Fig. 7.

Intraoperative photographs and technique notes for RSA: initial beach chair setup with arm positioner (a); deltopectoral exposure to include release of anterior ½ of supraspinatus (which can be antagonistic to a tension free, anatomic reduction) (b); tagging the rotator cuff tendons with four no. 2 braided nonabsorbable sutures placed from anterior to posterior in the supraspinatus, infraspinatus, and teres minor. A no. 5 braided nonabsorbable suture is placed through the teres minor and around the posterior greater tuberosity to be cerclaged around the stem of the implant for tuberosity reduction (c); glenoid exposure with Bankart retractors anteroinferior and posteroinferior. If necessary, a Hohman is placed short of the spinoglenoid notch superiorly (d); two no. 2 braided nonabsorbable sutures are placed in and out of two drill holes on either side of the bicipital groove and around the stem. These vertical stitches are later passed through the infraspinatus and subscapularis to prevent superior escape (e); the no.5 braided nonabsorbable suture previously passed through the teres minor (b) is passed around the stem of the implant to eventually “bear hug” the tuberosities down to the porous coated portion of the implant (f). After the no. 2 stitches from the subscapularis and teres minor are provisionally tensioned for trial reduction, intraoperative fluoroscopy is obtained to check implant positioning and tuberosity reduction by rolling over from the head of the bed for a Grashey view (g). The rotator cuff sutures are sequentially tied starting with the subscapularis to teres minor, conforming on imaging that the tuberosity reduction is satisfactory (h). Finally, the vertical and cerclage sutures are tied to complete the construct (i)