This publication is not intended for distribution in the USA. SURGICAL TECHNIQUE

The GLOBAL ADVANTAGE™ Humeral Body 2 The GLOBAL ADVANTAGE Humeral Head 2 Pectoralis Major Tendon Release 5 Anterior Humeral Circumflex Vessels Management 5 Subscapularis Tendon Release 7 Capsule Release and Humeral Head Resection 8 Humeral Head Resection 8 Technique for Head Removal Using the Intramedullary Humeral Resection Guide 10 Sizing the Resected Humeral Head 12 Medullary Canal Preparation and Broaching the Humerus 13 Medullary Canal Reaming 13 Using the Body Sizing Osteotome 14 Pegged Glenoid Trial 18 Keeled Glenoid Trial 19 Humeral Head Trials...

Design Rationale The multiple sizes of the glenoids, humeral bodies and heads allow the GLOBAL ADVANTAGE Shoulder System to be used worldwide. Its design is based on the detailed investigations of the structure and mechanics of normal and prosthetic glenohumeral joints conducted at the University of Texas at San Antonio, University of Washington, University of Pennsylvania and DePuy Synthes, Warsaw, Indiana. The challenges encountered by shoulder arthroplasty surgeons include surgical exposure, soft tissue balancing and component fixation. The instruments, technique and components of this arthroplasty...

The Technique Recognising that a successful shoulder arthroplasty is critically dependent on soft tissue balancing, this document provides a detailed guide to the techniques of tendon lengthening and capsular releases, that are integral parts of this procedure. These steps cannot be effected with jigs and guides, but rather require an understanding of the principles of shoulder mechanics. With the aim that each shoulder arthroplasty is adapted to the patient’s combination of soft tissue and bone anatomy, the system is designed to maximise the surgeon’s flexibility in matching a wide variety of...

SURGICAL TECHNIQUE Charles A. Rockwood, Jr., MD Patient Positioning Place the patient in a semi-Fowler position on the operating table (Fig. 1). Remove the standard headrest portion of the table and replace it with a special headrest such as the Mayfield or the McConnell (McConnell, Greenville, TX). Position the patient so that the involved shoulder extends over the top corner of the table (Figs. 1, 2 and 3). Secure the patient’s head with tape. Drape to isolate anesthesia equipment from sterile field. Special headrest Figure 3 GLOBAL ADVANTAGE  Surgical Technique  DePuy Synth

SURGICAL INCISION Musculocutaneous and Axillary Nerve Identification and Pectoralis Major and Subscapularis Tendon Release Incision Make an incision running from the clavicle over the top of the coracoid down the anterior aspect of the arm (Figs. 4 and 5). Once the incision has been made, locate the cephalic vein on the deltoid muscle near the deltopectoral interval (Fig. 6). The cephalic vein is usually intimately associated with the deltoid because there are many feeders from the deltoid into the cephalic vein. For this reason, it is recommended that the vein be taken laterally with the deltoid...

Pectoralis Major Tendon Release Release the upper 25 percent of the pectoralis major tendon from its insertion on the humerus with an electro-cautery cutting blade. This will aid in the exposure of the inferior aspect of the joint (Fig. 7). Richardson retractor If the patient has marked internal rotation contracture, release most of the pectoralis major tendon from its insertion. This tendon release should not be repaired at the completion of the operation since it will limit external rotation postoperatively. Pectoralis major tendon Anterior Humeral Circumflex Vessels Management Isolate, clamp...

NERVE IDENTIFICATION Musculocutaneous Nerve It is important to identify the musculocutaneous and axillary nerves. Palpate the musculocutaneous nerve as it comes from the plexus into the medial and posterior aspect of the conjoined tendon (Fig. 9). Usually, the nerve penetrates the muscle approximately 4 to 5 cm - or - 3.8 to 5.1 cm. down from the tip of the coracoid, but in some instances the nerve has a higher penetration into the conjoined muscle tendon unit. Remember the proximity of this nerve to the tendon during the retraction of the conjoined tendon. Coracoid process Conjoined tendon Musculocutaneous...

SUBSCAPULARIS TENDON RELEASE If when under anesthesia the shoulder has zero degrees or more of external rotation, release the subscapularis tendon from its insertion on the lesser tuberosity (Fig. 12) or divide the tendon. We believe that the ultimate repair of the tendon back to bone is stronger than a tendon to tendon repair. We prefer to free the tendon from the underlying thickened capsule and continue to free up the tendon until it is clear of any adhesions from the back of the coracoid process and from the capsule as it attaches on the anterior glenoid rim. This process requires that the...

CAPSULE RELEASE AND HUMERAL HEAD RESECTION Occasionally, the capsule will be released from the neck of the humerus with the subscapularis tendon. If that occurs, dissect the anterior capsule from the posterior surface of the subscapularis to maintain a free, dynamic subscapularis tendon. Use a Scoffield retractor to retract the previously identified axillary nerve anteriorly/ inferiorly away from the inferior capsule. Externally rotate the arm, which will place tension on the capsule, and then release the capsule from its attachment to the humerus all the way down inferiorly to at least the six...

Curved crego retractor Place the template along the anterior aspect of the arm parallel to the shaft of the humerus, and mark the angle at which the head will be removed with an osteotome or the electro-cautery blade (Fig. 21). The plastic template prevents arcing from the electro-cautery knife. Use of the template ensures the proper seating of the prosthesis on the bone (Fig. 22). In many instances, the inferior portion of the mark will be above the inferior osteophyte of the flattened and deformed head of the humerus. If the resection is made in line with an articular surface which is in varus,...