presentatione grand dorsale

1. How to manage Loss of Rotation with a Reverse Shoulder Prosthesis Nicola Ivaldo Mario Rossoni Giovanni Caione Luca Pizzella Private hospital - Villa Igea , Acqui Terme, Italy

2. Delta Reverse Prostheses : Result on active elevation Patient - Pre - op See Below Video 1

3. Delta Reverse Prostheses : Result on active elevation Patient - Post - op See Below Video 2

4. Rotation 1) Internal rotation

5. Reason for poor internal rotation with Reverse Shoulder Prosthesis Limited ROM ( semi-constrained implant ) Perhaps also pect major, lat dorsi & teres mayor strenght. reduced anterior deltoid strenght

6. Less efficient subscapularis Reason for poor internal rotation with Reverse Shoulder Prosthesis

7. Internal rotation Sirveaux & cw: ( JBJS B Apr 2004 )

8. S-scap Capsule Solutions 1) Respect the subscapularis

9. Solutions 2) Reconstruct the subscapularis

10. Solutions 3) Respect the Lesser Tuberosity L T L T

11. Respecting the lesser tuberosity means retroversion of the humeral component

12. Delta in severe trauma sequelae

13. Delta in severe trauma sequelae See Below Video 3

14. reverse in acute fractures

15. Tuberosity partial reconstruction L T G T

16. reverse pt in acute fractures BD 4 m.

17. Rotation 2) External rotation

18. Delta reverse prosthesis : Result with external rotation Sirveaux : RE 1 3.5° -11.2° ( JBJS B Apr 2004 ) RE 2 17° - 40° Boileau: RE 1 7° -11° ( JSES Jan Feb 2005 ) Gerber: RE 1 17° -12° ( JBJS A Jul 2005 )

19. Average Constant Score = 67 pts CS in cases of torn Teres Minor = 58 pts Sirveaux and cw J.B.J.S. Br. Apr 2004 Constant Score results depend on Teres Minor status teres minor

20. Teres minor status (113 Delta) Teres minor Intraoperative observation NORMAL MIDDLE DEGENERATION TORN OR SEVERE DEGEN 22 ( 19.5 %) 49 ( 43.3% ) 42 ( 37.2 %)

21. The dropping sign in abduction See Below Video 4

22. The dropping sign in adduction See Below Video 5 Teres minor intact or middle degeneration Teres minor torn or severe degeneration AVG Active Ex Rot 1 + 18.3° AVG Active Ex Rot 1 - 11.5°

23. Medialization of humeral center of rotation Decrease in the strength of posterior deltoid Reason for poor external rotation

24. Frankle M. and cw. JBJS A. August 2005 Delta offset increase offset Pre op Post op gain p external rotation 12.0 41.1 29.1 < 0.0001

25. Simovitch & cw J.B.J.S. Am. Mar 2007 Pre op Post op gain p external rotation 11.2 17.6 6.4 0.28 ( ns)

26. baseplate failures Frankle M. and cw. JBJS A. August 2005

27. How to increase active external rotation? Latissimus dorsi transfer

28. Advantages of latissimus dorsi transfer througth a deltopectoral approach Commonly used approach for TSA Entire procedure in beach chair position Single incision Operative time 20 – 30 m more than standard Delta Reverse Shoulder Prosthesis

31. Surgical technique Pect major Pect major

32. Surgical technique Latissimus dorsi Latissimus dorsi

33. Surgical technique teres major

34. Surgical technique

35. Surgical technique See Below Video 6

36. Miniaci A. and cw JSES Sept Oct 2004 … .Axillary nerve crosses from anterior to posterior over the superior border of teres major approximately 27.1 ± 8.9 mm from this muscle's humeral attachment….. Axillary nerve Latissimus dorsi Axillary nerve

37. Surgical technique Humeral implant

38. Surgical technique Pect major

39. Delta and latissimus dorsi: pre-op Initials age G pain use AFE AER2 AIR Strenght pts CS SO 78 m 0 sternum 70 0 sacrum 0 16 AE 75 m 7 neck 70 +10 D8 0 36 PL 72 f 3 belt 20 -10 trocant 0 9 RA 77 f 7 neck 60 0 D12 0 29 BM 79 f 3 neck 100 +20 D12 6 44 Average 76.2 4.4 neck 64 +4 L3 1,2 26.8

40. Delta and latissimus dorsi: post-op case pain use AFE AER2 AIR Strenght pts CS SO 15 head 140 +60 L3 8 66 AE 15 normal 160 +50 D12 6 69 PL 13 head 110 +30 D12 4 56 RA 10 head 140 +40 D12 5 56 BM 15 head 170 +70 gluteus 10 69 Average GAIN 13.6 9.2 head 144 +80 +50 +46 L3 6.6 4.4 63.2 36.4

41. Recover of external rotation in abduction after Delta + GD at 6 months = 50 ° at 2 y = 38 °

42. Delta + latissimus + teres mayor TM LD

43. We should replace Teres Minor ! Teres minor LD and TM

44. Delta compared to delta + LD transfer

45. Delta compared to delta + LD transfer Delta Delta + LD Transfer See Below Video 7