Total Shoulder

Arthroplasty—Indications, Technique, and Results

Eric T. Ricchetti, MD,* and Gerald R. Williams Jr, MD†

More patients are becoming candidates for total shoulder arthroplasty (TSA), with an
increase in frequency of the procedure paralleling the increase in other total joint arthro-
plasties. TSA is indicated in the treatment of advanced primary and secondary arthritic
conditions of the shoulder after failure of nonoperative management. Studies have shown
survivorship rates comparable with other joint arthroplasties at short-, mid-, and long-term
follow-up, and substantial improvements in pain relief, patient satisfaction, and objective
measures, such as range of motion, strength, and shoulder outcome scores. Complications
can occur, however, and technical problems, such as component placement and fixation,
are prominent features among unsatisfactory arthroplasties. Therefore, appropriate surgi-
cal technique is essential in minimizing complications and maximizing functional outcomes
after shoulder arthroplasty. The purpose of this article is to review the indications, surgical
technique, and results of TSA. Careful patient selection, preoperative planning, surgical
technique, and postoperative management remain essential to a successful patient out-
come after TSA.
Oper Tech Orthop 21:28-38 © 2011 Elsevier Inc. All rights reserved.

KEYWORDS indications, results, surgical technique, total shoulder arthroplasty

M ore patients are becoming candidates for total shoulder

arthroplasty (TSA), with an increase in frequency of the
procedure paralleling the increase in other total joint arthro-
plasties.1,2 In the United States, a 40% increase in the annual
rate of TSA occurred from 1990 to 1992 to 1996 to 2002,
increasing from 5000 to 7000 TSAs per year during each
respective period.1,3-11 Adams et al12 showed a steady in-
crease in the age- and sex-adjusted annual operative inci-
*Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH.
†Department of Orthopaedic Surgery, Rothman Institute at Thomas Jeffer-
son University, Philadelphia, PA.
Dr Williams has the following conflict of interests to disclose: royalties from
a company or supplier (DePuy); speakers bureau/paid presentations
for a company or supplier (DePuy, Mitek); paid consultant or employee
for a company or supplier (Tornier); stock or stock options in a company
or supplier (in vivo Therapeutics); research or institutional support from
a company or supplier (Tornier); royalties, financial or material support
from publishers (Journal of Shoulder and Elbow Surgery, Wolters Klu-
wer Health—Lippincott Williams and Wilkins); medical/orthopedic
publications editorial/governing board (operative Techniques in ortho-
pedics, Techniques in Shoulder and Elbow Surgery); board member/
committee appointments for a society (American Shoulder and Elbow
surgeons, Pennsylvania Orthopaedic Society).
Address reprint requests to Gerald R. Williams Jr, MD, Department of Or-
thopaedic Surgery, Rothman Institute at Thomas Jefferson University,
925 Chestnut Street, 5th Fl, Philadelphia, PA 19107. E-mail: gerald.
williams@rothmaninstitute.com
dence rate of shoulder arthroplasty for every 5-year period
from 1976 to 1980 (1.4 per 100,000 person-years) to 1996-
2000 (10.1 per 100,000 person-years). More recently, a
319% increase in procedure rate has been reported for TSA
during the period 1993-2007 in the United States, increasing
to almost 25,000 TSAs in 2007 and corresponding to annual
growth in the procedure rate of 10.6%.2
TSA is indicated in the treatment of primary and secondary
arthritic conditions of the shoulder, with survivorship rates
comparable to other joint arthroplasties at short-, mid-, and
long-term follow-up, and substantial improvements in objec-
tive measures, such as range of motion (ROM), strength, and
shoulder outcome scores.1,11,13-18 Rates of complete to near-
complete pain relief have ranged from 68% to 91% among
patients, with ⬎90% reported patient satisfaction when stan-
dardized measures, such as the Constant-Murley, American
Shoulder and Elbow surgeons, and UCLA scores, and the
simple Shoulder Test, are used.13,15,19
As use of patient-based outcomes becomes a more integral
part of evaluating the success of shoulder arthroplasty, a bet-
ter understanding of the variables involved in patient satis-
faction is as important as traditional measures used to define
success or failure. Franta et al20 recently identified traits com-
mon to a series of 282 shoulders in patients referred for
dissatisfaction with the result of their shoulder arthroplasty.

28 1048-6666/11/$-see front matter © 2011 Elsevier Inc. All rights reserved.

doi:10.1053/j.oto.2010.11.001
TSA: indications, technique, and results
Patients were found to present with poor function and pri-
mary subjective complaints of pain (85%) and stiffness
(43%), with the most common objective traits, including
component malalignment (67%), stiffness (66%), compo-
nent malposition (65%), glenoid loosening (33%), polyeth-
ylene wear (30%), and glenoid erosion (28%).20 The authors
concluded that technical problems, such as component
placement and fixation, are prominent features among unsat-
isfactory arthroplasties, therefore, appropriate surgical tech-
nique is essential in minimizing complications and maximiz-
ing functional outcomes after shoulder arthroplasty.
The purpose of this article is to review the indications,
surgical technique, and results of TSA. Although future ad-
vances in implant design, glenoid fixation, and bearing
surfaces will likely lead to improved implant longevity; ap-
propriate patient selection, surgical technique, and postop-
erative rehabilitation will remain essential to a successful pa-
tient outcome following TSA.
Indications
The indications for anatomic TSA include advanced, painful
glenohumeral arthritis that has become unresponsive to non-
operative treatment, such as activity modification, nonsteroi-
dal anti-inflammatory drugs, and intra-articular injections of
corticosteroid or viscosupplementation. In addition to pain
complaints, symptoms include shoulder dysfunction and
loss of motion that have become unacceptable to the pa-
tient.19 The etiology of glenohumeral arthritis in surgical can-
didates most commonly is from osteoarthritis, avascular ne-
crosis with glenoid involvement (stage V), inflammatory
arthropathies (rheumatoid arthritis, ankylosing spondylitis,
psoriatic arthritis, etc.), posttraumatic arthritis, arthritis of
dislocation, and post-surgical arthritis (ie, post-stabilization).
Less common causes include crystalline diseases (eg, gout,
calcium pyrophosphate dehydrate deposition disease) dialy-
sis arthropathy, hemophilia arthropathy, and postinfectious
arthritis.19
The only absolute contraindication to TSA is active infec-
tion. A previous history of infection, particularly if recent,
may be a relative contraindication to shoulder arthroplasty.
Such patients should be approached cautiously, and an ap-
propriate work-up to confirm that the infection has been
eradicated (ie, normal erythrocyte sedimentation rate, nor-
mal C-reactive protein, negative joint cultures) should be
performed preoperatively. Other relative contraindications
include concomitant rotator cuff and deltoid dysfunction,
neuropathic arthropathy (Charcot arthropathy), severe bra-
chial plexopathy, intractable shoulder instability, and pa-
tients whose medical comorbidities make them too great a
risk for surgery. Although patients with severe rotator cuff
dysfunction as the result of a massive, irreparable rotator cuff
tear or cuff tear arthropathy are candidates for shoulder ar-
throplasty, anatomic TSA is associated with a high rate of
failure in these patients, and the reverse shoulder prosthesis
has become the implant of choice in this situation.21-26 Patient
age should also be taken into account when considering TSA.
Survival rates have traditionally been reported to be lower
29
Figure 1 Beach-chair position with the arm suspended for prepping.
after TSA in patients who are 50 years of age and younger.17,19
Therefore, TSA is often only considered in patients older than
50, with hemiarthroplasty recommended in younger pa-
tients. These age cutoffs are only general guidelines, however,
and other factors, such as activity level, degree of glenoid
wear, and general medical condition, should be taken into
account when making recommendations on an individual-
ized basis.19
Surgical Technique
Positioning and Draping
Patients are typically placed under general anesthesia for
TSA, and this is often coupled with regional anesthesia, such
as an interscalene nerve block or catheter that can provide
extended postoperative pain control.19 Once intubated, the
patient is placed in a beach-chair position, with the back at
approximately 30° relative to the horizontal and the opera-
tive arm and shoulder completely off the edge of the table to
allow full shoulder ROM (Fig. 1). Adequate shoulder adduc-
tion and extension is important to confirm before draping, as
this position is beneficial during humeral exposure and prep-
aration and can be blocked by not bringing the arm far
enough off the table. Once the patient is well positioned,
passive shoulder ROM, particularly forward flexion and ex-
ternal rotation at the side, should be noted.
After prepping and draping, a deltopectoral skin incision is
marked out. The incision should extend from the coracoid
process proximally to the level of the deltoid insertion dis-
tally, measuring approximately 10-15 cm in length (Fig. 2).
Avoid making the incision too lateral, in the substance of the
deltoid muscle. The interval is typically more medial than
may be appreciated. Once the skin incision has been drawn,
the arm can be supported during the procedure in several
different ways, including an assistant, a padded Mayo stand,
or a mechanical arm-holding device.19 We prefer a mechan-
ical arm-holding device, such as a McConnell (McConnell
Orthopaedic Manufacturing company, Greenville, TX) or
30
Figure 2 Deltopectoral incision marked out.
Spider limb positioner (Tenet medical Engineering, Calgary,
Canada), as it allows the arm to be placed and held in the
optimal position (Fig. 3).
Surgical Approach
We prefer a standard deltopectoral approach for most pri-
mary and revision TSA. For patients undergoing revision
surgery, the previous incision is usually adequate for use. A
superior approach has also been reported as a technique to
limit subscapularis takedown.27,28 We have occasionally used
this approach in special circumstances, such as in patients
Figure 3 Fully draped out shoulder with extremity held in mechan-
ical arm-holding device.
E.T. Ricchetti and G.R. Williams Jr
Figure 4 Deltopectoral interval exposed with the deltoid laterally
(left), pectoralis major medially (right), and the fat stripe overlying
the cephalic vein pointed out.
with known lymphedema in the operative extremity, when
concern for avoiding the cephalic vein is high.
The deltopectoral skin incision is made and the subcuta-
neous tissues split with a knife or electrocautery down to the
level of the deltopectoral interval. The location of the cephalic
vein is typically identified by a fat stripe overlying the vessel
(Fig. 4). As a major draining vessel of the arm, the cephalic
vein should be preserved and can be taken medially or later-
ally when developing the interval. Lateral retraction is gener-
ally preferred because of the many cephalic branches that
come in on the lateral side of the vein. Medial retraction
places less tension on the vein, but sacrifices the numerous
feeding vessels.19
Deep to the deltopectoral interval, the underlying clavi-
pectoral fascia and conjoined tendon must be exposed (Fig.
5). We prefer the use of 2 Cobb elevators to open this space;
a larger elevator to retract the deltoid muscle laterally, and a
smaller elevator to sweep medially to expose the clavipectoral
Figure 5 Deltoid retracted laterally (left retractor) and the pectoralis
major retracted medially (right retractor) to expose the conjoined
tendon with the clavipectoral fascia overlying it.
TSA: indications, technique, and results 31

nerves by extreme arm positioning, excessive retraction, or

direct injury.30
With the conjoint tendon retracted, the insertion of the
subscapularis tendon on the lesser tuberosity is exposed. The
tendon, as well as the remaining rotator cuff, should be in-
spected for evidence of tears, although rotator cuff tears are
rare in association with osteoarthritis (5%-10%).19 The ante-
rior humeral circumflex artery and veins are next exposed
and isolated as a group. External rotation can help with iden-
tification of the vessels, which run along the inferior border of
the subscapularis tendon (Fig. 7). The vessels should be co-
agulated or tied off to prevent excessive bleeding during take
down of the subscapularis tendon and anterior joint capsule.
The bicipital groove and long head of the biceps tendon are
next identified just lateral to the lesser tuberosity. The biceps
tendon is most easily found distally, deep to the insertion of
Figure 6 Mobilization of the conjoined tendon (arrow) with the use
of a Cobb elevator. the pectoralis major tendon. The biceps tendon sheath is
opened up from distal to proximal, following the tendon into
the rotator interval and to its origin at the superior glenoid.
fascia and conjoint tendon. The small Cobb elevator can then We routinely perform a biceps tenodesis to the upper border
be used laterally to open up the subdeltoid space. It is first of the pectoralis major tendon. After tenodesis, the proximal
placed distally, along the surface of the lateral humerus just tendon can be cut at its origin and removed. Any remaining
proximal to the deltoid insertion, then exchanged for a blunt synovium or soft tissue of the bicipital sheath should be re-
Hohmann retractor. A small lap sponge can be packed into moved and the rotator interval opened up to expose the floor
this opening, distal and deep to the Hohmann retractor, for of the bicipital groove and the lesser tuberosity.
hemostasis and to further open up the subdeltoid space. The subscapularis tendon is released to expose the gleno-
Once this distal recess has been defined, a Cobb elevator is humeral joint. The tendon may be taken down intratendi-
used to open the subdeltoid space more proximally and enter
into the subacromial space. All adhesions should be freed up
anteriorly and posteriorly to maximize exposure of the prox-
imal humerus during the procedure. A blunt Hohmann re-
tractor is placed deep to the coracoacromial ligament in the
subacromial space to increase exposure of the superior part of
the incision in the subsequent steps.
A self-retaining retractor is next placed deep to the deltoid
and pectoralis major muscles to maintain exposure of the
clavipectoral fascia. The clavipectoral fascia is then incised
just lateral to the conjoined tendon and retracted to expose
the subscapularis tendon. This layer can be released medially
by the use of a Cobb elevator to release any adhesions or
fascial bands between the conjoint tendon and subscapularis
(Fig. 6). If additional exposure of this layer is needed, the
upper border of the pectoralis major tendon can be released
(approximately 1-1.5 cm). Proximally, the incision should be
taken up to, but not through, the coracoacromial ligament
because of its role in superior restraint of the humeral head.
The axillary and musculocutaneous nerves should be pal-
pated deep to the conjoint tendon. External rotation of the
arm improves palpation of the axillary nerve, which can be
felt as it passes from anteromedial to posterolateral under-
neath the subscapularis tendon and through the quadrilateral
space. The musculocutaneous nerve is felt as it enters the
undersurface of the conjoint tendon, but often is not palpable
because of a more distal entry point (5-8 cm distal to the
coracoid process).29 If the nerve can be felt more proximally,
excessive retraction on the conjoint tendon should be mon-
itored closely.19 Care must be taken throughout the proce- Figure 7 Anterior humeral circumflex vessels pointed out along the
dure to avoid injury to the axillary and musculocutaneous inferior border of the subscapularis tendon.
32 E.T. Ricchetti and G.R. Williams Jr

Figure 8 Wide, curved osteotome placed at base of bicipital groove to make lesser tuberosity osteotomy (A). A Cobb
elevator can be used to help free up the osteotomy piece completely (B), before the piece is controlled by passing 3
heavy, nonabsorbable sutures through the tendon-bone junction (C).

nously (approximately 2 cm medial to the lesser tuberosity), capsule to allow a complete capsular release at the inferior
at its origin on the lesser tuberosity, or by retaining its bony aspect of the anatomic neck and around any inferior humeral
insertion with a lesser tuberosity osteotomy.31 When the sub- osteophyte. The joint capsule should be released past the
scapularis tendon is completely intact, we prefer a lesser tu- 6-o’clock position, as this maneuver not only provides im-
berosity osteotomy in most cases of both primary and revi- proved exposure of the humeral head following dislocation,
sion surgery, as evidence suggests that bone-to-bone healing but also improved exposure of the glenoid in subsequent
leads to improved postoperative function.31-33 Starting at the steps.19 The upper 1 cm of the latissimus dorsi insertion may
base of the bicipital groove and using a wide (1 inch) curved be released with this maneuver. The humeral head can now
osteotome, an approximately 5-mm thick osteotomy is taken. be dislocated by simultaneous adduction, external rotation,
Any remaining soft-tissue attachments of the osteotomy and and extension of the arm. This delivers the head for prepara-
subscapularis tendon to the rotator interval, including the tion and implant insertion (Fig. 9). Avoid excessive external
coracohumeral ligament, are released. The osteotomy piece is rotation while dislocating, because this motion may cause
immediately controlled by passing 3 heavy, nonabsorbable spiral fractures in the humeral shaft of patients with os-
sutures in a simple fashion through the tendon-bone junc- teopenic or osteoporotic bone.34 Adduction and extension
tion, from superior to inferior (Fig. 8A-C). We prefer a 1-mm are safer maneuvers.
Dacron suture, and the sutures will be used for the osteotomy
repair at the end of the case. Initial Humeral Head Preparation
We routinely perform an anterior capsulectomy as part of After humeral head dislocation and exposure, osteophytes
our exposure and define the plane between the subscapularis are removed from the head to identify the true anatomic
and anterior joint capsule at this point. The muscular, infe- neck. Finding the capsular insertion can help identify the
rior insertion of the subscapularis is incised in line with its
muscle fibers at approximately the level of the inferior edge of
the lesser tuberosity osteotomy, and a freer elevator is used to
enter the plane between the muscle and joint capsule. Replac-
ing the freer with progressively larger Cobb elevators allows
further development of this plane in a medial-lateral and
superior-inferior direction. The lesser tuberosity osteotomy
and attached subscapularis are then peeled away from the
anterior and inferior joint capsule, starting laterally while
pulling up on the osteotomy anteriorly. As the plane is de-
veloped medially, care must be taken not to button hole
through the subscapularis muscle belly. Once the subscapu-
laris has been adequately freed from the joint capsule, it can
be placed deep to the self-retaining retractor, leaving the
anterior capsule behind to be released.
The anterior joint capsule is taken down from its insertion
on the anatomic neck of the humerus, starting proximally at
the rotator interval. As the capsule is released inferiorly, care
should be taken to protect the axillary nerve. A blunt Hohm-
ann retractor can be placed between the inferior capsule and
the remaining, inferior muscular insertion of the subscapu-
laris to keep the nerve protected. Flexion and external rota-
tion of the shoulder will increase exposure of the inferior Figure 9 Exposure of the humeral head following dislocation.
TSA: indications, technique, and results
Figure 10 The humeral head being cut with an oscillating saw (A), with the cut head removed (B), and the remaining
humeral neck cut surface shown (C).
correct location and depth of the anatomic neck. The inferior
humeral osteophyte is usually the most prominent, but os-
teophytes can develop circumferentially and should all be
removed. Overaggressive resection can violate the cortical
margin of the proximal humerus and potentially compromise
fixation of the humeral implant or lead to tuberosity fracture.
After removing the osteophyte, we prefer the use of an exter-
nal 135° cutting guide to mark the humeral neck cut. In most
cases, use of a fixed neck-shaft angle in combination with
offset humeral heads allows for recreation of the normal
proximal humeral relationships.19 The guide should sit on
the cut surface of the lesser tuberosity osteotomy, in line with
the supraspinatus insertion proximally and the humeral shaft
distally, and along the anatomic neck anteriorly. The hu-
meral neck cut is made to recreate the natural version of the
humeral head (approximately 30° retroversion). The saw
should exit proximal to the posterior rotator cuff reflection.
The ideal neck cut is just proximal to the rotator cuff inser-
tion superiorly and posteriorly (within 5 mm), without vio-
lating these insertions (Fig. 10A-C).19 The cut humeral sur-
face is next sized with trial humeral heads. Trial humeral
head sizing will allow appropriate sizing of the glenoid com-
ponent. Avoid choosing too large a head and overstuffing the
joint.11,35 We prefer completing the remaining humeral prep-
aration following glenoid exposure and implantation.
Glenoid Exposure and Preparation
Adequate glenoid exposure is typically the most difficult part
of TSA. It can be particularly challenging in larger patients,
such as muscular men with a large deltoid muscle. Appropri-
ate muscle paralysis, an adequate humeral neck cut, proper
arm positioning and retractor placement, and adequate soft
tissue releases all contribute to optimal glenoid exposure.19
As noted previously, releases on the humeral side are essen-
tial in glenoid exposure, as they mobilize the proximal hu-
merus for easier retraction away from the glenoid.
After the humeral neck cut is performed, the arm is ab-
ducted, externally rotated, and extended to relax the poste-
rior and superior joint capsule. In this position, the cut sur-
face of the humerus should line up approximately parallel to
the glenoid surface. A Fukuda retractor is placed on the pos-
tero-inferior glenoid rim to retract the humerus posteriorly.
Before the anterior glenoid retractors are placed, the anterior
33
joint capsule is freed up for excision. Small and large Cobb
elevators are used to completely release the anterior surface of
the capsule down to the level of the inferior glenoid. Two
blunt Hohmann retractors can then be placed anteriorly and
inferiorly, respectively, to protect the axillary nerve before
capsulectomy. The anterior capsule is excised down to the
level of the glenoid rim, and one should take care to cut away
from the axillary nerve.
A reverse, double-pronged Bankart retractor is then placed
along the anterior rim of the glenoid, followed by placement
of a single-pronged Bankart retractor along the superior rim
of the glenoid, just posterior to the biceps origin (Fig. 11).
These 2 retractors in combination with the Fukuda retractor
are usually sufficient for adequate glenoid exposure, but oc-
casionally a blunt Hohmann can be placed on the anteroin-
ferior or posteroinferior glenoid for additional retraction. The
labrum is next circumferentially removed to expose the bony
rim of the glenoid, including removal of any remnant of the
long head of the biceps tendon. Joint capsule can be released
from the inferior glenoid rim as needed for additional expo-
sure, again taking care to protect the axillary nerve.
With the bony rim completely exposed, the glenoid can be
sized and marked at its center point. We prefer to mark the
center point with a sizer guide pin system that allows for
Figure 11 Exposure of the glenoid, with anterior, posterior, and
superior retractors in place.
34
Figure 12 Guide pin placed in center point of glenoid to allow for
cannulated drilling and reaming.
cannulated reaming of the glenoid (Fig. 12). This cannulated
system maintains alignment of the glenoid centering drills
and reamers to avoid drilling and reaming in different planes.
The center hole drill is used first, followed by the appropri-
ately sized glenoid reamer. Lower-profile reamers are now
available to allow complete seating of the reamer on the gle-
noid without the need to remove the Fukuda retractor. Neu-
tral version with concentric seating should be recreated by
reaming down the high side of the glenoid (typically anterior
in osteoarthritis). Never start the reamer when in contact
with the glenoid, because of the risk of glenoid fracture.
Reaming should be performed in a controlled manner to
avoid violating subchondral bone and removing too much
glenoid bone stock. Reaming is complete when the reamer
sits flush on the glenoid surface.36-38 We prefer an anchor peg
glenoid component design in most cases. The center and 3
peripheral peg holes are drilled with their respective guides
following reaming (Fig. 13). The glenoid should be checked
after this step for penetration of any of the peg holes through
the deep cortical bone. If the cortex is violated in any hole,
Figure 13 Glenoid following drilling of the center and peripheral peg
holes.
E.T. Ricchetti and G.R. Williams Jr
Figure 14 Glenoid component in place following cementing.
cancellous bone graft from the cut humeral head can be used
to fill the defect before cementing. Before final component
implantation, a trial glenoid should be placed to confirm
correct sizing and appropriate seating of the implant. The
glenoid is then irrigated, dried, and the peg holes packed for
hemostasis before cementing. The peripheral peg holes are
sequentially cemented. The cement should be pressurized if
deep cortical bone has not been violated.39 If there has been a
cortical breach, the peg hole should be filled with nonpres-
surized cement following bone grafting. We typically do not
cement the central peg hole, as the center peg is designed for
an immediate interference fit.40 The glenoid component is
impacted in place and complete seating of the implant should
be confirmed, with excess cement removed (Fig. 14). The
glenoid retractors are taken out once the cement has hard-
ened, with care not to dislodge the glenoid component dur-
ing instrument removal.
Final Humeral Head
Preparation and Component Placement
The arm is brought back into adduction, external rotation,
and extension for exposure of the humeral head. An entry
reamer is used to enter the intramedullary canal from the cut
surface of the humerus. Typically the entry point is slightly
lateral, approximately 1-1.5 cm posterior to the bicipital
groove. The canal is then opened up with sequentially larger
reamers until cortical contact is achieved. Each reamer
should be aimed centrally down the canal, with care not to
ream in a varus or valgus position. A box osteotome is next
used to set the version of the stem in the humeral canal,
followed by placement of the appropriately sized broach. A
calcar reamer can be used to fine tune the cut humeral sur-
face, reaming away any remnant bone so the cut is flush to the
broach and flush with the rotator cuff insertion. Trial heads
are placed to assess for appropriate coverage of the cut hu-
meral head, including diameter, head height, and offset.19
The head component should be similar in size to the resected
native head and should be well centered on the cut surface of
the proximal humerus, with coverage of the cut surface max-
TSA: indications, technique, and results
imized and overhang of the component minimized. When an
appropriate sized trial is found, the shoulder is reduced and
checked for glenohumeral joint laxity and soft tissue tension-
ing. An ideal prosthesis provides a stable joint with appropri-
ate soft-tissue tension. With the shoulder in neutral position,
the prosthesis should permit approximately 50%-100% pos-
terior translation of the humeral head when a posterior force
is applied, with spontaneous reduction of the head when the
force is removed.19
Once the properly sized humeral head is selected, the hu-
meral trial is removed and the final humeral prosthesis is
assembled, making sure to place the humeral head in the
correct position of offset on the stem. Before impacting the
prosthesis, we wrap a heavy, nonabsorbable suture around
the neck of the implant for use in the lesser tuberosity osteot-
omy repair. We again prefer a 1-mm Dacron suture. The
prosthesis is then impacted into the humeral canal until it
is fully seated (Fig. 15). In most instances, we prefer the
use of an uncemented, press-fit stem. However, patients
with poor bone quality and a large diaphysis-to-metaphy-
sis diameter ratio are at increased risk of fracture with
press-fit implantation, and should have the humeral pros-
thesis cemented into place.34,35 Once the final components
are in place and the glenohumeral joint has been reduced,
the incision site should be thoroughly irrigated before soft
tissue closure.
Wound Closure
For repair of the lesser tuberosity osteotomy, the arm is po-
sitioned in slight abduction, flexion, and neutral rotation. A
self-retaining retractor is placed deep to the deltoid laterally
and conjoint tendon medially to expose the subscapularis
and lesser tuberosity. The heavy suture passed around the
neck of the prosthesis is first passed as a horizontal mattress
Figure 15 Humeral prosthesis in place following impaction.
35
Figure 16 Heavy suture passed around the neck of the humeral
prosthesis is first passed through the subscapularis tendon as a
horizontal mattress (arrow), medial to the 3 stitches previously
placed, for repair of the lesser tuberosity osteotomy.
just medial to the 3 stitches previously placed at the tendon-
bone junction (Fig. 16). With the use of a large cutting free
needle, the remaining 3 sutures are then passed through bone
as simple stitches. While moving from a superior to inferior
direction, the deep limb of each stitch is passed into the
cancellous bone at the lateral edge of the lesser tuberosity
osteotomy bed on the proximal humerus. Each deep limb is
then brought out through the cortical bone of the lateral
bicipital groove. One final, heavy, nonabsorbable suture is
passed as a figure-of-8 stitch at the corner of the rotator
interval, just proximal to the superior edge of the osteotomy.
This stitch is tied down first to set the correct position of the
lesser tuberosity osteotomy piece within the osteotomy bed.
The 3 simple sutures passed through the lateral bicipital
groove are then tied. The middle of these stitches is typically
tied first to reduce the central portion of the osteotomy down
to bone. After all 3 stitches are tied, the arm is slightly exter-
nally rotated and the medial horizontal mattress stitch is tied
last, preventing lift-off of the medial edge of the osteotomy
(Fig. 17).
Any remaining retractors and sponges are removed, and
the axillary nerve is palpated a final time to confirm that it is
intact. Passive ROM is checked in forward flexion and exter-
nal rotation at the side to determine the limits of passive
motion postoperatively. We typically start with a postopera-
tive ROM protocol of 130-140° of passive supine forward
flexion and 30-40° of supine passive external rotation at the
side. The incision is then irrigated a final time and a hemovac
drain is placed in the subdeltoid space and brought out
through the skin distally and laterally. We do not routinely
close the deltopectoral interval. The subcutaneous layer and
skin are closed and the wound is sterilely dressed. The arm is
placed in a standard sling. Formal radiographs of the shoul-
der are obtained once the patient has awoken and been taken
to the recovery room (Fig. 18).
36 E.T. Ricchetti and G.R. Williams Jr

0.025), with 8.1% of hemiarthroplasties requiring conver-

sion to TSA because of pain. Bryant et al51 performed a more
stringent meta-analysis that included only randomized trials
comparing TSA and hemiarthroplasty with a minimum
2-year follow-up. Four studies met inclusion criteria, totaling
112 patients (mean age, 68 years). A significant effect was
found for the function component of the UCLA score (P ⬍
0.001) and in the overall change in forward elevation (P ⫽
0.008), both in favor of TSA. A significant difference in pain
also favored TSA (P ⬍ 0.0001), but the large degree of study
variability on this measure decreased the authors’ confidence
in this finding. Interestingly, 2 of the 4 studies included in
this meta-analysis were presented as abstracts, but never for-
mally published. Of the 2 published studies,44,52 Gartsman et
al44 (n ⫽ 51) reported no significant differences in shoulder
scores, but significantly less pain (P ⫽ 0.002) and greater
Figure 17 Complete lesser tuberosity osteotomy repair with 1 rotator
interval stitch, 3 simple stitches over the osteotomy, and 1 horizon- internal rotation (P ⫽ 0.003) with TSA. Unsatisfactory results
tal mattress stitch to prevent lift off the medial edge of the osteot- were reported by 1 patient with TSA and 5 patients with
omy. hemiarthroplasty, with 3 of the 5 ultimately being revised to
TSA. In the second published study, Lo et al52 (n ⫽ 41) found
no significant differences between TSA and hemiarthroplasty
in any outcome measures at 1 or 2 years postoperatively.
Results Three hemiarthroplasty patients ultimately underwent revi-
In properly selected patients, TSA for the treatment of gleno- sion to TSA.
humeral arthritis provides significant improvements in pain Mean complication rates after TSA have ranged from 10%
relief and function, with a high rate of patient satisfaction by to 16% in the past,1,11,53 and most commonly have included
standardized measures.1,11,13-18,41-46 Survivorship rates vary prosthetic loosening on either the glenoid or humeral side,
across studies and with age and activity level, but generally glenohumeral instability, periprosthetic fracture, rotator cuff
have been reported as 95%-98% at 5 years, 93%-97% at 10 tears, infection, nerve injury, and deltoid muscle dysfunc-
years, 84%-88% at 15 years, and 80%-85% at 20 tion. Data are available to suggest that complication rates
years.13,19,47,48 A recent study on the survival of 6 different have decreased in recent years, with less major complications
glenoid components has shown survival rates as high as 94%
at 15 years for certain cemented, all-polyethylene glenoid
designs.49 Although these findings on patient outcomes and
implant longevity have been drawn from numerous pub-
lished reports, the studies have been of relatively low quality
to date. In the recently released American Academy of Ortho-
pedic Surgeons (AAOS) clinical practice guidelines on the
treatment of glenohumeral arthritis, the strength of recom-
mendation for nearly all the guidelines pertaining to shoulder
arthroplasty were weak, or based on overall poor quality
evidence.50
The only AAOS recommendation considered of moderate
strength, or based on overall fair quality evidence, was for the
use of TSA over hemiarthroplasty in the treatment of gleno-
humeral osteoarthritis.50 Important data in this recommen-
dation included 2 recent systematic reviews comparing out-
comes of TSA and hemiarthroplasty in the treatment of
primary glenohumeral osteoarthritis.15,51 Radnay et al15 iden-
tified 23 studies in which the authors addressed TSA and
hemiarthroplasty, totaling 1952 patients (mean age, 66
years) with a mean follow-up of 43.4 months. The mean level
of evidence was 3.73. TSA was found to provide significantly
greater pain relief (P ⬍ 0.0001), gain in forward elevation
(P ⬍ 0.0001) and external rotation (P ⫽ 0.0002), and patient
satisfaction (P ⬍ 0.0001) then hemiarthroplasty. A signifi-
cantly lower rate of revision surgery was also found with TSA Figure 18 Postoperative shoulder anteroposterior radiograph after
compared with hemiarthroplasty (6.5% vs 10.2%, P ⬍ TSA.
TSA: indications, technique, and results
and less need for revision surgery because of complications,
particularly in regard to revision for component loosening.54
Recently, Bohsali et al1 performed a systematic review of all
studies in the TSA literature from 1996 to 2005 that docu-
mented complications of TSA. Thirty-three studies with a
minimum of 2-years follow-up were included (mean fol-
low-up of 5.3 years), with an overall mean complication
rate of 16.3%. Glenoid loosening was the most common
complication (39% of all complications), followed by su-
perior instability (19%), periprosthetic fracture (11%), ro-
tator cuff tear (7.7%), humeral loosening (6.5%), posterior
(6%) and anterior (5%) instability, nerve injury (4.8%),
and infection (4.6%).1
Several larger, epidemiologic studies have also provided
mean complication and mortality rates in the early perioper-
ative period for patients undergoing TSA, as well as data on
mean length of hospital stay.2,55-58 Perioperative complica-
tions rates have ranged from 1.2% to 7.55%55-57 and periop-
erative mortality rates from 0% to 0.58%,55-59 with mean
length of stay varying from 2.4 to 4.7 days,2,55-58 depending
on the period studied. Most recently, a significant decrease in
length of stay from 5.8 to 2.4 days (P ⬍ 0.0001) was reported
by Day et al2 from 1993 to 2007 in the United States.
Conclusions
TSA is indicated in the treatment of advanced primary and
secondary arthritic conditions of the glenohumeral joint after
failure of nonoperative management. Careful patient selec-
tion, preoperative planning, surgical technique, and postop-
erative management are essential in minimizing complica-
tions and maximizing functional outcomes of shoulder
arthroplasty. Although TSA has been shown to provide sub-
stantial improvements in pain relief, function, and patient
satisfaction, as well as good implant longevity, the quality of
the scientific data has remained poor.50 In the future, greater
levels evidence will be needed from appropriately designed
studies to determine the optimal treatments, both nonopera-
tive and operative, for these arthritic conditions.
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