Thank you so much. My name is Steve Parada. I'm at the Medical College of Georgia in Augusta, Georgia. I'm going to be talking to you about reverse shoulder arthroplasty and obviously this is going to focus on technique. Here are my disclosures. Obviously these are pertinent as I'm going to be discussing and showing you a reverse shoulder arthroplasty technique. And this is our patient. He's a 70-year-old male. He has a pseudoparalytic shoulder with chronic pain. You can see it does not have significant deformity on the humerus side or the glenoid side. That's why we're using this as a representative case. And obviously the patient has failed non-operative care and you can see his medical history there that are not going to impact our surgical decision making or our technique at all. And again, this patient has a massive irreparable rotator cuff with fatty infiltration, pseudoparalytic shoulder, very limited range of motion and weakness. And so we're planning for a reverse shoulder arthroplasty. We're going to start with a delta pectoral approach. You can see I use an oblique incision coming down from the coracoid. I find the interval between the deltoid and the pectoralis. I take the cephalic lateral. I do release the upper border of the pectoralis. I put a brown retractor under the deltoid. You can see I have the patient sitting up in a fair amount of flexion. That obviously varies a lot by surgeon. I'm going to release the inferior capsule here off the humerus. After I do that, I can get a smooth retractor in and dislocate the shoulder. When the humerus is dislocated, I can start putting my retractors in a sharp homing around the cuff. And then that big Bennett retractor inferiorly. So I can see both the head neck angle and also the version. I can use a cutting guide to kind of see and look at the axis of the forearm to see what lines up with this patient. Most of these are going to be between 20 and 30 degrees of retroversion. That does differ for patient. I like to see the intact posterior cuff and then mark out my version. I freehand this cut with a saw. I do save that portion of the humeral head for later in the case. When that is removed, we can then look back here over the top and look at the posterior cuff insertion and make sure that we like the amount of retroversion that were cut in. At this point, now we have to start off trying to figure out where we're going to instrument the humerus. You can look at the lateral and the medial aspect as well as the anterior aspect and see that to instrument the humerus in line. It's usually posterior to the bicipital groove. I start with an end cutting reamer by hand. This should flow down very easily in the canal without hitting either the medial or lateral aspect. And then we're going to upsize every two until we just get some diaphysial engagement with this, making sure we prepare distally enough. Then I start with the broach. I've got it marked in the version of my cut. And again, I'm going to slide this down the lateral aspect. I don't want this to tip in varus or valgus, and I want to look down, orient that little version bar with the plane there of the forearm and make sure I'm not changing the version of my cut. I start impacting that. I start with the smallest one. I feel like that gives me the best control, and then I move up until I get rotational security with this. When we do have this and I move it, there might be some movement at the guide to the handle to the broach, but not of the broach inside. I can plane over the top if there's some residual bone there around the lesser tuberosity to remove that and make that smooth by removing that bone with a ronger before I put a metaphyseal protector there to protect the humerus during retraction and then move to the glenoid. We're going to move to the glenoid. I like this humeral head, this angled retractor that kind of sits around the posterior labrum. I put that in place. I make sure I don't hit the cephalic vein, and then I move the arm into external rotation. I do use paralysis for this part, and then I can remove any intact labrum superiorly or posteriorly. For my anterior retractor, I put a smooth retractor in before I put the glenoid neck retractor in just to protect the axillary nerve. Now that that's in place on the anterior glenoid, I'm going to just bring the drapes around that and then clamp that into place. That's a self-retaining retractor. I don't like to ream a lot in these cases without deformity, so I'm just removing the cartilage with a curette. Now I can put my guide in. I really want to be able to visualize the inferior aspect there. I'm just going to start with a drill and make a small hole. I know which guide to use based on my preoperative planning. You can see I don't remove a glenoid bone. I really want that bone. Now that I have that little pilot tip there, then I can drill for my center hole. I use a system that has a cage, and so I'm going to drill that. We start slow. The drill is tapered. I'm going to take that humeral head bone that I had now and just use a cob to create a hole in that. Now with the ronger, I can remove that nice metaphyseal bone. With the system I use with the cage, I'm going to fill that cage with the patient's own bone. I don't touch these implants with my gloves. I just kind of touch around them using the plastic. I fill the hole there with the DeBakey. I fill that cage with the patient's own bone, and then I'm ready to impact this into place. This center cage is tapered, so light taps to get it started. Then I can really send it home, impacting that into place. When that's in place, I'm now going to drill. With this base plate, I'm typically trying to get at least three screws. I want these screws to be bicortical, and so I'm taking those in place. These screws, I do have a locking end cap, and I can use a fourth screw if I want. I put these screws in on power, going slow, using retractors to keep myself out of the pectoralis, out of the deltoid, and put all these screws in, first under power, and then I'll do final tightening with the hand driver. But I think under power for these is fine. Certainly, we don't want to strip these screw heads, but we do want to get these screws in place for all the holes I've drilled. In the beginning, you might want to place each screw after you drill each hole, just so you don't lose your angle. Now I'm going in again with my ratcheting screwdriver, and I'm really trying to get great compression here with these screws, especially the inferior and the superior one. Then this system utilizes locking end caps that turns each one of these compression screws now into a locking screw by locking it into place. So now I'm just locking these screws in place with a locking end cap over each screw that I put in place. There's lots of different ways now to put the glenosphere in. The size of my glenosphere is based on my preoperative plan. I'm going to take this blunt bone hook. I've removed my metaphyseal cap here, and I'm going to put that blunt bone hook in the stem just to get a little abduction. I changed my gloves because, again, now I am going to touch this implant. There's my glenosphere, and with the blunt bone hook, I'm just moving the arm out. Not a lot of retractors, not a posterior retractor. I'm just going to slide that around the humerus, and then when that's in place, I can externally rotate the humerus, take these retractors out so there's no metal hitting that, and then I do have a locking screw. You can see I changed my gloves because I'm using my finger to hold that into place. Now my glenosphere is in place, and I'm ready to move back to the humerus. With my humerus, now that I have the glenosphere in place, I use this skid to protect that, and I'm going to trial. I usually am trialing my smallest tray in poly, take my retractors out, check my motion, make sure I can't dislocate it anteriorly, making sure we have wide external rotation. There's my subscap that I've tagged on the way in in this patient. There's my final stem. You can see, again, I'm using the plastic so I don't have to touch it directly, lining it up, sliding it down, that lateral aspect there, impacting that into place while someone cups the elbow to protect the plexus, and I insert that into place, take my stem handle off, and now since it's flush, I go right to my final implants, and you can see I've changed my gloves again. I'm going to loop a suture around the tray, and then this device tightens the screw. It's just a torque-limiting device that tightens the screw, and then I'm going to impact my poly into place as well, and again, a nice gentle reduction. I'm keeping my final implants off of skin. I have the skid in there, and again, with one thumb, I can easily bring this in, check my final motion again, and in a patient like this where I've been able to save his subscap, I can repair the subscap. You don't have to do that with a lateralized humerus system. Certainly, if I'm going to do that, I bring the arm into external rotation, and generally, I just do one simple throw with one side of the suture and then a locking stitch with a free needle with the other suture and tighten that into place after I've moved the arm into 30 degrees of external rotation. The closure is then pretty standard at this point, and so in summary, I think find the setup and positioning that works for you, and then be consistent so you can get used to that. Some surgeons don't use an arm holder. Some surgeons have these patients only in like 20 degrees of waist flexion. I like them sitting up higher. These steps of the actual case can be very different based on the system you use, so get comfortable with one system in the beginning so you can kind of learn the fine points before you start branching out. Don't worry about the speed of the case. Do a good job for each patient, and as your numbers increase, the cases are going to get faster, and so here's our final x-rays on this patient. Again, like you, I don't get perfect x-rays in clinic, and so you can see that axillary view is really over-rotated. I can't see my screws great, but I'm comfortable with the placement of those screws, the length of the screws, and certainly the placement of my press fit stem, and so thank you very much. Please don't hesitate to reach out to me or any of the instructors that you meet during this course if you ever have any questions, and thank you again for attending.

reverse shoulder arthroplasty

surgical technique

patient-specific planning

surgical system proficiency

Dr. Steve Parada