Depuy Synthes Delta Xtend Reverse Surgical technique
Templating
Xray
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
Coronal
- often superior wear
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
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
- 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