The Riverine Herald - - NEWS -

When CHAR­MAYNE AL­LI­SON and LACH­LAN DURL­ING were in­vited into the op­er­at­ing the­atre to wit­ness Aus­tralian first surgery they were not sure what to ex­pect. But blood and guts aside they watched visit­ing sur­geon Devin­der Gare­wal lead a pre­ci­sion team through ground­break­ing re­con­struc­tive surgery and it all went like clock­work

THE SUN is barely up and or­thopaedic sur­geon Devin­der Gare­wal is strid­ing through Echuca Re­gional Health, prep­ping the the­atre team trav­el­ling in his wake.

They are good to go for the first pro­ce­dure of the day.

But this one would be way out of the or­di­nary – it was the first pro­ce­dure of its kind in Aus­tralian his­tory.

The coun­try’s first nav­i­gated short-stem re­verse shoul­der surgery.

A med­i­cal mouth­ful that in English means a 74-year-old suf­fer­ing chronic pain was about to get his life back.

Best of all, he was go­ing to be able to give his wife (and his grand­chil­dren) a proper hug.

And get back to the out­door life he loves – fish­ing, prospect­ing and gar­den­ing – but has not been able to do prop­erly for longer than he cares to think about. Dev, how­ever, had big­ger fish to fry. He was about to cre­ate his own lit­tle piece of Aus­tralian med­i­cal pi­o­neer­ing in part­ner­ship with the braini­acs from Ex­actech who had made the new ‘short-stem’ pros­the­sis about to be in­serted into the pa­tient’s shoul­der.

The cut­ting-edge pros­the­sis is just 50 mm shorter than the tra­di­tional long-stem model but is far less in­va­sive as less bone needs to be re­moved and gives the pa­tient fu­ture op­tions if there is any sort of re­lapse or dam­age.

It was a first here but Dev’s done more shoul­der surg­eries of this type (nav­i­gated re­verse shoul­der) than he can re­mem­ber.

“I think it’s some­where be­tween 40 and 50,” he said. “So to­day, for me, is not daunt­ing.” While Dev is ty­ing up loose ends, Ex­actech’s An­drew Stubbs is around the cor­ner set­ting up the pe­ri­op­er­a­tive plan for the surgery.

So­phis­ti­cated 3D mod­els flash onto the screen, show­ing where bone has been lost to wear and tear and where, ac­cord­ing to the CT scan; the ideal spots are to in­sert the pros­the­ses.

“If you look at this view, it shows where the vault is, that’s where the best bone is. We need it to be right in the mid­dle,” Dev said, ex­am­in­ing the plan with An­drew.

“We also need to cal­cu­late depth so the back of the pros­the­sis is at the cor­rect an­gle and low enough so the base­plate doesn’t touch on the un­der­sur­face of the socket side. “That looks like it’s in a good po­si­tion.” Once signed off the plan is saved to be used dur­ing surgery. For this type of op­er­a­tion the tech is in the the­atre ac­tu­ally call­ing most of the shots.

Like a player in a chess game he must be steps ahead of Dev, en­sur­ing the scrub nurse has all the in­stru­ments at the ready while keeping an ea­gle eye on the tech­nol­ogy in case disas­ter strikes.

Then the re­hearsals are over, the team have checked ev­ery­thing off, the pa­tient, now com­pletely un­der, is swept out of the anaes­thetic room with lo­cal GP/anaes­thetist Sam Kennedy by his side, the sur­geon looks ev­ery­one in the eye and it’s cur­tains up.

There are 10 peo­ple and so many things that go ping packed into the the­atre but like the ul­ti­mate con­duc­tor (to the sooth­ing jazz sound­track on the stereo) Dev kept ev­ery­one in tune and kept ev­ery­thing go­ing for­ward. “Here we go,” Dev said. “We’re about to per­form Aus­tralia’s first nav­i­gated short-stem shoul­der re­place­ment.”

Mo­men­tous words for what turned out to be a pretty tame start to the surgery.

As tubes, cords and sup­ports are set up and the pa­tient’s arm ster­ilised, ban­ter ric­o­chets around the room.

The team clearly take the life-or-death na­ture of their job se­ri­ously – but like any high-pres­sure, high-stakes role, they still need to have a bit of fun.

The set-up com­plete, Dev makes the first cut boldly and deeply.

The cut is clean, amaz­ingly to the unini­ti­ated, there is no gush­ing blood, and ERH sur­gi­cal res­i­dent Luke Bren­nan is there to suck away any stray blood.

Forc­ing the cut open with a re­trac­tor, Dev ex­poses the stri­ated mus­cle be­neath.

“So we’re go­ing into an in­ter­val be­tween two mus­cles at the front of the shoul­der,” he said.

“One is the del­toid and one is the pec­toral – that in­ter­val is in­di­cated by a vein that comes up the arm.

“So the first job is to try to find that vein.” A burnt-hair smell hangs in the air as Dev singes away scar tis­sue be­neath the mus­cle us­ing a diathermy or ‘fire­stick’ – clear­ing the site to get at the shoul­der joint.

That takes him through a thin, slip­pery-white bi­ceps ten­don which he sim­ply cuts and then sews it to the ma­jor pec­toral mus­cle to hold its po­si­tion.

The shoul­der’s sud­den ap­pear­ance is con­fronting as the bone, usu­ally hid­den be­neath lay­ers of mus­cle, tis­sue and ten­dons – and wrapped in skin – is grad­u­ally ex­posed.

Re­mov­ing the front mus­cle, Dev fi­nally has clear ac­cess to the joint and, us­ing clamps, he and Luke gen­tly wedge it out of the body.

“His humerus bone has a very big head and he’s lost all the ten­dons at the top of it, as we’d seen in the scan,” Dev said, touching the tip of the bone.

“He’s miss­ing a bit of the car­ti­lage on the head as well, plus there are lots of lumps and bumps from arthri­tis.”

And now the real work – the blood, sweat and tears of the op­er­a­tion – be­gins.

Handed an os­cil­lat­ing saw with a blade the width of his fin­ger, Dev be­gins to grind away at the head of the ex­posed humerus.

Slic­ing it clean off, he knocks the sev­ered piece, the size of a small plum, with a pair of pli­ers. “See, that’s not the nor­mal sound,” he said. “We’re left with the rest of the humerus. So now we’re go­ing to pre­pare to put the pros­the­sis in.”

Grab­bing a mal­let and broach (a ta­pered in­stru­ment a bit like a chisel), Dev doesn’t just ham­mer it into the humerus it al­most looks like he’s belt­ing it, each blow is so firm, mak­ing room for the pros­the­sis.

“We’re go­ing up in sizes un­til we get one that fits the bone,” Dev said, swap­ping the chisel twice.

“And we’re not try­ing to re­move a chan­nel of bone here. We’re ac­tu­ally im­pact­ing what bone is there, com­pact­ing it so the stem is sur­rounded by strong bone.”

This is no place for the squea­mish, for these sur­geons ev­ery­thing from saw­ing to ham­mer­ing needs to be as force­ful as any handy­man’s project. Only, this is flesh and bone in­stead of wood. And ev­ery mil­lime­tre counts. So while Dev bangs away, he is ex­pertly nav­i­gat­ing that fine line be­tween prac­ti­cal­ity and pre­ci­sion.

Mean­while, scrub nurse Bec Gray is us­ing what is surely an ap­ple corer in its spare time to cut tiny col­umns of bone from the re­moved head of the humerus which will be used to graft the plate of the pros­the­sis to the old socket.

“It’s like she’s mak­ing a fruit salad; like mak­ing melon balls,” a team mem­ber jokes.

Af­ter drilling a tracker into a bone just above the shoul­der, Dev uses it to com­mu­ni­cate with the pe­ri­op­er­a­tive plan on the mon­i­tor in front of him.

His gaze glued to the screen, he lines up an elec­tric screw­driver ex­actly where the plan has marked out.

Now we are talk­ing real surgery, if it’s not mi­cron ex­act it’s just not go­ing to work.

The drilling done, Dev scrubs just enough car­ti­lage from the socket (aka glenoid cav­ity) so a pros­thetic joint can be in­stalled.

Then with tweez­ers he squeezes the tiny col­umns of bone Bec ex­tracted into the peg which will con­nect the pros­the­sis to the socket – and then it’s screwed snugly in to place.

“The screws are much longer and bet­ter fixed be­cause of the nav­i­ga­tion,” Dev said.

“This gives more sta­bil­ity to the pros­the­sis un­til that peg is even­tu­ally held by bone.”

The peg in­tact, Dev screws the ‘ball’ – a hol­low half-sphere of me­tal – on top. Now, the ball sits where the socket once lived. While the short-stem pros­the­sis will pro­vide a socket where the ball used to be – a to­tal re­ver­sal.

Mean­ing the dam­aged ro­ta­tor cuff ten­dons which pre­vi­ously helped the shoul­der move are no longer needed – from to­day the joint will be moved by the del­toid mus­cle.

Dev taps in a trial pros­the­sis, 1mm smaller than the per­ma­nent one.

“This way, be­fore I put it in I know it feels right and the tight­ness is good,” he said. At last, it’s time for the real deal. An­drew presents the pros­the­sis to Dev with the dra­matic flair of an ex­pert sales­man.

“Here we have Aus­tralia’s first nav­i­gated pre­serve 10mm stem. Congratulations Mr Gare­wal and Echuca Re­gional Health,” he said.

Once the pros­the­sis is ham­mered in, a poly­eth­yl­ene cap is tapped on and the new joint is popped into place.

The wound still open, Dev moves the arm around to show the smooth move­ment of the new joint, the ball and socket glid­ing eas­ily.

“So it’s been re­versed and it’s very sta­ble, this pa­tient should be able to lift his arm into the air and to the side with­out any dif­fi­culty.” And just like that it’s over. Dev stitches the skin back to­gether, hid­ing his hand­i­work; nurses pack up in­stru­ments; the pa­tient is wheeled to the ward.

Sud­denly what had been the cen­tre of the world is all but aban­doned; no ev­i­dence re­mains of the life-chang­ing and his­toric surgery that just un­folded.

Ex­cept some­where, down the hall, there’s a pa­tient who will soon wake up.

If Dev got it right it will be the pa­tient’s last surgery.

And be­cause he did get it right, Dev has many more to come.

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