What are the steps for performing a reverse total shoulder arthroplasty (RTSA)?

From the Guidelines

The steps for performing a reverse total shoulder arthroplasty (RTSA) involve patient positioning, a deltopectoral approach, detachment of the subscapularis tendon, joint capsule release, humeral head resection, glenoid preparation, and implantation of the prosthetic components, with attention to detail and careful handling of surrounding tissues to minimize complications, as described in recent studies 1. The procedure begins with patient positioning in a beach chair position under general anesthesia with regional nerve block.

• A deltopectoral approach is typically used, making an incision from the coracoid process toward the deltoid insertion.
• After identifying and protecting the cephalic vein and axillary nerve, the subscapularis tendon is detached and the joint capsule is released.
• The humeral head is dislocated, exposed, and resected using a cutting guide at approximately 20-30 degrees of retroversion.
• The humeral canal is then prepared with sequential reamers and broaches.
• Attention is shifted to the glenoid, where the labrum and remaining cartilage are removed.
• The glenoid is reamed to create a flat surface, and a baseplate is secured with screws, followed by attachment of the glenosphere component.
• The humeral stem is then implanted with or without cement, and a polyethylene humeral cup is attached.
• After trialing to assess stability, range of motion, and tension, the final components are secured.
• The subscapularis is repaired if possible, and the wound is closed in layers. Postoperatively, patients typically wear a sling for 4-6 weeks with gradual rehabilitation focusing initially on passive range of motion, followed by active motion and strengthening exercises, as the goal is to improve function and reduce morbidity and mortality, while enhancing quality of life 1. The most common complications associated with reverse total shoulder arthroplasties are scapular notching, dislocation, periprosthetic fractures, glenoid baseplate failure, and acromial fractures 1, which highlights the importance of careful patient selection, precise surgical technique, and thorough postoperative care to minimize these risks and optimize outcomes.

From the Research

Steps for Performing a Reverse Total Shoulder Arthroplasty (RTSA)

• Preoperative planning: Careful preoperative planning is required for a successful RTSA, including assessment of preoperative comorbidity risks and planning for perioperative pain management 2.
• Surgical approach: The procedure can be performed through one of two surgical approaches: deltopectoral or anterosuperior, each with its advantages and disadvantages 3.
• Patient positioning: The patient is placed in a semi-beach-chair position 4.
• Exposure and preparation:
  • Release deltoid adhesions
  • Remove humeral osteophytes
  • Make generous humeral head cuts
  • Perform thorough humeral and glenoid capsular release
  • Optimize glenoid retractor placement 5
• Implantation:
  • Use 3D preoperative planning and patient-specific instrumentation (PSI) to improve accuracy of glenoid component implantation 4
  • Implant the glenosphere and humeral component and reduce the prosthesis 4
• Postoperative care:
  • Start passive and active-assisted exercises immediately
  • Begin muscle strengthening and active exercises at 6 weeks 4
  • Consider outpatient vs. inpatient setting, with outpatient RTSA showing significant improvements in clinical outcome scores and fewer complications in proper candidates 6