Chapter 3 Total Shoulder Arthroplasty
Surgical Overview
• Many variations exist to the surgical procedure of a TSA. A surgeon’s surgical experience and preference, as well as a patient’s soft tissue and bone quality, are integral factors to the technique of choice. Described is a surgical overview for patients undergoing primary TSA.
• TSA is performed using either an interscalene regional block or general anesthesia, depending on the surgeon’s preference.
• The patient is typically in a beach chair position and passive range of motion (PROM) is assessed under anesthesia, which will enable the surgeon to determine the expected postoperative ROM outcomes.
• Superficial soft tissue structures are identified and retracted at the level of the deltopectoral interval.
• The cephalic vein can be preserved and retracted with the pectoralis major, or ligated and removed.
• The clavipectoral fascia is incised superiorly to the level of the coracoacromial ligament. This allows medial retraction of the “strap muscles” (the short head of the biceps, coracobrachialis, and pectoralis minor).
• The coracoacromial ligament may be released (assuming there is an intact rotator cuff with good quality tissue) to more effectively expose the rotator interval.
• The superior third of the pectoralis major tendon may be released and tagged for later repair, if necessary, for exposure as well.
• To obtain greater exposure of the glenohumeral joint, the subscapularis tendon can be divided just medial to its insertion on the lesser tubercle, or a release of the tendon from its insertion into the lesser tuberosity may be performed.
• If an internal rotation (IR) (40 degrees) contracture is present, a lengthening of the tendon may be performed.
• Once soft tissue dissection is complete, the shoulder joint is dislocated; an osteotomy of the humeral head is performed, and degenerative bone and osteophytes are excised from the humerus and glenoid.
• When trial components are fitted and joint mechanics are restored, final components of titanium alloy humeral stem and head and polyethylene glenoid are cemented with methyl methacrylate.
• Appropriate sizing is critical to avoid mechanical impingement or “overstuffing” of the joint and ensure that the stability of the joint is not sacrificed.
Rehabilitation Overview
• Secondary to the amount of bone dissection during the procedure, pain management becomes an important treatment intervention in the early days and weeks following the procedure.
• Therapeutic interventions are progressed using the guidelines that follow. Each patient, however, is treated individually, because preoperative ROM, bone quality, and soft tissue integrity will have an influence on the progression of the program.
• Communication with the referring orthopedic surgeon to ascertain this information is imperative to ensure a safe and effective response to the rehabilitation program.
• A surgeon’s prognosis, determined by the success of the procedure, should be considered when establishing rehabilitation goals.
• ROM, flexibility, and strengthening exercises are progressed via a criteria based approach, based on basic science principles, healing response of surgically repaired tissues, and rehabilitative experience.
• Compliance to home therapeutic exercises as well as functional restrictions should be continually reinforced.
• Goals following TSA include maximizing ROM, flexibility, and muscle strength necessary for the pain-free performance of activities of daily living (ADL).
