import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' ## Clinical Assessment **Primary Indications:** - Cuff tear arthropathy (Hamada grade 4-5) - most common indication - Massive irreparable rotator cuff tear with pseudoparalysis (elevation less than 90°) - Complex proximal humerus fractures in elderly (>70 years, 3-4 part, head-split, fracture-dislocation) - Failed rotator cuff repair with stiffness and pain - Revision TSA with rotator cuff deficiency - Rheumatoid arthritis with cuff destruction **Expanding Indications:** - Tumour reconstruction of proximal humerus - Severe bone loss in revision setting - Complex instability in elderly with cuff deficiency - Selected cases of acute fractures (controversial in younger patients) **ABSOLUTE Requirement:** - Functioning deltoid muscle with intact axillary nerve - Without deltoid, RSA WILL NOT WORK **Examiner Question**: "A 65-year-old active man has cuff tear arthropathy. Is RSA appropriate at his age?" **Model Answer**: "Age 65 is at the **younger end** for RSA. Traditional threshold was 70+ years due to concerns about glenoid baseplate loosening (5-10% at 10 years) and limited revision options. However, **expanding indications** now include age 60-70 if: (1) True pseudoparalysis (elevation <90°); (2) Failed alternative treatments; (3) Realistic expectations about longevity and activity. I would counsel him about 10-15 year implant survival, limited external rotation, and that revision is more complex than primary. Australian AOANJRR data supports RSA in carefully selected patients >60." - **RSA for primary OA with intact cuff** - TSA is indicated, not RSA (higher complication rate) - **Missing axillary nerve palsy** - RSA will FAIL without functioning deltoid - **Young high-demand patient** - RSA is NOT for return to heavy sport/labor - **Not recognizing pseudoparalysis** - <90° active elevation indicates cuff deficiency regardless of X-ray **Absolute Contraindications:** - Deltoid insufficiency (paralysis, prior deltoid detachment failure) - Axillary nerve palsy - Active infection - Inadequate glenoid bone stock that cannot be reconstructed **Relative Contraindications:** - Age less than 60 (higher revision burden, glenoid loosening concerns) - High-demand patients expecting sport return - Prior radiation to shoulder (deltoid/soft tissue damage) - Charcot arthropathy - Uncontrolled diabetes, immunosuppression **RSA vs TSA Decision:** - Intact cuff + OA = TSA - Cuff deficient + OA = RSA - Pseudoparalysis (cannot elevate) = RSA regardless of X-ray appearance **Examiner Question**: "Why is deltoid insufficiency an absolute contraindication for RSA?" **Model Answer**: "In RSA, the **deltoid is the SOLE motor** for shoulder elevation. The Grammont design medializes the center of rotation and distalizes the humerus, increasing the deltoid moment arm by 30-40%. This allows the deltoid ALONE to power elevation without a functioning cuff. If the deltoid is paralyzed (axillary nerve injury) or severely atrophied (prior detachment failure, radiation), the patient **cannot elevate regardless** of implant design. Unlike TSA where cuff supplements deltoid, RSA depends entirely on deltoid. Axillary nerve examination is therefore **mandatory** preoperatively." - **Proceeding without examining deltoid** - axillary nerve palsy may be subtle, test sensation and active deltoid contraction - **Ignoring prior radiation** - causes deltoid fibrosis and poor soft tissue, high complication rate - **Not recognizing glenoid bone loss** - if baseplate cannot be fixed, RSA will fail - **Choosing RSA in young patient** - higher revision burden, consider alternatives first **Clinical Examination:** - Active elevation (pseudoparalysis = less than 90°) - External rotation lag sign (infraspinatus) - Hornblower sign (teres minor) - Belly-press test (subscapularis) - Deltoid bulk and function - CRITICAL for RSA success - Axillary nerve examination (sensation, deltoid contraction) **Imaging:** - X-rays: AP, axillary lateral, Y-view - assess glenoid bone stock, superior migration - CT scan: glenoid version, bone loss quantification, planning - MRI: confirm cuff status (fatty infiltration Goutallier grade), deltoid quality **Glenoid Assessment:** - Walch classification for glenoid morphology - Bone stock for baseplate fixation - Version (excessive retroversion may need correction or augment) **Key Measurements:** - Acromiohumeral interval (AHI) less than 7mm = superior escape = cuff deficiency - Glenoid retroversion (normal 0-10°) - Critical glenoid bone loss >30% may need bone graft **Patient Counselling:** - Realistic expectations: pain relief excellent, elevation 120-140°, external rotation limited (often neutral) - Complications: scapular notching (50-80%), instability (2-5%), infection (2-4%) - Longevity: 10-15 year implant survival 90-95% **Examiner Question**: "What imaging do you order before RSA and what are you looking for?" **Model Answer**: "I order three modalities: (1) **Plain X-rays** (AP, axillary, Y-view) - assess acromiohumeral interval (<7mm = superior escape), acetabularization, and glenoid morphology; (2) **CT scan** - essential for **glenoid bone stock**, version (retroversion >20° may need augment), and central bone quality for baseplate fixation; (3) **MRI** - confirms cuff status (irreparable), Goutallier grade, and critically the **deltoid quality** (fatty infiltration or atrophy predicts poor outcome). The CT is particularly important because baseplate fixation is the primary failure mode in RSA." - **Not assessing glenoid bone stock** - CT essential, if inadequate bone, baseplate will fail - **Missing excessive retroversion** - >20° may need augmented baseplate or bone grafting - **Not checking deltoid on MRI** - fatty infiltration predicts poor functional outcome - **Over-promising outcomes** - warn about limited ER (often neutral), scapular notching common **Location**: Exits quadrangular space, runs on ANTERIOR-INFERIOR capsule 5-7cm below acromion **Course**: Wraps around surgical neck of humerus posteriorly **CRITICAL**: Injury = complete RSA failure. Deltoid paralysis = no elevation **Protection**: Careful inferior capsular release UNDER DIRECT VISION. Do not blindly release inferiorly. Place inferior retractor carefully. **EXAM KEY**: RSA depends ENTIRELY on deltoid. Axillary nerve injury is CATASTROPHIC. **Location**: Enters conjoint tendon 5-8cm distal to coracoid (mean 5.5cm) **Course**: Pierces coracobrachialis, lies between biceps and brachialis **Risk**: Medial retractor placement too distal **Protection**: Place medial retractor SUPERIOR, within 5cm of coracoid **Injury Result**: Biceps weakness, lateral forearm numbness **Location**: Posterior to glenoid in suprascapular notch **Risk**: Posterior glenoid screw placement **Protection**: Direct posterior screw at scapular body, ANTERIOR to suprascapular notch **Injury Result**: Infraspinatus paralysis (already non-functional in RSA indication, but denervation pain possible) **Location**: Deep to conjoint tendon, medial **Risk**: Overzealous medial dissection, deep retractor placement **Protection**: Stay lateral to conjoint, avoid deep medial dissection **Injury**: Variable upper limb weakness and numbness ## Equipment **Glenoid Components:** - Baseplate (central fixation + peripheral locking screws) - Glenosphere: typically 36mm or 38mm diameter (larger = more stability, less notching) - Standard vs eccentric/lateralized designs (affect notching and ROM) **Humeral Components:** - Metaphyseal-engaging uncemented stem (most common) - Long cemented stem (for revision, poor bone quality) - Polyethylene liner (various thicknesses: 6mm, 9mm, 12mm, 15mm) - +/- humeral tray options **Instruments:** - Deltopectoral retractor set (Kolbel, Bankart) - Humeral resection guide - Sequential humeral broaches - Glenoid exposure retractors - Baseplate guide with central pin - Glenoid reamers (powered) - Impactors for baseplate and glenosphere - Fluoroscopy for baseplate positioning confirmation **Additional:** - Beach chair positioner with arm holder - Bump/bolster for medial scapular border - Bipolar cautery - Deep drain **Modern Design Variations:** - Standard Grammont (medialized, no lateral offset) - Lateralized glenoid (bony increase offset - BIO RSA) - Lateralized humeral (135° neck shaft angle with offset) - Combined lateralization designs (for better ROM, less notching) **Patient Position**: Beach chair at 70-80° (more upright than TSA - glenoid access critical) - Head secured in horseshoe headrest - Large bump under medial scapular border (brings glenoid anteriorly) - Table break at shoulder level - Arm draped free to fingertips **Landmarks:** - Coracoid process (KEY landmark - palpate for every step) - Clavicle - Acromion - AC joint - Spine of scapula (mark before draping) **Surgical Approach**: Deltopectoral - TRUE internervous plane **Incision**: 15-18cm curvilinear from coracoid distally toward deltoid insertion - Longer than TSA (glenoid access more demanding) - Can extend proximally along clavicle if needed **Key Setup Points:** - Fluoroscopy available for baseplate positioning confirmation - Patient cannot slide - secure torso - Arm must be freely mobile for manipulation ### Step 1: Positioning and Setup Beach chair position at 70-80° (more upright than TSA). Head secured. Large bump under medial scapular border - this is CRITICAL in RSA to bring the glenoid face anteriorly. Table break at shoulder. Arm draped completely free. Mark coracoid, clavicle, acromion, AC joint, spine of scapula. **Technical Tip**: Positioning in RSA is more upright than TSA because glenoid exposure, particularly the INFERIOR glenoid, is critical. The bump under the medial scapular border rotates the scapula and brings the glenoid face anteriorly. This makes the inferior glenoid accessible for correct baseplate positioning. - **Patient slipping** - secure torso well, steep beach chair position increases slide risk - **Inadequate scapular bump** - if glenoid not brought forward, inferior exposure impossible - **Brachial plexus stretch** - avoid excessive head tilt away from operative side - **Venous air embolism** - rare but reported in beach chair, keep BP adequate ### Step 2: Incision and Deltopectoral Interval 15-18cm incision from coracoid distally. Identify deltopectoral groove and cephalic vein. Retract vein LATERALLY with deltoid (90% of surgeons). Develop interval proximally to clavicle, distally 8-10cm. **TRUE INTERNERVOUS PLANE:** - Deltoid (axillary nerve) laterally - Pectoralis major (medial/lateral pectoral nerves) medially The deltoid is the MOTOR for RSA. Protect it absolutely. Use self-retaining retractors carefully. Avoid excessive lateral retraction. Any deltoid injury compromises RSA function significantly. **Examiner Question**: "Which way do you retract the cephalic vein in the deltopectoral approach?" **Model Answer**: "**90% of surgeons retract laterally with deltoid**. Rationale: the vein has more tributaries from the deltoid side, so lateral retraction keeps these tethered branches under direct vision. However, some retract medially claiming the pectoralis side is safer. The key is **consistency** - always retract the same way so you know where the vein is. If torn, ligate both ends and continue. The vein is not expendable but its injury is manageable." ### Step 3: Deep Exposure Identify conjoint tendon medially. Note that musculocutaneous nerve enters 5-8cm distal to coracoid - place medial retractor SUPERIOR to this. Release upper pectoralis major insertion if needed. Identify subscapularis - often ABSENT or severely atrophic in cuff tear arthropathy. If present, can release without repair (RSA does not depend on subscapularis). **Examiner Question**: "How do you protect the musculocutaneous nerve during RSA?" **Model Answer**: "The musculocutaneous nerve enters the **coracobrachialis (conjoint tendon) 5-8cm distal to the coracoid** (mean 5.5cm). I protect it by: (1) Palpating the coracoid as my reference; (2) Placing the medial retractor **within 5cm of the coracoid**; (3) Avoiding excessive medial dissection distal to this safe zone; (4) Never blindly retracting the conjoint. If injured, it causes biceps weakness and lateral forearm numbness." - **Musculocutaneous nerve** - enters conjoint 5-8cm from coracoid, keep medial retractor proximal - **Subscapularis in RSA** - often atrophied or absent, don't waste time searching - **Conjoint tendon traction** - gentle retraction only, excessive force risks brachial plexus - **Upper pec release** - if needed, stay on bone to protect anterior circumflex vessels ### Step 4: Capsulectomy and Joint Entry Perform AGGRESSIVE 360° capsular release - more extensive than TSA: - Superior release (remove remnant cuff) - Anterior release with subscapularis - INFERIOR release - CRITICAL but PROTECT axillary nerve (5-7cm below acromion on anterior-inferior capsule) - Posterior release **EXAM KEY**: The inferior capsular release in RSA is essential for glenoid exposure but is the most dangerous part of the operation. The axillary nerve runs on the anterior-inferior capsule 5-7cm below the acromion with the posterior circumflex humeral artery. Perform this release under DIRECT VISION, not blindly. - **Axillary nerve** - 5-7cm below acromion on anterior-inferior capsule, release UNDER DIRECT VISION - **Posterior circumflex humeral artery** - travels with axillary nerve, cauterise before transecting - **Blind inferior release** - NEVER acceptable, must visualise what you are cutting - **Incomplete release** - if cannot expose inferior glenoid, baseplate will be too superior ### Step 5: Humeral Head Removal Externally rotate, extend, and adduct to deliver humeral head. Make humeral neck cut at ANATOMIC NECK (more proximal than TSA). Cut angle 135-145° (more valgus than TSA). This preserves metaphyseal bone for stem fixation and accommodates the medialized center of rotation. **Examiner Question**: "How does the humeral cut in RSA differ from TSA?" **Model Answer**: "In RSA, the cut is more **proximal (anatomic neck)** and more **valgus (135-145°)** compared to TSA. Reasons: (1) The medialized center of rotation requires less lateral offset; (2) Preserving metaphyseal bone provides better stem fixation; (3) The higher cut accommodates the reversed biomechanics. In TSA, the cut is at the surgical neck with 20-30° retroversion to match native anatomy. RSA uses 0-20° retroversion to optimize external rotation." - **Fracture during delivery** - osteoporotic bone common in RSA indications, gentle manipulation - **Excessive bone removal** - cut too distal compromises metaphyseal fixation - **Varus cut** - leads to varus stem alignment and instability - **Soft tissue stripping** - preserve deltoid insertion, avoid excessive periosteal stripping ### Step 6: Glenoid Exposure (CRITICAL) Place three retractors: 1. Anterior retractor over anterior rim 2. Posterior retractor into capsule 3. INFERIOR retractor into axillary recess (protect axillary nerve!) Must expose ENTIRE glenoid face including INFERIOR border. Remove all labrum, capsule, osteophytes. If cannot see inferior glenoid, cannot position baseplate correctly. If you cannot see the inferior glenoid rim clearly, you will position the baseplate too superiorly, causing scapular notching. Take time for meticulous inferior exposure. This is the most technically demanding step. **Examiner Question**: "What is the most technically demanding step in RSA and why?" **Model Answer**: "**Glenoid exposure, particularly the inferior glenoid**. In RSA, the baseplate MUST sit flush with the inferior glenoid rim with 5-10° inferior tilt. If the inferior glenoid is not visible, the baseplate ends up too superior, causing scapular notching in 50-80% of cases. This exposure requires: (1) Complete capsulectomy; (2) Three retractors (anterior, posterior, inferior); (3) Adequate scapular bump positioning; (4) Patience. The inferior retractor placement must protect the axillary nerve." ### Step 7: Baseplate Positioning (CRITICAL DECISION) Baseplate position determines RSA success. Goals: 1. **INFERIOR TILT**: 5-10° inferior tilt, baseplate FLUSH with inferior glenoid rim 2. **NEUTRAL VERSION**: 0-5° anteversion or retroversion 3. **CENTRAL POSITION**: not superior Place central guide pin aiming toward coracoid base. Confirm position with fluoroscopy. Ream glenoid face flat to bleeding bone. **EXAM KEY**: Baseplate positioning is THE critical step in RSA. The baseplate must sit flush with the inferior glenoid with 5-10° of inferior tilt. If it sits too superiorly, scapular notching occurs in 50-80% of cases, leading to polyethylene wear and potential loosening. The central pin should aim toward the coracoid base. - **Superior placement** - most common error, causes scapular notching in 50-80% - **Excessive retroversion** - aim for neutral, >10° retroversion causes posterior instability - **Excessive anteversion** - causes anterior impingement and instability - **Not confirming with fluoroscopy** - use image guidance to verify inferior position ### Step 8: Baseplate Fixation Insert baseplate with central fixation (press-fit or screw). Place 2-4 peripheral locking screws: - **Superior screw**: aims toward coracoid base (strong bone) - **Inferior screw**: parallel to glenoid face or slight inferior - **Posterior screw**: aim at scapular body, ANTERIOR to suprascapular notch (nerve) - **Anterior screw**: safe direction All screws bicortical (28-40mm depending on bone stock). Insert glenosphere (typically 36mm or 38mm). **Examiner Question**: "Where do you aim the posterior screw in RSA baseplate fixation?" **Model Answer**: "The posterior screw must aim at the **scapular body ANTERIOR to the suprascapular notch**. The suprascapular nerve runs in the notch and can be injured by a posteriorly-directed screw. Safe technique: angle the screw 10-15° anterior to the glenoid plane, aiming toward the scapular spine base. I use bicortical fixation (28-40mm screws) for maximum purchase. The superior screw aims toward the coracoid base which has the strongest bone." - **Posterior screw** - avoid suprascapular notch, aim screw anterior to prevent nerve injury - **Unicortical screws** - always aim for bicortical purchase (28-40mm) - **Inadequate screw length** - poor fixation leads to baseplate loosening (5-10% at 10 years) - **Glenosphere size** - too small increases notching risk, 36-38mm preferred ### Step 9: Humeral Preparation Open humeral canal with box chisel in CENTER of metaphysis. Sequential broaching to metaphyseal contact. **Key RSA Difference**: Humeral retroversion is 0-20° (LESS than TSA's 20-30°). Decreased retroversion in RSA helps improve external rotation which is often limited in these patients. **Examiner Question**: "What humeral version do you use in RSA and why is it different from TSA?" **Model Answer**: "RSA uses **0-20° retroversion** compared to TSA's 20-30°. The reason is **external rotation optimization**. RSA patients have deficient external rotators (teres minor, infraspinatus) and the medialized center of rotation further limits ER. By reducing humeral retroversion, we position the arm in relatively more external rotation at rest, improving functional ER. Some modern stems allow intraoperative version adjustment to fine-tune ROM." - **Varus entry point** - causes stem malalignment and instability, enter CENTER of metaphysis - **Eccentric broaching** - risks perforation, follow anatomic axis - **Excessive retroversion** - worsens already limited external rotation - **Fracture during broaching** - osteoporotic bone common, gentle sequential broaching ### Step 10: Humeral Trial and Assessment Insert trial stem and polyethylene liner (typically 6mm, 9mm, or 12mm). Reduce shoulder. Assess: 1. **STABILITY**: Test in adduction (inferior instability most common in RSA) 2. **ROM**: Forward elevation should easily exceed 90°, aim for 120-140° 3. **External rotation**: Often limited (0-20°) due to loss of external rotators 4. **Scapular notching**: Feel for impingement between polyethylene and lateral scapula **Stability Testing**: In RSA, the most common direction of instability is INFERIOR (opposite to TSA where it's posterior). Test stability with the arm adducted and apply distraction. If unstable inferiorly, use a thicker polyethylene liner. - **Only testing forward elevation** - must test INFERIOR stability (arm adducted, distract) - **Accepting minimal instability** - leads to postoperative dislocation (2-5%) - **Not documenting ROM** - record intraoperative elevation and ER for medicolegal purposes - **Impingement with adduction** - indicates potential notching, may need larger glenosphere ### Step 11: Final Component Implantation Insert final humeral stem (cemented or uncemented based on bone quality). Assemble polyethylene liner. Reduce shoulder - may feel clunk as concave poly engages convex glenosphere. **Examiner Question**: "When do you cement the humeral stem in RSA?" **Model Answer**: "I consider cementing for: (1) **Poor bone quality** - severe osteoporosis with wide medullary canal; (2) **Metaphyseal defects** - from fractures or revisions; (3) **Channal/stem mismatch** - if broach doesn't achieve adequate metaphyseal fit; (4) **Periprosthetic fracture during surgery**. Most primary RSA uses **uncemented metaphyseal-engaging stems** in good bone. If cementing, I use third-generation technique with canal preparation, restrictor, pressurization, and stem centralizer." - **Periprosthetic fracture** - watch for proximal humerus fracture during impaction - **Component disengagement** - ensure polyethylene fully seated before reduction - **Cement extravasation** - if cementing, avoid posterior extrusion near nerves - **Wrong polyethylene size** - double-check liner matches trial that was stable ### Step 12: Subscapularis Management (Controversial) If subscapularis was present and released, repair is OPTIONAL in RSA (unlike TSA where it's critical). Many surgeons do NOT repair in RSA as function does not depend on it. If repairing: use heavy sutures to lesser tuberosity if good tissue quality. **Examiner Question**: "Do you repair the subscapularis in RSA? Why is this different from TSA?" **Model Answer**: "In RSA, subscapularis repair is **OPTIONAL** - many surgeons do not repair. Key differences: (1) **RSA does not depend on cuff** - deltoid is the sole motor via Grammont mechanism; (2) **Subscapularis is often atrophied/absent** in cuff tear arthropathy; (3) **Internal rotation is preserved** by pectoralis major, latissimus dorsi; (4) **Anterior stability** is inherent to conforming articulation. In **TSA**, subscapularis repair is CRITICAL because cuff function is required and anterior instability is the main concern. If I repair in RSA, it's for potential anterior stability benefit in borderline cases." - **Don't waste time searching** - in CTA, subscapularis is often absent or non-functional - **TSA thinking** - don't apply TSA principles to RSA, cuff repair is not essential - **Repair quality** - if you repair, ensure tissue is adequate, don't repair rubbish tissue - **Repair for stability only** - consider if borderline anterior stability on trials ### Step 13: Final Stability and ROM Check Systematic testing: - Inferior stability (arm adducted, distract) - Anterior stability (extension, external rotation) - Posterior stability (forward flexion, internal rotation) - ROM: Forward elevation >90° easily, external rotation to neutral Document intraoperative ROM. **Examiner Question**: "What is the most common direction of instability in RSA and how do you test for it?" **Model Answer**: "**INFERIOR** instability is most common in RSA - opposite to TSA where posterior instability predominates. Testing: (1) Hold arm **adducted at side**; (2) Apply **inferior distraction force**; (3) Assess for subluxation or dislocation inferiorly. If unstable: use **thicker polyethylene liner** (go from 6mm to 9mm or 12mm). Inferior instability occurs because the concave polyethylene sits on the convex glenosphere, and with arm adducted, the polyethylene can ride off inferiorly. The abduction pillow postoperatively helps prevent this." - **Test ALL directions** - inferior (most common), anterior, and posterior stability - **Accept nothing less than stable** - instability = dislocation postoperatively - **Document ROM** - record forward elevation and external rotation achieved - **Compare to trials** - if final stability differs from trial, reassess components ### Step 14: Closure and Immobilization Copious irrigation (9-12L). Meticulous hemostasis. Place deep drain. Close deltopectoral interval loosely (overtightening restricts deltoid). Layered closure. Apply sling with ABDUCTION PILLOW (30° abduction) - prevents inferior instability. **Examiner Question**: "Why do you use an abduction pillow after RSA and not a simple sling?" **Model Answer**: "The abduction pillow maintains the shoulder at **30° abduction** for two reasons: (1) **Prevents inferior instability** - the most common direction of dislocation in RSA. With arm adducted, the concave polyethylene can sublux off the glenosphere inferiorly; (2) **Reduces tension on deltopectoral repair** - the deltoid is the motor for RSA, so we must protect the soft tissue interval. This differs from TSA where posterior instability is the concern and a simple sling suffices. Duration is typically 6 weeks." - **Overtightening deltopectoral interval** - restricts deltoid function, the motor for RSA - **No drain** - hematoma common, increases infection risk - **Simple sling** - must use ABDUCTION pillow (30°) to prevent inferior instability - **Inadequate irrigation** - RSA has higher infection rate than TSA (2-4%), irrigate thoroughly **Immobilization:** - Sling with abduction pillow (30°) for 6 weeks - Different from TSA - can start passive forward elevation immediately (no subscapularis to protect) **Weeks 0-6:** - Passive ROM: forward elevation to 120°, external rotation to 20° - Pendulum exercises - NO active elevation (protect deltoid healing and soft tissue) **Weeks 6-12:** - Active-assisted then active ROM - Begin deltoid strengthening - Progressive ROM **Weeks 12+:** - Unrestricted activities - Advanced strengthening **Follow-up Imaging:** - X-rays at 6 weeks, 3 months, 1 year, then annually - Monitor for scapular notching and baseplate fixation **Expected Outcomes:** - Pain relief: excellent (90%+) - Forward elevation: 120-140° typically - External rotation: often limited (neutral to 20°) - Patient satisfaction: 90%+ ## References 1. Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993;16(1):65-68. 2. Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg. 2005;14(1 Suppl S):147S-161S. 3. Sirveaux F, Favard L, Oudet D, et al. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. J Bone Joint Surg Br. 2004;86(3):388-395. 4. Guery J, Favard L, Sirveaux F, et al. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am. 2006;88(8):1742-1747. 5. Wall B, Nove-Josserand L, O'Connor DP, et al. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89(7):1476-1485. 6. Frankle M, Siegal S, Pupello D, et al. The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone Joint Surg Am. 2005;87(8):1697-1705. 7. 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(5):827-836. 8. Lädermann A, Denard PJ, Boileau P, et al. Effect of humeral stem design on humeral position and range of motion in reverse shoulder arthroplasty. Int Orthop. 2015;39(11):2205-2213. 9. Australian Orthopaedic Association National Joint Replacement Registry. Annual Report 2023. Adelaide: AOA. 10. Flatow EL, Harrison AK. A history of reverse total shoulder arthroplasty. Clin Orthop Relat Res. 2011;469(9):2432-2439.

Reverse Shoulder Arthroplasty (RSA)

Reverse Shoulder Arthroplasty (RSA)