**2. Surgical approach**

The surgical technique for RTSA can be accomplished via two approaches: deltopectorally or superolaterally [3, 9]. The deltopectoral approach is the most common and requires an experienced surgeon [10]. This surgical technique begins with an incision overlying the deltopectoral interval, preserving the cephalic vein, then tenotomizing the biceps tendon and the subscapularis if still intact [3, 11, 12]. Next, the joint capsule is circumferentially released and humeral head exposed to perform a humeral head osteotomy. The humeral head is then reamed and broached. Subsequently, the glenoid is exposed, the labrum excised, and the glenoid prepared. The guidewire for the glenoid reamer is placed inferiorly so that the glenoid baseplate will be flush with the inferior border of the native glenoid rim. This will help decrease the risk of scapular notching. By adding an inferior tilt to the position of the baseplate, the risk of scapular notching can be decreased, which in turn, improves compressive forces and helps avoid shear forces on the glenoid component. The baseplate is impacted in place, and secured with screws to securely fix the baseplate to the patient's native glenoid. The selected glenosphere is then secured to the baseplate with a Morse Taper fixation mechanism. The selection of the appropriately sized glenosphere is multifactorial. It is based on the patient's size (i.e., 42 mm for larger patients, 39 mm for average size patients, 36 mm for smaller patients) and individual patient pathologies. Glenosphere components are available in central, lateral offset, and inferior offset designs.

Next, the humeral stem is prepared by sounding the inner diameter of the humeral shaft and broaching it to the appropriate size. The final implant is tested with the spacer trials in order to gain proper stability and range of motion. Then the real implants are seated and the shoulder is reduced. Lastly, the subscapularis is reattached and the biceps are tenodesed with heavy nonabsorbable sutures that are placed through drill holes in the humeral metaphysis prior to seating of the final implant. However, recent research acknowledges the controversy surrounding the reattachment of the subscapularis due to the potential for increasing the likelihood of dislocation [13]. The deltopectoral-interval is re-approximated and the incision closed. The patient is placed in a shoulder abduction sling for a period of immobilization lasting two to 6 weeks with a home physical therapy program [14]. As with all orthopedic procedures, the rehabilitation protocol is patient specific and additional rehabilitation may be deemed necessary if the patient needs to strengthen external rotation [14].
