Summary This overview reflects the INHANCE INTACT tissue sparing surgical technique for the anatomic stemless approach within the INHANCE Shoulder System The described procedure is an anatomic total shoulder replacement workflow using a humeral stemless anchor and referencing anatomic glenoid and anatomic hybrid glenoid options the technique emphasizes a subscapularis-sparing exposure followed by humeral resection, glenoid preparation, humeral preparation, trialing, and final implantation with dedicated INTACT instruments the INHANCE INTACT instruments are described for use with the INHANCE anatomic stemless shoulder system, and the cases and trays are intended to hold joint reconstruction instruments during sterilization and storage Indications Indications the INHANCE Shoulder System with the humeral stemless anchor is intended for use in anatomic total shoulder replacement procedures to address osteoarthritis post-traumatic arthrosis focal avascular necrosis of the humeral head previous surgeries of the shoulder that do not compromise the fixation Contraindications not specified in provided sources Anatomy Osteology humeral head greater tuberosity surgical neck of the humerus humeral shaft calcar bicipital groove glenoid face glenoid fossa glenoid neck glenoid vault coracoid Muscles subscapularis supraspinatus deltoid latissimus dorsi biceps Ligaments glenohumeral ligaments medial glenohumeral ligaments Nerves axillary nerve Blood supply circumflex vessels described as the three sisters Approach Place the patient in a beach chair position and ensure the humerus can be brought into full adduction, extension, and external rotation Make the skin incision identical to the standard deltopectoral incision Open the biceps sheath, follow the biceps into the rotator interval, and perform a biceps tenodesis Use a subscapularis-sparing exposure with inferior release, capsular release, osteophyte removal, and superior release Define the inferior border of the subscapularis by the circumflex vessels and the latissimus dorsi tendon, then coagulate or suture ligate the vessels Open the space between the subscapularis below and latissimus above, and separate the subscapularis and capsule medially with scissors Use the Inferior Subscap Retractor with a Senn or Lagenback retractor to lift the subscapularis and visualize the capsule beneath it Open the capsule along the curvature of the calcar, release the capsule from the surgical neck of the humeral head, and complete inferior capsular release from anterior to posterior with progressive external rotation and flexion Darrach or Hohmann retractors may be used to retract and protect the axillary nerve during capsular release Identify and remove osteophytes after inferior capsular release, with external rotation used to access posterior inferior osteophytes Locate the rotator interval bounded by the upper rolled border of the subscapularis, the anterior leading edge of the supraspinatus, and the lateral edge of the coracoid, then excise this tissue triangle Locate the glenohumeral ligaments posterior to the subscapularis, expose the medial glenohumeral ligaments with a Hohmann on the glenoid neck, and release or excise them Mark the articular cartilage at the bicipital groove for alignment of instruments during the procedure Technique Humeral resection use the resection guide to assist humeral head resection with the subscapularis intact place the superior radial arm tight against the supraspinatus insertion at the greater tuberosity to establish resection height use the fully captured saw slot for blade guidance during humeral resection align the Silhouette Resection Guide Pin with the humeral shaft anteriorly to approximate a 135° humeral resection angle use the 30° version handle for retroversion alignment with the forearm, or manually set an alternate version insert the superior radial arm through the rotator interval toward the posterior humeral articular margin, with the most superior saw-slot hole aligned with or slightly posterior to the bicipital groove for patient specific anatomic resection, use the resection guide extender to visualize the intended resection plane inferiorly and align the guide to the inferior articular margin for patient specific anatomic resection, place one pin most superior within the rotator interval or slightly posterior without violating the supraspinatus tissue, and a second pin in the inferior location selected to achieve the desired inclination for 135° resection, the resection guide extender is not required, although it may be used for inferior visual confirmation for 135° resection, align the vertical extension rod with the distal humeral bone and place one superior pin in the rotator interval or slightly posterior and a second inferior pin through the subscapularis if there is high potential for poor bone quality, the source recommends 135° resection as the primary approach because it allows easier conversion to the standard INHANCE Shoulder System anatomic surgical technique after bone quality evaluation use Anterior Subscap and Posterior Cuff Retractors to visualize and protect the subscapularis and supraspinatus during resection, and place a Darrach or Curved Hohmann over the humeral head against the glenoid for protection align the saw blade planar with the resection guide and under the saw slot, and keep the blade flat within the captured slot during the plunge cut minimize twisting or levering of the blade while it is under the saw slot, and slide in a linear motion in some patients, minimal release of the upper border of the subscapularis may provide additional saw-blade clearance after osteotomy, assess bone quality with thumb pressure on the resection if the resected bone depresses without much resistance, the source states that the bone may be insufficient for the stemless INTACT approach and that a stemmed implant may provide better fixation if bone quality evaluation fails, stop the INTACT approach and proceed with the standard INHANCE Shoulder System anatomic surgical technique remove the pins and resection guide, complete any incomplete cut with an osteotome if necessary, and remove residual bone or osteophytes above the resection plane before proceeding Glenoid preparation depending on patient anatomy, glenoid preparation may be performed with inferior and posterior humeral head retraction or transhumerally if guide pin placement and reaming along the desired glenoid axis are not possible use glenoid retractors, including an anterior glenoid neck retractor, forked posterior retractor, and superior Hohmann as described, with optional bone hook assistance for lateral humeral manipulation and visualization use the INHANCE Glenoid Sizers and Sizer Handle to determine the implant size create a 3 to 5 mm deep starter hole in the optimal location on the glenoid face with the Stepped Glenoid Drill position the arm in neutral with the resection plane facing the glenoid fossa when planning the transhumeral pilot hole target a lateral entry point for the Drill Cannula teeth 1 to 2 cm below the resection plane insert the Offset Glenoid Guide through the rotator interval, advance the Drill Cannula to the lateral humeral cortex, and drill through the lateral cortex and resection to visualize the drill tip beyond the distal threads of the guide dock the drill tip into the previously created starter hole on the glenoid fossa, then slide the Offset Glenoid Guide to the glenoid face and adjust version and inclination an external articulated arm positioner attached to the OR bed is recommended for transhumeral glenoid preparation an optional Glenoid Sizer disc may be used during drilling to enhance tactile feedback, although the source notes that it may limit visualization advance the Stepped Glenoid Drill down the glenoid vault at least 25 mm or until bicortical penetration is achieved for transhumeral reaming, position the arm in adduction with slight external rotation, insert the INTACT Glenoid Reamer through the rotator interval, and connect it to the Glenoid Drive Shaft confirm proper engagement of the Glenoid Drive Shaft before reaming by visual and tactile confirmation, including the shaft laser mark and protrusion of the bullet tip power ream with the reamer already rotating before contacting bone, and prepare the glenoid surface while removing as little bone as possible avoid overly aggressive reaming and do not ream to cancellous bone if excess force is required during reaming, remove the reamer and realign the drive shaft with the pre-drilled pilot hole maintain rotation while entering and exiting bone to avoid disengagement of the friction-fit reamer and drive shaft place the appropriately sized Glenoid Trial into the prepared glenoid, and if desired, use the Convex Impactor Tip on the Offset Glenoid Guide to fully seat the trial use the windows in the Glenoid Trial to visually assess acceptable backside support for glenoid implantation, clean and dry the glenoid surface, central peg hole, and peripheral ring place cement into the peripheral ring with a syringe and avoid cement in the central hole or on the backside of the implant use the Offset Glenoid Guide with the attached inserter tip for implant introduction and initial seating while maintaining axial alignment with the prepared glenoid remove the inserter tip and complete final seating with the Convex Impactor Tip once a specific anchorage size has been prepared, the source advises against upsizing or downsizing the anchorage size docking the implant post into the prepared glenoid hole without contact from other bone or soft tissue is described as improving retainment on the inserter tip Humeral preparation assemble the Pin Clamp Posts to the Pin Clamps and attach them to the Humeral Guide, using the side of the guide that matches the operative shoulder use the resected humeral head to choose the best fit stemless implant size with the Humeral Sizer align the mark placed in the bicipital groove with the window in the Humeral Sizer and reference the laser line and approximate head size that intersect the cortex at that mark attach the Humeral Sizer to the Humeral Guide and introduce the construct through the retracted rotator interval use the Reverse Hohmann Retractor and Anterior Glenoid Neck Retractor to visualize the resection plane position the Humeral Sizer planar with the resection, centralize it using the bicipital groove mark, laser line, palpation, and visual confirmation, and hold it with downward pressure advance the Drill Cannula to the lateral cortex of the humerus for initial securement, using its one-way ratchet feature to maintain position if needed, extend the skin incision distally to accommodate Drill Cannula contact with bone advance the Humeral Drill to the laser mark, approximately 10 mm, to dock in bone and improve guide stability plan Humeral Guide Pin placement before drilling so that the pins do not interfere with subsequent bone preparation or implant placement give primary consideration to soft tissue and neurovascular structures during pin placement, clean soft tissue from the entry point, and avoid tissue wrapping during insertion place the superior Humeral Guide Pin no higher than the Drill Cannula entry point and approximately parallel to the resection plane, without crossing the Drill Cannula axis place the inferior Humeral Guide Pin with at least 2 cm of vertical spacing from the superior pin, with percutaneous placement permitted if desired advance the 4.0 mm Humeral Guide Pin through the initial cortex and then an additional 3 to 5 mm into the far cortex while engaging the proximal threads, but do not let the pin exit the far cortex tighten the Pin Clamp nuts while maintaining downward pressure at the center of the Humeral Sizer and counter resistance so guide position does not change before transhumeral drilling, micro adjustment is permitted by loosening the Pin Clamp nuts, releasing Drill Cannula tension, repositioning the guide and sizer, re-tensioning the Drill Cannula, and re-tightening the nuts create the transhumeral tunnel by advancing the Humeral Drill through the Humeral Guide until it exits in the central portion of the Humeral Sizer, then remove the sizer attach the single-use Humeral Reamer Bearing to the appropriately sized Humeral Reamer, then assemble the reamer to the Humeral Handle place the Humeral Handle Adapter on the Humeral Guide, align the Humeral Handle parallel to the resection, and engage the handle to the adapter until there is face-to-face contact with no visible gap insert the Humeral Drive Shaft through the Drill Cannula and connect it to the cannulated Humeral Reamer with slight twisting motion, then confirm connection by hand ream under power with forward rotation beginning before bone contact, while pulling lightly on the drive shaft and pushing down on the Humeral Handle in line with the guide ream until the bottom of the Humeral Handle Adapter covers the black line on the Humeral Guide post remove the reamer from bone under power, disconnect the shaft only when not under power, and remove and discard the single-use humeral reamer bearing after use for blazing, thread the Blazer Adapter into the appropriately sized Humeral Blazer with the fin aligned between the bosses on the adapter load the Humeral Blazer construct into the Humeral Handle, connect the handle to the Humeral Handle Adapter, and pass the Humeral Drive Shaft through the Drill Cannula and blazer cannulation to confirm axial alignment connect the Impactor Handle to the Impactor Handle Adapter, with the arrow on the adapter facing the patient impact the Humeral Blazer until the bottom of the Humeral Handle Adapter covers the laser line on the Humeral Guide, then reverse the impaction plate upward until the blazer is freed from the prepared bone for stemless implant insertion, place the appropriately sized implant over the Humeral Drive Shaft tip for guidance and align the implant fin with the bone preparation and Humeral Guide the stemless implant should seat approximately halfway into the prepared humerus with light finger pressure before impaction load the Stemless Impactor Tip into the Humeral Handle, connect the handle to the Humeral Handle Adapter, and advance the implant while maintaining planar and central axis alignment ensure no soft tissue is trapped while placing and advancing the stemless implant move the arm into adduction, slight external rotation, and extension to keep the impaction axis unobstructed, and use retractors to keep tissue clear impact the stemless implant until the bottom of the Humeral Handle Adapter covers the laser line on the Humeral Guide optional secondary manual impaction may be performed with the Stemless Impactor Tip connected directly to the Impactor Handle, and the source recommends leaving the implant slightly proud during this secondary manual impaction to facilitate humeral head assembly remove the Humeral Guide by loosening the Pin Clamp nuts and removing the Humeral Guide Pins with the power tool in reverse estimate humeral head size from the resected head and use the Humeral Head Inserter with INHANCE humeral head trials to assess range of motion and final head size assemble the final humeral head implant and offset taper adapter per the INHANCE technique, use the Humeral Head Inserter with the single-use protective sleeve, and align the offset taper adapter with the stemless implant use the INHANCE INTACT retractors to keep tissue clear during final head insertion impact the humeral head with the INHANCE Concave Impactor Tip and Impactor Handle until the construct sits flush against the resection humeral head impaction may also be performed with the INHANCE Concave Impactor Tip and the Offset Glenoid Guide Technical specifications For the INHANCE INTACT anatomic stemless approach, the humeral stemless anchor is intended for cementless use The anatomic glenoid and anatomic hybrid glenoid are intended for cemented use only The resection guide approximates a 135° humeral resection angle when the Silhouette Resection Guide Pin is aligned with the humeral shaft anteriorly The resection version handle is set at 30° of retroversion and may be aligned with the forearm or manually set to an alternate version The Stepped Glenoid Drill has a stepped diameter of 3.2 mm distally to 4.0 mm proximally The Humeral Drill has a 4.0 mm drill diameter with a 3.2 mm trocar tip The Humeral Guide Pin is 4.0 x 130 The humeral sizers and humeral reamers are available in XS 28, S 32, M 36, L 40, and XL 44 The glenoid reamers are available in XS, S, M, L, and XL The anatomic glenoid trials are available in XS, S, M, L, and XL The humeral head trial options listed in the source are 38 x 13.5, 40 x 13.75, 40 x 15.75, 42 x 14.5, 42 x 16.5, 44 x 15.25, 44 x 17.25, 46 x 16, 46 x 18.5, 48.5 x 17, 48.5 x 19.5, 51 x 18, 51 x 20.5, 54 x 19, 54 x 22, 57 x 20.5, and 57 x 24 Dedicated INTACT instrumentation described in the source includes left and right resection guides, a resection guide extender, an offset glenoid guide, a drill cannula, a glenoid drive shaft, a humeral guide, a humeral handle, a humeral handle adapter, a humeral blazer adapter, a stemless impactor tip, a humeral head insertion tool, an Inferior Subscap Retractor, Anterior Subscap Retractors, and Posterior Cuff Retractors The source also lists an INTACT Bearing and Sleeve Kit, including a sterile single-use humeral reamer bearing and a single-use humeral head protector sleeve After preparation of a specific glenoid anchorage size group, the source cautions against upsizing or downsizing between the prepared groups XS/S/M and L/XL