Reverse shoulder arthroplasty performed by Dr. George Athwal using AEQUALIS™ PERFORM™+ REVERSED and using BLUEPRINT™ Mixed Reality Visualization.
Hello. My name is George off the wall and on the shoulder noble surgeon from London, Ontario, Canada. And today I'll be presenting a re live video of versatile Sharp capacity is an augmented implant with mixed reality visualization. So this is my office, and this is how I start my preoperative planning in the morning before surgery. So I start by looking at the X rays and this patient. She's a seven year old woman with profound global human joint arthritis and a hypoplastic type C. Glennon, which is wrecked, reverted. And so here we're gonna start with the blueprint plan. As you can see, this patient has a substantial retro version of 27 degrees, zero degrees of inclination and 90% subluxation. So I'm going to manage this with a full wedge augmented implant dialed post here to reconstruct the retro version. And now here's a look at the human head. You can see it's quite arthritic. We'll go ahead and put the head neck Costea Oddity plane in and I'll have access to all this information. Inter operatively using mixed reality guidance. Here's a position off the stem within the diagnosis, and I'll go ahead and play the range of motion, and we see that there is some impingement post early with these humor lost two fights represented by the red sphere. So I go ahead and take off. These human lost two fights also have the option of taking off Glen oId Austin fights if they're impinge ing. And so once we take off these human lost, if it will re probably in the range of motion, now find out that the impingement has decreased, so I'll be using the whole ends to, as you can see here and now we're walking into the operating room. Everyone's getting set up for the reverse. Let's go ahead and take a look at the preoperative plan using mixed reality. And so here's our Glenwood Reconstruction. He's a full wedge. Augment. Oh, and here's Dr King, the director of the Hand Upper Limb center. Here's a view of the native Glenna human joint from post area. We can see that built up human lost ified, which will require removal on the degree of subluxation represented by the blue volume on the human head. And once again, there's her head, neck osteo bi plane, and we'll look at it from the front from medial and now here is going to be our Glenwood Reconstruction. This green line represents the guide pain insertion and this Allow us to recreate our correct Glenroy inversion to approximately 10 degrees director version, and we use a 39 millimeter Glennis here with that will obtain good range of motion. Now, this is a reciprocal type of You are almost a negative type view which allows us to see the implant within the bone. And you could see only use a single central screw as opposed to a post. Let's go ahead and play the range of motion. Once again, we could really get a close up view of where the sites of impingement ar and they're once again those post your human had Austin fights which will be removed a time of surgery. These right here. Let's go to the operating room now. So I'm gonna use a Delta pectoral approach starting approximately one centimeter latell to the core coId. Here's my hololens and this is what I could see with the video through the hollow lens. I could see the human head, the osteo bi plane and I can position this any which where, like I'm going to move it off the side to start the operation and let's go ahead and starter approach. This is a Delta factor approach, and it's gonna go through a soft tissues using a bovie identify the Delta Vector. Typically, I like to identify the Delta Pectoral interval, approximately identifying the insertion of the deltoid onto the clavicle. And there's the clavicle right there. This is more in Heinz Triangle, and there is a tennis insertion of deltoid. Let's now go ahead and place in a tractor, attracted deltoid laterally and develop the interval between the deltoid and the tech. There's a cork would we're going to keep on working distantly here and here. Is this a phallic vein? We're going to keep that immediately and dissect through this tissue. There's a core record one more time in order to start work, distantly, completing the Delta pectoral approach from proximal to distal direction. Always trying to preserve the Sofala, Fain and I typically always retracted immediately. There is a C a ligament, and here's a contract tenants. I'm gonna do a lateral Clavet Peck fashion release up to the CIA ligament and just skirt just underneath the city. Let me into the subtle crawl space. Create some space in the sub criminal area to insert a tractor. So I'll go ahead and bring in my deltoid a tractor right now. So this is our brown deltoid. A tractor. I'll insert this into the sub McConnell space to attract the deltoid. And then we're gonna start by looking for the biceps. Make a small horizontal decision directly over the peck. Major, identify the biceps center right here. Dissect this out. And I typically do a Tina DCIS immediately to the Peck major. So I put multiple figure of eight suitors from long and biceps into the peck Major and tie it off. Once you've done that, we're gonna tag the sub scapular, remove or excise the remnant long in the biceps. Developed the rotator interval. Start with our throttle me. And now I'm going to conduct appeal type approach to the shoulder. So I'll put this small Dera tractor into the shoulder joint and levered against the anterior portion of the human head. To place tension onto the sub scapular is to allow me to peel it off of the anti human solicitor ferocity. They were going to transition into an unfair capture release. And here's the Austin film that we're going to use to remove those poster Austria fights right there. Now we'll go ahead and dislocate with this, okay? I'm going to start this large Dara within the global human joint to function as a skid. We'll carefully translate the human head and dislocated out. You can see it's quite arthritic. Now let's take a look through our Holland's. This is what I'm seeing. At the time of surgery, I could see this hologram off the proximal humerus with the head, neck, osteo, bi plane and Aiken. Position this anywhere. I can position this on the drapes. As you can see here I can position directly over the human head. I typically the place it right over the drapes, and so let's identify some areas there. You can see that osteo fight, which is present in the human head and also on the hologram, and that's essentially the level off my head. Neck cost economies are going to reference that and go ahead and create a free hand cut in the an atomic version. And so there's our human head and let's take a look and this is our cut surface. You can see the cut surface on our plan. Matches that cut surface off the patient's anatomy. So what? I've done the human head cut under. Go ahead and proceed onto the glen. OId are typically use a large flat dare a tractor post you're in fairly to attract the human had osteo to me. Then we'll bring in a sponge, give us a clean and then we consider Glenn I'd a type c hypoplastic Leno, which is quite retro voted. I typically start soup here, Lee, identify the longer the bicep tendon assertion and remove the post cheerier superior labor and a poster in fair labor. Once I've done that, then I'm gonna go ahead and release the cork a human ligament and mobilize the upper aspect of sub scapegoats. This is a sub scapular. Is there completely release this tissue such that can mobilize a sub scapular errors and then release the capsule on labor from the Glenroy and place in this bank are type of character and I'm going to dissect here in fairly releasing the long headed triceps, using the longer to attract the capsule in fairly in our place this smaller bank card type er, tractor posters securely, Let's take a look at our goal, annoyed so you can see there's, ah, hypoplastic retro ver glenn. I'd with a very large poster labral analog, which I just excised, and this is going to be our Glenn oId guide pin insurgents. I'm going to go ahead, move the M R mixed reality hologram directly adjacent to my native Glenn oId. I'll bring in the guide pin. I'm going to reconstruct this with a full wedge augmented implant. As you can see, here is a 25 millimeter diameter, 15 degree wedge. We'll go ahead and place that onto the Glen oId. I like to measure this distance right here to give me an idea of how deep my pin goes. And minimally, I'm looking for a least 20 to 25 millimeters. And so let's take a look and compare the two so I'll go ahead and prepare for the full wedge. Augment. Now we're going to bring in the Glen Oy dreamer, so this adjustable remain allows us to ream at a 15 degree angle, a 25 degree angle or a 35 degree angle. You can see here. But for the 15 degree wedge, we're going to ream at 15 degrees. So I'll bring in the neo River, dial it correctly, and then start reaming. Ideally, I'm looking for a minimum of 80% seating. And now we're ready to drill for the central boss. And here's the boss drill. Once we've done that, we're gonna go ahead and drill for the central compression screw here. You can see this is the augmented drill guide. It recreates that 15 degree full wedge augment. We're gonna go ahead. Insert that into the pre drilled hole for the boss. Now, go ahead. Drill for that central Compressions group. And so here's our implant. 25 millimeter diameter 15 to be wedged. We're going to dial it mostly post early, a little bit, posters securely to recreate the version down the 10 degrees, you know, position. And now go ahead and screw this down. You get excellent compression. Now we'll go ahead and drill the purple screws with this particular design of full wedges. Three locking screws and one compressions grew places a maximum thickness off the augment. Let's go ahead and take a look at our preoperative plan. We can see where the base plate is dialing posters securely just as it is clinically. Now go ahead and insert our screws typically insert the in fear screws superior. And then we'll do the poster and anti air screws. Let's go ahead and place in our 39 millimeter glass sphere. We'll create some post here, offset between the proximal humerus and the Glenarden base paid by putting a twist on that large post hairdryer tractor this creates based, which allows us to insert the glass. Here. We'll go ahead and engage the Morris Taper and set the securities group, and here's our negative are reciprocal model, and we could see the Glen oId reconstruction with the full wedge augmented implant. Now it's time to move on to the humerus. We're gonna apply some lateral attention to the deltoid place in this medium. Dare, a tractor on the Kallick are very gently translate the humorous laterally and then, naturally, to avoid catching the poster aspect of greater truth rosti on the Glennis here and this case, I'm going to do a subtle inlay, and once I've used my inlaid reamer, I'll enter the canal. It will start broaching up so this is size one Flex size two compact er three, four, five and six. So you can see with a size six implant, we're gonna fairly high canal feel ratio, which is something I'd like to avoid. So in this case, because of his patients osteopenia, I'm gonna go ahead and cement this implant in looking up to Cal Car ream. Try a trial reduction, so I'm just going to get it just over the edge of the Glenister. Once I'm happy with that, we're gonna have to call for the true implants and we're going to prepare for our sub scapular repair. So these air very large number five braided Esteban suitors past transactions see around the lesser true ferocity. We'll go ahead and insert our antibiotics cement. Here's our flex cemented stem. We'll go ahead and circus Remove the access cement. Wait till the cement hardens Carefully reduce the shoulder assess for a range motion impingement and stability. Now I'm gonna go ahead and repair the sub. Scapular is with our number five Esteban suitors back to the lesser to Brosque. In all cases, I attempt to repair the subs calculators. And here's our final plan and we could circle it through, and there we can see it in drop early. I'm going to typically place 1 g of bank of mice and powder within the joint and then close the rotator interval right here. So this is a super spicy repair to the sub scapular wrist. And once we've done that, we'll go ahead and close. So a typical place, one or two suitors and then we'll speed up the video to close the Delta Bechtel approach. I typically do run the Delta practical approach to minimize now the hematoma and we'll do interrupted subcutaneous closure, followed by staples for skin. And here's our postoperative X rays. We could see our wedge. Glen Innes reconstructed the type of plastic Glenn and we have a cemented human stem. Do those patients osteo Pena. Thank you for the opportunity to present this mixed reality visualization augmented implant. Reverse told Shorts Plastic Case here at the C s