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Total Shoulder Arthroplasty for Arthritis

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Radiographic templating


Execute surgical walkthrough

  • describe the steps of the procedure verbally prior to the start of the case


Description of potential complications and steps to avoid them


Room Preparation


Surgical Instrumentation

  • TSA system


Room setup and Equipment

  • standard operating table in the beach chair position
  • fluoroscopy


Patient Positioning

  • rotate the table 90 degrees so that the operative shoulder is opposite the anesthesia team

Deltopectoral Incision


Identify and mark the deltopectoral groove

  • make a 10-15 cm incision following the line of the deltopectoral groove
  • in obese patients, this may be difficult to palpate; the incision starts at the coracoid process, which is usually more easily palpable


Identify the deltopectoral fascia

  • the interval can be found by identifying the cephalic vein


Develop the interval

  • retract the cephalic vein medially or laterally
  • retract the deltoid laterally and the pectoralis medially
  • identify and protect the axillary and the musculocutaneous nerves

Subscapularis Takedown


Start the osteotomy (for Lesser Tuberosity Osteotomy)

  • use a 2 inch curved osteotome to make a 0.5 to 1 cm thick osteotomy
  • start by placing the osteotome at the base of the bicipital groove
  • palpate the most anterior aspect of the tuberosity with the index finger of the other hand
  • once the osteotomy is complete, place a straight osteotome in the osteotomy site and rotate about the long axis to free the osteotomy fragment from the soft tissue attachments


Deliver the fragment (for Lesser Tuberosity Osteotomy)

  • place a large Cobb elevator in the osteotomy site to lever the fragment anteriorly


Prepare the lesser tuberosity (for Lesser Tuberosity Osteotomy)

  • place 3 nonabsorbable sutures around the lesser tuberosity fragment
  • sutures should be placed in the bone subscapularis junction
  • externally rotate the arm to expose the most inferior portion of the subscapularis muscle
  • incise the muscle belly superficially in line with the fibers about 1 cm superior to the most inferior border


Develop interval (for Lesser Tuberosity Osteotomy)

  • use a blunt elevator to dissect the interval between the subscapularis and the underlying capsule
  • once the interval is developed use a scalpel and pass it laterally so that it exits inferior to the fragment
  • continue this from inferior to superior to release the subscapularis and the lesser tuberosity from the underlying anterior and inferior capsule


Alternative Approach: Transtendinous release.

  • mark the location of the biceps tendon
  • perform a tenotomy of the subscapularis approximately 1 cm away from the biceps tendon
  • go through the capsule and the subscapularis simultaneously
  • place 1 suture superiorly
  • place 1 suture inferiorly

Humeral Neck Cut and Humeral Preparation


Resect the humeral head

  • remove the humeral head with a saw at or near the anatomic neck
  • leave a small amount of bone medial to the supraspinatus tendon


Ream the humeral canal

  • ream the humeral canal with sequentially larger reamers until light purchase is obtained
  • use a boxed osteotome that is the same size of the final reamer and pass into the humerus
  • cut the footprint of the humeral implant


Sequential broaching and trial stem placement

  • place a broach that corresponds to the size of the box osteotome and final canal reamer to the appropriate depth


Place collar (optional depending on prosthesis)

  • screw a collar into the broach that creates a 135 degree neck shaft angle
  • place a calcar over the reamer
  • if the reamer is nearly parallel to the osteotomy surface, it is used to plane the surface to 135 degrees

Glenoid Prepatation and Prosthesis Placement


Place retractors

  • place a fukuda ring retractor in the joint and retract the humerus posteriorly
  • place a double pronged bankhart retractor on the scapular neck anteriorly between the anterior capsule and the subscapularis
  • place a blunt hohmann retractor along the anteriorinferior portion of the scapular neck
  • this Is to retract and protect the axillary nerve


Remove the capsule

  • excise the anterior and inferior capsule
  • release the posterior capsule unless the preoperative humeral subluxation is greater than 25%


Remove the labrum

  • excise the labrum circumferentially


Size the glenoid

  • size the glenoid with a sizing disk


Drill holes in the glenoid

  • drill a pilot hole in the center of the glenoid
  • use special glenoid reamers to ream concentrically around the center pilot hole
  • create the anchoring holes for the glenoid
  • drill the center hole for the larger fluted central peg
  • drill the holes for the three peripheral pegs


Place a trial glenoid component

  • check that the component is seated well and stable


Place bone cement

  • irrigate and dry the holes
  • place bone cement into the three peripheral holes


Place the final component

  • impact the glenoid component into position
  • hold the glenoid component into position with digital pressure until the cement hardens

Humeral Stem Placement


Redeliver the humerus into the wound


Place final humeral stem


Pass a nonabsorbable suture around the neck of the prosthesis


Humeral Head Trialing and Placement


Place a trial humeral head over the collar


Verify components


Remove trial head


Place the final head component

  • rotate into the offset position that gives the most symmetrical coverage of the humeral metaphysis and lock the collar into the broach


Impact the head implant onto the humeral stem.


Subscapularis Repair and Wound Closure


Pass sutures for repair (for Lesser Tuberosity Osteotomy)

  • pass the sutures that were previously placed in a mattress configuration through the subscapularis tendon from deep to superficial at the bone tendon junction
  • clamp but do not tie the sutures
  • the deep limbs of the sutures that have already been passed around the lesser tuberosity are passed through the cancellous bone of the osteotomy bed as far laterally as possible deep to the bicipital groove and out of the lateral cortex of the humerus
  • use a large, cutting free needle
  • use a fresh needle for each pass


Tie sutures (for Lesser Tuberosity Osteotomy)

  • tie sutures beginning with the tuberosity to shaft reapproximation then the tuberosity to tuberosity closure using the previously placed suture limbs
  • pull the clamps on these sutures laterally to hold the lesser tuberosity in a reduced position
  • close the rotator interval with 1 mm nonabsorbable suture
  • tie the three interfragmentary sutures next
  • tie the sutures from the anchors


Transtendinous repair

  • place 3 mason allon sutures with non absorbable suture for tendinous repair
  • tie the sutures
  • test external rotation and the integrity of the repair



  • copiously irrigate wound


Deep closure

  • use 0-vicryl for fascia


Superficial closure

  • use 2-0 vicryl for subcutaneous tissue
  • use 3-0 monocryl for skin



  • place in sling
Postoperative Patient Care
Private Note

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