Extended deltopectoral approach | Intermediate complexity
- Indications: failed anatomic TSA with irreparable cuff, failed hemiarthroplasty with pain and dysfunction, severe glenoid loosening with bone loss, proximal humerus fracture sequelae, and recurrent instability not reconstructable anatomically.
- The reverse (Grammont) prosthesis medialises the centre of rotation and lateralises the humerus, lengthening the deltoid lever arm so that deltoid alone can elevate the arm despite an absent rotator cuff.
- Preserve bone stock during component removal — use manufacturer-specific extractors, thin osteotomes at the interfaces, and an extended humeral osteotomy for well-fixed stems rather than brute force.
- Baseplate positioning is decisive: 10 to 15 degrees of inferior tilt optimises impingement-free motion and reduces scapular notching; the central peg supplies 30 to 40 percent of fixation.
- “Know the Grammont design principles: medialized centre of rotation, lateralized humerus, 155-degree neck-shaft angle, creating a stable fulcrum that recruits deltoid.
- “Understand glenoid bone-graft options for deficiency: structural allograft (femoral head or distal tibia), BIO-RSA augmented baseplates, and impaction grafting for contained defects.
- “Respect the axillary nerve: 5 to 7 cm inferior to the acromion, at risk during inferior capsular release and inferior screw insertion.
- “Discuss complications systematically: infection 3-5 percent, instability 6-10 percent, baseplate failure 2-4 percent, acromial stress fracture 1-4 percent, scapular notching 10-40 percent.
When & Why
Indication. Revision of a failed shoulder arthroplasty to a reverse configuration, in a patient with an irreparable or deficient rotator cuff where a reverse prosthesis is the only way to restore active elevation. The classic scenarios are a failed anatomic total shoulder arthroplasty (TSA) with cuff failure and superior escape, a painful failed hemiarthroplasty, severe glenoid loosening with bone loss, proximal humeral fracture sequelae (tuberosity nonunion or malunion with cuff dysfunction), and recurrent instability that cannot be reconstructed anatomically. Relative contraindications. Active infection (manage with a two-stage exchange and antibiotic spacer), severe glenoid bone loss with no grafting option (Favard E4 with less than 40 percent stock remaining), deltoid dysfunction or axillary nerve palsy (the reverse prosthesis is deltoid-driven), neuropathic arthropathy, and medical comorbidities that prohibit a major revision. Pre-operative workup is the operation. The result is won before the incision: - CT with 3D reconstruction is essential — quantify glenoid bone loss (Favard classification), measure version and wear, plan screw trajectories, and assess humeral bone stock. Confirm the minimum glenoid dimensions for a standard baseplate: at least 20 mm anterior-posterior and 25 mm superior-inferior.
- AP and axillary radiographs assess component loosening (radiolucent lines, migration), tuberosity position and healing, humeral cortical integrity, acromial morphology and any prior acromial fracture, and heterotopic ossification.
- Obtain the previous operative report — the original implant manufacturer and model (so you can order matching extraction instruments), the fixation method (cemented versus press-fit), any complications at the index procedure, and the soft-tissue state (subscapularis repair, cuff integrity).
- Exclude infection — inflammatory markers (CRP, ESR) and aspiration if there is any suspicion; a silent infected loose component is a disaster if revised in a single stage.
- Arrange the extras a revision demands: manufacturer-specific extraction tools, structural bone graft (femoral head or distal tibia allograft), extended revision instrumentation (long stems, augments, bone-graft screws), a longer theatre slot (90 to 150 minutes typical), and cross-matched blood.
3D CT reconstruction is mandatory for revision cases — it is the only way to assess glenoid bone stock, version, wear pattern and screw trajectories, and to plan bone grafting needs before you are in the middle of the operation.
Consent honestly for the higher revision risks: infection, instability (dislocation), nerve injury (especially axillary), baseplate failure and the possibility of further surgery; for limited external rotation; and for a long rehabilitation with no active elevation for six weeks. Setup. Beach-chair position, arm free and prepped to the hemithorax, patient positioned far lateral on the table so the operative shoulder sits at the table edge — this allows full extension and adduction for humeral work without the table obstructing you.
The Operation
The goal: remove the failed components while preserving every gram of bone, reconstruct the glenoid (grafting if needed) and seat a reverse baseplate in the correct position and version, then reconstruct the humerus and tension the joint — all through an extended deltopectoral exposure that protects five named danger structures. The exposure and component removal are laid out step by step below.
Operative sequence
- Beach chair: back 30 to 45 degrees, head secured in a padded headrest in neutral rotation, operative shoulder at the table edge, entire upper limb and hemithorax prepped, arm freely mobile in all planes.
- Position the patient far lateral so the shoulder clears the table — this gives full extension and adduction access for humeral preparation.
- Pad bony prominences (sacrum, heels, contralateral elbow), support with a kidney rest, and apply sequential compression devices.
- Mark the coracoid process and palpate the deltopectoral interval (the cephalic vein in the fat stripe is the guide).
- Start about 2 cm lateral to the coracoid tip and run inferiorly along the deltopectoral interval toward the deltoid insertion, typically 12 to 15 cm.
- Extend distally onto the mid-humeral shaft if a well-fixed stem will need an extended osteotomy, and proximally toward the clavicle if more superior exposure is required.
- Raise subcutaneous flaps to visualise the cephalic vein, preserving the lateral cutaneous nerve branches where possible and minimising cautery to reduce wound problems.
- The cephalic vein usually lies on the deltoid side of the interval — retract it laterally with the deltoid (preferred) or ligate it if needed.
- Blunt dissection between deltoid (lateral, axillary nerve) and pectoralis major (medial, pectoral nerve) — an internervous plane.
- Release the clavipectoral fascia; identify and protect the musculocutaneous nerve as it enters coracobrachialis 3 to 8 cm distal to the coracoid.
- In a revision this interval is often obliterated by scarring — stay superficial initially, find the cephalic vein first, then work deep to the interval plane with blunt technique.
- Place a self-retaining retractor (Kolbel, Fukuda) with gentle lateral retraction on the deltoid — avoid aggressive lateral traction, which endangers the axillary nerve.
- Release the superior 1 to 2 cm of the pectoralis major insertion if more exposure is needed; perform the inferior capsular release carefully with the axillary nerve protected (5 to 7 cm inferior to the acromion).
- Tag any residual subscapularis for later repair.
Before any deeper work, know the five structures you can injure in this exposure and reconstruction:
Exits the quadrilateral space 5 to 7 cm inferior to the lateral acromion and curls around the surgical neck. Stay superior during the inferior capsular release, palpate the nerve before any inferior screw, and limit inferior retraction.
Enters coracobrachialis 3 to 8 cm distal to the coracoid, lateral to the conjoined tendon. Identify it before the subscapularis release and avoid aggressive lateral retraction of the conjoined tendon.
Lie medial to the coracoid, deep to pectoralis minor, about 2 to 3 cm from the deltopectoral interval. Use gentle medial retraction only and avoid deep medial dissection.
Run superficially in the deltopectoral fat, crossing the interval proximally and distally. Dissect the subcutaneous layer carefully and minimise superficial cautery to avoid a painful neuroma.
Pass through the suprascapular notch posteriorly, 2 to 3 cm from the glenoid rim, and are at risk with the posterior-superior baseplate screw. Limit that screw to 20 mm and angle it away from the notch, using a drill guide.
Component removal & reconstruction
- If subscapularis is present and intact, take it down by a lesser tuberosity osteotomy (preferred for later bony healing) or a direct tendon peel; tag it with heavy braided suture and protect it throughout for final repair.
- Release the anterior capsule from the humeral neck, then the inferior capsule carefully (axillary nerve 5 to 7 cm from the acromion), and the posterior capsule as needed for exposure, preserving tissue for later repair.
- Determine fixation from the operative note: cemented stems need cement removal after extraction; uncemented stems may have significant bony ingrowth; note modular versus monoblock design.
- Cemented stem: cut a slot along the anterior stem with a burr, work thin curved osteotomes at the cement-bone interface, then extract with the manufacturer-specific device and slap hammer using progressive small taps rather than large impacts; clear all cement with hand instruments or an ultrasonic system (Sontec) down to a bleeding bone bed.
- Well-fixed uncemented stem: proceed to an extended humeral osteotomy rather than forcing extraction.
- Loose stem: mobilise with curved osteotomes, twist and extract with minimal bone loss.
- Plan an anterior longitudinal osteotomy in the proximal third, typically 8 to 10 cm, using an oscillating saw.
- Preserve lateral and posterior cortical continuity (a distal bone bridge) to keep the shaft stable, and mark the osteotomy edges for anatomic reduction.
- Extract the stem through the window, remove the cement under direct vision, then reconstruct the osteotomy with cerclage cables or wires before proceeding. A revision-length stem that bypasses the compromised bone by at least two shaft diameters is used if bone stock is poor.
- Remove the polyethylene insert first (identify the locking mechanism, use the manufacturer tool), then address the metal baseplate or keel.
- Metal-backed: remove the screws first, then mobilise the baseplate with a thin curved osteotome worked circumferentially at the bone-implant interface with gentle levering — avoid plunging into the glenoid vault. A keeled component may need drill troughs alongside the keel.
- All-polyethylene: score around it with a saw, mobilise with curved gouges, and remove any cement.
- Throughout, the goal is to remove the component while preserving maximum glenoid bone stock for the reverse baseplate.
- Measure the anterior-posterior diameter (minimum 20 mm needed), superior-inferior height (minimum 25 mm), central depth for the peg, and peripheral bone for screw purchase.
- Graft when bone is insufficient for stable fixation — Favard E2 to E4 defects, an AP diameter less than 20 mm, superior loss preventing rim contact, or a contained central defect greater than 10 mm deep.
- Options: structural allograft (femoral head or distal tibia) shaped to the defect and fixed with 3.5 or 4.0 mm screws; BIO-RSA augmented baseplate (a metallic wedge) for superior loss, avoiding graft entirely; impaction grafting with cancellous chips for small contained central defects only.
- Complete the capsular release, place retractors (Fukuda, Darrach), and expose the whole glenoid rim, clearing labrum and soft tissue.
- Ream with a spherical reamer to a flat surface of bleeding, viable bone; correct excessive retroversion (common in revision) by reaming more anteriorly, aiming for neutral to 5 degrees of retroversion.
- Confirm complete peripheral rim contact with the trial baseplate — reream if there are gaps.
- Drill the central peg hole just inferior to the centre of the glenoid face, typically 25 to 30 mm deep, and ream it to the baseplate peg diameter for firm rotational stability — the central peg provides 30 to 40 percent of fixation.
- Set 10 to 15 degrees of inferior tilt (critical — it reduces scapular notching and optimises the impingement-free arc) and aim for neutral to 5 degrees of retroversion. Excessive anteversion risks anterior instability; excessive retroversion limits external rotation.
- Impact the baseplate with the central peg fully seated and complete peripheral rim contact, checking there is no rocking.
- Insert a minimum of four (some systems allow six) divergent screws for bicortical purchase.
- Superior screw (anterior-superior quadrant) angled toward the base of the coracoid — usually the longest (30 to 40 mm), avoiding the suprascapular notch.
- Anterior-inferior screw toward the glenoid pillar (20 to 30 mm).
- Posterior-superior screw — limit to 20 mm and angle away from the notch; this is the most dangerous trajectory (suprascapular nerve 2 to 3 cm from the rim).
- Posterior-inferior screw toward the lateral scapular border (25 to 35 mm).
- Remove all residual cement and ream the canal to bleeding bone, broaching to size; use a revision-length stem if there is bone loss or an osteotomy.
- Set humeral version at 0 to 20 degrees of retroversion (less than an anatomic TSA), referencing the posterior humeral cut or the epicondyles.
- Cemented fixation is common in revision: clean dry canal, cement restrictor if needed, retrograde pressurised cementation, insert in correct version. A press-fit stem needs progressive broaching to rotational stability.
- Select the modular polyethylene liner thickness on trial reduction.
- Check stability through a full arc with no dislocation tendency; tension with moderate resistance to distraction (not over-tight or loose); and motion — impingement-free elevation, smooth rotation, no scapular notching on adduction. Upsize or downsize the liner to tune tension.
- Avoid over-stuffing: excessive joint tension causes scapular notching, stiffness and acromial stress fracture.
- Insert the final humeral liner onto the glenosphere, engage the locking mechanism, reduce the humeral component, and confirm stability in neutral.
- Repair the subscapularis if possible — re-fix the lesser tuberosity fragment anatomically with heavy braided suture through drill holes (or suture anchors), and repair the anterior capsule to reinforce stability.
- Close in layers: re-approximate the deltopectoral interval and clavipectoral fascia (0 or 2-0 absorbable), close subcutaneous dead space (2-0 or 3-0 absorbable), and skin with a running subcuticular suture plus adhesive strips.
- Apply a sterile dressing and a shoulder immobilizer.
This is the most dangerous screw — the suprascapular nerve lies 2 to 3 cm from the glenoid rim at the notch. Limit it to 20 mm and angle it away from the notch with a drill guide. Anterior screws must not perforate medially into the thorax (pneumothorax risk); inferior screws threaten the axillary nerve 5 to 7 cm below the acromion. Always use drill guides and depth control.
Inferior baseplate tilt (10 to 15 degrees) combined with appropriate lateralisation increases the deltoid moment arm, reduces shear at the glenoid-baseplate interface, and minimises scapular notching — the single most controllable determinant of impingement-free motion.
If a cemented stem will not extract, do not force it — an extended humeral osteotomy (anterior window 8 to 10 cm, preserving the posterior and lateral cortex as a bridge) gives controlled access to the cement-bone interface, avoids an iatrogenic fracture, and is reconstructed with cerclage cables.
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation & restrictions | Therapy & milestones | |-------|--------|-------------------------------|----------------------| | 1 | 0 to 2 weeks | Sling except for exercises; passive motion only | Passive forward elevation to 90 degrees and external rotation to 30 degrees (therapist only); active elbow, wrist and hand; wound check at 2 weeks | | 2 | 2 to 6 weeks | Continue sling; no active shoulder elevation | Progress passive elevation to 140 degrees and external rotation to 45 degrees; gentle pendulums | | 3 | 6 to 12 weeks | Wean the sling from 6 weeks | Active-assisted then active elevation from 6 weeks; isometrics from 6 weeks, strengthening from 8 to 12 weeks; most reach 120 to 130 degrees elevation | | 4 | 3 to 6 months | No restrictions | Progressive resistance and sport- or work-specific training; final motion typically 120 to 140 degrees elevation and 30 to 40 degrees external rotation |
No active shoulder elevation for a minimum of 6 weeks — the deltoid must heal to its restored tension before it is loaded. Violating this risks deltoid compromise and loss of function.
Expected outcomes. Around 85 to 90 percent report significant pain relief (VAS reduction of 6 to 7 points), with ASES scores improving by 35 to 45 points and forward elevation reaching 120 to 140 degrees; external rotation remains limited (typically 30 to 40 degrees). Patients return to light activities at about 3 months and full activities at 6 months, with continued improvement out to 12 to 18 months. Outcomes are less predictable, and complication and revision rates higher, in the revision than the primary setting. Complications
- Recognition
- Wound drainage, fever, raised CRP/ESR, purulence, radiographic loosening, positive aspiration culture
- Prevention
- Antibiotic prophylaxis, meticulous sterile technique, minimise operative time, optimise nutrition and glucose, chlorhexidine prep
- Management
- Acute (under 3 weeks): washout and component retention. Chronic: two-stage revision with antibiotic spacer, 6 to 12 weeks IV antibiotics, reimplantation when infection cleared
- Recognition
- Pain, clunk, visible deformity, loss of function; radiographs show malalignment; anterior direction most common
- Prevention
- Appropriate component sizing, avoid over- or under-stuffing, subscapularis repair if possible, correct version, patient education
- Management
- Closed reduction if acute. Recurrent: assess component position on CT, revise to increase constraint (larger liner, lateralised glenoid, revised baseplate angle)
- Recognition
- Pain with motion, lucencies around baseplate or screws, component migration on serial films, late screw breakage
- Prevention
- Bleeding-bone glenoid preparation, divergent screws, central peg purchase, bone-graft defects, inferior tilt positioning
- Management
- Early (under 6 months): revise with better fixation and bone graft. Late: revision baseplate with structural graft; consider arthrodesis as salvage
- Recognition
- Sudden acromial pain, often 3 to 12 months post-op; tenderness; radiograph or CT shows fracture (often lateral third)
- Prevention
- Avoid over-stuffing, optimise baseplate position, counsel against early heavy lifting, good bone quality
- Management
- Non-operative: sling and activity restriction; most heal conservatively. Painful nonunion: ORIF with plate and graft. Deltoid dysfunction carries a poor prognosis
- Recognition
- Inferior glenoid erosion on AP radiograph (Sirveaux grade 1 to 4); often asymptomatic but may cause pain or late loosening
- Prevention
- 10 to 15 degrees inferior baseplate tilt, avoid superior placement, appropriate medialisation and lateralisation
- Management
- Asymptomatic: observe and monitor. Symptomatic with loosening: revise the baseplate position with bone graft
- Recognition
- Deltoid weakness, inability to actively elevate, sensory loss over the lateral shoulder; EMG confirms at 3 to 4 weeks
- Prevention
- Gentle inferior capsular release, stay superior, palpate the nerve, limit inferior retraction, careful screw insertion
- Management
- Neuropraxia (most common): observe and maintain motion with PT, expect recovery by 3 to 6 months. No recovery by 6 months: explore, possible graft; chronic injury has a poor prognosis
- Recognition
- Intraoperative: crack or fracture during removal or insertion. Postoperative: pain, deformity, fracture around the stem
- Prevention
- Gentle removal technique, extended osteotomy for well-fixed stems, avoid excessive impaction, appropriate stem sizing
- Management
- Intraoperative: cerclage cables for stability, longer stem if unstable, bone graft. Postoperative: non-displaced is treated conservatively; displaced is treated with ORIF and cables, with possible stem revision
Viva & Exam Focus
REVERSEREVERSE — indications for revision to reverse TSA
BASEPLATEBASEPLATE — glenoid component fixation principles
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 68-year-old presents 4 years post-anatomic TSA with progressive pain and weakness. Radiographs show superior glenoid erosion and component loosening. How would you approach this patient?”
“During revision of a failed hemiarthroplasty to reverse TSA, you encounter a well-fixed cemented humeral stem that will not extract easily. What are your options and how would you proceed?”
“Discuss the glenoid bone grafting options when you encounter severe glenoid bone loss during revision to reverse TSA. What are the indications, techniques and outcomes for each approach?”
Indications
- Failed anatomic TSA with irreparable cuff deficiency (most common)
- Failed hemiarthroplasty with pain and dysfunction
- Severe glenoid loosening with bone loss (Favard E2 to E4)
- Proximal humeral fracture sequelae with cuff dysfunction
- Recurrent instability not reconstructable anatomically
- Contraindications: active infection, severe ungraftable bone loss, deltoid or axillary nerve dysfunction, neuropathic joint
Exposure
- Extended deltopectoral approach
- Cephalic vein on the deltoid side — retract or ligate
- Internervous plane: deltoid (axillary nerve) versus pectoralis major (pectoral nerve)
- In revision the interval is scarred — stay superficial and find the vein first
Danger structures
- Axillary nerve 5 to 7 cm inferior to the acromion
- Musculocutaneous nerve 3 to 8 cm from the coracoid
- Suprascapular nerve 2 to 3 cm from the glenoid rim at the notch
- Brachial plexus and axillary vessels medial to the coracoid
- Posterior-superior baseplate screw is the most dangerous trajectory
Component removal
- Manufacturer-specific extractors and a slap hammer with small progressive taps
- Extended humeral osteotomy (8 to 10 cm anterior window, preserve the posterior bridge, cerclage repair) for well-fixed stems
- Thin curved osteotomes peripherally on the glenoid — preserve maximum bone
Baseplate
- Ream to bleeding bone; correct version to neutral to 5 degrees retroversion
- 10 to 15 degrees inferior tilt reduces scapular notching
- Central peg provides 30 to 40 percent of fixation
- Minimum of four divergent bicortical screws
Finish & rehab
- Humeral version 0 to 20 degrees retroversion
- Trial reduction: stability, tension, impingement-free motion — avoid over-stuffing
- No active elevation until 6 weeks
- Outcomes: 85 to 90 percent pain relief, 120 to 140 degrees elevation
Complications
- Infection 3-5 percent
- Instability 6-10 percent
- Baseplate failure 2-4 percent
- Acromial stress fracture 1-4 percent
- Scapular notching 10-40 percent
- Axillary nerve injury 1-3 percent
- Periprosthetic humeral fracture 1-2 percent
Background & Evidence
Why the reverse prosthesis works without a cuff. The Grammont reverse design medialises and lowers the centre of rotation with a large neckless glenosphere and a 155-degree humeral cup, minimising torque at the glenoid-bone interface and recruiting the deltoid to compensate for the absent cuff. Lowering the humerus relative to the acromion restores and increases deltoid tension, allowing active elevation above 90 degrees in cuff-deficient shoulders. The trade-off is that rotation (especially external rotation) is often not restored, and inadequate deltoid tension risks prosthetic instability. Crucially, results are less predictable and complication and revision rates are higher in the revision than the primary setting. Durability. In a large multicentre series of 527 reverse arthroplasties, survivorship free of revision was 89 percent at 10 years, though survivorship to a Constant-Murley score above 30 fell to 72 percent with marked deterioration after 8 years and progressive radiographic change — supporting use in lower-demand older patients and careful counselling of younger ones. Glenoid bone loss — the Favard classification. Bone loss drives the difficulty of the revision and the need for grafting.
- Bone-loss pattern
- Intact bone stock
- Typical management
- Proceed without grafting
- Bone-loss pattern
- Centered erosion, minor contained defect
- Typical management
- Usually no graft needed
- Bone-loss pattern
- Superior defect with a biconcave wear pattern
- Typical management
- Structural allograft or BIO-RSA
- Bone-loss pattern
- Superior plus posterior defect, greater than 25 mm loss
- Typical management
- Structural graft with an augmented baseplate
- Bone-loss pattern
- Severe global bone loss, less than 50 percent intact
- Typical management
- Salvage — custom implant, hemi-reverse, or arthrodesis
Key evidence. The Grammont biomechanical rationale (Boileau, 2005) explains why the reverse works and which levers the surgeon controls. Favard (2011) provides the durability figures, and Zumstein (2011) anchors the complication discussion — revision-to-reverse carries higher infection and instability risk than primary surgery. For massive proximal humeral bone loss, the allograft-prosthetic composite (Sanchez-Sotelo, 2017) restores length and offset with reliable union, and for severe glenoid bone loss a staged hemi-reverse strategy (Walch, 2022) can protect the glenoid reconstruction.
References
Grammont reverse prosthesis: design, rationale, and biomechanics
- The Grammont design medialises and lowers the centre of rotation with a large neckless glenosphere and a 155-degree humeral cup, minimising glenoid torque and recruiting the deltoid to compensate for the absent cuff
- Lowering the humerus relative to the acromion restores and increases deltoid tension, allowing active elevation above 90 degrees in cuff-deficient shoulders
- External and internal rotation are often not restored, and inadequate deltoid tension risks prosthetic instability
- The authors explicitly flag that results are less predictable and complication and revision rates are higher in the revision setting
Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time?
- 527 reverse arthroplasties (1985 to 2003); survivorship free of revision was 89 percent at 10 years
- Survivorship to a Constant-Murley score above 30 was 72 percent at 10 years, with a marked deterioration after 8 years
- Progressive radiographic change and increasing scapular notch size were seen with longer follow-up
- The authors urge caution in younger patients given functional and radiographic decline over time
Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review
- A systematic review defining standardised terminology for problems, complications, reoperations and revisions in reverse arthroplasty
- Overall complication rate is substantially higher in the revision than the primary setting, with instability and infection the leading complications
- Scapular notching was the most frequent radiographic finding across cohorts
- Reoperation and revision rates exceed those of anatomic arthroplasty, driven largely by instability, infection and glenoid loosening
Allograft-prosthetic composite reconstruction for massive proximal humeral bone loss in reverse shoulder arthroplasty
- 26 patients (18 revisions) with massive proximal humeral bone loss reconstructed with an allograft-prosthetic composite and compression plating
- Significant gains in pain, elevation and external rotation with no significant difference between primary and revision cases
- Mean time to host-allograft union was 7 months; no revisions for nonunion at the junction
- Two- and five-year revision-free survival was 96 percent
Hemi-reverse revision arthroplasty in the setting of severe glenoid bone loss
- 15 revisions with severe glenoid bone loss treated with bone grafting plus a baseplate and glenosphere, leaving the humeral component out (a hemi-reverse)
- 13 of 15 grafts and implants healed and stayed radiographically stable (86 percent); the single mechanical failure had absent central post fixation in native bone
- Five patients went on to a second-stage humeral reconstruction once the graft had healed
- Demonstrates a staged strategy that protects the glenoid reconstruction and preserves the joint space