The results of revision TSA do not historically match the results of primary TSA. This is especially true if the diagnosis is a soft tissue related problem that leads to the revision. When a revision TSA is considered in this setting, instability is the major problem to overcome and a reverse TSA is most often needed. In the past this would require that the glenoid and humeral components be removed. Some manufacturers have produced shoulder prosthetic systems that can be converted to a reverse TSA without removing the humeral stem making the revision surgery potentially easier for both the patient and the surgeon. The data bank from two academic shoulder services were utilised to compare outcomes of revision TSA with and without removing the humeral stem at the time of revision surgery. Sixty-seven patients were identified in which 22 did not have the stem removed and 45 required the stem to be revised. The pre-operative and post-operative data for 1 and 2 years were available. Codman's scores, range of motion, estimated blood loss, time in the operating room, complications and cost of the implants were evaluated. The average blood loss was 280 cc vs. 500 cc, 145 minutes vs. 211 minutes, constant scores were 32 pre-op and 75 post-op vs. 32 pre-op and 70 post-op, complications 0 vs. 9 and the cost of the implants were 23% more in the stem removal group. The results of revision TSA do not match the results of primary arthroplasty. The results of not having to remove the humeral stem when doing a revision arthroplasty vs. using a system that has to remove both components has certain advantages. The overall outcome score are similar, however, the complication rate, blood loss, time in the operating room and cost of the implants are significantly less

Indications for total shoulder arthroplasty (TSA) require that the patient have a functioning rotator cuff to stabilise the glenohumeral joint. Without rotator cuff integrity the prosthesis will be unstable and the functional result will be less than expected. Physical exam can be difficult in the arthritic shoulder as contractures will limit the range of motion needed to adequately exam the rotator cuff status. The diagnosis can help as osteoarthritis has a 5% incidence of rotator cuff tear while rheumatoid arthritis has an incidence of greater than 40%. MRI can be obtained to determine the rotator cuff status before arthroplasty is performed but may not be necessary. Most total shoulder implant companies have both reverse and anatomic implants available. More recently the uses of platform stems that can be used with either RSA or TSA have been available. With this development in prosthetic design it is no longer necessary to determine the status of the rotator cuff before surgery. The surgeon can make the decision at the time of surgery which implants RSA or TSA will be necessary based on the status of the rotator cuff. There have been recent reports of longer follow up of TSA patients that had fatty atrophy of the infraspinatus muscle that had rotator cuff tears at 10–15 years. MRI may still be warranted in the older individual that is being considered for TSA to determine the quality of the rotator cuff musculature

We know little regarding the long head of the biceps tendon's function but it is generally felt that it serves as a humeral head stabiliser by resisting superior migration during shoulder elevation. In total shoulder arthroplasty (TSA) the long head tendon is most commonly tenodesed as some have reported post-operative pain generated from an intact long head tendon. How does tenotomy or tenodesis of the long head tendon after TSA effect superior translation of the humeral head? We do not know the answer to this or if this increased tension causes any increase in subscapularis tendon failure. This will be presented as a possible reason to not remove the long head tendon of the biceps during TSA

The current standard of care in the United States for the treatment of an infected arthroplasty, whether it be a TKA, THA or TSA remains two stage revision. We performed a systematic review of the English literature to answer the question of whether one-stage or two-stage revision of infected shoulder arthroplasty was better in terms of re-infection rate, patient satisfaction and patient function. There were no prospective, randomised studies comparing these two approaches. We found 19 studies with a minimum one year follow up which described 99 patients with two-stage revision, 38 with one-stage revision and 36 with spacers. There were no significant differences between the groups for recurrent infection rate or complication rate. The spacer only group had higher satisfaction than the one-stage group, but the satisfaction rate between the one- and two-stage groups was not statistically different. Unfortunately, the numbers in our study were small and based upon level IV evidence. It is interesting that currently the data do not support two-stage over one-stage revision of an infected TSA. So why do we continue to use two-stage revision? I believe it is the fear of litigation to a certain degree but also historical bias toward two-stage revisions. The only time I would do a one-stage revision is if (1) it is a low virulence organism, (2) the prosthesis can be easily removed and (3) the patient was too sick to tolerate multiple operations

Scapular spine fracture is a serious complication of reverse total shoulder arthroplasty (RTSA) often caused by a fall on an outstretched arm or a forced movement to the shoulder. The incidence of scapular fractures occurring after RTSA is reported between 5.8% and 10.2%. These fractures have been classified into 3 discrete fracture patterns. Avulsion of the anterior acromion (Type I), Acromion fractures (Type II) and Scapular spine fractures (Type III). This discussion will review the incidence of these post-operative peri-prosthetic fractures of the scapula after reverse TSA and describe potential treatment options and prevention methods to avoid this complication

There are unfortunately many reasons a TSA can be painful after implantation, but the most common reason is sepsis. Making the diagnosis can be a major challenge, but the biggest challenge is to think of that as a diagnosis! The most important steps are to first obtain plain radiographs one week after surgery so that you can compare subsequent radiographs to the immediate post-operative films. Progressive radiolucent lines in the glenoid or especially around the humerus are important hints. A loose humeral component is infected until proven otherwise. Next blood work to include CRP and ESR are critical. Other markers of infection have not been used on a widespread basis. If there is concern that there might be rotator cuff pathology and not sepsis, then we obtain an arthrogram CT scan at the time of aspiration. A cell count is helpful but often there is a dry tap. It is important to create a “p. acnes protocol” at your hospital to take cultures out 15 days. If still not sure and revision is necessary then we aspirate the joint at the time of surgery for cell count. The WBC cell count at the time of surgery keeps changing but over 3000 is considered diagnostic. Multiple specimens are sent for frozen section, culture and permanent section. The more WBC per high powered field the more likely there is an infection. Gram stains are worthless and we do not rely on them. We have no experience with implant sonification or use of IL-6

INTRODUCTION. The glenoid version assessment is crucial step for any Total Shoulder Arthroplasty (TSA) procedure. New methods to compute 3D version angle of the glenoid have been proposed. These methods proposed different definitions of the glenoid plane and only used 3 points to define each plane on the 3D model of the scapula. In practice, patients often come to consultation with their CT-scans. In order to reduce the x-ray dose, the scapulae are often truncated on the inferior part. In these cases, the traditional scapula plane cannot be calculated. We hypothesised that a new plane definition, of the scapula and the glenoid, that takes into account all the 3D points, would have the least variation and provide more reliable measures whatever the scapula is truncated or not. The purpose of the study is to introduce new fully automatic method to compute 3D glenoid version for TSA preoperating planning and test its results on artificially truncated scapulae. MATERIAL AND METHODS. Volumetric preoperative CT datasets have been used to derive a surface model shape of the shoulder. The glenoid surface is detected and a 3D version and inclination angle of the glenoid surface are computed. We propose a new reference plane of the scapula without picking points on the 3D model. The method is based on the mathematical skeleton of the scapula and the least squares plane fitting. Specific software has been developed to apply the plane fitting in addition the automatic segmentation process. An orthopedic surgeon defined the traditional scapular plane based on 3 points and applied the measures on 12 patients. The manual process has been repeated 3 times and the intra-class correlation coefficient (ICC) was calculated to compare the results with our automatic method. To validate the reliability of the new plane relating to truncated scapulae, we have measured the 3D orientation variation on 37 scapulae. Nine iterations have been applied on each scapula by cutting 5mm of the scapular inferior part. RESULTS. The ICC of the scapula plane orientation for the three orientation components (x, y, z) were 0.98, 0.99 and 0.89 respectively. The reliability results applied by cutting the inferior side show good results with means: 0.01±0.01 mm, 0.01±0.01 mm and 0.02±0.02 mm for X, Y, Z respectively. CONCLUSION. New referential scapular plane has been proposed to compute 3D glenoid version. The method is fully automatic and doesn't need manual positioning of points on the 3D points. The orientation of the new plane is correlated with the standard scapular plane. The study showed that plane orientation is reasonably constant while truncating the scapula body till 45mm of cut on the inferior and the medial side. This is the only study that proposes a reference plane for truncated scapula

Accurate glenoid component placement continues to be a challenge. Knowledge that glenoid loosening is affected by malpositioning of the glenoid component has led to the development of patient specific instrumentation (PSI) in an attempt to optimise glenoid positioning. The ideal PSI would be reusable, reliable, cost-effective and robust enough to tolerate the stresses applied by the surgeon in the context of difficult glenohumeral exposure. The VIP system is a CT scan-based PSI with a reusable instrument. The subtle nuances of pre-operative planning will be discussed in a separate short video.

The live surgery will incorporate use of the patient specific instrumentation during glenoid placement and the use of a short stemmed fourth generation total shoulder arthroplasty.

Anatomic and accurate placement of components is a primary goal in all arthroplasty procedures. Unique to total shoulder arthroplasty, challenging glenoid exposure and osteoarthritic glenoid deformity offer significant challenges and impediments to this goal. Despite thorough pre-operative planning strategies and contemporary cannulated pin-based shoulder systems, it is often times still difficult to accurately aim the guide pin to the medial border of the scapula when the deformity is substantial or exposure is difficult. Even small errors in guide pin position can result in problems with final component version, inclination and glenoid vault perforation. In addition, a malpositioned glenoid component has been shown to have a negative impact on implant longevity and clinical performance.

Image-based patient specific instrumentation has been available in the lower extremity for nearly a decade with reliable results. The application of similar technology in the shoulder has demonstrated reliable positioning of the guide pin to a pre-operative plan with subsequent accurate placement of the glenoid component. This surgical demonstration will feature one of the currently available CT-based patient specific glenoid guides using a standard deltopectoral approach.

Complication rate after total shoulder arthroplasty ranges around 10%. These can be divided into intra-operative and post-operative complications. Intra-operative complications are periprosthetic fracture, nerve injury and malpositioning of components. Post-operative complications are instability, infection, rotator cuff tear, periprosthetic fracture, aseptic loosening, stiffness, heterotopic ossification and implant dissociation. The most effective means of preventing a complication are meticulous pre-operative planning, experience of the surgeon, adherence to sound surgical technique and intelligent patient selection and education.

Revision shoulder arthroplasty for failure secondary to soft tissue problems has improved with the availability of the reverse total shoulder system. The initial concept of a platform (convertible) stem was introduced in 2006. Removal of a well-fixed humeral stem can be a significant challenge and may require the surgeon to use osteotomy windows to successfully remove the implant. The increased time in the operating room, potential for complications and the cost of replacing the humeral component are all factors that make platform stem use a important consideration. The first report on total shoulder arthroplasty revision utilizing the platform stem concept confirmed improvements in patient morbidity and decreased costs. However, the overall functional improvement did not reveal a statistically significant improvement in pain relief or range of motion compared to those patients that had the humeral stem revised. Almost all major companies have adopted this concept of a convertible stem system for shoulder arthroplasty.

Analysis of orthopaedic malpractice claims has shown that highest impact allegations (highest payment dollars per claim) were those that were related to failure to protect anatomic structures in surgical fields. The prevalence of subclinical peripheral neurologic deficit following reverse and anatomic shoulder arthroplasty has been reported to be 47% and 4%, respectively. We propose the following five rules in order to avoid neurovascular injury during shoulder arthroplasty cases:

Pre-operative planning would assure a smooth operation without intra-operative difficulties. Adequate planning would include appropriate imaging, obtaining previous operative reports, complete pre-operative neurovascular examination and requesting the necessary operative equipment.

Neuromonitoring has been utilised in shoulder surgery in the past. Nagda et al showed that nerve alerts during shoulder arthroplasty occurred 56.7% of the time and 50% of the events were with the arm in abduction, external rotation and extension; 76.7% of signals returned to normal with retractor removal and change in arm positioning. We recommend removing all retractors and returning the arm to neutral position several times during surgery, especially during the glenoid exposure when the arm is in abduction and external rotation.

Newer commercially available nerve stimulators are extremely useful in locating and protecting neurovascular structures. We recommend brachial plexus exploration and axillary nerve dissection with the aid of a nerve stimulator in all revision cases.

Availability of a nerve/microvascular surgeon as an assistant in revision cases for brachial plexus exploration using a microscope is crucial for successful revision surgery.

Aseptic loosening of the glenoid after total shoulder replacement is a challenging problem to manage clinically. In the right circumstances, arthroscopic retrieval of loose polyethylene glenoids can be a valuable tool in the shoulder surgeon's repertoire for dealing with this uncommon problem. The purpose of this talk is to demonstrate the technique for arthroscopic removal of a loose glenoid and review the clinical circumstances where this procedure may play a valuable role.

Reverse total shoulder arthroplasty has become popular for primary replacement in complex proximal humerus fractures. Hemiarthroplasty and open reduction and internal fixation (ORIF) with locked plating were the treatment of choice but with variable functional outcomes and concerns of glenohumeral arthritis, rotator cuff problems, and tuberosity healing difficulties. This is especially concerning in the older population that has a higher incidence of rotator cuff problems and poor bone quality. Reverse total shoulder arthroplasty has resulted in excellent pain relief and seems to have a more consistent functional outcome in early reports when compared to hemiarthroplasty.

The infected shoulder arthroplasty is a devastating complication that can be very difficult to diagnose and treat. This presentation will compare the data on two-stage and single-stage exchange arthroplasty as pertains to functional outcomes and efficacy of eradication of the infection. Traditionally, the two-stage exchange arthroplasty has been the gold standard in the United States for the treatment of infected total shoulder replacements. In Europe, the trend seems to be moving towards a single-stage exchange with results that are reportedly comparable for eradication of infection to those of two-stage exchange although with seemingly better results for shoulder function. The surgeon's clinical experience with both techniques will be highlighted. A lively debate of the virtues and pitfalls of both approaches is the goal.

Despite reverse total shoulder arthroplasty (RTSA) being primarily indicated for massive rotator cuff tears, it is often possible to repair portions of the infraspinatus and subscapularis of patients undergoing this procedure. However, there is disagreement regarding whether these tissues should be repaired, as their effects remain unclear. Therefore, we investigated the effects of rotator cuff repair and changes in humeral and glenosphere lateralisation (HLat & GLat) on deltoid and joint loading.

Six shoulders were tested on an in-vitro muscle driven active motion simulator. Cuff tear arthropathy was simulated in each specimen, which was then implanted with a custom adjustable RTSA fitted with a six axis load sensor. We assessed the effects of 4 RTSA configurations (i.e. all combinations of 0&10mm of HLat & GLat) on deltoid force, joint load, and joint load angle during abduction with/out rotator cuff repair. Deltoid and joint loads recorded by the load cell are reported as a % of Body Weight (%BW). Repeated measures ANOVAs and pairwise comparisons were performed with p<0.05 indicating significance.

Cuff repair interacted with HLat & GLat (p=0.005, Fig. 1) such that with no HLat, GLat increased deltoid force without cuff repair (8.1±2.1%BW, p=0.012) and this effect was significantly increased with cuff repair (12.8±3.2%BW, p=0.010). However, adding HLat mitigated this such that differences were not significant. HLat and GLat affected deltoid force regardless of cuff status (−2.5±0.7%BW, p=0.016 & +7.7±2.3%BW, p=0.016, respectively). Rotator cuff repair did significantly increase joint load (+11.9±2.1%BW, p=0.002), as did GLat (+13.3±1.5%BW, p<0.001).

The increases in deltoid and joint load caused by rotator cuff repair confirm that it acts as an adductor following RTSA and increases deltoid work. Additionally, cuff repair's negative effects are exacerbated by GLat, which strengthens its adduction affect, while Hlat increases the deltoid's abduction effect thus mitigating the cuff's antagonistic effects. Cuff repair increases concavity compression within the joint; however, Hlat produces a similar effect by wrapping the deltoid around the greater tuberosity – which redirects its force – and does so without increasing the magnitude of muscle and joint loading. The long-term effects of increased joint loading due to rotator cuff repair are unknown, however, it can be postulated that it may increase implant wear, and the risk of deltoid fatigue. Therefore, RTSA implant designs which improve joint compression without increasing muscle and joint loading may be preferable to rotator cuff repair.

Total shoulder arthroplasty is becoming increasingly common. A biceps tenodesis or tenotomy has become a routine part of the operation. There are several advantages to a tenodesis or tenotomy. First, the long head of the biceps tendon is routinely pathologic. One study has shown that there are differences in gene expression and mechanical properties in the long head of the biceps tendon in the setting of glenohumeral joint arthritis. Clinically, we often see inflammation, tearing, adhesions, or other pathology. Second, it is largely accepted that the long head of the biceps tendon has minimal function at the shoulder. The biceps muscle primarily functions at the elbow. Therefore, there is little downside to performing a tenodesis if there is a chance of it generating pain after surgery. Another major reason to perform a tenodesis or a tenotomy is that the technique of total shoulder arthroplasty requires a subscapularis takedown or lesser tuberosity osteotomy. The ligaments and tendon associated with the subscapularis contribute to the stability of the biceps tendon and after subscapularis takedown, it is unlikely that the tendon would remain reduced in the groove. In addition, it is part of a technique to incise and release the rotator interval, additionally creating scarring and/or instability associated with the biceps tendon. Given those reasons, this is a very common and reasonable routine part of the procedure of total shoulder arthroplasty.

The functional importance of the long head of biceps tendon remains controversial, but it is well accepted as an important source of anterior shoulder pain. Both biceps tenotomy and tenodesis have well-documented results in the native shoulder. Management of the long head of biceps tendon during shoulder arthroplasty remains controversial. The existing literature supports surgical treatment of the biceps during shoulder arthroplasty. Walch et al. reported the largest series in multicenter study of over eight hundred shoulder arthroplasty patients with or without biceps tenodesis. The authors found more reproducible pain relief with biceps tenodesis and no difference in range of motion. Similarly, Soliman et al. reported on a prospective review of 37 patients undergoing hemiarthroplasty for fracture randomly assigned to biceps tenodesis vs. no treatment. The authors found a statistically significant improvement in Constant score and shoulder pain with biceps tenodesis. If left untreated during shoulder arthroplasty, the intact biceps tendon may be a source of anterior shoulder pain requiring revision surgery. Tuckman et al. reported excellent pain relief after biceps tenotomy or tenodesis for biceps-related pain after previous shoulder arthroplasty. The decision to perform a biceps tenotomy versus a tenodesis during shoulder arthroplasty also remains controversial. Tenotomy may increase the risk of cosmetic pop-eye deformity and muscle cramping or fatigue over tenodesis. Therefore, routine long head of biceps soft tissue tenodesis is recommended during shoulder arthroplasty as it safe, reproducible, cost-effective, associated with improved outcome scores, and minimises the risk of cosmetic deformity and pain associated with biceps tenotomy.

Peri-prosthetic fractures around implants in the proximal humerus can present substantial challenges. Most individuals who undergo upper limb arthroplasty tend to be osteopenic to begin with, and the anatomy of the proximal humerus does not provide an excess of bone to work with. Therefore, peri-prosthetic fractures pose difficulties to rotator cuff function and implant stability. There are multiple classification systems, but series are small and the classification does not always lead to treatment algorithms. Risk factors for humeral fractures after shoulder arthroplasty include endosteal notching, cortical perforation, varus malalignment, stem perforation, ipsilateral shoulder and elbow arthroplasties, and loose stems. Many of these risk factors are directly related to technical errors at the time of surgery. Poor exposure can lead to aberrant starting point and errors in reaming. Oversized prostheses can lead to cortical perforation or even stem perforation. Proper positioning of the patient on the table and surgical releases help avoid these technical errors. Peri-prosthetic fractures should be carefully evaluated radiographically for stability. Two important considerations: 1. Is the implant stable? 2. Is the fracture stable? Generally, if the implant is unstable, the implant must be revised. In the setting of a stable implant, many humeral fractures can be treated nonoperatively. Many fractures at or below the level of the tip of the implant can be treated as typical humeral fractures. Options for fixation include plates with cables or long stem prostheses which bypass the fracture. Displaced tuberosity fractures are treated with suture or wire fixation. Risk factors for a poor outcome include increased time to union, skin breakdown, and stiff shoulder.

Proximal humerus fractures (PHF) are common, accounting for approximately 5% of all fractures. Approximately 30% require surgical intervention which can range from open reduction with internal fixation (ORIF) to shoulder arthroplasty (including hemiarthroplasty, total shoulder arthroplasty, (TSA) or reverse total shoulder arthroplasty (RTSA)). The aim of this study was to assess trends in operative interventions for PHF in an Australian population. Data was retrospectively collected for patients diagnosed with a PHF and requiring surgical intervention between January 2001 and December 2020. Data for patients undergoing ORIF were extracted from the Medicare database, while data for patients receiving arthroplasty for PHF were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Across the study period, ORIF was the most common surgical procedure for management of PHFs. However, since 2019, RTSA has surpassed ORIF as the most common surgical procedure to treat PHFs, accounting for 51% of operations. While the number of RTSA procedures for PHF has increased, ORIF and shoulder hemiarthroplasty has significantly reduced since 2007 (p < 0.001). TSA has remained uncommon across the follow-up period, accounting for less than 1% of all operations. Patients younger than 65 years were more likely to receive ORIF, while those aged 65 years or greater were more likely to receive hemiarthroplasty or RTSA. While the number of ORIF procedures has increased during the period of interest, it has diminished as a proportion of overall procedure volume. RTSA is becoming increasingly popular, with decreasing utilization of hemiarthroplasty, and TSA for fracture remaining uncommon. These trends provide information that can be used to guide resource allocation and health provision in the future. A comparison to similar data from other nations would be useful