Reverse total shoulder arthroplasty is used to restore our mobility in patients with severe disability from rotator cuff pathology and associated arthritis in conventional shoulder arthroplasty. The metal ball of the prosthesis is attached to the humerus or upper arm, and the socket is attached to the G glenoid or shoulder blade. In contrast, in reverse total shoulder arthroplasty, the plastic socket is fastened to the arm and Theos sphere is implanted on the G glenoid to implant a reverse shoulder prosthesis following anesthesia and retraction of the overlying muscle.
The humerus or upper arm bone is exposed and the humeral head is reamed following exposure and reaming of the G glenoid. The G glenoid base plate and g Glens sphere are inserted and screwed into place. The next step is to cement the humeral component in place.
This patient is a 78-year-old female with rotator cuff arthropathy. Prior to surgery, her symptoms were managed by conservative measures including activity modifications and injections of corticosteroids. Her last two steroid injections provided minimal relief of her pain.
However, additionally, her shoulder became increasingly stiff causing decreased effective function. Her preoperative examination showed significant limitation in range of motion with 40 degrees of forward flexion, 10 degrees of external rotation and internal rotation to the gluteus. She had notable weakness in resisting external rotation and elevation in the scapular plane.
Her subscapularis Anter minor function was intact by examination with a negative lag sign and a negative belly press test. Radiographic examination of the patient showed some mild decrease of the acromial humeral distance with noted G glenohumeral joint space narrowing. There was no notable g glenoid erosion.
The patient therefore elected to undergo a reverse total shoulder arthroplasty. The author's preferred method for management of such pathology. The standard delto pectoral approach is used.
The cephalic vein is identified and mobilized. The subdeltoid adhesions are released and a brown retractor is placed in the subdeltoid space. The superior border of the pectoralis major tendon is identified and tenotomized.
The long head of the biceps is then identified medial to the superior border of the pectoralis major tendon. The sheath is then opened at this level and the tendon is extracted. The tendon is then tagged and transected for later tenodesis to the posterior leaflet of the pectoralis major tendon.
A pair of curved mayo scissors are then placed in the bicipital groove and advanced through the rotator interval to the G glenoid. The anterior humeral circumflex vessels are identified and cauterized using bipolar cautery. The inferior and lateral margins of the subscapularis tendon are elevated and traction sutures are placed laterally.
The medial blunt homan retractor is removed and a sharp homan is placed directly along the medial cortex of the inferior humeral neck. The remainder of the subscapularis is elevated from attachment at the lesser tuberosity. A second sharp home and retractor is placed around the posterior humeral head retracting The subscapularis medially, the humeral cutting guide is impacted and the retroversion is set.
Using the version guide inserted into the handle. The initial humeral cut is made below the guide and the guide is removed. The humeral cut is then completed in the same plane.
The humeral head is then reamed removing the remaining cancellous bone. The medullary reamers are then inserted to the appropriate depth for the selected stem. The medial cortical rim is then removed with a own juror.
Both medial retractor and the brown deltoid retractor are removed. A facu retractor is then placed behind the posterior G glenoid retracting. The humerus laterally the plane between the subscapularis tendon and the anterior inferior capsule is identified and the capsule is transected to a level of the inferior anterior G glenoid.
An anterior G glenoid retractor is placed and the biceps labral complex is excised. The true center of the G glenoid is then marked and the staring drill is used to create a guide for reaming. The G glenoid is then reamed.
The G glenoid base plate is then inserted after the center hole is drilled with a larger 7.5 millimeter drill. The anterior and posterior non locking screws are placed first. Then the inferior and superior locking screws are placed.
The GLE sphere is then impacted onto the base plate and locked in place with the center screw. The brown retractor and medial sharp homan retractor are replaced. Two drill holes are made in the bicipital groove and number five non-absorbable sutures are placed through the drill holes.
Cement is pressurized into the humeral canal. The humeral component is placed at the appropriate retroversion and the cement is allowed to cure. A trial liner is placed.
The shoulder is reduced and the stability and range of motion are checked. The final polyethylene component is then impacted in place and the shoulder is reduced. The subscapularis tendon is then repaired using the stitches placed through the bicipital groove.
Finally, the long head of the biceps tendon is tend these to the posterior leaflet of the pectoralis major tendon. A deep drain is placed with the closure of the wound and the patient is placed into a sling postoperatively at six months.Follow-up. This patient ranked her postoperative pain as a zero on the visual analog scale.
Her active range of motion included forward flexion to 140 degrees, active external rotation of 25 degrees and internal rotation to her gluteus. This patient had no intraoperative or postoperative complications at last follow up. The reverse total shoulder arthroplasty procedure involves exposing and reaming the humerus and G glenoid.
The G glenoid base plate, g glen sphere and humeral component are then placed. Successful reverse total shoulder arthroplasty allows the patient to use the deltoid muscle to lift the arm leading to a significant improvement in the patient's quality of life.
