import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: 5-7cm below acromion anteriorly, crosses inferior subscapularis **Protection**: Blunt retractors only, avoid anteroinferior retraction beyond safe zone, gentle inferior capsular release from lateral to medial **Location**: Enters coracobrachialis 5-8cm distal to coracoid tip **Protection**: Limit medial retraction of conjoint tendon, identify nerve before aggressive releases, avoid prolonged retractor pressure **Location**: Medial to surgical field in axilla **Protection**: Avoid excessive or prolonged medial retraction, maintain proper patient positioning to prevent traction injury **Location**: Deltopectoral interval, variable anatomy **Protection**: Take laterally with deltoid (preserves drainage) or medially with pectoralis (preserves vein), ligate if injured rather than sacrifice exposure **Location**: Medial cortex of scapula separates shoulder from thoracic cavity **Protection**: Careful central screw drilling aimed at scapular spine, avoid excessive reaming depth, fluoroscopy confirmation when available ## Preoperative Assessment and Planning ### Clinical Evaluation **Patient History** - Previous TSA indication and timeline - determine failure mechanism (rotator cuff tear, instability, loosening, infection, fracture) - Current symptoms: pain severity (VAS), functional limitations (forward elevation, activities of daily living), instability episodes - Infection history: previous wound complications, systemic infections, immunosuppression, diabetes control - Medical optimization: cardiac clearance for beach chair position, anticoagulation management, osteoporosis treatment - Deltoid function assessment: critical for reverse TSA success - test manual muscle strength, observe active elevation **Physical Examination** - Active ROM: forward elevation (average 60-80° pre-revision), external rotation at side, internal rotation (hand behind back level) - Passive ROM: assess stiffness vs pseudoparalysis (passive full, active limited suggests rotator cuff deficiency) - Deltoid function: palpate muscle bulk, test against resistance - ESSENTIAL for reverse TSA outcomes - Subscapularis integrity: belly press test, lift-off test (often difficult in stiff shoulders) - Neurovascular examination: axillary nerve (deltoid contraction, lateral arm sensation), overall upper extremity function - Wound assessment: previous surgical scars, skin quality, soft tissue envelope ### Imaging Protocol **Plain Radiographs** - True AP (Grashey view): glenoid bone stock, component loosening (radiolucent lines, migration), humeral subsidence - Scapular Y lateral: anterior/posterior component position, glenoid version assessment - Axillary lateral: glenoid bone stock, version, component position, humeral head subluxation/dislocation - Assess for: glenoid loosening (progressive radiolucent lines, migration), humeral stem loosening, osteolysis, fracture, heterotopic ossification **CT Scan with 3D Reconstruction (MANDATORY)** - Glenoid bone stock assessment using Sirveaux/Nerot classification (E0-E4) - Anterior and posterior column integrity - critical for baseplate screw fixation - Superior pillar and inferior pillar assessment for peripheral screw options - Measure glenoid version: normal 2-10° retroversion, excessive retroversion common in failed TSA - Humeral bone stock: canal diameter, cortical thickness, previous screw holes, cement extent if cemented - 3D reconstruction for surgical planning: baseplate size, screw trajectory planning, bone graft needs **MRI (If Concern for Infection or Soft Tissue Assessment)** - Rotator cuff status: subscapularis, supraspinatus, infraspinatus, teres minor integrity - Deltoid muscle quality: atrophy, fatty infiltration (Goutallier classification) - Soft tissue edema, fluid collections concerning for infection - Labral remnants, capsular integrity for reconstruction planning **Laboratory Workup** - Inflammatory markers if any infection concern: ESR (>30mm/hr concerning), CRP (>10mg/L concerning) - Complete blood count: white blood cell count elevation concerning for infection - Consider aspiration if elevated inflammatory markers: cell count (>3000 concerning), PMN% (>80% concerning), culture - Medical clearance: CBC, basic metabolic panel, cardiac evaluation for beach chair position ### Classification System - Sirveaux/Nerot Glenoid Bone Loss **E0: Intact Glenoid** - No erosion, preserved bone stock - Management: Standard baseplate, central compression screw, 3-4 peripheral screws - Excellent prognosis for durable fixation **E1: Central Erosion Minimal** - Central defect <2mm depth - Columns and periphery intact - Management: Standard baseplate with central compression screw - May need slightly smaller baseplate for optimal contact **E2: Central Erosion Moderate** - Central defect 2-5mm depth - Peripheral rim preserved - Management: Standard baseplate, consider posterior bone graft for support - Ensure adequate peripheral screw purchase into columns **E3: Posterior Erosion Significant** - Posterior defect >5mm depth - Altered glenoid version (excessive retroversion) - Management: BIO-RSA technique - posterior bone graft behind baseplate to restore version and increase contact area - Morselized autograft (humeral head) or allograft, compressed by baseplate creating 'autograft effect' **E4: Massive Bone Loss** - Extensive central and/or peripheral defects - Column compromise possible - Management: May require structural allograft, custom augmented baseplate, or smaller baseplate with extensive grafting - Consider higher failure risk - counsel patient appropriately ### Surgical Planning Checklist **Implant Options Prepared** - Reverse TSA system: multiple baseplate sizes (25mm, 29mm, 33mm), glenosphere options (36mm, 40mm standard vs lateralized) - Humeral stems: revision lengths, various diameters, cemented vs cementless options - Polyethylene liner thickness: 6mm, 9mm, 12mm, 15mm for stability adjustment - Metal augments if needed for bone loss reconstruction **Bone Graft Preparation** - Autograft: humeral head from removed components (morselized for glenoid, structural for humerus) - Allograft availability: cancellous chips for glenoid, structural allograft for massive defects - Bone graft preparation equipment: rongeurs, bone mill for morselization **Extraction and Revision Instruments** - Humeral component extraction: universal extraction system, curved osteotomes, flexible osteotomes - Cement removal: high-speed burr, hand instruments, ultrasonic cement removal device - Glenoid component removal: curved explant osteotomes, thin flexible osteotomes - Extended trochanteric osteotomy equipment: oscillating saw, cables/wires for fixation - C-arm fluoroscopy if available for screw trajectory confirmation **Anticipated Surgical Time** - Standard revision: 90-120 minutes - Complex revision with ETO, significant bone loss: 120-180 minutes - Factor additional time for: well-fixed component extraction, extensive cement removal, bone grafting ## Surgical Anatomy and Approach ### Surface Anatomy and Landmarks **Bony Landmarks** - Acromion: lateral edge, anterior border, posterolateral corner - reference for incision and axillary nerve location - Clavicle: medial border defines deltopectoral interval superiorly - Coracoid process: palpable 2cm below clavicle at deltopectoral interval - reference for musculocutaneous nerve (5-8cm distal to tip) - Acromioclavicular joint: useful landmark for superior extent of exposure **Neurovascular Structures at Risk** **Axillary Nerve** - Course: exits quadrangular space with posterior humeral circumflex artery, wraps around surgical neck of humerus - Location: 5-7cm below acromion anteriorly (range 3-10cm), crosses inferior border of subscapularis - At risk: inferior subscapularis/capsular release, anteroinferior retractor placement, humeral manipulation - Protection: blunt retractors only below acromion, gentle inferior release from lateral to medial, limit retraction depth to <7cm **Musculocutaneous Nerve** - Course: branches from lateral cord of brachial plexus, enters coracobrachialis muscle - Location: enters coracobrachialis 5-8cm (range 3-12cm) distal to coracoid tip - At risk: medial retraction of conjoint tendon, aggressive subscapularis releases - Protection: identify nerve before extensive releases, limit medial retraction force and duration **Brachial Plexus** - Location: medial to operative field in axilla - At risk: excessive or prolonged medial retraction, poor patient positioning causing traction - Protection: proper positioning with arm support, gentle retraction, periodic retractor relaxation **Cephalic Vein** - Course: runs in deltopectoral interval, variable anatomy (lateral vs medial vs bifid) - At risk: initial deltopectoral interval development - Protection: identify early, take laterally with deltoid (better healing, preserves drainage) or medially with pectoralis (preserves vein) ### Deltopectoral Approach **Incision** - Utilize previous deltopectoral incision in most cases - Extend proximally if needed: 2-3cm above clavicle for superior glenoid exposure - Extend distally if needed: 10-12cm down arm for humeral component extraction, cement removal, or extended trochanteric osteotomy - Mark incision with patient upright if possible to assess cosmetic positioning **Interval Development** - Identify deltopectoral interval by palpation: depression between deltoid (lateral) and pectoralis major (medial) - Locate cephalic vein in interval - variable position (35% lateral, 40% medial, 25% bifid) - Take vein laterally with deltoid (preserves drainage, better deltoid healing) or medially with pectoralis (vein preservation) - Sharp dissection through subcutaneous tissue to deltoid and pectoralis fascia - Blunt dissection to develop interval - finger sweep to break adhesions from previous surgery - Place self-retaining retractor (Kolbel, Browne) to maintain deltopectoral interval **Deep Exposure** - Identify clavipectoral fascia lateral to conjoint tendon (coracobrachialis and short head biceps) - Tag clavipectoral fascia with suture or clamp for later repair - Incise clavipectoral fascia 1cm lateral to conjoint tendon to avoid musculocutaneous nerve - Identify and protect musculocutaneous nerve: enters coracobrachialis 5-8cm below coracoid tip - Avoid aggressive medial retraction of conjoint tendon to prevent nerve injury **Extensile Exposure Options** **Superior Extension** - Indication: difficult glenoid exposure, superior glenoid bone loss, need for superior baseplate screw placement - Technique: extend incision above clavicle, release deltoid from anterior clavicle with tagged sutures for repair - Risk: deltoid denervation if extend too far laterally (preserve anterior deltoid nerve branches) **Inferior Extension** - Indication: humeral component extraction, cement removal, extended trochanteric osteotomy - Technique: extend incision 10-15cm down arm, develop plane between deltoid and brachialis - Protection: axillary nerve at highest risk - stays with deltoid, avoid periosteal stripping of proximal humerus ### Three-Retractor Technique for Glenoid Exposure **Anteroinferior Retractor (Fukuda or Darrach)** - Position: along anterior glenoid rim, gentle traction inferiorly and medially - Purpose: displaces humeral head anteriorly and inferiorly, exposes glenoid face - Danger: axillary nerve injury if placed >7cm below acromion or excessive force applied - Safety: blunt retractor tip, place along bone (not soft tissue), gentle gradual traction **Anterosuperior Retractor (Blunt Hohmann)** - Position: over coracoid base superiorly, lifts conjoint tendon - Purpose: retracts superior soft tissues, improves superior glenoid visualization - Danger: musculocutaneous nerve if retractor slips medially - Safety: secure placement on bone, assistant maintains retractor position **Posterior Retractor (Blunt Hohmann)** - Position: behind glenoid, placed after capsulectomy - Purpose: critical for posterior glenoid visualization - allows assessment of bone stock, baseplate positioning - Danger: suprascapular nerve posterosuperiorly, circumflex scapular vessels inferiorly - Safety: stay on bone, avoid soft tissue retraction, place under direct vision **Lighting for Glenoid Visualization** - Headlamp mandatory for all shoulder arthroplasty - critical for posterior glenoid visualization - Adjust patient position and retractors to optimize light angle onto glenoid - Assistant headlamp helpful for dual illumination ## Detailed Operative Technique ### Step 1: Preoperative Planning and Preparation **Imaging Review** Review preoperative CT scan with 3D reconstruction to assess glenoid bone stock using Sirveaux/Nerot classification (E0-E4 glenoid erosion). Identify previous operative approach from notes and scars. Plan reconstruction strategy: standard baseplate for E0-E2, BIO-RSA (bone graft augmentation) for E3, custom components/bone graft for E4. Assess rotator cuff status on MRI - subscapularis integrity particularly important. Verify deltoid function clinically. Templating for component size and position. Have full revision tray available including metal augments, bone graft options, cables/wires for trochanteric osteotomy if needed, and extraction instruments for well-fixed components. **Technical Tip**: EXAM KEY: Preoperative CT is MANDATORY for revision shoulder arthroplasty - must assess glenoid bone stock and plan reconstruction. The Sirveaux classification (E0-E4) determines treatment: E0-E2 standard baseplate, E3 BIO-RSA with posterior bone graft, E4 may need custom implants. BIO-RSA technique: autograft or allograft behind baseplate to augment bone and restore glenoid version. Subscapularis repair significantly improves stability and internal rotation - always attempt if tissue quality allows. - Inadequate preoperative planning leads to intraoperative surprises and prolonged surgical time - Missing glenoid bone loss on imaging results in intraoperative baseplate stability issues or failure - Not having revision instruments available (extraction devices, cement removal tools) prolongs surgery and increases complication risk ### Step 2: Patient Positioning and Draping **Positioning** Beach chair position with back at 30-45 degrees. Head secured in neutral with slight extension using well-padded headrest. Arm free to move through full range of motion - use arm holder or sterile assistant. Mark anatomic landmarks: acromion, clavicle, coracoid, previous incision. Wide preparation from midline medially to posterior scapula, from base of neck to mid-humerus. Ensure C-arm access if intraoperative imaging needed for baseplate screw placement. Position Mayo stand over abdomen for arm rest during procedure. **Technical Tip**: EXAM KEY: Beach chair position allows better anatomic orientation and easier conversion to open if needed. Arm must be completely mobile - test full ROM before draping. Wide prep essential for extensile exposure if complications arise. Have all revision instruments opened - humeral extraction devices, cement removal tools, curved osteotomes for component removal. - Inadequate arm mobility restricts humeral exposure and component extraction - Poor positioning creates brachial plexus traction injury from arm weight - Restricted draping prevents extensile approaches if complications occur (fracture, difficult extraction) ### Step 3: Approach and Initial Exposure **Deltopectoral Interval** Incise through previous deltopectoral scar - typically starts 2cm lateral to coracoid and extends 12-15cm distally. Identify cephalic vein in deltopectoral interval - take laterally with deltoid (better healing) or medially with pectoralis (preserves vein). Carefully mobilize deltoid laterally and pectoralis medially through scar tissue using combination of sharp and blunt dissection. Place Kolbel or blunt retractors to maintain interval. Palpate for deltoid dehiscence from previous surgery - repair any defects at closure. Tag clavipectoral fascia and incise lateral to conjoint tendon. Identify and protect musculocutaneous nerve (enters coracobrachialis 5-8cm below coracoid) - avoid excessive medial retraction. **Technical Tip**: EXAM KEY: Revision surgery has extensive scar tissue - patient, meticulous dissection essential. Protect cephalic vein if possible but sacrifice if needed for exposure (taking laterally with deltoid may preserve drainage). The deltoid MUST be functional for reverse TSA - carefully assess for prior damage or denervation. Avoid prolonged or forceful medial retraction which can injure musculocutaneous nerve. EXAM TIP: If examiner asks about deltopectoral interval - 'internervous plane between pectoralis major (medial and lateral pectoral nerves) and deltoid (axillary nerve).' - Cephalic vein injury causes bleeding and postoperative edema - Deltoid injury or denervation compromises reverse TSA function - primary elevator - Musculocutaneous nerve traction from excessive medial retraction of conjoint tendon ### Step 4: Subscapularis Assessment and Management **Subscapularis Evaluation** Identify subscapularis or remnants from previous surgery. In revision cases, subscapularis may be: (1) previously repaired and intact, (2) attenuated/deficient, (3) completely absent, or (4) scarred to anterior capsule. If subscapularis present: carefully develop plane between subscapularis and anterior capsule using blunt dissection and electrocautery. Tag with heavy braided sutures (#2 Ethibond) for later repair. If deficient: plan conjoint tendon transfer or pectoralis major transfer for anterior stability. Preserve long head biceps if intact (provides some anterior stability) or tenotomize if frayed/degenerated. Release inferior subscapularis carefully to protect axillary nerve (5-7cm below acromion). **Technical Tip**: EXAM KEY: Subscapularis status critically affects reverse TSA stability and internal rotation. Repair if any tissue available - improves outcomes. If deficient, options include: (1) pectoralis major transfer, (2) allograft augmentation, (3) accept deficiency but counsel patient on IR weakness and increased instability risk. EXAM PEARL: In revision to reverse TSA, you're trading rotator cuff function for deltoid-powered arm elevation, but subscapularis still helps stability. EXAM TIP: Axillary nerve at HIGHEST risk during inferior subscapularis/capsule release - stay anterior, release from lateral to medial, use finger to sweep gently. - Axillary nerve injury during inferior subscapularis or capsular release - Irreparable subscapularis damage from overly aggressive dissection compromises stability - Overly aggressive vascular release causes excessive bleeding and hematoma risk ### Step 5: Humeral Component Exposure and Extraction **Component Removal** Externally rotate and extend arm to deliver proximal humerus into wound. Remove any heterotopic ossification with rongeurs/osteotomes. Perform anterior capsulectomy to expose humeral component. Assess stem fixation - loose vs well-fixed determines extraction technique. For LOOSE stem: use curved osteotomes at bone-implant interface working circumferentially, gentle extraction devices. For WELL-FIXED stem: may require extended trochanteric osteotomy (ETO) or humeral window osteotomy for cement removal. ETO technique if needed: mark osteotomy line 12-15cm along lateral humerus preserving vastus lateralis insertion, create controlled fracture with osteotomes, hinge open preserving soft tissue envelope. Remove stem using extraction devices - universal extraction systems attach to Morse taper. For cemented stems: remove all cement using high-speed burr, hand instruments, ultrasonic cement removal tools - critical to reach pristine bleeding bone. **Technical Tip**: EXAM KEY: Well-fixed humeral components are the biggest challenge in revision shoulder. Extended trochanteric osteotomy (ETO) dramatically improves exposure and cement removal - key steps: 12-15cm length, preserve soft tissue hinge posterolaterally, repair with cables/wires at closure. NEVER force a well-fixed stem - high risk of humeral fracture. If cemented, ALL cement must be removed - retained cement causes stress risers and subsidence. EXAM PEARL: Humeral window osteotomy alternative to ETO - create rectangular window distally to access cement, replace and fix with plate. Registry data shows cemented stems in revision have excellent outcomes if cement technique perfect. - Humeral shaft fracture from forced stem extraction - highest risk in osteopenic bone - Incomplete cement removal leads to stress risers and early loosening - Thermal injury to bone from excessive burring during cement removal ### Step 6: Glenoid Component Exposure **Glenoid Visualization** Circumferential release of anterior, inferior, and posterior capsule from glenoid rim using electrocautery and elevator. Place Fukuda or glenoid retractors: anteroinferior retractor (protect axillary nerve), anterosuperior retractor over coracoid base, posterior retractor behind glenoid. Release rotator cuff remnants from greater tuberosity to improve glenoid visualization. Remove any remaining labrum/soft tissue from glenoid face. Identify anatomic landmarks: anterosuperior/inferior quadrants, bare area centrally, coracoid base superiorly. Use headlamp and assistant retraction for optimal visualization of posterior glenoid. Assess bone stock - palpate columns, walls, and central glenoid. **Technical Tip**: EXAM KEY: Glenoid exposure is CRITICAL and most challenging part of revision shoulder. Three-retractor technique: (1) anteroinferior (Fukuda/Darrach) protects axillary nerve, (2) anterosuperior over coracoid, (3) posterior (blunt Hohmann) behind glenoid. EXAM TIP: Axillary nerve is at HIGHEST RISK during anteroinferior retractor placement - never place retractor more than 5-7cm below acromion, use blunt retractor only, gentle pressure. Complete capsulectomy essential for baseplate positioning assessment. Lighting critical - headlamp mandatory for posterior glenoid visualization. - Axillary nerve injury from anteroinferior retractor placed too deep or with excessive force - Inadequate exposure leads to malpositioned baseplate and early failure - Overly aggressive retraction fractures osteopenic scapula (glenoid neck, coracoid) ### Step 7: Glenoid Component Removal **Explantation Technique** Remove polyethylene liner first if metal-backed glenoid. For cemented all-poly glenoid: use high-speed burr to thin cement mantle, curved osteotomes at bone-cement interface working from periphery to center, careful extraction avoiding glenoid fracture. For cementless metal-backed glenoid: remove screws first (may be stripped - use screw extractors), use curved explant osteotomes at bone-implant interface starting anterosuperiorly and working circumferentially, gentle rocking motion to break ingrowth interface. Use flexible osteotomes and curettes to remove cement from glenoid face. Pulsatile lavage to clear debris. Send multiple tissue samples (minimum 5) for culture to rule out occult infection. Assess bone stock after component removal - often worse than preoperative CT suggested. **Technical Tip**: EXAM KEY: Glenoid component removal is high-risk for glenoid fracture - patient technique essential. Use thin, flexible osteotomes, work from periphery to center, never lever forcefully. For well-fixed components, burring down the component may be safer than extraction attempts. EXAM PEARL: ALL cement must be removed from glenoid - retained cement prevents baseplate contact with bone and causes loosening. Send cultures even if no clinical infection signs - 10-15% of aseptic revisions grow organisms. Bone loss often MORE severe than CT shows - have augmentation options ready. - Glenoid fracture during component extraction - can compromise entire reconstruction - Medial wall perforation into chest cavity - life-threatening complication - Incomplete cement removal compromises baseplate-bone contact and fixation ### Step 8: Glenoid Bone Stock Assessment and Reconstruction Planning **Sirveaux Classification Application** Assess bone defects using Sirveaux classification: E0 (intact), E1 (central erosion minimal), E2 (central erosion moderate less than 5mm), E3 (posterior erosion greater than 5mm), E4 (massive bone loss). Palpate glenoid columns and walls - anterior column, posterior column, superior pillar, inferior pillar. Measure bone loss with calibrated instruments. Plan reconstruction: TYPE E0-E1: standard baseplate with compression screw and peripheral screws; TYPE E2: standard baseplate, may need posterior bone graft for support; TYPE E3: BIO-RSA technique - posterior bone graft behind baseplate to restore version and increase contact area; TYPE E4: may need custom implant, structural allograft, or bone graft with smaller baseplate. Prepare bone graft if needed - autograft from humeral head or allograft cancellous chips morselized. **Technical Tip**: EXAM KEY: Sirveaux/Nerot classification E0-E4 determines glenoid reconstruction strategy. BIO-RSA (Bone Increased Offset Reverse Shoulder Arthroplasty) for E3 defects: posterior bone graft restores version, increases contact area, lateralizes glenosphere for better deltoid mechanics. Technique: morselized cancellous graft packed posteriorly, baseplate placed with compression creating 'auto-graft' effect. EXAM PEARL: Glenoid columns must be intact for stable baseplate - anterior column from coracoid, posterior column from scapular spine. If columns deficient, consider custom implants or accept higher failure risk. AOANJRR data: reverse TSA for revision has 5-year survival 85-90%, baseplate loosening main failure mode. - Underestimating bone loss leads to inadequate reconstruction and early failure - Baseplate positioning without adequate bone support causes immediate or early loosening - Medial wall perforation during assessment - stay oriented to anatomy ### Step 9: Glenoid Baseplate Preparation and Insertion **Baseplate Fixation** Determine baseplate position: inferiorly positioned (lower half of glenoid), 10-15 degrees inferior tilt to reduce scapular notching, maximize screw fixation into scapular spine and pillars. Use glenoid guide pin for central screw - aim perpendicular to glenoid face toward scapular spine/body junction. Confirm position with fluoroscopy if available. Ream glenoid face to create flat surface for baseplate contact - reaming depth 2-3mm to bleeding subchondral bone, preserve columns and walls. Trial baseplate to confirm fit, assess contact area (greater than 70% contact optimal). For BIO-RSA: pack morselized bone graft posterior to baseplate before final insertion. Insert baseplate using compression screw first (6.5mm central screw aimed at scapular spine/body junction for maximum purchase), then peripheral locking screws (typically 2-4 screws into superior pillar, anterior column, or posterior column). Aim screws to engage strongest bone: superior pillar (superiorly), scapular spine (posterosuperiorly), coracoid base (anterosuperiorly). Verify all screws have good purchase - no toggling. Final baseplate stability check - should be rock-solid. **Technical Tip**: EXAM KEY: Baseplate position and screw placement are CRITICAL for longevity. Central compression screw must engage scapular spine/body junction (strongest bone) - aim guide pin there first. Inferior baseplate positioning reduces scapular notching (glenosphere impingement on inferior scapula) from 60% to 20-30%. Inferior tilt 10-15 degrees further reduces notching. Peripheral screws: (1) superior into pillar/spine, (2) anterior into coracoid base/column, (3-4) posterior into column/spine. EXAM PEARL: Minimum 4 screws for baseplate fixation (compression screw + 3 locking screws). More screws if bone quality poor or significant defects. BIO-RSA: bone graft placed BEHIND baseplate acts as autograft, restores version, increases contact. EXAM TIP: If asked about scapular notching - 'contact between glenosphere and inferior scapula in adduction, reduced by inferior glenoid positioning, inferior tilt, lateralization, and large glenosphere diameter.' - Central screw misplacement medially risks perforation into thoracic cavity - Inadequate screw purchase in poor bone leads to early loosening - Excessive reaming weakens glenoid columns and reduces fixation ### Step 10: Glenosphere Assembly and Attachment **Glenosphere Configuration** Select glenosphere size: 36mm or 40mm diameter (larger equals more deltoid tension, less notching, but increased joint forces). Select glenosphere lateralization: standard (0mm), lateralized +4mm (BIO-RSA or increased deltoid tension). Lateralized glenospheres increase deltoid moment arm, improve ROM and strength, but increase shear forces on baseplate. Clean baseplate Morse taper thoroughly. Attach glenosphere to baseplate using manufacturer's specific technique - typically Morse taper with locking screw mechanism. Ensure secure seating with firm impaction. Verify glenosphere position: eccentric inferior to maximize inferior ROM, avoid superior overhang which limits abduction. Trial ROM with trial humeral components. **Technical Tip**: EXAM KEY: Glenosphere diameter affects outcomes - 36mm standard but 40mm reduces notching and improves deltoid mechanics. Lateralization (+4mm eccentric glenosphere or BIO-RSA with graft) increases deltoid moment arm by 5-10mm, significantly improves abduction strength and ROM. Grammont principles of reverse TSA: (1) medialized center of rotation increases deltoid moment arm, (2) distalized humerus increases deltoid tension, (3) larger glenosphere increases ROM and reduces impingement. Modern trend: lateral offset to reduce baseplate stress and improve deltoid mechanics. EXAM TIP: If asked reverse TSA biomechanics - 'semiconstrained design with fixed fulcrum at glenosphere, deltoid becomes primary elevator because rotator cuff deficient, medialization and distalization optimize deltoid function.' - Glenosphere dissociation from inadequate Morse taper seating or locking - Excessive lateralization increases baseplate shear stress and loosening risk - Poor positioning (too superior) limits ROM or causes impingement ### Step 11: Humeral Canal Preparation **Stem Preparation** Prepare humeral canal using sequential broaches or reamers per implant system. Goal: achieve stable fixation of humeral stem (metaphyseal fit for cementless, cement mantle space for cemented). For cementless stem: broach to final size achieving press-fit in metaphysis, ensure no toggle or subsidence. For cemented stem: broach 1-2 sizes under-reamed to create space for 2-3mm cement mantle. Assess stem version: 20-30 degrees retroversion referenced off forearm with elbow 90 degrees. Version guide on broach/implant helps. Mark version on proximal humerus to maintain during final implant insertion. Prepare proximal humerus for humeral component seating - ensure flat surface, remove osteophytes. Consider bone graft of any humeral defects from previous screw holes or fractures. Pulse lavage canal thoroughly, dry canal if cementing. **Technical Tip**: EXAM KEY: Humeral preparation in revision often complicated by previous screw holes, fractures, or bone loss. Cemented stems preferred in revision if adequate bone stock - third generation technique: pulsatile lavage, canal drying, distal restrictor, vacuum mixed cement, cement gun insertion, pressurization. Version is critical: 20-30 degrees retroversion (referenced off forearm with elbow 90°). Too much anteversion causes anterior instability, too much retroversion limits internal rotation. EXAM PEARL: Humeral stem options in revision: (1) standard primary stem if good bone, (2) calcar-replacing stem if proximal bone loss, (3) longer stem if diaphyseal fixation needed. Extended trochanteric osteotomy (ETO) repair: minimum 3 cables, may add cerclage wires or plate if unstable. - Humeral fracture during broaching in osteopenic bone - use gentle controlled force - Malversion causes instability (too much anteversion) or limited ROM (too much retroversion) - Inadequate fixation leads to subsidence and loosening ### Step 12: Trial Reduction and Assessment **Stability Testing** Insert trial humeral stem at planned version (20-30° retroversion). Select trial polyethylene insert thickness: options typically 6mm, 9mm, 12mm, 15mm. Start with thinnest and assess stability. Reduce trial components. Assess stability through range of motion: internal rotation, external rotation, abduction, forward elevation, combined motions. Stability criteria: no subluxation with arm at side in internal rotation (most unstable position for reverse TSA), stable through full ROM, firm endpoint with stress testing. Assess soft tissue tension: should feel moderate tension, not too tight (limits ROM) or too loose (unstable). Check ROM: forward elevation greater than 130°, external rotation 30-40°, internal rotation to sacrum optimal. Assess impingement: arm at side, combined extension-adduction-IR should not cause anterior impingement. If unstable: increase poly thickness, check component position (glenosphere too superior, humeral component malversion common causes), consider lateralized glenosphere. If limited ROM: ensure adequate soft tissue releases, check for impingement, consider larger glenosphere. **Technical Tip**: EXAM KEY: Trial reduction is CRITICAL - identifies problems before final implants. Stability testing: internal rotation with arm at side is most unstable position for reverse TSA (unlike anatomic TSA where external rotation/abduction unstable). Causes of instability: (1) glenosphere too superior, (2) humeral component excessive retroversion, (3) insufficient soft tissue tension (poly too thin), (4) subscapularis deficiency. Poly thickness selection: thicker equals more stable but less ROM; start thin and increase until stable. EXAM PEARL: Impingement patterns in reverse TSA: (1) scapular notching (glenosphere hits inferior scapula in adduction), (2) acromial impingement (poly hits acromion in elevation), (3) coracoid impingement (rare, subscapularis releases prevent). EXAM TIP: If examiner asks about instability after reverse TSA - 'less common than anatomic TSA (5-10% vs 20-30%), usually posterior, causes include component malposition, inadequate soft tissue tension, subscapularis deficiency.' - Inadequate trial testing misses instability - manifests postoperatively - Excessive poly thickness limits ROM - patient dissatisfaction - Impingement not identified leads to poor outcomes and potential component failure ### Step 13: Final Component Implantation **Definitive Fixation** Remove trial components. Pulse lavage all surfaces. For CEMENTED humeral stem: insert distal cement restrictor, vacuum mix polymethylmethacrylate cement (consider antibiotic-loaded if concerned about infection), use cement gun for retrograde insertion, pressurize cement, insert stem in correct version (20-30° retroversion), maintain position during polymerization (3-5 minutes), remove excess cement. For CEMENTLESS stem: irrigate canal, ensure dry, insert stem with firm impaction achieving press-fit, verify version with forearm reference, confirm no subsidence. Insert final polyethylene liner onto humeral component - ensure proper seating with snap/lock mechanism per implant design. Select final poly thickness based on trials (typically 6-12mm). Reduce components with gentle traction and rotation. Verify stability identical to trials. Remove all retractors. Inspect for retained instruments/sponges. **Technical Tip**: EXAM KEY: Final implant technique must be meticulous. For cemented stems, third-generation cementing technique essential: pulsatile lavage, drying, distal restrictor, vacuum mixing, cement gun, pressurization, maintain version during polymerization. Version critical - mark proximal humerus during trials, reference off forearm. Cement polymerization takes 8-10 minutes to full strength - maintain position without moving stem. EXAM PEARL: Antibiotic-loaded cement considerations in revision: NOT routine but consider if any infection concern (positive cultures, elevated inflammatory markers, suspicious intraoperative findings). Most common: vancomycin 1-2g or gentamicin 1-2g per 40g cement packet. AOANJRR data: reverse TSA for revision has excellent outcomes - 5-year survival 85-90%, significant functional improvement in 85% of patients. - Cement extravasation into soft tissues causes thermal injury and inflammation - Version lost during cement polymerization if stem not held stable - Poly liner malseating causes intraoperative dissociation - verify locked ### Step 14: Subscapularis Repair and Soft Tissue Closure **Tendon Reconstruction** Subscapularis repair if any viable tissue available - significantly improves stability and internal rotation. Technique: arm in neutral rotation, gentle tension on subscapularis, repair to lesser tuberosity using: (1) transosseous sutures through bone tunnels (#2 non-absorbable), (2) suture anchors in tuberosity, or (3) direct repair to capsule if tuberosity bone poor quality. If subscapularis deficient: consider pectoralis major transfer for anterior stability (transfer along conjoint tendon, attach to lesser tuberosity). If subscapularis irreparable: counsel patient on limited internal rotation and higher instability risk. Repair extended trochanteric osteotomy if performed: reduce fragment, fix with 2-3 cables around humerus, ensure stable fixation. Irrigate wound copiously with 3-6 liters saline (antibiotic irrigation controversial, not routine). Inspect for hemostasis - meticulous cautery to prevent hematoma. Close clavipectoral fascia with absorbable sutures. Repair deltoid to pectoralis major if split extended. Close subcutaneous tissue in layers with absorbable sutures. Skin closure per surgeon preference (subcuticular, staples, or nylon sutures). Sterile dressing and sling application. **Technical Tip**: EXAM KEY: Subscapularis repair is CRITICAL when possible - randomized trials show improved internal rotation (10-15°) and stability with repair vs no repair. Repair techniques: transosseous tunnels gold standard but suture anchors acceptable if bone quality poor. Tension during repair: arm in neutral rotation, gentle tension on subscapularis, repair should hold without excessive force. EXAM PEARL: Pectoralis major transfer technique for subscapularis deficiency: release pectoralis from humeral insertion, mobilize along conjoint tendon, transfer laterally to lesser tuberosity, secure with transosseous sutures or anchors. Provides anterior stability but less function than intact subscapularis. EXAM TIP: Postoperative protocol after subscapularis repair: protect repair with sling for 6 weeks, no active IR for 6 weeks, passive ROM starts week 2-3, active ROM week 6-8. Without subscapularis repair: earlier ROM acceptable (immediate passive, active at 3 weeks). - Subscapularis repair failure from excessive tension or poor tissue quality - Hematoma formation from inadequate hemostasis - increases infection risk - Wound dehiscence from tissue tension in revision setting with compromised soft tissue envelope ### Step 15: Postoperative Management and Rehabilitation Protocol **Recovery Protocol** Immediate postoperative: sling immobilization with arm in neutral rotation, ice therapy for pain and swelling, neurovascular checks hourly x4 then q4h x24 hours. Pain management: multimodal analgesia (regional block if placed, oral opioids, NSAIDs, acetaminophen). DVT prophylaxis per protocol (mechanical compression, aspirin 81-325mg daily, or pharmacologic anticoagulation per patient risk). Antibiotics: cefazolin 1-2g (or vancomycin if MRSA risk) for 24 hours per institutional protocol. Immediate radiographs: true AP and scapular Y views to confirm component position. REHABILITATION PROTOCOL with subscapularis repair: Week 0-6 sling immobilization with gentle passive ROM starting week 2 (forward elevation, external rotation with arm at side, NO internal rotation), week 6-8 sling discontinuation and active ROM begins, week 8-12 progressive strengthening, week 12+ unrestricted activity as tolerated. WITHOUT subscapularis repair: earlier mobilization acceptable (passive ROM immediate, active ROM week 3-4). Avoid pushing, pulling, lifting greater than 5 pounds x 3 months. Follow-up: 2 weeks (wound check), 6 weeks (radiographs, advance PT), 3 months, 6 months, annually. Monitor for complications: infection (wound drainage, fever), instability (recurrent subluxation/dislocation), stiffness (persistent limited ROM), nerve injury (deltoid weakness from axillary nerve, IR weakness from musculocutaneous nerve). **Technical Tip**: EXAM KEY: Rehabilitation protocol depends on subscapularis repair status - IF REPAIRED protect 6 weeks (critical for healing), if NOT REPAIRED earlier motion acceptable. Reverse TSA rehabilitation different from anatomic TSA - deltoid is primary elevator so focus on deltoid strengthening once soft tissues healed. EXAM PEARL: Expected outcomes after reverse TSA for failed anatomic TSA: forward elevation improves from average 60-80° to 120-140°, external rotation maintained (30-40°), internal rotation often limited especially if subscapularis deficient (average sacrum vs L3-L5 with repair). Pain relief excellent in 85-90% of patients. Patient satisfaction high (80-85%). EXAM TIP: Complications of reverse TSA: infection 1-3%, instability 5-10% (less than anatomic), scapular notching 30-60% (radiographic, often asymptomatic), baseplate loosening 3-5% at 5 years, acromial stress fracture 2-4% (risk factors: superior glenosphere position, lateral acromion type), neurologic injury less than 1% (axillary nerve most common). - Early aggressive ROM disrupts subscapularis repair - leads to repair failure and instability - Missed infection presents with wound drainage or persistent pain - early recognition critical - Unrecognized nerve injury causes permanent deficit - examine deltoid and document function ## Complications: Recognition and Management 36mm), lateralization with BIO-RSA or eccentric glenosphere, lateralized center of rotation designs.", "Management": "Asymptomatic notching: observation only, monitor for progression. Symptomatic notching with pain: activity modification, NSAIDs. Progressive erosion with baseplate compromise: may require revision with better positioning or lateralization." }, { "Complication": "**Baseplate Loosening (3-5% at 5 years)** - Primary failure mode in reverse TSA", "Recognition": "Progressive pain with use, loss of function. Radiographs show progressive radiolucent lines around baseplate/screws, baseplate migration, screw breakage. May develop glenoid bone loss.", "Prevention": "Adequate initial bone stock (address E3-E4 defects with BIO-RSA/grafting), inferior baseplate position reduces shear stress, minimum 4 screws with good purchase, 70%+ baseplate-bone contact, avoid excessive lateralization in poor bone.", "Management": "Early loosening (within 2 years): likely technical issue - revision with bone grafting, larger baseplate if possible, improved screw purchase. Late loosening (5-10 years): wear or bone loss - revision with structural graft, custom components if massive loss." }, { "Complication": "**Periprosthetic Fracture (1-3% intraop, 2-3% postop)** - Humerus greater than scapula", "Recognition": "Intraoperative: felt or heard during impaction/reduction, direct visualization. Postoperative: sudden pain with trauma, inability to use arm, radiographs confirm fracture location and implant stability.", "Prevention": "Gentle technique during broaching/impaction especially in osteoporotic bone, avoid forced stem extraction (use ETO if needed), adequate humeral exposure before reduction maneuvers, treat osteoporosis preoperatively.", "Management": "Intraoperative humeral fracture: if stable stem - cerclage cables/wires, if unstable stem - longer revision stem bypassing fracture 2 cortical diameters, consider plate fixation. Postoperative: ORIF if implant stable, revision to longer stem if implant loose." }, { "Complication": "**Infection (1-3%)** - Higher than primary TSA due to revision setting", "Recognition": "Early (within 3 months): wound drainage, erythema, fever, elevated WBC/CRP/ESR. Late (greater than 3 months): persistent pain, stiffness, elevated inflammatory markers. Aspiration: cell count greater than 3000, PMN greater than 80%, positive culture.", "Prevention": "Meticulous sterile technique, antibiotic prophylaxis (cefazolin 2g or vancomycin 15mg/kg), minimize operative time, copious irrigation, send intraoperative cultures, dead space closure, hematoma prevention.", "Management": "Acute infection (within 3 months): irrigation and debridement with component retention if stable, exchange poly liner, 6 weeks IV antibiotics. Chronic infection: two-stage revision - component removal, antibiotic spacer, 6 weeks IV antibiotics, reimplantation if markers normalized." }, { "Complication": "**Nerve Injury (less than 1%)** - Axillary nerve most common, usually neuropraxia", "Recognition": "Immediate postop: deltoid weakness (axillary nerve), biceps/coracobrachialis weakness (musculocutaneous), sensory changes. Delayed: progressive weakness suggesting traction injury. EMG/NCS after 3 weeks if not improving.", "Prevention": "Axillary nerve: limit anteroinferior retractor depth to less than 7cm below acromion, gentle inferior capsule release lateral to medial. Musculocutaneous: avoid forceful medial conjoint tendon retraction, identify nerve if extensile release needed. Proper positioning prevents traction.", "Management": "Most neuropraxias recover spontaneously 3-6 months. Initial: sling support, ROM exercises to prevent stiffness, neuro monitoring. If no recovery by 3 months: EMG to differentiate neuropraxia (will recover) vs axonotmesis (may not recover). Neurotmesis (rare): nerve exploration/grafting if diagnosed early." }, { "Complication": "**Acromial Stress Fracture (2-4%)** - Unique to reverse TSA, may require surgery", "Recognition": "Sudden worsening shoulder pain 3-12 months postop, often after fall or increased activity. Weakness in forward elevation. Radiographs may show fracture (subtle initially), CT or MRI confirms acromion fracture - base, shaft, or lateral edge.", "Prevention": "Avoid superior glenosphere position (increases acromion stress), consider lateral acromion anatomy (type III higher risk), ensure adequate glenoid offset, optimize bone health preoperatively, gradual strengthening protocol.", "Management": "Non-displaced: conservative management with sling immobilization 6 weeks, gradual ROM/strengthening. Displaced or non-union: ORIF with plate fixation (superior or lateral acromion plate), may need bone graft for non-union. Most heal with appropriate treatment." } ]} /> ### Additional Complications **Hematoma (2-3%)** - Recognition: excessive postoperative swelling, wound drainage, ecchymosis, wound tension - Prevention: meticulous intraoperative hemostasis, avoid anticoagulation immediately postoperatively, maintain compression dressing - Management: small hematoma - observation; large/expanding hematoma - return to OR for evacuation to prevent infection and stiffness **Component Dissociation (rare less than 1%)** - Glenosphere dissociation from baseplate: Morse taper failure or locking screw breakage - Polyethylene dissociation from humeral component: inadequate locking mechanism engagement - Prevention: verify secure seating, proper impaction, locking mechanism engaged per manufacturer protocol - Management: requires reoperation for component exchange, assess why dissociation occurred **Stiffness (5-10%)** - Persistent limited ROM despite appropriate PT, often multifactorial (scar tissue, heterotopic ossification, patient factors) - Prevention: early appropriate ROM protocol per subscapularis status, PT compliance, treat heterotopic ossification risk factors (burns, head injury, ankylosing spondylitis) with indomethacin - Management: manipulation under anesthesia if severe and early (less than 3 months), arthroscopic or open capsular release for late stiffness ## Evidence-Based Outcomes and Registry Data ### Australian Registry Data (AOANJRR) **Survival Rates for Reverse TSA Revision** - 5-year survival rate: 85-90% (primary reverse TSA: 92-94%) - 10-year survival rate: 80-85% (primary reverse TSA: 88-90%) - Main failure mode: baseplate loosening (40%), infection (25%), instability (15%), fracture (10%) - Younger patients (less than 65 years) have higher revision rates due to increased activity and longer follow-up **Indications for Revision to Reverse TSA** - Rotator cuff deficiency with failed anatomic TSA: most common, excellent outcomes - Glenoid loosening: good outcomes if bone stock adequate for baseplate fixation - Instability: variable outcomes depending on soft tissue quality - Periprosthetic fracture: acceptable outcomes with appropriate fracture management - Infection: lower success rates, two-stage protocol improves outcomes **Factors Affecting Outcomes** - Glenoid bone stock: E0-E2 best outcomes, E3 good with BIO-RSA, E4 higher failure risk - Subscapularis integrity: repair significantly improves stability and internal rotation - Deltoid function: essential for success - assess preoperatively, protect intraoperatively - Patient age: younger patients higher expectations but increased revision risk over time - Number of previous surgeries: each revision decreases survival and outcomes ### Functional Outcomes After Revision to Reverse TSA **Range of Motion Improvements** - Forward elevation: preoperative average 60-80° → postoperative 120-140° (significant improvement) - External rotation: generally maintained at 30-40° (sometimes limited by subscapularis scarring) - Internal rotation: variable, depends on subscapularis status - with repair average sacrum level, without repair L3-L5 level - Abduction: improved to 100-120° in most patients (deltoid-powered motion) **Pain Relief and Function** - Pain relief: excellent in 85-90% of patients using VAS improvement - Patient satisfaction: high in 80-85% despite ROM limitations compared to primary reverse TSA - Activities of daily living: significant improvement in combing hair, reaching overhead shelves, personal hygiene - American Shoulder and Elbow Surgeons (ASES) score: improves from average 35-45 preop to 65-75 postop - Constant-Murley score: improves from 30-40 to 55-65 (lower than primary due to revision setting) ### Biomechanical Principles - Grammont Design **Medialized Center of Rotation** - Glenosphere placed at glenoid face (medial) increases deltoid moment arm by moving fulcrum medially - Increased moment arm reduces force needed for deltoid to elevate arm - Reduces joint reaction forces on glenoid by approximately 30% compared to anatomic TSA - Disadvantage: increases scapular notching risk (addressed by inferior positioning and tilt) **Distalized Humerus** - Humeral component sits distal to anatomic position, increasing deltoid tension - Pre-tensions deltoid, improving force generation across ROM - Compensates for loss of rotator cuff compressive force - Creates stable fulcrum allowing deltoid to function as primary elevator **Semiconstrained Design** - Fixed fulcrum at glenosphere-polyethylene articulation provides inherent stability - Less dependent on soft tissue balancing than anatomic TSA - Allows function despite rotator cuff deficiency - Trade-off: higher component stresses, particularly baseplate shear forces ### Modern Modifications - Lateralization **BIO-RSA Technique (Bone Increased Offset)** - Posterior bone graft behind baseplate for E3 glenoid defects - Advantages: restores glenoid version, increases glenoid-baseplate contact area, lateralizes center of rotation - Lateralization benefits: increased deltoid moment arm, reduced scapular notching, improved ROM and strength - Technique: morselized cancellous graft packed posterior to glenoid, baseplate compressed creating autograft effect - Outcomes: similar survival to standard reverse TSA with better ROM in E3 defects **Lateralized Glenosphere Designs** - Eccentric glenosphere (+4mm to +10mm lateral offset) - Increases deltoid moment arm similar to BIO-RSA - Reduces scapular notching by moving center of rotation laterally - Disadvantage: increases shear stress on baseplate - requires excellent bone stock and screw fixation - Best for: patients with adequate bone stock, higher functional demands, desire for better ROM ### Complications - Evidence-Based Rates **Revision Reverse TSA Complication Rates** - Infection: 1-3% (higher than primary 0.5-1.5%) - Instability: 5-10% (lower than anatomic TSA 15-30%, higher than primary reverse 2-5%) - Scapular notching: 30-60% radiographic (reduced to 20-30% with modern techniques) - Baseplate loosening: 3-5% at 5 years (1-2% for primary reverse TSA) - Nerve injury: less than 1% (axillary nerve most common) - Acromial fracture: 2-4% (unique to reverse TSA) - Periprosthetic fracture: 1-3% intraoperative, 2-3% postoperative **Factors Reducing Complications** - Inferior glenoid positioning: reduces notching from 60% to 20-30% - Subscapularis repair: reduces instability by 30-40%, improves internal rotation 10-15° - Adequate baseplate screws (minimum 4): reduces loosening risk - Proper version (20-30° retroversion): optimizes stability and ROM - High-volume surgeon (greater than 25 reverse TSA per year): reduces complications 20-30% ### Cost-Effectiveness **Economic Analysis** - Revision shoulder arthroplasty costs 1.5-2x primary arthroplasty due to longer operative time, revision implants, potential complications - Reverse TSA for revision more cost-effective than repeat anatomic TSA due to lower re-revision rates - Successful revision provides significant QALY (quality-adjusted life year) improvement - Cost per QALY well within acceptable thresholds (under AUD $50,000 per QALY in Australian healthcare system) ## References 1. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report. Adelaide: AOA; 2023. Available at: https://aoanjrr.sahmri.com/annual-reports-2023 2. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. Neer Award 2005: The Grammont reverse shoulder prosthesis - results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006;15(5):527-540. PMID: 16979046 3. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br. 2004;86(3):388-395. PMID: 15125127 4. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am. 2005;87(8):1697-1705. PMID: 16085607 5. Nerot C, Ohl X. Primary glenoid bone grafting in reverse shoulder arthroplasty: Technique and short-term results. J Shoulder Elbow Surg. 2015;24(6):e147-e154. PMID: 25648170 6. Levigne C, Boileau P, Favard L, Garaud P, Mole D, Sirveaux F, Walch G. Scapular notching in reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2008;17(6):925-935. PMID: 18558499 7. Clark JC, Ritchie J, Song FS, Kissenberth MJ, Tolan SJ, Hart ND, Hawkins RJ. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg. 2012;21(1):36-41. PMID: 21803609 8. Wiater JM, Moravek JE Jr, Budge MD, Koueiter DM, Marcantonio D, Wiater BP. Clinical and radiographic results of cementless reverse total shoulder arthroplasty: a comparative study with 2 to 5 years of follow-up. J Shoulder Elbow Surg. 2014;23(8):1208-1214. PMID: 24433628 9. Wagner ER, Houdek MT, Elhassan BT, Sanchez-Sotelo J, Cofield RH, Sperling JW. What Are Risk Factors for Intraoperative Humerus Fractures During Revision Reverse Shoulder Arthroplasty and Do They Influence Outcomes? Clin Orthop Relat Res. 2015;473(11):3543-3551. PMID: 26150263 10. Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2011;20(1):146-157. PMID: 21134666

Revision Total Shoulder Arthroplasty to Reverse TSA

Revision Total Shoulder Arthroplasty to Reverse TSA