TSA Technique



Gilles Walch vumedi video




Head that translates 50% in all directions

- allows 30o ER with arm at side

- stable posteriorly






Cutibacterium acnes (formerly propionobacterium) cover


Tranexamic acid


Kirsch et al. JBJS Rev 2017

- systematic review and meta-analysis

- 5 studies and 629 patients

- decreased hemoglobin change and drain output with TXA




Beach-chair position

- McConnell head rest

- patient at table edge / removable edge

- shoulder must overhand table to allow GHJ extension

- need this to insert stem


Extended deltopectoral approach


Coracoid to deltoid insertion 


Cephalic vein

- retracting cephalic vein laterally causes less bleeding

- retracting cephalic medially prevents cephalic avulsion from subclavian vein


Deep dissection

- divide clavipectoral fascia on lateral edge conjoint tendon

- replace medial retractor blade under conjoint tendon

- externally rotate humerus and expose subscapularis


Open Approach Shoulder

Deltopectoral approach left shoulder


Identify and release biceps and open rotator interval


Identify and tag biceps tendon

- lateral edge of subscapularis

- divide

- tenodesis to soft tissue


Identify the interval between subscapularis and supraspinatus


Open rotator interval at superior border of subscapularis


Additional Releases


1.  Coraco-acromial ligament

- place retractor on coracoid

- don't divide in full or risk superior escape of humeral component

- take anterior triangle with diathermy


2.  Pectoralis major insertion

- divide upper 50%

- can release more if needed, but repair at end

- allows ER of humerus


3.  Release Lat Dorsi / Teres Major if needed

- externally rotate humerus

- identify inferior to lower border of subscapularis and anterior circumflex vessels

- subperiosteal dissection with diathermy


4.  Release anterior deltoid


5.  Can release conjoint tendon if needed

- usually via coracoid osteotomy

- predrill

- secure with screw later




Identify lower border of SSC

- anterior circumflex humeral blood vessels

- at inferior SSC tendon

- can tie off with stay sutures




Subscapularis tenotomy

Lesser tuberosity osteotomy

Subscapularis peel

Subscapularis sparing


A. Subscapularis tenotomy


Vumedi video



- easy to do



- tendon healing - need to protect ER post operatively

- risk of weakness

- potential for shortening



- insert medial stay sutures

- divide subscapularis and capsule medial to lesser tuberosity

- leave cuff of subscapularis medially for repair

- repair with arm in 30o external rotation


B.  Lesser tuberosity Osteotomy


Vumedi video



- bone to bone healing may be more reliable



- expose inferior humeral flare

- don't want inferior cut venturing into humeral shaft / is a fracture risk

- use oscillating saw beginning in intertubercular groove

- usually small 2 cm oval piece

- place ethibond stay sutures

- repair with sutures


C.  Subscapularis peel


Vumedi video



- release SSC tendon and capsule off the insertion

- repair SSC at end via drill holes or with anchor


Aibinder et al. JSES 2019

- 68 subscap tenotomy versus 65 subscap peel versus 55 LT osteotomy

- no difference in outcomes at 2 years

- 2 patients with subscap peel required reoperation for subscap failure


Lapner et al.  JSES 2021

- RCT 100 patients SSC tenotomy versus SSC peel

- no difference in outcome, healing, or internal rotation strength


D.  Subscapularis sparing


Vumedi video


Insert prosthesis via rotator interval


Kwon et al. Orthopedics 2019

- RCT of SSC sparing versus SSC tenotomy

- no differences in outcomes or complications


Subscapularis releases


Used to be 360o release

- fatty infiltration post operatively was identified on MRI

- thought to be due to denervation anteriorly


180o release

- superior release - superior glenohumeral ligament and coracohumeral ligament from superior border of subscapularis

- posterior release - dissect away and resect capsule from posterior border of subscapularis

- inferior release - inferior glenohumeral ligament

- ensure good excursion of subscapularis


Humeral Osteotomy



- externally rotate humerus to put tissues on tension

- release capsule anteriorly all the way posteriorly

- may need to release lat dorsi and teres major tendon

- deliver humeral head by extending and externally rotating


Humeral osteotomy

- identify true anatomical neck which is osteotomy site

- usually need to remove humeral head osteophytes

- posterior retractor to protect rotator cuff

- anterior retractor to protect glenoid

- use saw to resect articular cartilage in line with anatomical neck

- broach humerus as needed

- insert trial stem as leaving the stem in prevents fractures while preparing the glenoid

- placing a cap on the stem on prevents crushing cancellous bone


Glenoid Exposure


Glenoid Releases




Resect superior / anterior / posterior labrum


Release inferior labrum from bone while protecting axillary nerve


Continue humeral neck release

- release capsule around neck all the way to posterior aspect




TSR Glenoid Exposure 1TSR Glenoid Exposure 2


Anterior retractor under subscapularis


Posterior retractor

- humerus is flexed, internally rotated

- head pushed posteriorly


Interior retractor to protect axillary nerve


Glenoid component


TSR Cemented Glenoid APTSR Cemented Glenoid Lateral


Glenoid center point crucial


Vault is a triangle

- pilot hole critical

- must not penetrate vault with keel or peg drilling

- get vault perforation  / blowout

- cannot pressurise cement


TSR Central Peg BreachTSR Glenoid Vault Breach

Vault blowout / perforation


1. Freehand technique

- identify center of glenoid articular surface

- glenoid center point slightly inferior and anterior to center of the articular surface glenoid

- match inclination of glenoid

- insert guide pin aiming anteriorly


Glenoid center 1Glenoid center 2


2.  3D CT templating

- templates glenoid component

- creates guide that matches glenoid

- allows placement of guide pin


Glenoid template 1Glenoid template 2Glenoid template 3


Insert guide pin

- ream only articular cartilage

- preserve subchondral bone

- reamers often semi-circle to aide insertion and removal


Ream peg / keel

- ensure no blowout with arthroscopy probe


Glenoid cementing

- keep holes dry

- insert cement into peg / keel holes using syringe

- no cement under poly as is generally too thin and will crack

- pressurise

- insert poly


Humeral component


Modern components


Variety of thickness options of humeral head

- overstuffing of joint reduces ROM and places excessive stress on rotator cuff


Offset options

- normal head offset from neck posteriorly and medially

- placing head more anterior than normal can impinge on SSC and cause late rupture




Should be able to

A.  Inferiorly sublux head 50% glenoid and return to center

B.  Posteriorly sublux head 50% and return to center

C.  Able to close subscapularis without impingement on head