Technique

 

Depuy Synthes Delta Xtend Reverse Surgical technique

 

Templating

 

Xray

 

Rotator Cuff Arthropathy

 

AP in plane of scapula

- template glenoid 

- most inferior screw is in thick bone of scapular axillary border

 

AP humerus

- size and fit of diaphyseal and metaphyseal humeral components

 

CT

 

Axial

- assess glenoid bone stock / version

- normally no posterior wear in cuff arthropathy

 

Glenoid Pre Rev TSR Axial CT

 

Coronal

- often superior wear

 

Glenoid Pre Rev TSR Coronal CTGlenoid Pre Rev TSR Coronal CT 2

 

Approach options

 

Deltopectoral approach

Anterosuperior approach

 

Deltopectoral approach

 

Incision based upon coracoid

- identify and protect cephalic vein

- biceps tenotomy

 

Subscapularis options

- tenotomy

- peel

- lesser tuberosity osteotomy

 

Capsulotomy

 

Humeral head resection using cutting guide

 

Identify anatomical neck

- osteotomy 2 mm below cartilage

- insert stem

- 0o or 20o retroversion

- leave trial stem in while preparing glenoid to prevent fracture

 

Glenosphere

 

Remove all labrum and release capsule from glenoid

- identify inferior border of scapula

- ? release triceps from inferior border

- insert retractors to expose glenoid

 

Centering guide wire passed 

 

Center of inferior circle of glenoid

- should exit scapula anteriorly about 3cm medial to glenoid

- ensure not too anterior as anterior screws can have little purchase

- ensure inferior screw will be in inferior good bone

- metaglene needs to be positioned low to prevent inferior impingement and dislocation

- wire needs to angle slightly inferior rather than slightly superior

- ream cartilage to subchondral bone

 

Options

- glenoid guides

- patient specific implants

- navigation

 

Metaglene / baseplate fixation

 

Screws as long as possible

- inferior screw - long into scapular pillar

- superior screw - aim for coracoid

- anterior / posterior screws - convergent / divergent

 

 Reverse TSR APReverse TSR Axillary View

 

 

Reverse TSR Coracoid ScrewReverse TSR Axillary

 

Trial components

 

Insert humeral stem

 

Trial glenosphere and humeral liner options

- shuck test

- stable through range of motion

- no inferior impingement

 

Subscapularis

 

? Repair

- does it heal

- does it improve or worsen range of motion

 

Collin et al J Should Elbow Surg 2022

- 86 patients with rTSA and repaired subscapularis tenotomy

- 2 year ultrasound - subscapularis healed in 53%

- no difference in outcome scores between healed and not healed

- improved IR with healed, with no difference in ER

 

Tendon transfers

 

Indication

 

Limited external rotation

 

Options

 

Latissimus dorsi

T major

 

Results

 

Young et al JSES 2020

- RCT of rTSA +/- LD/Tmajor transfer

- no difference outcome scores

- improved external rotation rTSA 58% v rTSA+tendon transfers 73%

 

Hones et al Clin Shoulder Elbow 2024

- systematic review of external rotation in rTSA
- lateralized rTSA versus rTSA + LD tendon transfer

- better external rotation with lateralized rTSA

 

Technique

 

Detach latissmus dorsi

- pass anterior to posterior

- suture via drill holes to the posterior aspect of the humerus

 

LEpiscopo 1LEpiscopo 2