but not through subchondral bone anteriorly. After reaming the paleo glenoid, the glenoid reamer is set up on the back table. The dotted line is in reference to the anterior part of the glenoid. The posterior saw line is in line with the defect superiorly. There's also a line, as you can see on the top of the reamer where we previously reamed the paleo glenoid. A positive stop to prevent over reaming anteriorly has been placed on the glenoid reamer. The glenoid reamer is then inserted. Dotted line is matched anteriorly and then we ream. [00:02:01] There we go. Prior to removing the guide pin, the ream verification trial will be inserted to make sure that it lines well in is flush. Next, we will begin preparation for the glenoid by first drilling the central peg. The drill guide is then inserted and the superior drill is then used, and then this is drilled. And this is left in place with a quick connect. Next, you will then use the 4.5 to drill for the inferior keel. The appropriate sized broach. This is a small broach is then used. And there's a positive stop. Next the trial is then inserted. As the trial is inserted, it's very important to check the stability to make sure there's no rocking superiorly or inferiorly or anterior posteriorly. As you can see in this situation, it is an excellent fit. This is completed the glenoid preparation. Next we will begin preparing to cement in our 15 degree AugMend VaultLock. This can be used additionally when you're putting in putting in your cement to help have first and foremost a dry glenoid vault. And then this can be used with cement placed at the superior hole and at the inferior keel. We will not place cement into the middle hole, which will be the fluted peg placed in superior and inferior. You can compress with this as well, and repeat that step a couple times, to get as much good cement into the glenoid vowel as possible. This is the bone graft compression tool used around the central flute. This slurry taken from the humeral head can be placed in this compression device. This is a good example of bone graft placed around the central fluted peg. Cement will be used superiorly and inferior at the keel. Next the glenoid is inserted and impacted. After the VaultLock has been impacted. You can see an excellent initial fixation, but all cement debris should be removed and then pressure held until the cement has cured.

Anthony A. Romeo, MD (Chicago, IL), discusses the features and benefits of the Eclipse™ total shoulder arthroplasty system, which he uses to perform surgery for primary osteoarthritis.

Total Shoulder Replacement Using Eclipse™ Total Shoulder Arthroplasty System

So in summary, it's a 64 year old gentleman with osteoarthritis. He's got the typical findings of a narrow joint space, large, inferior osteophyte, multiple loose bodies. And so he needs a total shoulder replacement. That's the gold standard. And our goal is to put a humeral head in the place that's anatomic for him and to get it to stay there. Traditionally that's required to stem anywhere from 12 to 15cm or longer. There are now a number of new stems that are shorter than that that are working very well. But for him we're going to use a stemless device, the Arthrex Eclipse. And this is a device that uses a trunnion that sits very nicely on our cut surface. And then a cage screw that fixes that trunnion in place. And then the humeral head of the appropriate size goes directly over the top of this. We really think this is going to be a great advancement in terms of the care of our patients with osteoarthritis. And we think that's for a number of reasons. One, it is a little simpler for all of us to do, which should make it that we're more consistent with it. We remove less bone. So it's a bone sparing operation, and we already know from our European colleagues for over a decade of experience. That's a very effective device. As we know, the keys to an anatomic shoulder arthroplasty is to pick out the correct humeral head size and then put it in the right spot. So what we're going to demonstrate now is the Eclipse shoulder arthroplasty system, which allows us to put a humeral head without a stem and keep it in the right spot. And this will be a nice demonstration of how this implant can work very effectively, minimize the amount of bone resection and stabilize the humeral head in the proper anatomic position. Typically, we'll operate on those patients early in the morning, and we can get them out by the evening time skin incision is made. He's an active individual so there's not as much fat. So we're just trying to free up our cephalic vein here. Continue on down. And you can see we have a pretty good size inferior Osteophyte, which again, we anticipated from our preoperative use that we're going to have to deal with this. It goes down quite a ways. In fact, he has quite a few loose bodies in his subscapularis recess, too. So we'll get to those later. And then we're going to take the Fukuda retractor and work across the glenohumeral joint and do our anterior capsule release, and then we'll come back to our humerus. So we'll take the humerus and we'll internally rotate. So now let's go back to our humeral side. We've got our release done on the humeral side and the glenoid side. And we're going to go back to take care of our humeral preparation. We'll take our large Darrah. We'll move our arm holder out of position. We'll put our Darrah across our glenohumeral joint, and then we'll dislocate the humerus from the glenoid. So we just want to look at the top here and see what we have in terms of the osteophyte. And just make sure that we have a nice understanding of where his anatomic neck is up here, even around the Around the rotator cuff. So we can see that. Well, and then we'll proceed on inferiorly. And trying to keep that plane right along the anatomic neck there. Oftentimes with these osteophytes you can come underneath them. And what you want to see is that little synovial fold. And that marks the normal plane of the cortical bone of the humerus. So that gets our bone off of the humerus. And now we have to go back to doing our humeral head cut. And we'll put this across the glenohumeral joint to dislocate the humerus. We'll now take a pointed medium sized home in. And we have a couple of options with regards to resecting our humeral head. One. The easiest one and one that we frequently do is just a freehanded head cut. So we can look at the rotator cuff and identify where the top of the rotator cuff is at, and mark that position. We can then look at the normal position of the articular surface, and then see that Inferiorly and get a pretty good idea of what we need to do to make the cut. To resect the articular surface. There are a number of guides available that can be helpful, such as this one. So if you're confused about the cut, you can put a guide pin down the humeral canal and use this to help you identify where you think the proper inclination is. This is at the mean of normal human inclination, which is between a 125 and a 140, or one 32.5. And again, you can also just put this up here and look at it and say, oh yeah, that looks pretty good. That's where I want to be. And we're in good shape with that. So now we're going to go ahead and use our saw to make our cut. [00:04:56] And. What we're going to do. Is just identify exactly where his articular surface should be. So this is more of his osteophyte still up front. You can see with that thick white line. And we'll just take that off so we don't overestimate the proper size. So on the Eclipse system, the sizes are all an odd number. So 49, 51, 53. So we'll go ahead and see what the 49 looks like. It's probably a little bit bigger than that, but we just want to check that out and we'll put that into position. And it actually looks really nice. Let's just see what one size smaller looks and see what the 47. You don't have to put it on the handle. Let's just take a look and see how that looks here. I think that one looks best. So we're going to do the 47. We'll tap in so we can see that up there. We'll tap in our little we'll tap in the pegs with a hammer. Once we have the the actual trunnion guide in position we'll then take our handheld reamer and prepare the bone. And then we'll take our center drill guide. And then we'll take our guide pin, which will help to identify the depth of the screw that we'll be using. So we'll slide in until we touch the opposite cortex. So small medium. And it's just short of the large. So we're going to use the medium. And then we can take out our center drill guide. We can lift up our trunion guide with an elevator. And then we can put our head cut Protector in position. Okay. That looks great. So now we'll go. And that's all the preparation we need to do for the humeral side. And we'll take out our head cut. Protector. We have to make sure this goes down nice and comfortably. So we don't want to push this too hard, but we got to get it back down to where it was at. So that looks very good. It looks like it's seated well. We want to identify the front and the back. Make sure we're seeing everything really well. Our trunnion will sit right over the center guide. And as you can see it's got a bone in growth. And on growth the surface, that's bone it. It's got the fins in place here to prevent rotation and give it some primary stability as it goes into position. And what we'd really like to see when this goes down is that it's sitting right on that inferior cortex. This is the ideal place for it to be where it's going to most of its stability. This gentleman has such a hard bone, we're going to be fine. But this is where you really want to make sure that it sits well. You don't want it sitting up high. You want it right on that inferior cortex. For it to be nice and secure, we'll slide the tube over the top, and then we'll unpack that into its position and hold everything steady. Let me see. That looks good there. Then we can take out our center guide. And we're going to put our screw in here. And just to hold the trunnion down that's going to go inside the end of the tube here to hold this in place. So what we can do is just kind of set this in position. So we're ready to go. We take our screwdriver, pass it through our handle and slide that down so that we engage our screw. We want to make sure it's engaged properly as you see there. We'll just check and make sure that it's all the way down and seated. And then we'll hold that steady with our hand. All change hands so we can see it well enough. And this will keep it from rotating or tilting. And then we screw it into position. And we just advance that cage screw until it's all the way seated. Okay. So then once we get down to here, it's really nice and secure. And this is just rock solid. You can listen to it squeak its way down. You don't need to be that tight, but this one just happens to be. So we're really happy with how secure that is. And that's all the fixation that we need. Now with anatomic shoulder replacement, you'd have to dial in the humeral head to fit the offset. But we've already chosen exactly where the offset is because we've centered our trunnion right over the cut surface. So now all we have to do is take the head and we place this directly over the top. Make sure there's this little debris as possible. And then we unpack that into its final resting position. Check to make sure it's secure. And that looks great. So now we'll drop this down into place and we'll take out our superior. We'll check. And again we have all the parameters that we're looking for. In the past we have 50% of posterior translation with good bounce back, 40 degrees of external rotation with stability and 60 degrees of internal rotation. Nice and secure. We'll go ahead and bring this in. Now there are a couple of different ways to fix the subscapularis. So this is just nice and very mobile. Nice solid repair should work out extremely well for him.

Shoulder

This animation demonstrates subscapularis repair in anatomic total shoulder arthroplasty using the Eclipse™ SpeedScap™ technique and trunnion adapter.

Eclipse™ SpeedScap™ Subscapularis Repair

Eclipse. Speedscap repair is a knotless double row method used in conjunction with the subscapularis peel for anatomic total shoulder arthroplasty. After preparation of the humerus, including humeral head osteotomy and trunnion and cage screw sizing. The final trunnion is guided over the centering device and slotted into place. The cage screw is then inserted until the final fixation is achieved. The Eclipse trunnion adapter is placed onto the trunnion, appropriately sized to the implanted cage screw length. This provides an outline of the cage screw so it can be avoided during both medial and lateral row humeral anchor. Preparation. The medial row of the repair is completed by placing three FiberTak Dr anchors in the appropriate position to maximize native subscapularis footprint contact on the lesser tuberosity. The trunnion adapter can be rotated as needed to optimize anchor position and avoid the cage screw. The short FiberTak Dr drill is used to prepare the humerus for anchor insertion. The drill is kept parallel or divergent to the trunnion adapter to ensure the drill tip will not contact the cage screw. After drilling, insert a FiberTak Dr anchor, remove the driver and set the anchor FiberWire suture can be removed from the anchor or retained for use later in the repair. Using the drill for the 3.9mm SwiveLock anchor. Prepare two holes adequately spaced to cover the native subscapularis footprint on the lesser tuberosity. After all medial row anchors are placed, pass each limb of LabralTape in sequential fashion and appropriately spaced through the tendon of the subscapularis, ensuring to remain lateral to the musculotendinous junction. Secure one limb from each FiberTak Dr. Anchor three altogether, and insert through the eyelet of a 3.9mm SwiveLock anchor. Finalize tension of the LabralTape suture prior to inserting the eyelet into the prepared socket. This completes the knotless double row Eclipse SpeedScap repair.

Representing a significant step forward in glenoid design, the Univers VaultLock® glenoid system provides enhanced fixation and bone-conserving features.

Univers VaultLock®

Patrick J. Denard, MD (Medford, OR), discusses implant selection, preoperative planning, and relevant literature regarding glenoid bone loss in shoulder arthroplasty.

Glenoid Treatment Options: Managing Complex Morphology With Augmented Implants

I'm Patrick Denard from Medford, Oregon, and I want to share with you my algorithms for complex glenoid treatment. We have a lot of options available at our disposal. So I want to walk through my approach of how I choose each of these implants. On the anatomic side, when I'm addressing primary glenohumeral arthritis, the first two things I ask myself are, are there a stability problem and is there sufficient bone stock in particular, when we're talking about stability, when we're dealing with B1, B2 and B3 glenoid, we're dealing with an imbalance or stability issue because we know the natural history is that once that head sublux is posteriorly in a B1 type glenoid, it then wants to become a B2 and subsequently a B3 glenoid. This has been elegantly shown by Walker in a previous study, where they looked at type A glenoid and took CT scans 24 months later, and found that the A glenoid is 39 to 41, remained the same, but the B1 glenoid is 17 and 19 progressed, so 90% progressed on to B2 or B3 glenoid. So once you start down this path, it's hard to reverse. And this is why we know we have a high failure rate with B2. As Joe Walsh has shown us in 2012, where he had a 16% rate of revision and 21% rate of glenoid loosening at five years, in particular, when Retroversion was greater than 27 degrees and posterior subluxation was greater than 80%. So important numbers for us to remember. Conversely, when he looked at the same types of patients and treated those patients with B2 glenoid with a reverse, they had no loosening or posterior instability at five years post-operative. So a big change. What about the bone stock? We want to think about what are the limits of deformity correction, both from a Peg perforation standpoint and from a standpoint of violation of the subchondral bone. And then also, I think it's important to look at the results of bone grafting and augmented implants or the limits to correction. In general, there's several studies that have looked at this, but in general, they have concluded that it's about 15 degrees is the amount that you can correct without penetration of the of the glenoid vault. How about the subchondral bone? How deep is that? This study here suggests that depth is about 3.5mm in the setting of an eccentric glenoid. So you want to limit your reaming to less than that because we know that that's important for long term support. Augmented glenoid Ionadi has looked at his results and at 2.4 year follow up. Overall, many patients did well, but 6.9mm of bone loss predicted Radiolucency. And what does that mean? Well, that equates to about 25 degrees of retroversion, which happens to be similar to what we found in the other study reported by Walsh, where they had patients with 27 degrees of glenoid retroversion. Lastly, if we consider a convertible glenoid, we need to think about the thickness that is afforded by this implant, in particular with the universal base plate. We have about 4.5mm of offset that is provided by the metal implant alone. So you want to think about how much bone loss you're correcting with the use of this implant. Bottom line, what this all adds up to is that you really need to use 3-D planning to properly assess these patients, because we're talking about very small numbers in millimeters and very small degrees that have big implications for implants. So this is what my general primary osteoarthritis algorithm looks like in a patient with 15 degrees of retroversion or less. They are very amenable to anatomic glenoid placement with correction aversion. And this is based on the subchondral bone violation being minimal and the correction being affordable being less than 15 degrees. The studies I showed you earlier in a patient with greater than 25 degrees of retroversion, we know we're going to go to reverse shoulder arthroplasty almost regardless of age, because the risk of failure long term is so high with an anatomic implant, given that natural history of the glenoid. And then we have our in-between ranges that are 16 to 25 degrees that we can choose between AugMend, convertible and RSA based on age and activity level. And particularly that middle zone is what's going to perform well with an augmented implant. So here's some case examples. Kind of looking at this. This is a patient with an A-1 or concentric glenoid. We plan this in VIP and we have version of ten degrees with no evidence of eccentric wear. This is a patient that's very amenable to a VaultLock glenoid or a standard polyethylene glenoid. Here you can see post-operative x rays with a stemless implant centering of the head postoperatively. Let's move on to another case here. This is a mild B2 glenoid deformity. You can see a little bit of posterior wear on the axial view. We put this in the CT scanner in VIP. And we see there's 18 degrees of retroversion. Again falling into that middle range that I think is idealized for an augmented implant that between that 25 and 15 degrees of range. So this is an excellent one in my opinion for a augmented posterior glenoid. Now about options for addressing deformity with reverse shoulder arthroplasty. We really have three approaches we can use. We can collectively ream and lateralize the metal. We can use bone graft and we can augment. At our disposal is the MGS implant, which has offset options from 0 to 8mm in two millimeter increments. The nice thing about this technique is we can really regain a lot of offset through the actual metal itself. Bone grafting is described by Pascal Boileau is a well described solution for bone loss in the setting of reverse shoulder arthroplasty. We know this is associated with high rates of osseous integration on CT scans. Postoperatively. However, when we compare metal to bone in finite element analysis, we find that metal performs better. In particular, the further lateral you go, the more subject bone is to displacement under stress compared to metal implants. So the ideal scenario probably is metal. All things being equal. Now with reverse augment system with the Emgs, we have a couple of options available for us. We have full wedges with ten degrees of retroversion and 20 degrees of retroversion. And then we have half wedges in 15, 25 or 35 degrees. So how much gaps do the augments restore? I think this is something that's important to consider when you do your planning. If you look at these implant pictures here, you see that with the ten degree implant you're having four millimeters additional posterior. Whereas with the 20 degree implant you have eight millimeters additional posterior. With the half wedges you have three five and eight millimeters respectively. So you can use these numbers and consider when you're planning in VIP and really decide which one is going to fit most appropriately. So first we need to consider some questions to think about what position we're going to accept at the implant. And this is going to vary based on your interpretation of literature. But how much retroversion can I accept? In my view, that's about ten degrees. How much inclination can I accept based on the study here, if we do not have glenoid erosion, we can typically accept the normal superior inclination that is there. And then a very important one is how much base plate contact is required. And this varies between 50 and 75% in the literature. I think that also varies by the implant. This study in particular here looked at contact area of a base plate with a central screw, which is similar to the MGS, and in this study as little as 50% of contact was acceptable. You see really an increase in displacement once the contact only went down to 25%. So in my view, with a threaded implant, 50% is acceptable in most cases. So this is what my deformity algorithm looks like with reverse shoulder arthroplasty. And I've established my parameters here that at 50% contact. And based on my assessment of the glenoid data I showed you earlier, on the anatomic side, I like to limit reaming to only 2 or 3mm. So if I have 50% contact in VIP with the version inclination parameters I suggested, I will first try to get metallic lateralization. If I can get 50% contact with only reaming 2 to 3mm. If I set those parameters and I have less than 50% contact based on the VIP plan, then I'm going to move up the chain. If I have a four millimeter gap posteriorly, I'm going to use a ten degree augmented base plate in most cases, because that's going to match up really nicely with my GAP. If I have a 4 to 8 millimeter gap, then I'm going to go up to a 20 degree AugMend because as I showed you earlier, you have about eight millimeters of additional area posteriorly. And then as you can see with an 8 to 15 millimeter gap, this is probably where I need to use bone graft, although it doesn't perform as well. Biomechanically that's the limit of what our augmented implants can go to. And I know that CT scans show a high rate of integration. And then finally, if that graft gets over 15mm, I want to think about a custom glenoid, because I'm really reaching the limits of what I can actually obtain with a bone graft. Now, if your parameters are different, say you want to you want to shoot for 75% contact. You can do the exact same thing using these same approaches. Your selection or threshold for augmented implants is just going to change appropriately, but the decision tree ends up being the same. So we'll look at some cases here. This is an individual with a B2 glenoid posterior subluxation, as you can see on the CT scan here. Pretty significant B2 glenoid. We plan this in VIP and we first look at what can we do with an anatomic glenoid. And you can see to get contact we have to ream over four millimeters of bone. So we violated the subchondral bone based on those rules I showed you earlier. In addition we have a lot of posterior subluxation. So we need to remove to reverse shoulder arthroplasty. And you can see here with just two millimeters of reaming, I can get complete contact with a little bit of acceptance of retroversion. So this is a patient where I'm going to accept metallic lateralization. Here's another case though. This is an example of a half wedge case. We look at our CT scan here. We have a really significant B2 glenoid occupying about 70% of the glenoid. And you can see in the scan here we have 26 degrees of glenoid retroversion. So we of course are going to have a higher rate of failure with an anatomic arthroplasty. So we select an augmented implant. In this case the half wedge lines up very nicely. And we're able to get correction of this deformity. And yet another example here of a full wedge case. This is a patient with a more symmetric deformity. You can see on the CT scan here we have posterior subluxation with retroversion of the glenoid. And you can see this one has become essentially a B3 type of glenoid where we have that posterior erosion. I plan to correct with ten degrees of retroversion excepting ten degrees of retroversion, but this resulted in a gap of 8.5mm posteriorly with only 8% contact. So this one is going to line up perfectly for a 20 degree augmented implant. Posteriorly is that you can see as I'm selecting here in my VIP plan, once I select that implant, I'm able to get good contact and therefore restore the joint line. And there's the final post-operative radiographs. So thank you for your attention. I hope this approach to treatment of the glenoid helps you in your practice.

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Eclipse™ Stemless Implant Scientific Update - A Review of Existing Literature

ShARC Publication List

Eclipse™ Total Shoulder System

Univers VaultLock Keel Glenoid Instrument Set, Upgrade

Univers VaultLock <(>&<)> Keel Glenoid Instrumentensatz, Upgrade

Univers VaultLock <(>&<)> Keel Glenoid Instrument Set, Upgrade

Glenoid mit Kiel, PE, Größe S, steril, IM

Componente glenoideo, polietileno con quilla, pequeño

Glenoid mit Kiel, PE, Größe M, steril, IM

Arthrex UNIVERS Glenoid Poly with Keel, Medium

Componente glenoideo, polietileno con quilla, mediano

Glenoid mit Kiel, PE, Größe L, steril, IM

Arthrex UNIVERS Glenoid Poly with Keel, Large

Componente glenoideo, polietileno con quilla, grande

Glenoid mit Kiel, PE, Größe XL, steril, IM

Child (D)

With anatomic restoration of the humerus and glenoid, soft-tissue balancing of the rotator cuff is more accurate, allowing for improved functional outcome. Therefore, the Univers Apex OptiFit humeral component was designed to account for common anatomical variations of the proximal humerus and allow the surgeon to adapt the humeral stem and articular surface to the position that best represents the patient’s normal anatomy. Variable adjustments with respect to the inclination angle, version, and head offset can be made intraoperatively with the implant in the humeral canal.&nbsp;
The midrange stem length in combination with the titanium plasma spray optimizes stability and bone preservation1, while the rectangular stem body and removable trunnion optimize revisability. In addition, strategically incorporated suture holes allow for unique subscapularis repair options. 

 
 
Reference&nbsp;
1. Bents EJ, Werner BC, Griffin JW, Raiss P, Denard PJ. A radiographic analysis of proximal humeral anatomy in patients with primary glenohumeral arthritis and implications for press-fit stem length. J Clin Med. 2022;11(10):2867. doi:10.3390/jcm11102867

The Univers Apex OptiFit™ total shoulder system stem features in situ anatomic reconstruction, stable bony fixation with a midsize stem length and proximal titanium plasma spray, a removable trunnion for optimal revisability, and strategic suture holes for secure subscapularis repair.

Univers Apex OptiFit™ Optimized Anatomic Arthroplasty

Univers Apex OptiFit™ Total Shoulder System

Arthroplasty and Shoulder Fracture - Next Generation in Repair and Reconstruction

Patrick J. Denard, MD, (Medford, OR) performs a subscapularis repair using the FiberTape® tendon compression bridge kit.

Total Shoulder Arthroplasty (TSA) Subscapularis Repair Using FiberTape® Suture Tendon Compression Bridge Kit

This is the FiberTape tendon compression bridge kit. Here we have a FiberTape and a TigerTape. The two ends of each suture are wedged together with a large needle, and on the other end there's a pre fashioned half racking suture, which is pre-placed with a nitinol wire for suture passage. There's two millimeter drill to pass the sutures through bone tunnels. There's two number two fiber wires, which can be used for tagging soft tissue and also for rotator interval closure. There's a free needle with a nitinol wire as well. And then finally, this is a separate reusable instrument which is a suture tensioner. The FiberTape tendon compression bridge can be used in many situations. Here we're going to demonstrate using this in a standard length stem. We have a osteotomy of the lesser tuberosity which has been created. And then I've previously broached the humeral canal. The first thing we need to do is drill two holes in the bicipital groove, superiorly and inferiorly. And I'm going to draw one hole medially medial to the tuberosity osteotomy. In the case of a colorless stem, you want to drill two holes. But again, in this case we're using a stem. So we're going to drill one hole here immediately. So first we're going to drill our superior hole in the bicipital groove. This is a two millimeter drill. We don't want to drill a second hole in fairly in the bicipital groove. And then again medially medial to the tuberosity. We're first going to pass our inferior suture from lateral to medial. We're going to go through the bicipital groove hole first. And then we'll go through our hole that is medial to the tuberosity. We want to remove the slack from the suture so that this flag sits flush down against the bone. And we need to unwind the suture from the flag. But we need to make sure it stays on this dowel as it goes down. Now we're going to pass the TigerTape through the superior hole alone. The medial aspect of this is going to go around the stem. Again, we unwind from the flag and deliver the dowel down to the bicipital groove. But making sure the suture stays on the dowel. Now we want to place the stem, and we want to make sure those sutures go posterior to the stem. So here are the stems delivered into the canal. And we want to make sure all the slack is removed from the system. I'm going to start inferiorly with the FiberTape and then superiorly with the TigerTape. The stem is locked into place and then we'll place our humeral head. An option at this step is to provisionally close the rotator interval. The next step is to pass our sutures medial to the tuberosity. We're going to first pass the FiberTape inferiorly. We're going to go just medial to the bone. This is followed by our TigerTape superiorly. We then remove all the slack. And then we can cut these limbs apart so they're separated. Now that we have these sutures passed we want to deliver these through our half racking hitch. We use the nitinol loop to do this. We're going to pass a superior one first. And the suture ends are tapered so they can be delivered through the flag. Here you can see the dowel and the nitinol wire were removed as I pull those through. And then we'll repeat that process inferiorly. Once these sutures are delivered through the half racking hitch. I can alternately tension and reduce the osteotomy down. I'll first do this by hand. Once I'm happy I've removed provisional slack, I can remove the remainder of the slack in the system with this suture tensioning device. Suture tensioning device has two holes here for the sutures. So we deliver one suture through the hole, and then the second suture can go through the slot. We want to wind these sutures around the thumb pad. One suture on each side. We can then hold the thumb pad and turn the handle clockwise. As we wind this handle We'll see the slack being removed from the system and the suture tightening down there. We can see it sucking in very nicely. At this point. We want to place half racking hitch to lock the suture in place. The placement of one of these allows us to secure the construct. And we can also retention at this point, if we'd like, we then move superiorly again. We can see the slack being removed from the system, and the tuberosity is nicely reducing to the bone. We go to we're satisfied that all the slack is removed. Once that slack is removed, we can back it up with a half hitch. And at this point we can retention if we'd like, inferiorly. Or we can secure the final construct with another alternating half hitch. The limbs are cut short. We can close the rotator interval. At this point I tend to close the rotator interval in all cases. And if we do this with a slight external rotation, we do not find that it limits external rotation Postoperatively. Additionally, it provides support for the subscapularis repair. So here you can see our final FiberTape tendon compression bridge repair. You can see its efficient low profile. All the slack is removed from the system. In this case we did an osteotomy and we can barely even appreciate that line after completion of the repair, because we've been able to remove all the slack from the system. One of the nice things about this repair is it can be used with a variety of implants, whether that's a standard length stem, a short stem, or a stemless device. It can be also be used with a variety of approaches to the subscapularis, including a subscapularis peel or an osteotomy, as we did in this case.

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Now Available in the VIP™ Preoperative Planning System: Humeral Planning

It's been in our mission statement since day one, helping surgeons treat their patients better. And that is why our VIP preoperative planning software was developed by surgeons. For surgeons to maximize the personalization and level of care we can give to your patients. The most seamless preoperative planning system is here. Now available. Humoral planning to help size your implant to match the patient's anatomy. Optimize your stem component selection for complex humoral problems, including fracture to achieve maximum fixation. Vip is also the only system capable of providing a patient specific plan and execution in less than 48 hours of approval, and with the new VIP reamer, you can ensure that your depth of glenoid rim in surgery matches the depth you planned. Backed by clinically proven implant systems with a largest range of lateralization options tailored to each patient. This is VIP.

The Univers II humeral component was designed to account for commonly encountered anatomical variations of the proximal humerus. Variable adjustment with respect to the inclination angle, version, and head offset is critical to reconstruction of the proximal humerus. The simplified design of the Univers II humeral component enables for adapting the humeral stem and articular surface to the position that best represents the patient’s normal anatomy. Implant adjustments can be made intraoperatively within the humeral canal. This unique feature allows more accurate recreation of the normal anatomical relationships of the shoulder joint. With anatomic restoration of the humerus and glenoid, soft-tissue balancing of the rotator cuff is more accurate, allowing for improved functional outcome.1
Reference
1. Mueller M, Hoy G. Soft tissue balancing in total shoulder replacement. Curr Rev Musculoskelet Med. 2014;7(1):16-21. doi:10.1007/s12178-013-9195-6
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The FiberTape® tendon compression bridge technique is used for subscapularis repair following total shoulder arthroplasty.

FiberTape® Tendon Compression Bridge Technique

The FiberTape tendon compression bridge technique may be utilized during total shoulder or hemiarthroplasty procedures as a method of repairing the subscapularis tendon. It may be used when either a subscapularis peel or lesser tuberosity osteotomy is employed for the subscapularis takedown, although this animation shows use with the LTO method. After the subscapularis is reflected, standard preparation for the humeral stem is completed. Bone tunnels are then established in the proximal humerus using the supplied 2.0mm drill bit. If a collared humeral stem is being used, only one hole is needed medial to the lesser tuberosity. Two additional holes are drilled inside the bicipital groove, spaced approximately 15mm apart. The FiberTape loop is removed from the card and its needle is passed through the inferolateral humeral bone tunnel. Configure the suture loader so that suture limbs enter the bone tunnel directly from the suture loader. Care should be taken to ensure the knot does not migrate off of the suture loader, as the suture strands are being pulled proximally through the bone tunnel. The needle is then passed from the interior of the humeral canal through the medial bone tunnel. The suture is pulled through the medial bone tunnel while ensuring that a loop of suture is maintained external to the humerus. Next, the TigerTape loop is removed from the card and its needle is passed through the superior lateral bone tunnel. Again, the suture is unwrapped from the suture passer tab and pulled through the tunnel proximally, similar to the FiberTape strands. In this case, when a collared implant is used, there is no need to pass the TigerTape strands through the medial bone tunnel. These suture limbs will rest on the humeral resection plane and under the stem collar. The distal tip of the humeral stem is then placed inside of the loops created by the FiberTape and TigerTape sutures. Slack is removed from the suture loops by gently pulling on the medial suture strands as the humeral stem is being inserted. The humeral head component is then placed on the humeral stem and the humerus is reduced. Using the attached needle past the inferior sutures through the subscapularis tendon. Follow with superior sutures in the same manner. The needles are then cut from the sutures and discarded. The tapered end of a suture of each type, FiberTape and TigerTape are passed through the suture. Passer. Eyelid. The suture loader is pulled, which passes the tapered ends through the preformed knot. This process is repeated with the remaining suture. Limbs. Hand tensioning should be performed alternately between the superior and inferior knots. A half hitch is then tied over the inferior racking hitch knot. The superior suture limbs are loaded through the tip of the suture tensioner and passed around the paddle, and cleated securely. The suture tensioner handle is then rotated clockwise until adequate suture tensioning is achieved. Alternating half hitches are then thrown over the superior knot stack. The same tensioning steps are followed on the inferior suture. Limbs. One final alternating half hitch is then thrown over the inferior knot stack if desired. Suture tensioning can be repeated. The excess suture limbs are cut, which completes the repair.

Our goal was to create an elevated experience that simplifies presurgical planning without compromising your control or capability. We started by focusing on clinical outcomes because a plan is only as good as its execution. The Virtual Implant Positioning™ (VIP™) preoperative planning system and software create an immersive experience that comes to life in the OR with the fastest reusable and patient-specific transfer technology on the market.

The VIP™ Experience: Next-Generation Preoperative Planning

Our goal was to create an elevated experience that simplified presurgical planning without compromising your control or capability. We started by focusing on clinical outcomes because a plan is only as good as its execution. Our VIP system achieves this by creating an immersive experience within our software that comes to life in the O.R. with the fastest reusable and patient specific transfer technology on the market. During development, we scrutinize the details to make planning as effortless as possible for you. We partnered with gaming software experts to generate high definition renderings and new iconography, giving you a whole new perspective to the anatomy. We aimed to convert complex tasks into intuitive decisions to deliver quick and accurate plans within your busy schedule, unlike any other system. You are backed by a team of dedicated surgical planners who support every case with best in class customization and support to empower you further. Now available on your mobile and iOS tablet devices, you can pinch, pan and zoom to see every angle against our new dark mode to accentuate the things you need to see most. And when life takes you away from the workplace, you can always stay up to date on your upcoming cases in an improved calendar view on your smartphone. We recognize that even if you perform the perfect surgery, patients can still be unsatisfied with details outside of the Or. So we've also created a VIP experience for them to elevate you even further. Effortlessly increase patient engagement and satisfaction by adding their phone number to their case to receive automated communication and education at specific time points in their pre-surgical journey. By transforming the VIP software into an experience for you and your patients, we can partner every step of the way to provide the best clinical outcomes.

Univers Revers™ System Scientific Update

Univers™ II Total Shoulder System

Univers VaultLock® glenoids are compatible with Eclipse™, Univers™ II, and Apex shoulder systems. These glenoids feature a fluted central peg for immediate fixation and bony ingrowth, variable backside radius of curvature for conserving subchondral bone, and streamlined instrumentation for inline preparation. Univers VaultLock glenoids are available in four sizes and augmented options of 15° and 25°.
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This animation illustrates the features and benefits of the Univers VaultLock® augmented glenoid and instrument system.

Univers VaultLock® Augmented Glenoid: Features and Benefits

Patrick J. Denard, MD, (Medford, OR) demonstrates the Univers VaultLock® Glenoid System technique. The Univers VaultLock Glenoid System represents a significant step forward in glenoid design – providing both enhanced fixation and bone conserving features.

Univers VaultLock® Glenoid System

So here we have a good exposure of the glenoid. We have our anterior aspect of our glenoid and posterior aspect superior and inferior. And we have a cannulated system. First we have a guide here. As you can see we're going to center it and and then insert our guide pin. This is a 2.8mm guide pin. Once the pin is inserted we remove the guide. And then we can ream over the top of that guide. And the way this reamer is designed is that it will enlarge as it goes in a circle, so that it can push the posterior retractors out of the way. In addition, the reamer is appropriately sized for each glenoid, and the reason for that is the radius of curvature of the reamer is going to match the back side radius of curvature of the glenoid, which is specific for each glenoid size. For our large glenoid, we have a flatter radius of curvature, and for our smaller glenoid we have a more curved radius of curvature to match the normal anatomy. So we're going to reme as minimal as possible just to scratch the surface. Once our reaming is complete, we need to establish the center hole. This reamer has a positive stop. The guide pin is then removed and then we can prep our glenoid. So we insert our glenoid prep guide next. And there's a superior hole which we're going to use to establish our role of the glenoid implant. Once that drill is inserted, we remove the drill and leave it in place. That's going to establish rotational control for us. So that preps the superior and the inferior peg. And now we need to prep the inferior keg or keel. We now need to prep the remaining portion of the keg in fairly, so we need to punch out the slot for the inferior aspect of the glenoid. There's our completed preparation. As you can see, we have an in-line preparation. The advantage here is that we have a pegged component. So we have the advantage of longevity of a pegged component. But we also have more of an in-line preparation which is going to avoid Peg perforation anteriorly and posteriorly. If we'd like we can insert a glenoid trial to assess our component seating. This is a semi radiolucent trial which allows us to check the component radius of curvature match to the glenoid. The VaultLock glenoid component is designed to achieve long term stability by having bony ingrowth, particularly with regard to the central peg. So you can see there are large fins there centrally, and our goal is to get bony interdigitation at that component. So we have several options for addressing that central component. One is to use no graft. Another is to use autogenous bone graft from the shoulder. And another is to use demineralized bone matrix. We're first going to demonstrate using a technique for humeral head bone graft, which is the most common source of graft that we use. Now there are two sources we can use for autogenous bone graft. One is to take remains from the glenoid preparation. You can see the reamers we use here have bone graft within the flutes. The most common source of bone graft that I use is to use bone graft from the humeral head itself. So what we've done here is we've preserved the humeral head that we resected. And now we're going to prep this as we would prep a glenoid. First we need to take a drill and create a pilot hole in the center aspect of the humeral head. And I'm holding the humeral head with a towel clip. Now that we've created a pilot hole, we're going to take the reamer from the standard glenoid set. This is a fully radiused reamer. We can then insert it into that pilot hole, and we're going to simply ream into the head in order to obtain bone graft. You can see here that we have a nice slurry. And this is going to apply nicely to the central peg of the VaultLock. So we have a graft compaction tool that's going to allow us to apply this bone graft to the central peg of the VaultLock. So we put this slurry inside of the graft compaction tool. And then we can simply clamp the central peg as such. And then we can rotate the glenoid component to compress the graft into the central peg. Then in terms of removal rather than opening, we want to pull the graft off to apply graft to the back of the glenoid component. Now typically this will apply graft to one side of the component but not necessarily get it to the other side. So we want to repeat this step. So again we're going to take our graft compaction tool. And now apply that graph to the opposite side and turn and pull it off. So here's our completed preparation where you can see we have circumferential bony opposition around the central peg. Now we're going to complete our insertion of the glenoid component. First we want to place cement peripherally. And we're going to place this both in the top and the bottom pegs. So we're going to place cement. And we're going to pressurize up to three times. Here we pressurize a third time. Now we're going to move to insertion of the final component. It. So here we can place cement on the bottom. We want to make sure that we get inside the keg in fairly. And then we can also place a light amount of cement around the top and the bottom fins. So we want to insert the glenoid component provisionally. And we want to make sure that our pegs are in line superiorly and inferiorly. And we do that by manual pressure. And then once we feel that we are aligned we then impact the glenoid component following impaction. We're going to use our freer here. And we're going to check peripherally for any cement extravasation and clean that if necessary. And then we're going to check that we have full seating of the glenoid component which you can see around here Circumferentially. We have full seating and excellent initial stability of the implant. Now an aspect of this glenoid component that is unique. Is it particularly with the impaction because of the inherent press fit design centrally, you do need to apply manual pressure to engage the central peg, and you are going to encounter slightly more resistance during impaction of the of the component, but that design has the advantage. Of course, of long term stability of the component. As an alternative to autogenous bone graft, one can use demineralized bone matrix and apply that around the central peg of the glenoid component. Here we have one cc of Demineralized bone matrix, and we can again use our graft compaction tool to apply this to the glenoid component. So we'll fill the jaw of the bone graft compaction tool and apply that to the central peg of the VaultLock. Similarly to how we applied this during the application of the bone graft. Again, you can see that we have one side primarily that's been filled. So we'll repeat the process so that we can complete the preparation. So we apply that twice to ensure that we have circumferential preparation of the VaultLock component. Here you can see the final preparation where we have circumferentially applied the putty around the central peg.

Univers VaultLock® Glenoid System

The Univers Apex system represents the evolution of Arthrex total shoulder arthroplasty systems. While maintaining all of the in situ variable adjustment capabilities of the Univers II total shoulder system (inclination, version, head offset), the Apex introduces advanced features important in the treatment of all total shoulder patients. The reduced diaphyseal stem length, rectangular stem body, and removable trunnion optimize stem removal and therefore revisability. In addition, strategically incorporated suture holes allow for unique subscapularis repair options. The system is compatible with Univers VaultLock®, pegged, and keeled glenoid systems, the Univeral Glenoid™ convertible baseplate with polyethelene inlays as well as with the Univers II humeral head options. In keeping with the Arthrex focus on intraoperative adaptability, the Apex restores normal patient glenohumeral anatomy in a stable, press-fit solution while allowing for bone-conserving stem revision.
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The Univers™ Apex total shoulder system stem features in situ anatomic reconstruction, stable bony fixation with reduced stem length, a removable trunnion for optimal revisability, and strategic suture holes for secure subscapularis repair.

Univers™ Apex Optimized Anatomic Arthroplasty

The Univers Apex OptiFit™ system represents the evolution of our stemmed anatomic systems.

Univers Apex OptiFit™ Surgical Technique

The humeral osteotomy is performed by either a freehand cut or with an intramedullary or extramedullary guide provided in the instrument set, taking care to maintain the patient's native articular inclination inversion. The Universe Apex OptiFit instrument set contains reamers and broaches designed to prepare the Intramedullary canal to match the stem's smaller footprint to minimize bone removal. The initial broach has an attachable version guide and version rods for proper broach orientation relative to the osteotomy broach until rotational stability is achieved and the appropriate laser marking is flush with the cut surface. Following canal preparation, a proximal humerus Protector is placed and attention is turned to glenoid preparation. There are three glenoid implants available. The universal glenoid convertible base plate. The keeled glenoid. And the VaultLock glenoid, which provides immediate press fit fixation on the central peg. The VaultLock is demonstrated here. A pin is placed in the center of the glenoid by using the pin guide. The appropriately sized VaultLock reamer is positioned over the pin, and the glenoid surface is then contoured to support the polyethylene component. The central hole is drilled with a six millimeter cannulated drill, stopping once the collar comes in contact with the glenoid surface. The glenoid drill guide is positioned by placing the central peg into the previously drilled hole. A short six millimeter drill bit is used to drill the superior peg hole. It's left in place to stabilize the guide for inferior drilling. The inferior 4.5mm drill bit is then used to prepare for the inferior keel. The glenoid brooch finalizes inferior keel. Preparation. Alternatively, the glenoid punch can be used with attention to impact just so the shoulder is flush with the reamed surface. Translucent glenoid trials are available. These provide visualization for the reamed surface while evaluating the proper orientation and fit prior to cementing the polyethylene component. The glenoid vault is cleansed and dried, followed by cement injection in the superior and inferior peg holes. A pressurizing tool is available for displacing cement throughout the vault. Bone graft can be used on the central peg. Autograft can be obtained from the native humeral head by creating a slurry with the bone graft reamer. The slurry is then placed into the graft compression tool, which is clamped around the central peg. Carefully spinning. The glenoid component on the grafting tool compresses the bone graft into the flutes of the central peg. Alternatively, a demineralized bone matrix product can be used for grafting the central peg. The VaultLock glenoid is then impacted into place. Attention is turned back to the humerus for stem implantation. The OptiFit stem has suture holes in the proximal body for soft tissue repair and subscapularis closure. The apex subscapularis repair technique takes advantage of these holes. Two holes are drilled vertically in the biceps groove for passage of the lateral suture. Limbs two. Number two FiberWire. Sutures are passed through the lateral holes, yielding four suture limbs labeled A through D from superior to inferior. A blue suture is used superiorly and TigerWire inferiorly for number two. Fiberwire sutures are passed through the medial holes, yielding eight suture limbs, labeled one through eight from superior to inferior. Blue and TigerWire. Sutures are alternated from lateral to medial limbs. C and d are passed through the inferior hole from the intramedullary canal out. Similarly, limbs A and B are passed through the superior hole from the Intramedullary canal out. All strands are held out to length on tension as the stem is impacted. Using the pointed stem impactor, followed by the angled Morse taper stem impactor, placing the trunnion flush to the osteotomy surface. The inclination inferior and version superior screws are then tightened with the torque driver. Trailheads are available to verify proper head size, head offset, shoulder motion, and stability prior to impacting the Definitiv head component. Suture limbs one through eight are evenly placed through the medial aspect of the subscapularis tendon. From superior to inferior. Your proper spacing is key to the final repair. The sutures are then tied in the following sequence one to A, eight to D, four to C. Five to B, 2 to 3 and 6 to 7. The suture color pattern is such that the first four knots are tied between similar colors, and the last two knots are tied between different colors. In addition, the last two knots are tensioned and create dynamic compression of the subscapularis tendon over the lesser tuberosity. The repair is then evaluated by externally rotating the arm with the arm abducted. The degree of external rotation achieved without stressing the repair is noted for postoperative therapy limitations. The wound is irrigated and superficial closure is performed according to the surgeon's protocol.

Univers™ Apex Total Shoulder System

Univers II- und Apex-Instrumentensieb, Humerusinstrumente

Instrument Case, Univers II and Apex Combined Humeral Instruments

Instrument Case, Univers Apex Humeral Canal Prep Instruments

Univers Apex-Instumentencontainer, Instrumente zur Präparation desHumeruskanals

Instrument Case, Univers Apex Humeral Canal Prep Instruments