VAIOS® - JRI Orthopaedics · The extended deltopectoral approach is commonly used for total shoulder replacement; however, with that procedure, it often proves difficult to obtain

VAIOS® Modular Shoulder System

Operative Technique

JRI Orthopaedics Limited is a British manufacturer of orthopaedic implants and surgical instrumentation. JRI manufacturing is based in our modern Sheffield facility, alongside Research, Product Development, Customer Service, Marketing, Warehousing and Distribution.

JRI was formed by Mr Ronald Furlong FRCS in 1969 and is renowned for the innovation of the Furlong® Hydroxyapatite Ceramic (H-A.C) Coated Total Hip Replacement (THR), which was the first H-A.C Coated THR in the world. Today, the Furlong® H-A.C Coated THR has achieved clinical success globally. New products are continuing to be developed and we are committed to delivering innovative and quality orthopaedic solutions for healthcare providers and patients worldwide.

JRI is wholly owned by a charity, Orthopaedic Research UK, to which it gift aids a significant proportion of its profits.The charity, guided by an independent Scientific Advisory Panel, allocates these funds to the advancement of orthopaedic research and clinical education.

Company Profile

VAIOS Modular Shoulder Arthroplasty System

VAIOS is designed to offer maximum versatility, allowing the surgeon to adapt intra-operatively to meet the patient’s clinical needs, whilst minimising the components and instruments required.

• Versatile - Hemi, Anatomic and Inverse total shoulder arthroplasty constructs can all be implanted using just three instrument trays.

• Modular humeral component provides either uncemented or cemented distal stem options.

• Humeral neck design with wiring holes facilitates reconstruction of the tuberosities in the treatment of proximal humeral fractures.

• Unique design allows for an easy conversion from anatomic to inverse shoulder arthroplasty without the need to replace the Glenoid metal-back or humeral stem components. This reduces operative time and preserves bone stock

• Common resection for anatomical and inverse procedures minimises the instrumentation required and increases reproducibility.

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Contents

Indications 3Hemiarthroplasty – The recommended surgical approach 4 Total shoulder replacement – The antero-superior surgical approach 5 Preparation of Humerus 6 Delto-pectoral Approach 7 Superior McKenzie Approach 9

Anatomic Shoulder Preparation and Implantation Surgical Technique Broaching the Humerus 12 Preparing the Glenoid surface Cemented and Uncemented 14Cemented all Polyethylene Glenoid Preparation and Trialling 18 Definitive Cemented Glenoid Implantation. 20Uncemented Glenoid Preparation and Trialling 22Uncemented Glenoid Definitive Implant Assembly and Implantation 23Humeral Component Definitive Implantation Assembly 26Cemented Humeral Stem Implantation 27Uncemented Humeral Stem Implantation 28Anatomic Shoulder Humeral Head Insertion 29Nottingham Tests 30

Inverse Shoulder Preparation and Implantation – Surgical TechniqueBroaching the Humerus 32 Preparing the Glenoid Surface – Uncemented 34 Glenoid Definitive Implant – Assembly and Implantation 38Inverse Shoulder Trialling 40Humeral Component Definitive Implantation Assembly 41Cemented Humeral Stem Implantation 42Uncemented Humeral Stem Implantation 43Inverse Definitive Glenoid Dome Implantation 44Inverse Definitive Humeral Component Implantation 45

Exchange from and Anatomic Shoulder Replacement to an Inverse Shoulder ReplacementRemoval of the Anatomic Components 47

Inverse Definitive Glenoid Dome Implantation 48

Inverse Definitive Humeral Component Implantation 49Reduce and Close 50

Vaios in Proximal Humeral Fractures 51

Instrument tray listings 55

Implant listings 59

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IndicationsAn anatomic shoulder system is indicated for the following conditions where the humerus is of sufficient bonestock and there is presence of an intact or reconstructable rotator cuff which is necessary for proper functioning and dislocation resistance. 1. Acute traumatic fracture of the humeral head.2. Correction of a painful and disabling functional deformity3. A painful and disabling arthritis with a reconstructable rotator cuff4. A painful and disabling post – traumatic arthritis5. Severely painful and/or disabled shoulder joint from osteoarthritis or rheumatoid arthritis.Where painful and disabling arthritis of the shoulder with a massive, irreparable rotator cuff tear is indicated, the inverse shoulder system is available. Specific indications include:1. Cuff tear arthropathy2. Difficult clinical management problems where other methods of treatment may not be suitable or

may be inadequate.The general principles of patient selection and sound surgical judgement apply to proximal humeral replacement and shoulder procedures. Preoperative planning and meticulous surgical technique are essential to achieve optimal results. Considerations of anatomic loading, soft tissue condition and component placement are critical to minimise a variety of postoperative complications.

Contraindications The device should NOT be implanted where there is active infection, sepsis, osteomyelitis, or insufficient bone stock to support the prosthesis or provide adequate fixation. Further contra-indications may be, but are not limited to the following conditions:1. Severe deformities, painful disabling deformities.2. Severe Osteoporosis.3. Neuropathic joints4. Paralytic disorders5. Tumours. 6. Systematic and metabolic disorders.7. Obesity.8. Drug addiction. 9. In the absence of a effective shoulder cuff a inverse is indicated, unless the Deltoid is ineffectuall.

Preoperative EvaluationThis prosthesis is to be used only under the control and supervision of an accredited Orthopaedic Surgeon. The surgeon is responsible for the operative technique used for implanting the product, however JRI recommend that to ensure optimum implantation of this device the recommended operative technique is used, with JRI specific instrumentation. Always use a trial for any test fit and to check the range of motion. No responsibility can be taken for complications due to improper implantation technique or non-specific instrumentation. Failure to use the optimum size of implant, to adequately seat the component adjacent to endosteal bone or to ensure the component is supported and stable, may result in dislocation, subsidence, fracture or loosening of the components. Implants MUST NOT be re-used as the fatigue strength and mechanical properties of the implant may be impaired from previous actions. All modular junctions must be firmly impacted together to prevent dissociation. Taper joints should be clean and dry prior to impaction. Repeated assembly and disassembly of modular components could compromise the locking action of the taper joint. Wherever possible, modular junctions should be assembled prior to implantation.

Indications

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Delto-pectoral surgical approach – Recommended for Hemi-arthroplasty and Total Shoulder Replacement

Patient position – common for both approachesThe patient should be placed in the beach chair position, with the head secured by a neurosurgical headpiece, and the arm resting on a short arm board attached to the side of the operating table. Bear in mind the humerus will have to be extended during the procedure to deliver the humeral head into the anterior wound.

The long anterior delto-pectoral approach, modified from that described by Neer, Watson and Stanton (1982), is the recommended standard surgical approach. Notably, this procedure exposes the front of the gleno-humeral joint and both the upper humeral shaft and the humeral head, but provides only limited access to the glenoid.

The incision The 15 cm incision should be made immediately below the clavicle downwards and across the tip of the coracoid; it should continue in a straight line to reach the anterior border of the insertion of the deltoid.

Primary dissection Mobilise the cephalic vein. This is achieved by appropriate cauterisation of the vein’s lateral tributaries in the delto-pectoral groove. The vein can then be retracted medially, whereas the deltoid is retracted laterally. The arm should be abducted by 40° - 60°, and resting on a suitably draped Mayo table or arm board is recommended. The clavipectoral fascia is then incised, the subacromial space cleared, and a broad

elevator positioned beneath the acromion as a retractor. Note: when this point is reached, an improved exposure may be gained by dividing the proximal 2 cm of the insertion of pectoralis major. The shoulder should then be flexed and externally rotated; this facilitates coagulation of the anterior circumflex humeral vessels. It is imperative, at this point, to insert stay sutures into the subscapularis muscle to control retraction, aid manipulation of the tendon during mobilization and the release of the soft tissues. Additionally, sutures will protect the adjacent brachial plexus which lies very close (only 2 to 3 cm medially).

The original description of this procedure recommended the tendon and underlying capsule was divided 2 cm medial to the bicipital groove, however, our preference is to ostetomise the lesser tuberosity (see below for description) as this provides a markedly stronger reattachment. Should the subscapularis appear to be tight, it can be mobilised by performing a capsulotomy along the anterior glenoid rim and releasing the tendon from the anterior scapula by blunt dissection using a finger as an elevator. We also recommend detaching the coraco-humeral ligament from the coracoid; this results in improved mobilization of the soft tissues.

Throughout this procedure it is vital to protect the axillary nerve with a blunt elevator where the nerve passes through the quadrilateral space. Subsequently, the glenohumeral joint can be dislocated anteriorly via external rotation and

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Antero-superior surgical approach – For Total Shoulder Replacements

extension, to give full exposure of the humeral head and neck.

The extended deltopectoral approach is commonly used for total shoulder replacement; however, with that procedure, it often proves difficult to obtain satisfactory exposure of the glenoid in well-muscled individuals. Inevitably, heavy retraction of the mid part of the deltoid is damaging, and partial detachment of the origins or insertion of the deltoid has to be performed to avoid this. By contrast, the antero-superior approach provides an excellent face-on view of the glenoid, and this allows more accurate preparation and implantation of a glenoid component. Additionally, deltoid retraction damage is avoided by splitting the anterior third fibres of the deltoid and preserving the cephalic vein. The limiting factor associated with the antero-superior approach is the distal split of the deltoid. This must not exceed 5 cm from the acromion; otherwise there is a risk of damaging the axillary nerve. Accordingly, the antero-superior approach is not recommended for proximal humerus reconstructions that involve displaced three- and four-part fractures and hemi-arthroplasty. For these procedures the deltopectoral approach is more suitable and gives improved exposure.

The incision Commence with a 9 cm skin incision that extends distally in a straight line from just posterior to the acromioclavicular joint. The anterior deltoid fibres are then split. Care is needed to ensure the split does not exceed 5 cm. Place a loose number 1 stay suture

in the distal end of the split; this will prevent further extension and avoid potential axillary nerve damage. Use of an periosteal flap to expose the anterior acromion (and preserve the superior acromioclavicular ligament) now allows the acromial attachment of the deltoid to be lifted. An anterior acromioplasty can now be now conducted. Should further exposure be needed, excision of the lateral end of 1 cm of clavicle will facilitate this.

Primary dissection The subscapularis tendon is brought into view by retraction of the conjoined tendons and is incised approximately 1.5 cm medial to its insertion. Note: a ‘Z- lengthening’ may be performed if the tendon is contracted; this can be achieved by incising the muscles separately from the capsule, so the muscle is divided laterally. This in turn is swept medially. The capsule is then divided separately and just lateral to the glenoid rim. Subsequently, when repairing the subscapularis, the surgeon has the option to attach the subscapularis tendon to the lateral capsule, thereby gaining further length and facilitating external rotation. The humeral head can now be removed and the medulla prepared by extending the arm and ensuring it is lying almost vertically. Reaching this point allows entrance of the medullary reamers. Now the glenoid can be exposed by inserting a Fukuda retractor behind the glenoid posterior rim, and a Carter Rowe spike in front of it. It is now possible to retract the anterior soft tissues medially. Depression of the proximal humerus will give a clearer view of the face of the glenoid.

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The surgical approach used depends on whether the Supraspinatus tendon is intact or torn. In patients with an intact Supraspinatus an Anterior Delto-Pectoral or Extensile Delto- Pectoral approach is recommended (page 5). If the supraspinatus is torn, a superior McKenzie type approach is recommended (page 5).

Pierce the humeral head using the universal drill, medial to the greater tuberosity, and drill to the maximum depth of drill (Fig. 1).

Preparation of Humerus –Common for Anatomic & Inverse

Fig. 1 Fig. 2

Depth marking

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Slide the jig body over the reamer and attach the cutting block by sliding it onto the jig body arm. Attach and tighten the locking screw to prevent the cutting block from moving (Note: the screw has a small ’nipple’ at the bottom of the thread which engages into the groove on the jig body arm). Align the cutting block with the anatomic neck of the humerus. Screw the alignment guide into the 20° retroversion hole and check the alignment of the rod with the forearm with the elbow at 90°. If alignment is not achieved, increase or decrease the degree of version incrementally until the alignment guide aligns with the forearm (Fig. 3).

When alignment is achieved, position the cutting block congruent with the humeral head. Check the height of resection by inserting the rotator cuff resection guide through the humeral cutting block slot, paying particular attention to the

position of the planned osteotomy in relation to the rotator cuff insertion point (Fig. 4).

If the position of the resection appears to be too aggressive, move the cutting jig superiorly and recheck the cuff footprint for potential violation.

Using the universal drill, drill pilot holes through one of the medial holes and one through a lateral hole until the cortices are breached. The decision on which hole to use depends on the diameter of the bone and which hole would provide the best anchorage (Fig. 5).

Insert the humeral cutting block screws using the humeral fixing screwdriver shaft attached to the screwdriver handle (Fig. 6), then disassemble the jig body, leaving the block in position.

Delto-Pectoral Approach

Fig. 3

Fig. 5

Fig. 4

Fig. 6

Cutting Block

Jig Body Arm

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Delto-Pectoral Approach

The neck resection angle is 130°. The resected articular surface is then sized using the humeral head sizing template and the best-fit diameter is noted (Fig. 10).

It is recommended that the saw blade used should be 1.5cm wide, with a maximum thickness of 0.75mm.

Remove the 8 mm diameter reamer leaving the jig in situ (Fig. 7). If additional security is required for the cutting block, drill a pilot hole into one of the central cutting block holes, and insert an additional cutting block screw. Use the superior slot of the cutting block as a resection guide, keeping the oscillating sawblade flat, resect the humeral head and inspect the resected surface for improper alignment and resection height (Fig. 8). If additional bone removal is required an additional cutting slot is available (this represents a 3 mm additional resection (Fig. 9).

Fig. 7

Fig. 9

Fig. 10

Fig. 8

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Superior McKenzie Approach

Assemble the superior cutting jig assembly as shown in the diagram and align the cutting block with the anatomic neck of the humerus.

Slide the cutting jig bush onto the arm of the jig body, aligning the laser marks B to B and secure in place with a screw. Slide the cutting block arm through the jig bush, aligning laser marks A to A and secure in place with a screw (Fig. 1).

The fully assembled cutting jig assembly is illustrated in (Fig. 2) .

Slide the cutting jig assembly over the 8 mm diameter reamer. Screw the alignment guide into the 20° retroversion hole and check for alignment of the rod with the forearm (Fig. 3). If alignment is not achieved, increase or decrease the degree of version incrementally until the alignment guide aligns with the forearm. When alignment is achieved, position the cutting block congruent with the humeral head.

Fig. 1 Fig. 2

Jig Bush

Jig Body

Cutting block

Fig. 3

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Superior McKenzie Approach

Check the height of the resection by inserting the rotator cuff resection guide through the cutting block slot, paying particular attention to the resection in relation to the remaining rotator cuff tendon insertions. If the resection is too aggressive, move the cutting jig superiorly and recheck the cuff footprint for potential violation (Fig. 4).

Using the universal drill, drill pilot holes through the anterior and posterior holes until the cortices are breached.

Insert the cutting block screws using the humeral fixing screwdriver shaft attached to the screwdriver handle (Fig.5). Disassemble the

jig body, leaving the cutting block in position. Remove the 8 mm diameter reamer and retighten the cutting block screws.

Keeping the oscillating saw-blade flat, resect the humeral head and inspect the resected surface for improper alignment and resection height (Fig. 6).

The resected articular surface is then sized using the humeral head sizing template and the best-fit diameter is noted ( Fig. 7).

Turn to page 32 for Total Inverse Shoulder Replacement Operative Technique.

Fig. 6

Fig. 4

Fig. 7

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Anatomic Shoulder Preparation and Implantation

Surgical Technique

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Remove the cutting block and continue to ream the humeral canal sequentially until cortical contact is achieved (Fig. 1).

Note: do not over ream. If the size required sits between two sizes, select the smaller size. i.e if the size is between 10 mm diameter and 12 mm diameter select the 10 mm diameter stem.

Broaching the Humerus

Assemble the humeral stem broach body onto the humeral broach handle. Having noted the reamer diameter used in the canal preparation, assemble the appropriate humeral broach centraliser with diameter one size down from the reamed cavity (Fig. 2) and hand tighten by engaging the hex screwdriver into the bottom of the centraliser.

Fig. 1

Fig. 2

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Place the broach assembly into the humeral canal and attach the alignment guide with 20 degrees of retroversion. If alignment is not achieved, increase or decrease the degree of version incrementally until the alignment guide aligns with the forearm (Fig. 3).

Broach the humeral canal in and out cautiously, such that the broach body is 1 mm above the resection line. Disengage the broach handle leaving the broach assembly in position (Fig. 4).

Inspect the resected surface to assess if the resection is uneven in relation to how the broach seats with the cut surface of the humerus. If the cut is slightly offline use the calcar reamer to trim the humerus evenly (Fig. 5).

The resected humeral surface is protected by engaging the humeral resection plate into the central hole of the broach body (Fig. 6).

Fig. 3

Fig. 5

Fig. 4

Fig. 6

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Preparing the Glenoid Surface – Cemented & Uncemented

Expose the whole of the glenoid and trim any osteophytes which might be present on the anterior glenoid rim (Fig. 1). Using the glenoid guide-wire centraliser (small or large size will be determined by the best glenoid coverage), align the superior and inferior aspects of the centraliser with the superior and inferior aspects of the glenoid. Ensure that the anterior glenoid jig guide-plate lies directly on the bone of the anterior scapular neck (Fig. 2).

Drill through the central-hole in the glenoid jig using the universal drill. Remove the drill and glenoid jig. Insert the sterile packed glenoid guide-wire using the guide-wire extractor. This now acts as a guide for the central-hole reamer (Fig. 4).

Fig. 1 Fig. 2

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Assemble the glenoid central-hole reamer either to the straight or angled reamer shaft and ream through the glenoid surface (Fig. 5) until the medial plane of the glenoid central-hole reamer sits flush with the subchondral bone ensuring you have bleeding bone present (Fig. 6).

The central peg hole and the central reaming is now complete (Fig. 7).

Note: the aim of the glenoid central–hole reamer is to create the central peg hole and to remove the articular cartilage on the central face of the glenoid. The glenoid reamer depth stop and the peripheral glenoid reamer are used to ream the articular surfaces of the superior and inferior aspects of the glenoid.

Fig. 6Fig. 5

Fig. 7

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Preparing the Glenoid Surface – Cemented & Uncemented

Remove the guide-wire (using the guide–wire extractor) and insert the glenoid reamer offset depth stop either standard or short (Fig. 8), positioning the offset depth stop pin in the 12 o’clock position on the glenoid face (Fig. 9).

Note: the depth stop must be countersunk 1 mm below the pre-reamed central hole before peripheral reaming is performed.

Using the peripheral glenoid reamer (Fig. 10) ream the superior aspect of the glenoid face (Fig. 11). The reamer will abut the offset depth stop at the required depth preventing excessive reaming.

Fig. 9

Fig. 10

Fig. 8

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Extract the depth stop and re-insert in the 6 o’clock position (Fig. 12). Ream the inferior aspect of the glenoid face (Fig. 13), using the peripheral glenoid reamer.

The glenoid face is now fully prepared leaving a concave surface ready for trialling (Fig. 14).

Fig. 13

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Cemented All Polyethylene Glenoid Preparation & Trialling – for Anatomical Shoulder Use Only

Assemble the cemented glenoid drill guide and handle, corresponding to a left (LH) or right (RH) shoulder (Fig. 1). Re-insert the glenoid guide-wire (Fig. 2). Screw the cement hole drill on to either the straight or angled glenoid reamer shaft. Drill the superior hole first (Fig. 3) ensuring the drill penetrates fully. Insert the glenoid drill dowel into the superior hole (Fig. 4). Continue to drill the remaining holes.

Note: when using the angled glenoid reamer it is important to grasp the angled part of the reamer shaft firmly to prevent the reamer from vibrating out of position.

Fig. 2

Fig. 3

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The glenoid is now fully prepared for trialling (Fig. 5).

Fig. 5

Remove the drill guide and dowel and proceed to trial the cemented glenoid component. Select the trial glenoid (small or large) depending upon the best coverage of the glenoid fossa. The liner bearing size is determined to be 4mm larger than that of the measured resected humeral head, i.e. if the resected head is 42mm the glenoid size should be 46mm. The glenoid bearing size should always be greater than that of the humeral head to allow a radial miss-match.

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Place the trial glenoid into position (Fig. 6).

Insert the trial humeral head into the humeral broach body (Fig. 7). The diameter of the trial head is determined by the diameter of the resected humeral head.

The humeral head central peg is eccentric and is offset by 3 mm or 6 mm (Fig. 8). Beginning with a 3 mm offset, attempt to cover fully the resected humerus by rotating the head. A humeral rotator

pin can be used to rotate the head by inserting it into one of the holes on the outer edge of the trial humeral head. If coverage is not achieved, replace with a 6 mm offset head and repeat until coverage is achieved. Make a note of which offset (3 mm or 6 mm) achieves best coverage of the resection.

Trial Reduction and Definitive Cemented Glenoid Implantation

Fig. 6Fig. 7

3 mm eccentric offset

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Reduce the shoulder (Fig. 9) and conduct the 6 Nottingham tests described on page 31.

Remove the trial glenoid and trial humeral head. Irrigate the cement holes carefully to remove any bone or blood. Dry the holes and insert a small amount of bone cement into each hole

and pressurise lightly with your fingertip. Place a small amount of cement on the back side of the glenoid and insert by pushing into place using finger pressure only. Do not impact the glenoid (Fig. 10).

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Select the trial glenoid metal-back, small or large depending upon the best coverage of the glenoid fossa (Fig. 1).

The liner bearing size is determined to be 4mm larger than that of the measured resected humeral head, i.e. if the resected head is 42mm the glenoid size should be 46mm. The glenoid bearing size should always be greater than that of the humeral head to allow a radial miss-match.

Insert the trial humeral head into the humeral broach body (Fig. 2). The diameter of the trial head is determined by the diameter of the resected humeral head.

The humeral head central peg is eccentric and is offset by 3 mm or 6 mm (Fig. 3). Beginning with a 3 mm offset, attempt to cover fully the resected humerus by rotating the head. A humeral rotator pin can be used to rotate the head by inserting it into one of the holes on the outer edge of the trial humeral head . If coverage is not achieved, replace with a 6 mm offset head and repeat until coverage is achieved. Make a note of which offset (3 mm or 6 mm) achieves best coverage of the resection.

Reduce the shoulder and conduct the 6 Nottingham tests described on page 31.

Uncemented Glenoid Preparation & Trialling – for Anatomic Shoulder Only

Fig. 1 Fig. 2

3 mm eccentric offset

Fig. 3

Fig. 4

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Anatomic

Uncemented

Remove all the trial components and insert the definitive metal-back glenoid component using the glenoid forceps (Fig. 1). Press firmly into position. Check the inferior glenoid hole is aligned with the lateral scapular spine. Using the tommy bar as an impactor, impact the glenoid metal-back using the central peg hole (Fig. 2).

Using the universal drill and the uncemented angled drill guide, pre-drill slightly divergent screw holes into the superior and inferior glenoid holes ensuring that the best bone stock is used for superior fixation (Fig. 3)

The screw position can be adjusted up to +/- 15° to obtain optimum positioning of the screws.

Use the depth gauge to measure the length of the screw required. Insert the superior and inferior screws first and tighten into position using the 3.5 mm screwdriver. Use the drill guide and universal drill to drill the anterior and posterior drill holes, converging the holes as much as possible. Once again, use the depth gauge to determine the correct length of screw.

Screws are provided in 5mm increments from 20mm to 40mm length.

Uncemented Glenoid Definitive Implant Assembly & Implantation

Fig. 1 Fig. 2

Fig. 4

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Once all of the screws have been tightened, impact the glenoid metal-back with the tommy bar and re-tighten all four screws.

Screw caps are used to lock the superior and inferior screws (Fig. 5). The screw caps come with their own introducer handle which snaps off at a specified torque. Engage the screw threads

Uncemented Glenoid Definitive Implant – Assembly & Implantation

by hand, once the threads are engaged use a 3.5 mm hex screwdriver to tighten the caps (Fig. 6). The introducer will break off when torqued to the required force, a screw cap handle is available to apply additional tightening to the screw caps if necessary (Fig. 7).

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Insert the definitive glenoid insert using the introduction plastic tipped forceps. Engage the liner into the groove on the inferior glenoid metal-back (Fig. 8), push the bearing peg into the central hole, remove the forceps and impact it fully with the V-shaped impactor (Fig. 9). Check the glenoid bearing is fully seated by running a McDonald around the rim of the liner.

The glenoid components are now fully assembled (Fig 10).

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Humeral Component Definitive Implantation Assembly

Remove the humeral broach from within the humeral shaft by reattaching the broach handle.

The humeral components come separately packed and require assembly before implantation. The humeral neck and the distal stems lock together using a screw fit and a Morse taper connection.

Separate the broach from the broach handle and mount the definitive humeral neck (H-A.C. coated) onto the broach handle using a no-touch technique.

Select either a cemented or uncemented (H-A.C.) distal humeral stem and mount onto the screwdriver/ torque handle using a no-touch technique. Screw the humeral stem into the humeral neck. Slide a tommy bar through the hole in the broach handle to counterforce the torque handle. Fully tighten the two components together ensuring that the torque handle ‘cracks’, indicating full assembly (Fig. 1).

For the 6 mm cemented humeral stem, assemble the stem to the neck using the 12 mm A/F spanner and locate it just distal to the Morse taper connection.

Cemented Uncemented(H-A.C.)

Universal humeral neck

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If the humeral component is being cemented, a stem the same size as the final humeral reamer should be selected as the fluted design of the stem allows for an appropriate cement mantle. Leaving cement around the proximal H-A.C. coated portion of the humeral neck must be avoided. Insert a cement restrictor below the depth of the definitive prosthesis and fill the humerus with cement using light finger pressure.

The use of pressurised cement is not required and its use may fracture the humerus if employed.

The cemented distal stem may, optionally, be

used as a cementless component, provided

that adequate proximal fixation can be

achieved with the hydroxyapatite coated

humeral neck component.

The alignment guide is used to position the

implant at the same version as determined

by the humeral broach (Fig. 3). The implant is

then pushed into the humerus with care and lightly impacted such that 1mm of the humeral neck component extends above the resection line (Fig. 4).

Note: long 220 mm cemented humeral stems are available for revision or fracture cases.

These stems are provided to bypass deficient areas in the humeral shaft and should not be used to provide distal fixation.

Periprosthetic fractures should be treated conservatively until the fracture has healed.

Cemented Humeral Stem Implantation

Fig. 2 Fig. 4Fig. 3

1 mm proud of the resection line

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Fig.1 Fig. 3Fig. 2


Uncemented Humeral Stem Implantation

Select the H-A.C. distal humeral stem based on the final reamer used (Fig. 1). The definitive prosthesis is assembled and pushed into the humerus with care and is lightly impacted. The

alignment guide is used to position the implant at the same version as determined by the broach (Fig. 2). Ensure the neck component extends 1 mm above the resection (Fig. 3).

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Anatomic Shoulder Humeral Head Insertion

Clean and dry the internal taper within the humeral neck with the sterile pack taper swab. Place the definitive humeral head, as determined by the trial reduction (3 mm or 6 mm eccentric) into the neck taper. Rotate the head to cover fully the resected humerus by rotating the humeral head. A humeral rotator pin can be used to rotate the head by inserting it into one of the holes on the outer edge of the humeral head and rotating it to achieve optimal coverage (Fig. 1).

Lock the humeral head in position using two sharp blows through the impactor (Fig. 2). Check the humeral head for complete engagement of the taper.

Reduce the shoulder and conduct the 6 Nottingham shoulder tests on page 31.

Full details on closure are described on page 52.

Fig. 1 Fig. 2

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Reduce the joint and confirm stability.Conduct the 6 Nottingham Tests for placement and soft tissue balance:

1 Is the apex of the humeral head in line with, or up to 3 mm above, the greater tuberosity?

2 Can the surgeon’s little finger be passed between the greater tuberosity and the acromion superiorly?

3 Is the posterior humeral head tenting the posterior rotator cuff (felt by slipping the surgeon’s finger between the deltoid and the proximal humerus/infraspinatus)?

4 In neutral rotation, if the humeral head is pushed backwards does it jump back to its centralised position on the glenoid?

5 Can the back of the patient’s hand be placed on the patient’s ipsilateral buttock (internal rotation test)?

6 With the subscapularis/lesser tuberosity held in position can the shoulder be externally rotated to over 40 degrees (external rotation test)?

These tests guide the surgeon to adjust the implants appropriately to achieve the ideal prosthesis placement and soft-tissue balances.

Nottingham Tests

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Inverse Shoulder Preperation and Implantation

Surgical Technique

Inverse

3232

Remove the cutting block and continue to ream the humeral canal sequentially until cortical contact is achieved (Fig. 1).

Note: do not over ream. If the size required sits between two sizes, select the smaller size. i.e if the size is between 10 mm diameter and 12 mm diameter select the 10 mm diameter stem.

Assemble the humeral stem broach body onto the humeral broach handle. Having noted the reamer diameter used in the canal preparation, assemble the appropriate humeral broach centraliser with diameter one size down from the reamed cavity (Fig. 2) and hand tighten by engaging the hex screwdriver into the bottom of the centraliser.

Broaching the Humerus

Fig. 1

Fig. 2

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Place the broach assembly into the humeral canal and attach the alignment guide with 20 degrees of retroversion. If alignment is not achieved, increase or decrease the degree of version incrementally until the alignment guide aligns with the forearm (Fig. 3).

Broach the humeral canal in and out cautiously, such that the broach body is 1 mm above the resection line. Disengage the broach handle leaving the broach assembly in position (Fig. 4).

Inspect the resected surface to assess if the resection is uneven in relation to how the broach seats with the cut surface of the humerus. If the cut is slightly offline use the calcar reamer to trim the humerus evenly (Fig. 5).

The resected humeral surface is protected by engaging the humeral resection plate into the central hole of the broach body (Fig. 6).

Fig. 3

Fig. 5

Fig. 4

Fig. 6

Cemented

InverseUncem

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3434

Preparing the Glenoid Surface – Uncemented

Expose the whole of the glenoid and trim any osteophytes which might be present on the anterior glenoid rim (Fig. 1). Using the glenoid guide-wire centraliser (small or large size will be determined by the best glenoid coverage), align the superior and inferior aspects of the centraliser with the superior and inferior aspects of the glenoid. Ensure that the anterior glenoid jig guide-plate lies directly on the bone of the anterior scapular neck (Fig. 2).

Drill through the central-hole in the glenoid jig using the universal drill. Remove the drill and glenoid jig. Insert the sterile packed glenoid guide-wire using the guide-wire extractor. This now acts as a guide for the central-hole reamer (Fig. 4).

Fig. 1 Fig. 2

Fig. 4Fig. 3

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InverseUncem

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Assemble the glenoid central-hole reamer either to the straight or angled reamer shaft and ream through the glenoid surface (Fig. 5) until the medial plane of the glenoid central-hole reamer sits flush with the subchondral bone ensuring you have bleeding bone present (Fig. 6).

The central peg hole and the central reaming is now complete (Fig. 7).

Note: the aim of the glenoid central–hole reamer is to create the central peg hole and to remove the articular cartilage on the central face of the glenoid. The glenoid reamer depth stop and the peripheral glenoid reamer are used to ream the articular surfaces of the superior and inferior aspects of the glenoid.

Fig. 6Fig. 5

Fig. 7

36

Remove the guide-wire (using the guide–wire extractor) and insert the glenoid reamer offset depth stop, either standard or short, (Fig. 8) positioning the offset depth stop pin in the 12 o’clock position on the glenoid face (Fig. 9).

Note: the depth stop must be countersunk 1 mm below the pre-reamed central hole before peripheral reaming is performed.

Using the peripheral glenoid reamer (Fig. 10) ream the superior aspect of glenoid face (Fig. 11). The reamer will abut the offset depth stop at the required depth preventing excessive reaming.

Fig. 9

Fig. 10

Fig. 8

Fig. 11

Preparing the Glenoid Surface – Uncemented

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InverseUncem

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Extract the depth stop and re-insert in the 6 o’clock position (Fig. 12). Ream the inferior aspect of the glenoid face (Fig. 13), using the peripheral glenoid reamer.

Following glenoid reaming the inferior surface of the glenoid should be examined; if any prominent bone is evident it should be carefully resected back to the level of the reamed glenoid surface.

The glenoid face is now fully prepared leaving a concave surface ready for trialling (Fig. 14).

Fig. 13

Fig. 14

Fig. 12

38

Glenoid Definitive Implant Assembly & Implantation

Prior to placing the Glenoid metal back into the prepared glenoid, the plug in the base of the metal back covering the threaded hole for the taper retaining screw should be removed (Fig. 1). For this use the cemented drill guide handle 870-09-01. If removed post fixation into the glenoid, then caution should be taken not to allow the small plug to fall into the wound.

Insert the definitive metal-back glenoid component using the glenoid forceps (Fig. 2). Press firmly into position. Check the inferior glenoid hole is aligned with the lateral scapular spine. Using the tommy bar as an impactor, impact the glenoid metal-back using the central peg hole (Fig. 3).

Using the universal drill and the uncemented angled drill guide, pre-drill slightly divergent screw holes into the superior and inferior glenoid holes, ensuring that the best bone stock is used for superior fixation (Fig. 4)

The screw position can be adjusted up to +/- 15° to obtain optimum positioning of the screws.

Use the depth gauge to measure the length of the screw required. Insert the superior and inferior screws first and tighten into position using the 3.5 mm screwdriver. Use the drill guide and universal drill to drill the anterior and posterior drill holes, converging the holes as much as possible. Once again use the depth gauge to determine the correct length of screw.

Fig. 2Fig. 1 Fig. 3

Fig. 5

Fig. 4

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InverseUncem

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Fig. 6

Screws are provided in 5 mm increments from 20 mm to 40 mm.

Once all of the screws have been tightened, impact the glenoid metal-back with the tommy bar and re-tighten all 4 screws.

Screw caps are used to lock the superior and inferior screws (Fig. 6). The screw caps come with their own introducer handle which snaps off at a specified torque. Engage the screw threads by hand, once the threads are engaged use a 3.5 mm hex screwdriver to tighten the caps (Fig. 7). The introducer will break off when torqued to the required force, a screw cap handle is available to apply additional tightening to the screw caps if necessary (Fig. 8). The glenoid metal-back is now fully prepared.

Fig. 7

Fig. 8

40

Insert the inverse glenoid dome trial into the glenoid metal-back (Fig. 1). There is only one diameter of dome available (42 mm).

Insert the inverse cup trial into the broach body ensuring the correct orientation of the trial, then insert the inverse cup trial insert. Three inverse cup liners are available, 0 mm, +3 mm and +6 mm, initially start with 0 mm thickness(Fig. 2).

Note: the neck shaft angle is increased to 150° once the inverse humeral cup and liner are in position.

Reduce the joint and check deltoid tension. If additional deltoid tension is required, insert a thicker inverse cup insert (+3 mm or +6 mm).

After the correct implants have been determined remove all trial components.

Inverse Shoulder Trialling

Fig. 1

Fig. 2

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Cemented

Inverse

Humeral Component Definitive Implantation Assembly

Remove the humeral broach from within the humeral shaft by reattaching the broach handle.

The humeral components come separately packed and require assembly before implantation. The humeral neck and the distal stems lock together using a screw fit and a Morse taper connection.

Separate the broach from the broach handle and mount the definitive humeral neck (H-A.C. coated) onto the broach handle using a no touch technique.

Select either a cemented or uncemented (H-A.C.) distal humeral stem and mount onto the screwdriver/ torque handle using a no-touch technique.

Screw the humeral stem into the humeral neck. Slide a tommy bar through the hole in the broach handle to counterforce the torque handle. Fully tighten the two components together ensuring that the torque handle ‘cracks’, indicating full assembly (Fig. 1).

For the 6 mm cemented humeral stem, assemble the stem to the neck using the 12 mm A/F spanner and locate it just distal to the Morse taper connection.

Cemented Uncemented(H-A.C.)

Universal humeral neck

Fig. 1

Uncemented

42

Fig. 1 Fig. 3Fig. 2


If the humeral component is being cemented, a stem the same size as the final humeral reamer should be selected as the fluted design of the stem allows for an appropriate cement mantle. Leaving cement around the proximal H-A.C. coated portion of the humeral neck must be avoided. Insert a cement restrictor below the depth of the definitive prosthesis and fill the humerus with cement using light finger pressure.

The use of pressurised cement is not required and its use may fracture the humerus if employed.

The cemented distal stem may, optionally, be

used as a cementless component, provided

that adequate proximal fixation can be

achieved with the hydroxyapatite coated

humeral neck component.

The alignment guide is used to position the

implant at the same version as determined by

the humeral broach (Fig. 2). The implant is then pushed into the humerus with care and lightly impacted such that 1 mm of the humeral neck component extends above the resection line (Fig. 3).

Note: long 220 mm cemented humeral stems are available for revision or fracture cases.

These stems are provided to bypass deficient areas in the humeral shaft and should not be used to provide distal fixation.

Periprosthetic fractures should be treated conservatively until the fracture has healed.

Cemented Humeral Stem Implantation

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Fig. 1 Fig. 3Fig. 2

Uncemented Humeral Stem Implantation

Select the H-A.C. distal humeral stem based on the final reamer used (Fig. 1). The definitive prosthesis is assembled and pushed into the humerus with care and lightly impacted. The

alignment guide is used to position the implant at the same version as determined by the broach (Fig. 2). Ensure the neck component extends 1 mm above the resection line (Fig. 3).

44

Inverse Definitive Glenoid Dome Implantation

Ensure that all osteophytes have been removed from the inferior glenoid rim as failure to do so will prevent the inverse dome from seating correctly.

Clean and dry the internal taper of the glenoid metal-back using a sterile packed taper swab.

Attach the inverse dome introducing forceps to the dome by locating the prongs into the dome’s anterior and posterior holes (Fig 1).

Using the introducer, guide the Morse taper peg into the glenoid metal-back. Once partially seated, remove the introducer. Check the dome is rotationally locked in the correct position. Lock the dome into position, using the head impactor, with two sharp

hammer blows (Fig. 2). Check the dome for complete engagement of the taper.

Once dome has been securely impacted insert a dome taper retaining screw 801.09.12 through the dome into the screw hole at the base of the metal back glenoid (Fig. 3). Tighten using the 3.5 hex screw driver (Fig. 4). Then, using the modular 3.5mm hex driver shaft fixed to the ‘T’ Handle tighten further by half a turn or so. But do not use excessive force (Fig. 5) and (Fig.6).

Fig. 3

Fig. 6

Fig. 4 Fig. 5

Fig. 1 Fig. 2

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Cemented

Uncemented

Insert the inverse cup baseplate component into position using finger pressure, ensuring the medial and lateral aspects of the plate are correctly orientated. Locate the taper impactor into the central hole in the baseplate. Lock the taper together by using two sharp blows on the strike plate of the taper impactor (Fig. 1).

A taper retaining screw is inserted through the hole in the baseplate and hand tightened using a 3.5 mm hex screwdriver (Fig. 2).

Insert the correct inverse cup insert, medial side first, by sliding it under the dome. Distract the humerus laterally to enable the liner to follow the curve of the dome until it engages under the medial lip of the humeral baseplate.Using the ‘V’ impactor, impact on the lateral aspect of the cup insert (Fig. 3).

Reduce the joint and check for stability (Fig. 4).

Inverse Definitive Humeral Dome Implantation

Fig. 1 Fig. 2

Fig. 3 Fig. 4

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Exchange from Anatomic Shoulder Replacement

to Inverse Shoulder Replacement

Exchange From Anatomic to Inverse

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Cemented

Uncemented

Exchange

Slide the wedge between the humeral head and the humeral neck and impact lightly (Fig. 1). This action separates the humeral head from the humeral neck.

Drill through the centre of the glenoid insert using the universal drill until the drill penetrates fully through the polyethylene insert (Fig. 2).

Use a 30 mm bone screw to screw through the hole until the screw hits the medial most part of the glenoid metal-back (Fig. 3). This action will force the insert out of the metal-back without causing any damage.

Once removal of Polyethylene insert is completed inspect the base central peg hole in the metal back glenoid and if present remove the screw cap plug.

Note: Taper retaining screws for the inverse domes where introduced in February 2012. If the metal back was inserted prior to this date it will not have a screw thread in the base of the metal back’s central peg and will not take a taper retaining screw. These older style metal backs will be either product code 801-09- 10 or a 801-09- 11 and will need the older style inversedomes 803-03-00.

These we can provide by special order only.

Removal of the Anatomic Components

Fig. 1 Fig. 2

Fig. 3

48

Inverse Definitive Glenoid Dome Implantation

Ensure that all osteophytes have been removed from the inferior glenoid rim as failure to do so will prevent the inverse dome from seating correctly.

Clean and dry the internal taper of the glenoid metal-back using a sterile packed taper swab.

Attach the inverse dome introducing forceps to the dome by locating the prongs into the dome’s anterior and posterior holes (Fig 1).

Using the introducer, guide the Morse taper peg into the glenoid metal-back. Once partially seated, remove the introducer. Check the dome is rotationally locked in the correct position. Lock the dome into position, using the head

impactor, with two sharp hammer blows (Fig. 2). Check the dome for complete engagement of the taper.

Once dome has been securely impacted insert a dome taper retaining screw 801.09.12 through the dome into the screw hole at the base of the metal back glenoid (Fig. 3). Tighten using the 3.5 hex screw driver (Fig. 4). Then, using the modular 3.5mm hex driver shaft fixed to the ‘T’ Handle tighten further by half a turn or so. But do not use excessive force (Fig. 5) and (Fig.6).

Fig. 3

Fig. 6

Fig. 4 Fig. 5

Fig. 1 Fig. 2

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After the correct implants have been determined remove all trial implants.

Insert the correct inverse cup insert, medialside first, by sliding it under the dome. Distract the humerus laterally to enable the liner to follow the curve of the dome until it engages under the medial lip of the humeral baseplate. Using the ‘V’ impactor, impact on the lateral aspect of the cup insert (Fig. 4).

Reduce the joint and check for stability (Fig. 5).

Insert the inverse cup baseplate component into position using finger pressure, ensuring the medial and lateral aspects of the plate are correctly orientated. Locate the taper impactor into the central hole in the baseplate. Lock the taper together by using two sharp blows on the strike plate of the taper impactor (Fig. 3).

A taper retaining screw is inserted through the hole in the baseplate and hand tightened using a 3.5 mm hex screwdriver (Fig. 2).

Insert the 0 mm inverse cup trial insert and reduce the joint. Check deltoid tension and stability (Fig. 3). If additional deltoid tension is required, insert a thicker inverse cup insert (+3 mm or +6 mm).

Inverse Definitive Humeral Component Implantation

Fig. 1 Fig. 2 Fig. 3

Fig. 4 Fig. 5

Cemented

Uncemented

Exchange

50

After reduction of the shoulder replacement the whole joint should be irrigated with saline. Next, the lesser tuberosity is reattached to the humerus. In patients where the long head of biceps tendon has been damaged or is degenerated, a tenotomy and tenodesis can be carried out. Use two or three intraosseous double loops of Ethibond No. 2 sutures around the bicipital groove and the lesser tuberosity fragment.

Cheese wiring of the sutures through the bone using this technique does not occur. This reattachment allows rehabilitation to begin on the first postoperative day, even including external rotation. The lateral part of the rotator interval can be closed with a No 1 Vicryl suture at the bicipital groove but only as far medially as the tip of the coracoid. If closed, any further shoulder movement may be restricted (the rotator interval is an interval for a very good reason – it allows the rotator cuff tendons to move, on the outside of the coracoid).

The coraco-acromial ligament is now reattached to the front edge of the acromion or the under surface of the deltoid using a No 1 Vicryl suture. The clavicle fragment is brought back to its anatomical position and using three double cerclage No 1 Vicryl sutures on a blunt needle around the clavicle, it is anchored back. This repair allows full mobilisation immediately after surgery, without the need to protect the deltiod. We recommend one vacuum type drain to be inserted deep to the deltoid in case of some post-operative oozing. This drain is removed at 24 hours. The deltoid interval is closed with three loose vicryl sutures.

A significant cosmetic defect can be the result if the muscles are not opposed. Finally skin closure can be carried out according to the surgeon’s own preference. In Nottingham we use subcutaneous Vicryl for the fat and a subcuticular No 2-0 Prolene suture for this which gives a very nice cosmetic result. The patient is placed in a polysling or broad arm sling in the operating theatre and returned to the ward.

Reduce & Close

51

The VAIOS Shoulder System has been designed to be used in the management of Proximal Humeral Fractures as a Hemi, Total or Inverse Shoulder Replacement. As with all aspects of the VAIOS Total Shoulder System we have kept the inventory to a minimum and simplified the operative technique, hence there is no need for unwieldy and complex jigs. The following technique is a guide and is based on VAIOS user experience. It assumes a level of surgical competence in dealing with Proximal Humeral Fractures.

The key objectives for a VAIOS Shoulder replacement for proximal humerus fractures as with other prostheses are;

1) Atraumatic exposure of the fracture site withprotection of the deltoid origin and insertion.

2) Avoiding further devascularization of thefracture fragments.

3) Proper positioning of the VAIOS stem both interms of height and version.

4) Secure anatomic fixation of the tuberosities.

Preparation of the Humerus with a Proximal Humeral Fracture

Exposure is as detailed on pages 5 and 6 of this operative technique, however additional considerations should be made when dealing with a Proximal Humeral Fracture these are:

1) The axillary nerve can be damaged by fracturefragments so should be examined to ensure itsintegrity this can be done by using the Tug Test(Flatow & Bigliani 1992).

2) The fracture hematoma should be fullyevacuated and the anatomy of the fractureshould be observed during exposure with keylandmarks being identified.

3) Sutures should be placed through the rotatorcuff attachments in to the lesser and greatertuberosity fragments as identified. Drill holes canalso be made in the proximal humeral shaft tofacilitate vertical repair of the tuberosities usingnon absorbable sutures.

The humeral head can now be removed including any fragments still connected to the tuberosities. It should then be assessed for size using the head sizing templates (Fig. 2).

VAIOS in Proximal Humeral Fractures®

Fig. 1 Fig. 2

52

the tuberosities and neck left in situ broaching should also be attempted with care. As on page 14 version can now be ascertained, in general version of 20 degrees is good as this places less tension on the greater tuberosity fragment during internal rotation and may benefit healing. The placement of the trial component will also help assess the height needed of the final prosthesis. As a guide the superior margin of the pectoralis insertion is typically 5 to 6mm from the superior aspect of the greater tuberosity and is a fairly standard measurement in patients of varying sizes (Murachovsky et al 2006) and the final position superior aspect of the VAIOS humeral head should be above the greater tuberosity (Fig.4)

4) Consideration should be given to a tenodesisof the long head of biceps. In younger patientsthe tenodesis is performed in the bicep sulcus.

Attention should also be paid to the amount of calcar attached medially. The size of this fragment is indicative of the amount of missing shaft medially and will help determine the exact positioning of the prosthesis. The VAIOS humeral head's final position should be superior to the shaft a distance equal to the amount of the calcar bone left attached to the fractured humeral head (Fig. 3). The humeral head should be saved for use as autograft if required.

Reaming of the intramedullary canal can now be performed as per page 13. Laser markings on the reamers give a guide to the total depth of the VAIOS Humeral stem, combined distal stem and proximal body. If there are parts of

Fig. 3 Fig. 4

53

De-bulking of the fragments may be necessary to reduce them around the VAIOS prosthesis neck. This is not an issue as the bioactive nature of the H-A.C. coating on the VAIOS humeral neck will facilitate secondary bonding and encourage new bone formation. There are no height markings on the definitive neck so as not to interfere with the coating. As a guide the height can be measured using key landmarks on the neck (fig. 5).

If placing a glenoid component for either anatomic or inverse constructs this should be done now as per the operative technique. Once this has been achieved the definitive neck and

Fig. 7

Fig. 6

Fig. 8

stem can be implanted. Following the general guidance on pages 27 to 30, again using the humeral stem introducer to ensure proper retroversion. If cementing, do not leave the introducer in situ during cement curing.

The anatomic head or inverse assembly can now be impacted onto the humeral stem, being sure to fully support the component.

The tuberosities can be reunited and sutured as follows:

Insert medial suture through medial hole before fully inserting prosthesis and then again check the head height is correct using the methods

Fig. 5

34mm29mm

24mm17.5

54

previously explained. (Fig. 6)

Use the anterior two holes on the VAIOS neck to re- attach the Greater Tuberosity. (Fig. 7)

The Medial suture is now passed through the Infraspinatus posteriorly and Subscapularis anteriorly. (Fig. 8)

Final suture assembly. Suture 1. pass through top lateral hole, suture 2. pass through the bottom lateral hole and suture 3 is a cerclage suture passed through the medial hole. (Fig. 9). Reduce and close.

Fig. 9

55

Catalogue No Quantity Description870-15-00 1 Cemented glenoid drill

860-36-00 1 Humeral head rotator pin

870-16-00 1 Glenoid screw cap driver standard

870-16-10 1 Glenoid screw cap driver long

870-04-01 1 Offset depth stop standard

870-04-02 1 Offset depth stop short

870-28-00 1 Cemented glenoid drill guide dowel

870-07-00 1 Angled glenoid reamer shaft

870-07-01 2 Straight glenoid reamer shaft

870-34-00 1 Universal drill

870-01-01 1 Glenoid guide-wire centraliser - Small

870-01-02 1 Glenoid guide-wire centraliser - Large

870-35-00 1 Screw depth gauge

870-12-00 1 Angled drill guide

870-09-01 1 Cemented drill guide handle and 2mm A/F screwdriver

870-09-00 1 Cemented glenoid drill guide

870-03-00 1 Guide-wire introducer/extractor

870-05-00 1 Glenoid central-hole reamer

870-06-00 1 Glenoid peripheral reamer

860-23-00 1 Inverse cup trial

860-24-00 1 Inverse trial insert 0 mm

860-24-03 1 Inverse trial insert + 3 mm

860-24-06 1 Inverse trial insert + 6 mm

870-13-00 1 Inverse dome trial ( 42 mm O/D) - 0 mm offset

870-14-00 1 Inverse dome trial ( 42 mm O/D) - 1.5 mm offset

Glenoid Tray

john.suggitt

Highlight

56

870-10-00 1 Uncemented glenoid trial - small

870-11-00 1 Uncemented glenoid trial - large

870-42-00 1 Cemented glenoid trial - small 42 mm





870-42-01 1 Cemented glenoid trial - large 42 mm





870-42-02 1 Glenoid insert trial - Large 42 mm





870-42-03 1 Glenoid insert trial - Small 42 mm





870-00-01 1 Glenoid liner forceps

870-00-02 1 Inverse dome introducer forceps

Humeral Tray 1

Catalogue No Quantity Description870-27-35 1 3.5 mm A/F screwdriver shaft

860-90-00 1 Torque limiting handle

860-27-01 1 Humeral jig screwdriver shaft

860-19-00 1 Humeral broach handle

860-16-00 1 Alignment guide

10-08-28 1 Tommy bar - 8 mm

860-01-06 1 Humeral canal reamer - 6 mm






860-20-00 1 Humeral neck broach

860-08-01 1 Humeral broach centraliser - 8 mm





860-08-22 1 Humeral broach centraliser - 8 mm dia x 220 mm long

860-10-22 1 Humeral broach centraliser - 10 mm dia x 220 mm long

860-26-00 1 Cutting jig bush (McKenzie jig)

860-09-00 1 Jig body (McKenzie jig)

860-07-00 1 Cutting block (McKenzie jig)

860-15-00 1 Jig Body (Delto-pectoral)

860-11-00 1 Cutting block (Delto-pectoral)

860-05-01 1 Pointed locking screw (Delto-pectoral)

860-05-00 4 Cutting jig locking screw

860-27-00 3 Humeral cutting block screw standard

860-27-01 3 Humeral cutting block screw long

860-11-01 1 Rotator cuff resection guide

860-42-46 1 Humeral head sizing template 42/46 mm

860-50-54 1 Humeral head sizing template 50/54 mm

57

58

Humeral Tray 2

Catalogue No Quantity Description860-31-00 1 Taper impactor

860-30-00 1 Wedge implant remover

860-01-00 1 Fukuda style retractor - Small

860-02-00 1 Fukuda style retractor - Large

860-42-03 1 Humeral head trial - 3 mm offset - 42 mm (O/D)








10-99-47 1 Head impactor assembly

860-22-00 1 Calcar Cutter

860-33-00 1 Humeral resection plate

860-90-00 1 Screwdriver handle

870-36-00 1 V-shaped impactor head

870-29-00 1 Forked retractor

860-25-00 1 Plate spanner 12 mm

860-17-00 1 Humeral resection guide

50-00-36 1 Glenoid forceps

50-00-70 1 Screwdriver 3.5 mm A/F

59

Catalogue No Description

801-42-03 Anatomic Head 42 mm O/D 3 mm Offset








801-09-10 Glenoid metal-back, small

801-09-11 Glenoid metal-back, large

801-05-42 Small glenoid insert 42 mm I/D





801-06-42 Large glenoid insert 42 mm I/D





802-03-42 Cemented glenoid Small, 42 mm I/D





802-04-42 Cemented glenoid Large, 42 mm I/D





802-04-54 Cemented Glenoid Large, 54 mm I/D

802-04-58 Cemented Glenoid Large, 58 mm I/D

Catalogue No Description

801-01-08 Humeral stem, H-A.C. 8 mm diameter





801-02-00 Humeral Neck

801-08-01 Locking screw Cap

801-08-20 Screw 20 mm long





801-09-12 Dome Taper retaining screw

802-01-06 Humeral stem, cemented, 6 mm diameter




802-22-08 Humeral stem LONG (220 mm), cemented, 8mm diameter

802-01-12 Humeral stem LONG (220 mm), cemented, 10mm diameter

803-01-00 Inverse cup baseplate

803-03-01 Inverse dome (42 mm O/D)

803-02-00 Inverse cup Insert (42 mm I/D), 0 mm

803-02-03 Inverse cup Insert (42 mm I/D), +3 mm

803-02-06 Inverse cup Insert (42 mm I/D), +6 mm

801-02-01 Baseplate taper retaining screw

870-01-00 Guide-wire (disposable)

25-1605 Foam tipped drying swab

Implants – Order Information

62

Notes

References 1) Source: Norwegian Arthoplsty Register 1994 - 2006

2) Frederick A. et al. J Bone Joint Surg Am. 2008;90:885-896. doi:10.2106/JBJS.G.01263

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Documents

VAIOS® - JRI Orthopaedics · The extended deltopectoral approach is commonly used for total shoulder replacement; however, with that procedure, it often proves difficult to obtain