Technique

1.  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

 

 

2.  Deltopectoral approach

 

Incision

- long

- need to be able to access clavicle

- make need to perform clavicular osteotomy

 

Approach

- take SSC and capsule off LT and humerus

- often done with osteotomy as per TSR

- identify and protect axillary nerve

- take part of CAL

- remove capsule from inferior humeral neck + any osteophytes

 

3.  Humeral resection using guide

 

Make entry point in humeral head

- hand ream to determine size of stem

- insert stem with cutting block attached

- 0^o or 20^o (c.f. TSR)

- 155^o cut

- plane of cut laterally just below anatomical neck

- usually takes a couple of millimetres of GT

 

4.  Glenoid

 

Remove capsule and labrum

- protect axillary nerve at all times

- mobilise SSC anteriorly

- need to be able to palpate anterior glenoid

- identify axillary border of scapula

- release triceps and capsule inferiorly

- must be able to feel inferior glenoid and spine

 

Good exposure of glenoid is key to reverse TSR

- sandbag behind spine / allows scapula to fall posterior

- tilt bed up on side of operation

- posterior and inferior glenoid retractors

 

Centering Guide wire passed 

- centre 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

- symmetrically ream

- remove only cartilage, just to subchondral bone

 

Drill central peg hole

 

Insert metaglene

- press fit central peg

- usually only one size

- rotate so superior screw will be in line with base of coracoid

 

Inferior screw

- drill long screw (minimum 35 mm)

- should be in good bone

- is most important screw

- will exit cortex somewhere

- insert locking screw

 

 

 

Superior locking screw

- feel anterior and posterior edges of coracoid

- aim between

- again will exit cortex

- 25 - 30 mm screw

 

 

Anterior and posterior non locking screws/ not in every design

- are predetermined to be divergent

- get best bite possible

- can use locking or non locking

 

Add glenosphere

- can wait until have done humeral component and trial

- do have option for eccentric glenosphere

- this overhangs inferiorly, preventing notching / impingement / possible dislocation

- otherwise, if happy with position, choose size and screw in place

 

5.  Ream and trial humeral component

 

Set rotation

- is an eccentric option

- ream over trial

- insert stem and metaphyseal component

- add liner (+3, +6, +9)

 

Trial stability

- in full ER will open slightly

- adduct and ensure not dislocating / put hand in armpit

- shuck test - entire shoulder should move first

 

7.  L'Episcopo

 

Consider Latissmus Dorsi transfer

- if no functioning external rotators

- cannot raise hand to mouth

- severe fatty infiltration / tears in IS / Tm

 

Detach LD anteriorly

- pass front to back

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

 

 

8.  Closure SSC / LT

 

Technique

- 5 ticron

- through drill holes in humerus

- pass around stem

 

9.  Rehab

 

Protocol

- 6/52 passive forward flexion

- 6/52 active assist

- at 3-12 begin muscle strengthening