Patent Publication Number: US-2005119531-A1

Title: Method of performing shoulder surgery

Description:
CROSS REFERENCE TO RELATED APPLICATIONS  
      This application is a continuation-in-part of application Ser. No. 10/728,202 filed on Dec. 4, 2003, which is hereby incorporated by reference in its entirety, which is a continuation of application Ser. No. 10/077,693, filed Feb. 15, 2002, which is incorporated by reference in its entirety, and resulting in U.S. Pat. No. 6,659,944, which is a continuation of application Ser. No. 09/990,420 filed on Nov. 21, 2001, which is incorporated by reference in its entirety, and resulting in U.S. Pat. No. 6,368,271.  
      This application is also a continuation-in-part of application Ser. No. 10/892,816 filed on Jul. 16, 2004, which is hereby incorporated by reference in its entirety, which is a continuation-in-part of application Ser. No. 10/623,179; filed Jul. 18, 2003, which is hereby incorporated by reference in its entirety, which claims priority of U.S. Provisional Application No. 60/396,850, filed Jul. 18, 2002, the content of which is hereby incorporated by reference in its entirety. 
    
    
     BACKGROUND OF THE INVENTION  
      The present invention relates to a method of surgical retraction. In particular, the present invention relates to a method of utilizing a table mounted retracting device during a surgical procedure on a shoulder of a patient.  
      Total shoulder replacement (arthroplasty) operations have been performed for many decades to repair shoulder components. These components include the glenoid cavity (socket portion of the shoulder) and the humeral head (ball portion of the shoulder). The shoulder is typically replaced due to deterioration or wear of the glenoid cavity and/or the humeral ball. Common causes of deterioration of the shoulder joint from smooth surfaces where the joint is properly articulating to rough surfaces where articulation of the joint is painful include osteoarthritis, Rheumatoid arthritis as well as trauma which injures the shoulder joint. The deterioration causes either the humeral ball, the glenoid cavity or both the humeral ball and the glenoid cavity become rough which results in pain when the shoulder joint is articulated.  
      Shoulder joint replacement procedures are successful in alleviating this type of shoulder pain. In a total shoulder replacement procedure, a cup shaped insert, typically manufactured of high density polyethylene, is inserted into the worn glenoid cavity and a metal ball is cemented to the humerus as a replacement to the humeral ball. In a partial shoulder replacement surgery, the worn component of the shoulder is replaced where either the humeral ball is replaced or an insert is positioned and retained in the glenoid cavity.  
      Typically, at least two physically strong people are needed to perform a total shoulder replacement. One person is needed to retract and retain the humerus from the glenoid cavity to gain access to both the glenoid cavity and the humerus. The other person is needed to prepare the glenoid cavity to accept the insert and also prepare the humerus to accept a metal ball.  
      After the replacement components are inserted, the shoulder is reducted (the humeral component is inserted into the glenoid cavity component) to check the angle and fit of the humeral ball into the glenoid cavity insert. If the shoulder components do not properly articulate, the shoulder joint is again dislocated, the components readjusted, and the humeral ball is repositioned in the glenoid cavity. When the stability and placement of the trial inserts are acceptable, the shoulder is dislocated and the humeral implant is secured to the humerus. The humeral ball is again positioned within the glenoid cavity and the stability of the arthroplasty is confirmed.  
      Due to the multiple dislocations and insertions of the humeral ball into the glenoid cavity, as well as retracting the humerus, the surgical procedure can become quite physically taxing on the surgeon or surgeons. The surgical procedure requires lifting and moving the patient&#39;s arm into multiple positions. At times, the surgeon may need to hold the arm in a selected position for an extended period of time. Depending on the size of the patient, the strenuous activity can lead to fatigue and contribute to surgical error.  
      Additionally, the repeated movement of the arm can cause nerve damage if it is not done precisely and with minimal adjustment. When the surgeon moves the humerus by hand it is common to have continual adjustment occur. Often, the surgeon holding the arm relaxes or becomes fatigued and allows the arm to move, requiring that the arm be readjusted. The movement can cause the arm to pinch or rub nerves or muscle tissue, possibly causing damage.  
     BRIEF SUMMARY OF THE INVENTION  
      The present invention includes a method of performing a shoulder joint surgery involving a scapula having a glenoid cavity, a humerus and a humeral ball on a surgical table. The method includes mounting a retractor support to the surgical table and positioning the retractor support about the shoulder joint. The skin and flesh layers proximate the shoulder joint are incised and the skin and flesh layers are manually retracted with a retractor. The retractor is secured in a selected retracting position by attaching the retractor to the retractor support. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       FIG. 1  is a perspective view of a table mounted support structure for a shoulder surgery.  
       FIG. 2  is a perspective view of an alternative embodiment of a table mounted support structure for a shoulder surgery.  
       FIG. 3  is a perspective view of the table mounted support structure exposing a shoulder joint for a complete shoulder reconstruction.  
       FIG. 4  is a perspective view of a reconstructed shoulder joint with a partial sectional view of a glenoid cavity within a scapula. 
    
    
     DETAILED DESCRIPTION  
      The present invention relates to a method of performing surgical procedures on a shoulder joint. An apparatus used in the surgical procedures of the present invention is generally indicated at  10  in  FIG. 1 .  
      The apparatus  10  includes a retractor support apparatus  12  that is rigidly mounted to a rail  11  of a surgical table  13  in a manner that is well known in the art and is described in U.S. Pat. Nos. 4,617,916, 4,718,151, 4,949,707, 5,400,772, 5,741,210, 6,042,541, 6,264,396 and 6,315,718 all of which are herein incorporated by reference. From the mount to the surgical table  13 , the retractor support apparatus  12  includes at least one support arm that extends over the surgical table  13 . The support arm  16  is removably attached to a clamping mechanism  18  having at least one pivot ball  20  rotatably movable within a clamping bore (not shown). The pivot ball  20  includes a cavity (not shown) into which an end of the support arm  16  is inserted. The support arm  16  is adjustable into an infinite number of selected positions by rotating the pivot ball  20  within the clamping bore (not shown).  
      The support arm  16  preferably has a configuration generally in the shape of the letter “J”. The generally “J” shaped support arm  16  provides a support structure about a shoulder area  30  that supports retractors that retract skin, muscle, blood vessels and nerves to expose the shoulder joint, as well as retract bone when the shoulder joint is separated. A rod  22  is preferably clamped to the generally “J” shaped support arm and extends over the patient to provide an additional support structure on an opposite side of a shoulder joint  32  from the generally “J” shaped support arm  16  while maintaining access thereto.  
      Alternatively, referring to  FIG. 2 , the apparatus  100  may include support arms  102  and  104  that are generally mirror images of each other that extend general horizontally over the surgical table  13  and are positioned on opposite sides the shoulder joint  30 . The support arms  102  and  104 , as well as the generally J-shaped support arm  16 , are independently adjustable into an infinite number of selected positions through use of the clamping mechanism  20  which is described in U.S. Pat. Nos. 5,899,627 and 6,264,396, which are herein incorporated by reference. The clamp  20  secures the adjustable support arms  102  and  104  or the generally J-shaped support arm in selected angular positions with respect to the shoulder joint  30 .  
      The surgical procedures on the shoulder joint  32  can be performed with any table mounted support structure and is not limited by the configurations illustrated and described herein. However, the table mounted support structure to must provide support for mounting retractors to retract skin, muscle, blood vessels, tendons and bone while providing access to the shoulder joint  32 .  
      Referring to  FIG. 1 , with the retractor support apparatus  12  positioned in a selected position about the shoulder joint, an incision  34  is made through the skin on the front of the shoulder joint  32 , otherwise known as an anterior approach to the shoulder joint  32 . Typically, the incision is about three inches long but may vary depending upon the surgical procedure being performed.  
      After making the incision  34  through the skin, the surgeon divides the tissue, muscle, blood vessels and nerves to expose the shoulder joint while causing minimal trauma. To expose the shoulder joint  32 , a retractor blade  38  of a lateral retractor  36  is positioned within the incision  34 . The tissue, muscle, blood vessels and nerves are laterally retracted from the shoulder joint  32  with manual force applied to the lateral retractor  36 . With the lateral retractor in the selected position, a handle  40  of the lateral retractor  36  is positioned within a clamping socket (not shown) of a clamp  42  positioned on the J shaped support arm  16  and is secured in the selected position by positioning the clamp  42  in the clamping position. Preferably, the clamp socket (not shown) allows the retractor handle to be manually forced therein without having to position an end of the handle through the clamp, although other clamps are within the scope of the present invention. By socket is meant an opening or a cavity into which an inserted part, such as a retractor support apparatus, is designed to fit and wherein the retractor support apparatus can be inserted into the socket from an infinite number of directions in a 180° range starting from a substantially parallel position to a back surface of the socket to a position substantially perpendicular to the back surface and continuing to position again substantially parallel to the back surface of the socket. By lateral is meant a position or direction generally away from the body.  
      A retractor blade  46  of a medial retractor  44  is positioned within the incision  32  generally opposite the lateral retractor  36 . Manual force is applied to the medial retractor  44  to retract tissue, muscle, blood vessels and nerves in a medial direction from the shoulder joint  32 . With the medial retractor  44  in a selected position, a handle  48  of the medial retractor  44  is positioned within a clamping socket (not shown) of a clamp  50  positioned on the rod  22  and secured in the selected position by positioning the clamp in the clamping position. By medial is meant a position or direction toward the body of the patient. Although a clamp with a socket is preferred, clamps with differently configured clamping surfaces are also within the scope of the present invention including a clamping bore.  
      Although two retractors  36 ,  44  are a preferred number of retractors for exposing the surgical site in the shoulder, more than two retractors supported by the table mounted retractor support apparatus  12  can be utilized to expose the surgical site in the shoulder area  30  while performing the surgical procedure of the present invention. Mechanical mechanisms on retractors may be used to adjust the vertical position of the retractor blade and the lateral or medial position of the retractor blade within the surgical site. Mechanical mechanism used to adjust the position of the retractor blade include, but are not limited to, articulated joints, rack and pinion systems, racheting mechanisms, wedges, ramps, camming mechanisms and threadable engagements are within the scope of the present invention.  
      With the shoulder joint  32  exposed by the retraction of the skin, tissue, muscle, blood vessels and nerves, the surgical procedure on the shoulder joint  32  can be performed. A non-exhaustive list of surgical procedures that can be performed on the shoulder include repair of a muscle tear, repair of a torn or ruptured tendon or ligament such as a torn rotator cuff, as well as a shoulder replacement surgery. The shoulder replacement surgery includes a complete shoulder replacement and a partial shoulder replacement surgery.  
      In a shoulder replacement surgery, the skin, muscle, blood vessels and nerves are preferably retracted without having to be severed with a scalpel to expose a shoulder joint  32  with at least the lateral and medial retractors  36 ,  44 , respectively. Performing the shoulder surgery while minimizing the damage the muscle, blood vessels and nerves minimizes the post-operative pain felt by the patient as well as reducing the time required to rehabilitate the shoulder joint. However, it is within the scope of the present invention to perform a surgical procedure that requires incising muscles, blood vessels and nerves around the shoulder joint.  
      Referring to  FIGS. 1, 3  and  4 , with the shoulder joint  32  exposed, a scapula  51  having a glenoid cavity  52 , a humeral ball  54  and an upper portion of a humerus  56  are viewable through the retracted incision  34 . In preparing the shoulder joint  32  for the shoulder replacement surgery, the surgeon has at least two options in gaining access to the surfaces that accept inserts. First, the humeral ball  54  may be separated from the humerus  56 , typically with a bone saw, while the humeral ball  54  remains within the glenoid cavity  52 . The humerus  56  is retracted laterally away from the shoulder joint  32  to gain access to a freshly cut surface  57  on the humerus  56  onto which a humeral replacement insert  70  is affixed.  
      The humerus  56  is retracted with a retractor  58  having a blade  60  described in detail in U.S. Pat. Nos. 6,368,271 and 6,659,944, previously incorporated by reference, which is similar to a Fakuda blade, which is known in the art. The blade  60  includes a generally flat portion and an arcuate end that is positioned about the upper end of the humerus  56 . The blade  60  also includes an aperture within both the generally flat portion and the arcuate end that aids in gripping the humerus and prevents the humerus from slipping along the blade. However, the aperture, while providing additional gripping capability to the retractor blade, is not necessary to retract the humerus from the glenoid cavity.  
      The humerus  56  can be retracted with manual force placed upon the retractor  58 . With the humerus  56  manually retracted into a selected position, the retractor  58  is clamped to the retractor support apparatus  12  by positioning a retractor handle  62  into a clamping socket (not shown) of a clamp  64  and positioning the clamp  64  into the clamping position. Alternatively, the humerus  56  can be retracted with a retractor blade attached to a retractor blade holder supported by the retractor support apparatus where the vertical position is adjusted with an articulated joint and the humerus is retracted with a rack and pinion mechanism on the retractor blade holder as disclosed in U.S. Pat. Nos. 6,368,271 and 6,659,944, previously incorporated by reference in their entirety.  
      The humerus  56  is retracted from the glenoid cavity  52  a selected distance to provide the surgeon access to both the freshly cut surface  57  on the humerus  56  and also to the glenoid cavity  52  within the scapula  51  after the detached humeral ball  54  is separated or dislocated from the glenoid cavity  52 .  
      Alternatively, the humeral ball  54  while attached to the humerus  56  may be first dislocated from the glenoid cavity  52  to gain access to the glenoid cavity  52  for preparation to accept an insert  68 . The humerus  56  is laterally retracted, either manually or with a mechanical mechanism as previously disclosed, from the shoulder joint  32  to gain access to both the humeral ball  54  and the glenoid cavity  52  within the scapula  57 . The humeral ball  54  is then separated from the humerus  56 , typically with a bone saw, thereby creating the surface  57  to which the humeral insert  70  is secured.  
      The humeral insert  70  that replaces the humeral ball  54  can be shaped to conform to the cut surface  57  of the humerus  56  and cemented into place. The insert  70  may also include a single shaft  72  or a plurality of pegs (not shown) that are inserted to cooperating cavities  72  that are reamed into the humerus  56  and cemented into place. Alternatively, the humeral insert  70  may include mesh-like surface may be positioned onto the humerus  56  or within the cavity  72  reamed into the humerus  56  such that mesh-like surfaces engage the humerus  56  and allow the bone to grow onto the humeral insert  70  to secure the insert  70  to the humerus  56 . The humeral insert  70  is preferably constructed of a highly polished stainless steel or titanium.  
      After the humeral insert  70  is secured to the humerus  56 , the scapula  51  having the glenoid cavity  52  is also prepared to accept the prosthetic insert  68  by reaming the scapula  51  such that the glenoid cavity  52  has a similar configuration to an outer surface of the insert  68 . One embodiment of the insert  68  that is positioned within the glenoid cavity  52  is constructed from a high density polymer, such as polyethylene, which interacts with the polished humeral insert  70  to reconstruct the shoulder joint  32 . The insert  68  preferably has a plurality of pegs  71  that are positioned within cavities reamed into the scapula  51  and intersecting the glenoid cavity  52  where the insert  68  is cemented into place.  
      Another embodiment of the insert  68  includes two components (not shown), a highly polished metal component that is secured to the scapula  51  having the glenoid cavity  52  and a polymer component that is secured to the metal component and interacts with the humeral insert  70 . The metal component may include a shaft (not shown) or a plurality of pegs that engage complimentary indentions that are reamed into the scapula that includes the glenoid cavity where the metal component is cemented to the scapula. Alternatively, the metallic portion insert may include a mesh-like surface that is positioned within the glenoid cavity where the scapula grows onto the insert to secure the metallic portion of the insert to the bone. Although either insert  68  is within the scope of the present invention, the two component insert provides an advantage of replacing only the polymeric portion of the insert without having to perform additional surgery on the scapula  51  in the event the polymeric portion of the insert wears and causes the patient discomfort. With the prosthetic insert secured to the scapula  51  and within the glenoid cavity  52 , the humeral insert  70  is reducted into the insert  68  secured within the glenoid cavity  52 .  
      The highly polished humeral insert  70  attached to the humerus  54  engages the high density polymer insert  68  attached to the scapula  51  within the glenoid cavity  52  such that the articulation of the inserts  68 ,  70  is almost frictionless and resembling the function of a healthy shoulder joint. One skilled in the art will recognize that in a total shoulder-joint replacement surgery all of the cartilage and synovial membrane attached to or positioned between the scapula  51  and the humerus  54  are removed, thereby requiring the nearly frictionless interaction between the inserts  70 ,  68  attached to the humerus  56  and the scapula  51 , respectively, for the reconstructed shoulder joint  32  to function properly.  
      Although the total shoulder-joint replacement surgery described first prepares the humerus  54  for the humeral insert  70  and then prepares the glenoid cavity  52  within the scapula  51  for the insert  68 , it is within the scope of the present invention to first prepare the glenoid cavity  52  within the scapula  51  followed by the humerus  54  for accepting prosthetic inserts  68 ,  70 , respectively. Additionally, it is within the scope of the present invention to replace the damaged end of either the humerus  54  or the glenoid cavity  52  within the scapula  51  with an insert while leaving the undamaged end of the other bone intact.  
      Once the inserts  70 ,  68  have been secured to the humerus  54  and the scapula  51  within the glenoid cavity  52 , the lateral and medial retractors  36 ,  44  are removed from the incision  34  and the incision  34  is sutured closed. A drain (not shown) may be positioned within the shoulder joint  32  to remove excess blood and fluids that may accumulate in the shoulder joint  32  caused by the trauma from the total or partial shoulder joint replacement surgery. Once the shoulder joint  32  stops draining, the drain is removed and the incision  34  is completely closed.  
      Although the present invention has been described with reference to preferred embodiments, workers skilled in the art will recognize that changes may be made in form and detail without departing from the spirit and scope of the invention.