DESCRIPTION OF OPERATION: The patient was taken to the operating room, and after a scalene block was administered by the anesthesia team, the patient was positioned on the operating room table in a beach-chair position. Preoperative antibiotics were given. The right shoulder was prescrubbed with Betadine. Next, the right upper extremity, including the right base of the neck and shoulder, were prepped and draped in the usual sterile fashion. After bony palpation, a longitudinal skin incision was made over the anterior aspect of the right shoulder. The subcutaneous tissue was dissected and hemostasis was obtained with electrocautery. Dissection was carried down to the deltopectoral interval. The cephalic vein was identified, protected, and preserved throughout the case. A deep retractor was placed between the deltoid and pectoralis major to help with deep exposure. The clavipectoral fascia was then incised. Upon doing this, large gelatinous material was expressed from the joint as well as the biceps tendon and this was removed with suction. This was characteristic of rheumatoid arthritis. The tissue quality about the rotator cuff as well as the surrounding musculature was friable and diseased due to her rheumatoid arthritis. The subscapularis was then split leaving a 1 cm cuff. The medial edge was tagged with #2 FiberWire in a Mason-Allen fashion. This was used for repair at the end of the case. Humeral head was identified and had pannus covering as well as significant degenerative changes. The proximal humeral cut was then performed with an oscillating saw at 20 degrees of retroversion. This was sized and removed and sent to Pathology for further evaluation. The glenoid was then exposed and a complete labrectomy was performed. Significant erosive changes were seen throughout with no evidence of articular surface. With further inspection and manual palpation, it was felt that there was good contour with central wear. Because of this, it was felt that no formal glenoid plasty need be performed. With the deficient rotator cuff identified more proximally as well as posteriorly, it was felt that no formal glenoid component would be replaced. Attention was then returned back to the proximal humerus. This was reamed and broached to accommodate an 8 mm stem. Due to the patient's soft bone, it was felt that this would be cemented. The cement plug was placed and an 8 mm Mini Biomet stem was then cemented into place. After sizing, it was felt that extended articular surface head would be used to help articulate with the acromion. A 44 x 17 was trialed which demonstrated 50-50% of anterior-posterior translation, as well as 30% inferior translation. This was then tapped into position. The shoulder was reduced and liberally irrigated with bacitracin solution under power irrigation. The rest of the synovium was resected with Metzenbaum and Mayo scissors. The subscapularis was then repaired with #2 FiberWire. The shoulder could easily be externally rotated to 90 degrees and forward flexed to 180 degrees with no stress on the subscapularis repair. The wound was again liberally irrigated with bacitracin solution. Hemostasis was meticulously obtained with electrocautery. The deltopectoral interval was closed with 0 Vicryl in a simple interrupted fashion. The subcutaneous tissue was closed with 2-0 Vicryl in a simple interrupted fashion and skin was closed with 4-0 Monocryl in a running subcuticular pull-out stitch. All sponge and instrument counts proved to be correct and estimated blood loss was 250 mL. The wound was then cleaned and Steri-Stripped and dressed under the sterile field. A Polar Care ice machine and a shoulder immobilizer was placed to the right upper extremity. The patient was taken to the recovery room in a stable condition.
