Synthes Delta Xtend User manual

SURGICAL TECHNIQUE
This publication is not intended for distribution in the USA.
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DELTA XTEND™ REVERSE SHOULDER SYSTEM
KEY SURGICAL STEPS
Superior-lateral
Approach
Humeral Surgical Steps
3. Proximal reaming guide
positioning
1. Approach 2. Humeral head resection
Modular Implant
Cementless Technique
Monobloc Implant
Cemented Technique
1. Approach
Delto-pectoral
Approach
2. Humeral head resection
1. Choice of optimal metaglene
positioning
2. Wire guided glenoid reaming 3. Metaglene central peg drilling
Glenoid Surgical Steps

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Modular Implant
Cementless Technique
Monobloc Implant
Cemented Technique
4. Determination of the epiphysis size 5. Proximal humeral
reaming
6. Final implant insertion 7. Cup impaction
4. Determination of the epiphysis size and
eccentricity
5. Proximal humeral
reaming
6. Diaphyseal broaching
and angulation
measurements
7. Epiphysis/diaphysis
assembly
8. Final implant insertion 9. Cup impaction
Standard Option Eccentric Option
4. Metaglene impaction 5. Inferior and superior locking
screw insertion
6. Anterior and posterior spherical
head screw insertion
7. Glenosphere implantation

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Cuff Tear Arthropathy (CTA) was described by Charles Neer in 19831and has historically been seen as a significant surgical
challenge.
Non-constrained total or hemi shoulder arthroplasties have poor clinical outcomes for such indications. The majority of
constrained and semi-constrained prostheses developed in the 70’s – 80’s for CTA (in particular all reversed ball and socket
designs) remained purely experimental due to poor range of motion, instability and a high rate of glenoid loosening.2,3
In 1985, Paul Grammont (Dijon University Hospital - France) designed the first semi-constrained reverse concept that met
the challenges inherent in cuff tear arthropathy cases:3Known today as the DePuy DELTA CTA™ Reverse Shoulder, this
shoulder prosthesis is a leading treatment for shoulder cuff tear arthropathy5, with more than 25 years of heritage3,4.5 and
40,0006cases performed all over the world.
Based on the experience of the DELTA CTA Reverse Shoulder, the next generation of implant evolved; the DePuy DELTA
XTEND Reverse Shoulder System. It has been designed using the latest scientific, engineering and clinical knowledge to
maximise the clinical outcomes and enhance long-term survivorship in CTA cases by:
•Respecting the three design features that differentiated the DELTA CTA Reverse Shoulder from previous
designs:
 3,4
 3,4
 5,7
•Reducing the risk of scapular neck erosion while maximising the shoulder range of motion:
 
system.8,9,19
 10
•Preserving bone for earlier intervention and faster recovery with:
 15,16
 ®anatomic shoulder history.
 
 
Based on the success of the DELTA CTA Reverse Shoulder, the DELTA XTEND Reverse Shoulder System is the next step
forward for appropriate management of patients with a grossly deficient rotator cuff joint with severe arthropathy. Its
20 The

that helps you treat your patient more effectively.
Dr Didier Capon
France
Dr David Collins
USA
Prof Anders Ekelund
Sweden
Dr Laurent Lafosse
France
Prof Lieven
De Wilde
Belgium
Dr Cécile Nérot
France
Dr Ludwig Seebauer
Germany
Dr Michael Wirth
USA
The DELTA XTEND Reverse Shoulder System Surgeon Design Team
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CONTENTS
Design Rationale .........................................................................................8
DELTA XTEND Reverse Shoulder System Features .......................................................8
Surgical Technique ...................................................................................10
Pre-operative Templating and Patient Positioning.....................................................10
Surgical Approach ...................................................................................................11
Intramedullary Canal Preparation.............................................................................13
Humeral Head Resection .........................................................................................14
Exposing the Glenoid ..............................................................................................18
Positioning the Metaglene.......................................................................................19
Reaming the Glenoid...............................................................................................22
Drilling the Central Hole ..........................................................................................23
Metaglene Implantation ..........................................................................................24
Inferior and Superior Metaglene Screw Placement ...................................................25
Anterior and Posterior Metaglene Screw Placement.................................................28
Placement of the Proximal Humeral Reaming Guide.................................................30
Cementless Modular Humeral Implants
Proximal Humeral Reaming ..................................................................................31
Distal Humeral Broaching.....................................................................................33
Humeral Trial Stem and Epiphysis Insertion ...........................................................34
Cemented Monobloc Humeral Implants
Proximal Humeral Reaming ..................................................................................36
Humeral Trial Implant Insertion.............................................................................37
Glenosphere Trial Placement....................................................................................38
Cup Trials and Trial Reduction ..................................................................................39

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 ................................................................40
Definitive Glenosphere Fixation................................................................................41
Cementless Modular Humeral Implants
Definitive Humeral Implant Insertion ....................................................................44
Cemented Monobloc Humeral Implants
Definitive Humeral Implant Insertion ....................................................................46
Cases of Proximal Humeral Bone Loss......................................................................48
Revision to Hemi-Arthroplasty..................................................................................50
Closure....................................................................................................................51
Post-operative Management....................................................................................51
Ordering Information................................................................................52
Implants ..................................................................................................................52
Instrumentation.......................................................................................................54

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Cemented Monobloc Stem
7Polished Cobalt Chromium alloy for increased mechanical
strength and optimised cemented fixation14
8Standard and long monobloc stems with suture hole
fins and proximal height laser marking on the trial stem
for use in proximal bone loss cases
9Thin proximal area for bone preservation
10 3
Cementless Modular Stem
1Hydroxyapatite (HA) coated titanium alloy for
optimal cementless fixation11,12
2Proximal filling stem design based on the
anatomic DePuy GLOBAL design - positioned
in anatomic version for optimal press-fit
fixation12
Modular Epiphysis
3Centred and eccentric options for bone preservation
and optimal press-fit fixation
4
for increased internal rotation13
53
6Reduced diameter for bone preservation
DELTA XTEND REVERSE SHOULDER SYSTEM FEATURES
The DELTA XTEND Reverse Shoulder System is a total semi-constrained shoulder arthroplasty that reverses the normal
biomechanics between the scapular and humeral components. It moves the gleno-humeral joint centre of rotation
medially and inferiorly, increasing the deltoid lever arm and the deltoid tension. This allows the muscles of the deltoid
group to compensate for rotator cuff deficiency.5,7 The DELTA XTEND Reverse Shoulder System is comprised of two
humeral stem types, providing the choice of press-fit or cemented fixation. The glenoid component is cementless
with 4 screws as primary fixation and HA coating for secondary fixation.11,12 Each design feature has been defined
to accelerate recovery, optimise function and maximise survivorship for the CTA patient treated by reverse shoulder
arthroplasty.

11
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15
16
13
9
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14 ±10˚
±10˚
Polyethylene Humeral Cups
11 High mobility option for maximised range
of motion & reduced risk of scapular
erosion10,15
12 Three cup thicknesses to balance soft tissue
for optimal deltoid tension based on clinical
heritage5
DELTA XTEND CTA Heads
 
 
 
Glenoid Component
13 Increased glenosphere diameter (38 and
42 mm) and eccentric option for improved
stability, maximised range of motion and
reduced risk of scapular erosion9
14 Centre of rotation on glenoid surface for high
resistance to loosening shear forces3,15
15 Locking cannulated screws with adjustable
angulation to enhance metaglene primary
fixation and maximise resistance to loosening
shear forces3,15
16 Curved back and smaller diameter metaglene,
for bone preservation and low positioning
on the glenoid to reduce risk of scapular
bone erosion15,16

Figure 3
Figure 2
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Pre-operative Templating
An initial assessment of the glenoid should be carried out
using radiographic and CT imaging to determine whether
the patient is suitable for treatment. The size of the
glenoid vault should be assessed to ensure that all four
metaglene screws can be placed within glenoid bone.
Pre-operative planning should also be carried out using AP
and lateral shoulder radiographs of known magnification
and the available template to help the surgeon determine
the size and alignment of the implant (Figure 1). The final
decision should be taken in the operating room, during
surgery.
Patient Positioning
The patient should be in the beach chair position, with the
affected arm completely free (Figures 2 and 3).
PRE-OPERATIVE TEMPLATING & PATIENT POSITIONING
Figure 1

Figure 4 Figure 5
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extend more than 4 cm from the external aspect of the
acromion in order to preserve the axillary nerve which is
located below the turning fold of the subacromial bursa.17
When the subacromial bursa is visible, gentle longitudinal
traction in line with the limb allows a retractor to be
placed in the subacromial space. The anterior deltoid is
then released subperiostally from its acromial insertion
up to the AC joint. The deltoid release from the anterior
acromion can include a small piece of bone to facilitate
repair and to protect the deltoid muscle.
Once the subacromial bursa has been removed, the
humeral head is visible at the anterior edge of the
acromion. Exposure may be improved, if necessary, by
dividing the AC ligament and performing acromioplasty.
The limb is then externally rotated and the head is
dislocated antero-superiorly to facilitate positioning of the
cutting guide. If the bicep is still present, a tenotomy or
tenodesis should be performed. The subscapularis, teres
minor and infraspinatus are retained when present. A
partial detachment of the subscapularis may be performed
when the superior dislocation of the humerus is difficult
to obtain.
SURGICAL APPROACH: SUPERIOR-LATERAL
The DELTA XTEND Reverse Shoulder System prosthesis
can be implanted using a superior-lateral deltoid split
approach or a delto-pectoral approach. The choice
depends on the surgeon’s preference and clinical
parameters.
The delto-pectoral approach has the advantage of offering
an enhanced view of the inferior part of the glenoid.
Revision surgery is usually performed using a delto-
pectoral approach so the approach can be made through
the original scar and it allows for a longer humeral incision
when faced with difficult removal of the humeral stem.
Alternatively, the superior-lateral approach enables clear
visualisation of the glenoid and therefore facilitates the
implantation of the glenoid components of the prosthesis,
in particular where the glenoid is retroverted. Moreover,
this approach does not necessitate the partial detachment
of the subscapularis muscle that could be seen as further
weakening of the remaining cuff structure.
Superior-lateral Approach
The skin incision is 10-12 cm and can be antero-posterior
along the lateral edge of the acromion or made in a lateral
direction (Figure 4). Following subcutaneous dissection,
separate the anterior and middle deltoid muscle bundles
opposite the lateral margin of the acromion using blunt
dissection (Figure 5).
The dissection starts at the level of the AC joint, 5-7 mm
posterior to the tip of the acromion and extends straight
laterally down into the deltoid muscle. It should not

Figure 9 Figure 10 Figure 11
Figure 6 Figure 7 Figure 8
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Delto-pectoral Approach
The skin incision follows a line from the midpoint
of the clavicle to the midpoint of the arm (Figure 6).
Subcutaneous flaps are elevated to expose the fatty strip
that demarcates the delto-pectoral interval (Figure 7).
Dissect medial to the cephalic vein and retract it laterally
with the deltoid muscle (Figure 8). Incise the clavipectoral
fascia from the inferior border of the coracoacromial
ligament distally to the superior border of the tendon of
the sternal head of the pectoralis major (Figure 9). Dissect
the humeroscapular motion interface (subacromial,
subdeltoid and subcoracoid). Palpate the axillary nerve at
the anterior-inferior border of the subscapularis muscle
(Figure 10). Electrocoagulate or ligate the anterior humeral
circumflex vessels (“three sisters”) near the humerus at
the inferior border of the subscapularis.
Place a tag suture in the tendon of the subscapularis
(Figure 11), 2 cm medial to its point of insertion, in the
lesser tuberosity. Release the tendon, along with the
underlying capsule, from the lesser tuberosity and the
proximal humerus.
Ascertain the integrity of the biceps long head tendon. If
still present, tenodese it in the groove or to the pectoralis
major tendon, or proceed with a tenotomy for elderly
patients.
If necessary strip the remaining inferior and posterior-
inferior capsule from the humerus. Dislocate the humeral
head.
SURGICAL APPROACH: DELTO-PECTORAL

Proximal Entry Point
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INTRAMEDULLARY CANAL PREPARATION
Using the 6 mm medullary canal reamer, make a pilot hole
in the humeral head, so that the reamer passes directly
down the axis of the intramedullary canal (Figure 12).
Hand ream the medullary canal using the T-handle on
the reamer. Do not use a power reamer since this could
damage the humerus.
When using the standard length prosthesis, pass the
reamer down the intramedullary canal until the mid-level
circular mark on the reamer is level with the pilot hole.
When using the long stem prosthesis, pass the entire
length of the cutting flutes down the intramedullary
canal.

contact with cortical bone of the intramedullary canal of
the humerus (Figure 13).
The final reamer size chosen will determine the size of the
cutting guide handle, the epiphyseal reaming guide, the
broach, trial stem and final implant. For example, if the
12 mm reamer begins to gain purchase in the
intramedullary cortical bone, use a 12 mm humeral
trial stem and final component, both for cemented and
cementless humeral implant versions.
Figure 12 Figure 13

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Figure 14
Select the appropriately sized cutting guide handle. Taking
the previous example, if reaming stopped at 12 mm,
select the 12 mm handle. Select the cutting guide and
cutting plate according to the surgical approach used:
superior-lateral or delto-pectoral.
Assemble the cutting plate on the cutting guide first 1
and then fix the cutting guide onto the cutting guide
handle 2(Figure 14). The cutting guide should be fully
seated on the cutting handle.
HUMERAL HEAD RESECTION
Superior-lateral Cutting Guide
Assembly
Delto-pectoral Cutting Guide
Assembly
Cutting Plate
Cutting Guide
Cutting Plate
Cutting Guide
1
1
2
2

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HUMERAL HEAD RESECTION
Drive the cutting assembly down the intramedullary
canal until full contact with the superior humeral head is
obtained.
Insert the orientation pin through the hole in the cutting
handle, to achieve desired retroversion. The retroversion
is calculated with reference to the forearm axis. This

retroversion can restrict joint motion, especially internal
rotation. However care should be taken not to damage
the subscapularis insertion by resecting the head with
excessive anteversion. The cutting handle should then
be rotated to align the orientation pin and the forearm
(Figure 15).
Slide the cutting plate to adjust the cutting level. The
cutting plate colour code indicates the appropriate
resection level. If the cutting level indicator is green,
the guide is at the correct height. If it is red, the cutting
plate needs to be adjusted (Figure 16).
Figure 15 Figure 16
Superior-lateral cutting plate Delto-pectoral cutting plate
Cutting plate level adjustment

17
16
Superior-lateral approach Delto-pectoral approach
Pre-drill the cortical bone through the cutting plate using
a 3.2 mm drill bit, and insert the two fixation pins to fix
the cutting plate to the humerus (Figure 17).
Following the colour code guidance, the surgeon should
resect 1 - 2 mm of the proximal area of the greater
tuberosity (at the level of the supraspinatus insertion in an
intact shoulder).
Note: the cutting angle is 155°, and therefore
different from the anatomical neck/shaft angle of
135°. 155˚ is recommended for reverse shoulder
systems.3
HUMERAL HEAD RESECTION
Figure 17

17
16
Superior-lateral approach Delto-pectoral approach
Remove the cutting guide assembly, add a third
(divergent) fixation pin through the middle hole of the
cutting plate to secure the assembly. Resect the humeral
head, aligning the saw blade with the superior aspect of
the cutting plate (Figure 18, Option 1).
Note: the two external pins are parallel, this enables
the cutting plate to be reversed before being secured
with the third divergent fixation pin, providing a flat
cutting surface (Figure 18, Option 2).
Place the humeral resection protecting plate onto the
resected surface to protect the bone from damage during
the following surgical steps (Figure 19).
Pass a forked retractor under the scapula to lower the
humerus. If this provides a clear sight of the glenoid
surface, the resection level is correct. If not, a further

HUMERAL HEAD RESECTION
Figure 18 Figure 19
Option 2
Option 1

19
18
EXPOSING THE GLENOID
The forked retractor should be placed under the
inferior glenoid labrum to move the humerus distally or
posteriorly, depending on the approach taken (Figure 20).
When exposing the glenoid, it is critical to note the
presence of the axillary nerve and protect it at all times.
Excise the biceps remnant and entire labrum. Release the
entire capsule from around the glenoid.
In certain cases, the capsule may have to be excised
depending on the extent of any contractures and the

long head may be incised from the infraglenoid tubercle.
Bluntly (finger or elevator) dissect in a circumferential
manner from the base of the coracoid process to well
beyond the most inferior aspect of the glenoid.
It is essential to palpate the following bony scapular
orientation points: the base of the coracoid process,
the inferior part of the glenoid neck and when possible,
infraglenoid tubercle and lateral border of the scapula.
Retractors should be placed so that the entire glenoid face
is in clear view to aid accurate placement of the guide pin.
Glenoid Preparation
Remove any remnants of labrum from the glenoid. Then
remove all articular cartilage from the glenoid face using a
large straight curette. In addition, any osteophytes present
may also have to be removed to determine the bony
anatomy.
Figure 20

19
18
To obtain good bone seating, the metaglene should
ideally be positioned on the inferior circular area of the
glenoid. The metaglene central peg should be positioned
in the centre of the inferior circle of the glenoid (This
point is often posterior and inferior to the intersection of
the glenoid axes) (Figure 21).
Using these anatomical reference points helps to position
the metaglene as inferior as possible on the glenoid in
order to limit potential bone impingement, while keeping
a secure glenoid implant fixation.
However, radiographic, CT images combined with X-ray
templates and the intra-operative view may indicate a
slightly more superior position, to obtain fixation in good
bone stock and complete sitting of the metaglene on the
bone.
Particular attention should be given to metaglene
positioning to achieve optimal glenoid fixation, range of
motion and limit potential bone impingement.
The position must be chosen to obtain maximum contact
with the glenoid surface and to allow secure fixation of
the screws in bone.
POSITIONING THE METAGLENE
Figure 21

21
20
The metaglene positioner is used to determine the optimal
metaglene position. The positioner plate is the same
diameter as the metaglene.
Assemble the positioner by inserting and screwing the
internal rod into the positioner handle (Figure 22).
POSITIONING THE METAGLENE
Then insert the hex head tip of the handle into the
corresponding plate hole (right or left depending on the
shoulder being operated upon) (Figure 23) and lock the
assembly by screwing the internal rod tight
(Figure 24).
Note: the handle is set at an angle of 20° to the plate
to ensure optimal visibility (Figure 24).
Figure 22 Figure 24Figure 23
20˚