Glenoid exposure is the name of the game in total shoulder arthroplasty. I can honestly say that it took me more than 5 years but less than 10 to feel confident exposing any glenoid, regardless of the degree of bone deformity and the severity of soft-tissue contracture. This lecture represents the synthesis of my experience exposing some of the most difficult glenoids. The basic principles are performing extensive soft-tissue release, minimizing the anteroposterior dimension of the humerus by osteophyte excision, making an accurate humeral neck cut, having a plethora of glenoid retractors, and knowing where to place them. The ten tips, in reverse order of importance are: 10.) Tilt the table away from operative side—this helps face the surface of the glenoid, especially in cases of posterior wear, toward the surgeon. 9.) Have multiple glenoid retractors—these include a large Darrach, a reverse double-pronged Bankart, one or two blunt Homans, small and large Fukudas. 8.) Remove all humeral osteophytes before attempting to retract the humerus posteriorly to expose the glenoid—this helps to decrease the overall anteroposterior dimension of the humerus and allows for maximum posterior displacement of the humerus. 7.) Make an accurate humeral neck cut—even 5mm of extra humeral bone will make glenoid exposure difficult. 6.) Optimal humeral position—it has been taught that abduction, external rotation, and extension is the optimal position. It may vary with each case. Therefore, experiment with humeral rotation to find the position that allows maximum visualization. This is often the position that makes the cut surface of the humerus parallel to the surface of the glenoid. 5.) Optimal retractor placement—my typical retractor placement is a Fukuda on the posterior lip of the glenoid, a reverse double-pronged Bankart on the anterior neck of the scapula, and a blunt Homan posterosuperiorly. Occasionally, a second blunt Homan anteroinferiorly is helpful, particularly in muscular males with a large pectoralis major. 4.) Laminar spreader for lateral humeral displacement—this can be helpful for posterior capsulorrhaphy or for posterior glenoid bone grafting. 3.) Maximal humeral capsular release—the release of the anterior capsule from the humerus must go well past the 6 o'clock position and up the posterior surface of the humerus. This aides in humeral exposure but also allows for more posterior displacement of the humerus during glenoid exposure. 2.) Anteroinferior capsular release or excision—extensive anteroinferior release or excision (my preference), allows for maximal posterior humeral displacement and also restores external rotation. 1.) Posterior or posteroinferior capsular release—release of the posteroinferior corner of the capsule from the glenoid results in a noticeable increase in posterior humeral retractability. In cases without substantial posterior subluxation, extensive release of the entire posterior capsule is performed

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant however without attending to releases and extra-articular correction may not suffice. Certain myths in deformity correction will be presented. Technical tips with regard to preoperative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Technique of performing TKA with concomitant extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain-free motion, and stability without necessarily using more constrained implants

Glenoid exposure is the name of the game in total shoulder arthroplasty. I can honestly say that it took me more than 5 years but less than 10 to feel confident exposing any glenoid, regardless of the degree of bone deformity and the severity of soft-tissue contracture. This lecture represents the synthesis of my experience exposing some of the most difficult glenoids. The basic principles are performing extensive soft-tissue release, minimizing the anteroposterior dimension of the humerus by osteophyte excision, making an accurate humeral neck cut, having a plethora of glenoid retractors, and knowing where to place them. The ten tips, in reverse order of importance are: 10.) Tilt the table away from operative side—this helps face the surface of the glenoid, especially in cases of posterior wear, toward the surgeon. 9.) Have multiple glenoid retractors—these include a large Darrach, a reverse double-pronged Bankart, one or two blunt Homans, small and large Fukudas. 8.) Remove all humeral osteophytes before attempting to retract the humerus posteriorly to expose the glenoid—this helps to decrease the overall anteroposterior dimension of the humerus and allows for maximum posterior displacement of the humerus. 7.) Make an accurate humeral neck cut—even 5mm of extra humeral bone will make glenoid exposure difficult. 6.) Optimal humeral position—it has been taught that abduction, external rotation, and extension is the optimal position. It may vary with each case. Therefore, experiment with humeral rotation to find the position that allows maximum visualization. This is often the position that makes the cut surface of the humerus parallel to the surface of the glenoid. 5.) Optimal retractor placement—my typical retractor placement is a Fukuda on the posterior lip of the glenoid, a reverse double-pronged Bankart on the anterior neck of the scapula, and a blunt Homan posterosuperiorly. Occasionally, a second blunt Homan anteroinferiorly is helpful, particularly in muscular males with a large pectoralis major. 4.) Laminar spreader for lateral humeral displacement—this can be helpful for posterior capsulorrhaphy or for posterior glenoid bone grafting. 3.) Maximal humeral capsular release—the release of the anterior capsule from the humerus must go well past the 6 o'clock position and up the posterior surface of the humerus. This aides in humeral exposure but also allows for more posterior displacement of the humerus during glenoid exposure. 2.) Anteroinferior capsular release or excision—extensive anteroinferior release or excision (my preference), allows for maximal posterior humeral displacement and also restores external rotation. 1.) Posterior or posteroinferior capsular release—release of the posteroinferior corner of the capsule from the glenoid results in a noticeable increase in posterior humeral retractability. In cases without substantial posterior subluxation, extensive release of the entire posterior capsule is performed. Following these steps will help the surgeon to gain adequate glenoid exposure, even in the most difficult cases

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant, however, without attending to releases and extra-articular correction may not suffice. Pre-operative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Results of a large series of TKA with extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain-free motion, and stability without necessarily using more constrained implants

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant however without attending to releases and extra-articular correction may not suffice. Preoperative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Results of a large series of TKA with extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain free motion, and stability without necessarily using more constrained implants