Surgical Technique for Cuff Tear Arthropathy

  • Stefano GuminaEmail author
  • Kamal I. Bohsali
  • Michael A. Wirth


Prior to surgical intervention, a thorough history and physical exam should be performed. Particular attention must be paid to previous or remote history of infection, prior shoulder surgery, and medical comorbidities which may contribute to a suboptimal outcome for the patient. The physical exam should focus on evaluation of the soft tissue envelope, integrity of the deltoid and teres minor, and coexisting cervical spine issues which may affect the ability to achieve pain relief and improved function after reverse shoulder arthroplasty. Appropriate imaging with plain radiographs and CT scan will allow for preoperative templating. Unless otherwise contraindicated, all anticoagulant and antiplatelet therapy should be discontinued at least 5–7 days prior to intervention. Glycemic control should be optimized to reduce the risk of postoperative infection. Perioperative IV antibiotics such as a first-generation cephalosporin or vancomycin (for patients allergic to penicillin) are administered within an hour of intervention.

The patient after induction is placed in the Semi-Fowler position on the operative table utilizing a commercially available beach chair positioner that permits unencumbered access to the shoulder. The operative extremity is prepped and draped free for the intervention.

A majority of surgeons utilize the delto-pectoral approach, though the European experience has demonstrated viability with the superior-lateral technique. Each approach has its proponents, opponents, advantages, and disadvantages.


Cuff tear arthropathy Reverse shoulder arthroplasty Reverse shoulder arthroplasty surgical technique Lateralization of reverse shoulder arthroplasty Eccentric reaming Glenoid erosion 


  1. 1.
    Walch G, Wall B, Mottier F. Complications and revision of the reverse prosthesis, a multicenter study of 457 cases. In: Walch G, Boileau P, Mole D, Favard L, Levigne C, Sirveaux F, editors. Reverse shoulder arthroplasty: clinical results, complications, revision. Montpellier: Sauramps Medical; 2006. p. 335–52.Google Scholar
  2. 2.
    Gerber C, Pennington SD, Nyffeler RW. Reverse Total Shoulder Arthroplasty. J Am Acad Orthop Surg. 2009;17:284–95.CrossRefGoogle Scholar
  3. 3.
    Mole D, Favard L. Excentered scapulohumeral osteoarthritis [French]. Rev Chir Orthop Reparatrice Appar Mot. 2007;93(6 suppl):37–94.CrossRefGoogle Scholar
  4. 4.
    Clark JC, Ritchie J, Song FA, Kissenberth MJ, Tolan SF, Hart ND, Hawkins RJ. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elb Surg. 2012;21:36–41.CrossRefGoogle Scholar
  5. 5.
    Berhouet J, Garaud P, Favard L. Evaluation of the role of glenosphere design and humeral component retroversion in avoiding scapular notching during reverse shoulder arthroplasty. J Shoulder Elb Surg. 2014;23:151–8. Scholar
  6. 6.
    Boileau P, Watkinson DJ, Hatzidakis AM, Baig F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elb Surg. 2005;14(1 Suppl S):147S–61S.CrossRefGoogle Scholar
  7. 7.
    Nyffeler RW, Werner CW, Gerber C. Biomechanical relevance of glenoid component positioning in the reverse Delta III total shoulder prosthesis. J Shoulder Elb Surg. 2005;14:524–8.CrossRefGoogle Scholar
  8. 8.
    Simovitch RW, Zumstein MA, Lohri E, Helmy N, Gerber C. Predictors of scapular notching in patients managed with the Delta III reverse total shoulder replacement. J Bone Joint Surg Am. 2007;89:588–600.CrossRefGoogle Scholar
  9. 9.
    Gutierrez S, Comiskey CA 4th, Luo ZP, Pupello DR, Frankle MA. Range of impingement-free abduction and adduction deficit after reverse shoulder arthroplasty. Hierarchy of surgical and implant design-related factors. J Bone Joint Surg Am. 2008;90:2606–15.CrossRefGoogle Scholar
  10. 10.
    Edwards TB, Trappey GJ, Riley C, O'Connor DP, Elkousy HA, Gartsman GM. Inferior tilt of the glenoid component does not decrease scapular notching in reverse shoulder arthroplasty: results of a prospective randomized study. J Shoulder Elb Surg. 2012;21:641–6.CrossRefGoogle Scholar
  11. 11.
    Parsons BO, Gruson KI, Accousti KJ, Klug RA, Flatow EL. Optimal rotation and screw positioning for initial glenosphere baseplate fixation in reverse shoulder arthroplasty. J Shoulder Elb Surg. 2009;18:886–91.CrossRefGoogle Scholar
  12. 12.
    Gabor PJ, Catanzaro S, Gerber C. Clinical outcome of reverse total shoulder arthroplasty combined with latissimus dorsi transfer for the treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder. J Shoulder Elb Surg. 2014;23:49–57.CrossRefGoogle Scholar
  13. 13.
    Favre P, Loeb MD, Helmy N, Gerber C. Latissimus dorsi transfer to restore external rotation with reverse shoulder arthroplasty: a biomechanical study. J Shoulder Elb Surg. 2008;17:650–8.CrossRefGoogle Scholar
  14. 14.
    Boileau P, Rumian AP, Zumstein M. Reversed shoulder arthroplasty with modified L'Episcopo for combined loss of active elevation and external rotation. J Shoulder Elb Surg. 2010;19:20–30.CrossRefGoogle Scholar
  15. 15.
    Simovitch RW, Helmy N, Zumstein MA, Gerber C. Impact of fatty infiltration of the teres minor muscle on the outcome of reverse total shoulder arthroplasty. J Bone Joint Surg Am. 2007;89:934–9.CrossRefGoogle Scholar
  16. 16.
    Frankle MA, Teramoto A, Luo ZP, Levy JC, Pupello D. Glenoid morphology in reverse shoulder arthroplasty: classification and surgical implications. J Shoulder Elb Surg. 2009;18(6):874–85. Epub 2009 May 30.CrossRefGoogle Scholar
  17. 17.
    Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319–37.CrossRefGoogle Scholar
  18. 18.
    Norris TR, Iannotti JP. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elb Surg. 2002;11(2):130–5.CrossRefGoogle Scholar
  19. 19.
    Singh JA, Sperling JW, Cofield RH. Revision surgery following total shoulder arthroplasty: analysis of 2588 shoulders over three decades (1976 to 2008). J Bone Joint Surg Br. 2011;93(11):1513–7.CrossRefGoogle Scholar
  20. 20.
    Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty 1999;14(6):756–760.Google Scholar
  21. 21.
    Iannotti JP, Norris TR. Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am. 2003;85(2):251–8.CrossRefGoogle Scholar
  22. 22.
    Walch G, Moraga C, Young A, Castellanos-Rosas J. Results of anatomic nonconstrained prosthesis in primary osteoarthritis with biconcave glenoid. J Shoulder Elb Surg. 2012;21(11):1526–33. Epub 2012 Mar 23.CrossRefGoogle Scholar
  23. 23.
    Nyffeler RW, Sheikh R, Atkinson TS, Jacob HAC, Favre P, Gerber C. Effects of glenoid component version on humeral head displacement and joint reaction forces: an experimental study. J Shoulder Elb Surg. 2006;15(5):625–9.CrossRefGoogle Scholar
  24. 24.
    Bryce CD, Davison AC, Okita N, Lewis GS, Sharkey NA, Armstrong AD. A biomechanical study of posterior glenoid bone loss and humeral head translation. J Shoulder Elb Surg. 2010;19(7):994–1002. Epub 2010 Jul 24.CrossRefGoogle Scholar
  25. 25.
    Matsen FA 3rd, Clinton J, Lynch J, Bertelsen A, Richardson ML. Glenoid component failure in total shoulder arthroplasty. J Bone Joint Surg Am. 2008;90(4):885–96.CrossRefGoogle Scholar
  26. 26.
    Farron A, Terrier A, Büchler P. Risks of loosening of a prosthetic glenoid implanted in retroversion. J Shoulder Elb Surg. 2006;15(4):521–6.CrossRefGoogle Scholar
  27. 27.
    Shapiro TA, McGarry MH, Gupta R, Lee YS, Lee TQ. Biomechanical effects of glenoid retroversion in total shoulder arthroplasty. J Shoulder Elb Surg. 2007;16(3 Suppl):S90–5. Epub 2006 Dec 12.CrossRefGoogle Scholar
  28. 28.
    Walch G, Young AA, Boileau P, Loew M, Gazielly D, Mol’e D. Patterns of loosening of polyethylene keeled glenoid components after shoulder arthroplasty for primary osteoarthritis: results of a multicenter study with more than five years of follow-up. J Bone Joint Surg Am. 2012;94(2):145–50.CrossRefGoogle Scholar
  29. 29.
    Gillespie R, Lyons R, Lazarus M. Eccentric reaming in total shoulder arthroplasty: a cadaveric study. Orthopedics. 2009;32(1):21.CrossRefGoogle Scholar
  30. 30.
    Clavert P, Millett PJ, Warner JJ. Glenoid resurfacing: what are the limits to asymmetric reaming for posterior erosion? J Shoulder Elb Surg. 2007;16(6):843–8.CrossRefGoogle Scholar
  31. 31.
    Iannotti JP, Greeson C, Downing D, Sabesan V, Bryan JA. Effect of glenoid deformity on glenoid component placement in primary shoulder arthroplasty. J Shoulder Elb Surg. 2012;21(1):48–55. Epub 2011 May 20.CrossRefGoogle Scholar
  32. 32.
    Nowak DD, Bahu MJ, Gardner TR, Dyrszka MD, Levine WN, Bigliani LU, Ahmad CS. Simulation of surgical glenoid resurfacing using three-dimensional computed tomography of the arthritic glenohumeral joint: the amount of glenoid retroversion that can be corrected. J Shoulder Elb Surg. 2009;18(5):680–8. Epub 2009 May 31.CrossRefGoogle Scholar
  33. 33.
    Friedman RJ, Hawthorne KB, Genez BM. The use of computerized tomography in the measurement of glenoid version. J Bone Joint Surg Am. 1992;74(7):1032–7.CrossRefGoogle Scholar
  34. 34.
    Hill JM, Norris TR. Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid. J Bone Joint Surg Am. 2001;83(6):877–83.CrossRefGoogle Scholar
  35. 35.
    Sabesan V, Callanan M, Ho J, Iannotti JP. Clinical and radiographic outcomes of total shoulder arthroplasty with bone graft for osteoarthritis with severe glenoid bone loss. J Bone Joint Surg Am. 2013;95(14):1290–6.CrossRefGoogle Scholar
  36. 36.
    Friedman RJ, Hawthorne KB, Genez BM. Glenoid augmentation for total shoulder arthroplasty. Orthop Trans. 1992;16:66.Google Scholar
  37. 37.
    Cheung EV, Sperling JW, Cofield RH. Reimplantation of a glenoid component following component removal and allogenic bone-grafting. J Bone Joint Surg Am. 2007;89(8):1777–83.CrossRefGoogle Scholar
  38. 38.
    Mizuno N, Denard PJ, Raiss P, Walch G. Reverse total shoulder arthroplasty for primary glenohumeral osteoarthritis in patients with a biconcave glenoid. J Bone Joint Surg Am. 2013;95(14):1297–304.CrossRefGoogle Scholar
  39. 39.
    Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89(7):1476–85.PubMedGoogle Scholar
  40. 40.
    Rice RS, Sperling JW, Miletti J, Schleck C, Cofield RH. Augmented glenoid component for bone deficiency in shoulder arthroplasty. Clin Orthop Relat Res. 2008;466(3):579–83. Epub 2008 Jan 8.CrossRefGoogle Scholar
  41. 41.
    Sabesan V, Callanan M, Sharma V, Iannotti JP. Correction of acquired glenoid bone loss in osteoarthritis with a standard versus an augmented glenoid component. J Shoulder Elb Surg. 2014;23(7):964–73. Epub 2014 Jan 7.CrossRefGoogle Scholar
  42. 42.
    Kirane YM, Lewis GS, Sharkey NA, Armstrong AD. Mechanical characteristics of a novel posterior-step prosthesis for biconcave glenoid defects. J Shoulder Elb Surg. 2012;21(1):105–15. Epub 2011 Mar 21.CrossRefGoogle Scholar
  43. 43.
    Iannotti JP, Lappin KE, Klotz CL, Reber EW, Swope SW. Liftoff resistance of augmented glenoid components during cyclic fatigue loading in the posterior-superior direction. J Shoulder Elb Surg. 2013;22(11):1530–6. Epub 2013 Mar 22.CrossRefGoogle Scholar
  44. 44.
    Allen B, Schoch B, Sperling JW, Cofield RH. Shoulder arthroplasty for osteoarthritis secondary to glenoid dysplasia: an update. J Shoulder Elb Surg. 2014;23(2):214–20. Epub 2013 Aug 9.CrossRefGoogle Scholar
  45. 45.
    Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. Neer Award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elb Surg. 2006;15:527–40.CrossRefGoogle Scholar
  46. 46.
    Terrier A, Reist A, Merlini F, Farron A. Simulated joint and muscle forces in reversed and anatomic shoulder prostheses. J Bone Joint Surg Br. 2008;90:751–6.CrossRefGoogle Scholar
  47. 47.
    Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am. 2006;88:1742–7.CrossRefGoogle Scholar
  48. 48.
    Levigne C, Boileau P, Favard L, Garaud P, Molé D, Sirveaux F, Walch G. Scapular notching in reverse shoulder arthroplasty. In: Walch G, Boileau P, Molé D, Favard L, Lévigne C, Sirveaux F, editors. Reverse shoulder arthroplasty. Montpellier: Sauramps Medical; 2006. p. 353–72.Google Scholar
  49. 49.
    Matsen FA 3rd, Boileau P, Walch G, Gerber C, Bicknell RT. The reverse total shoulder arthroplasty. Instr Course Lect. 2008;57:167–74.Google Scholar
  50. 50.
    Vanhove B, Beugnies A. Grammont’s reverse shoulder prosthesis for rotator cuff arthropathy: a retrospective study of 32 cases. Acta Orthop Belg. 2004;70:219–25.PubMedGoogle Scholar
  51. 51.
    Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87:1476–86.PubMedGoogle Scholar
  52. 52.
    Nové-Josserand L, Walch G. Instability after reverse shoulder arthroplasty. In: Walch G, Boileau P, Molé D, Favard L, Lévigne C, Sirveaux F, editors. Reverse shoulder arthroplasty. Montpellier: Sauramps Medical; 2006. p. 81–101.Google Scholar
  53. 53.
    Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elb Surg. 2007;16:717–21.CrossRefGoogle Scholar
  54. 54.
    Valenti P, Sauzieres P, Cogswell L, O’Toole G, Katz D. The reverse shoulder prosthesis: surgical technique. Tech Hand Up Extrem Surg. 2008;12:46–55.CrossRefGoogle Scholar
  55. 55.
    Frankle M, Levy JC, Pupello D, Siegal S, Saleem A, Mighell M, Vasey M. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients: surgical technique. J Bone Joint Surg Am. 2006;88(Suppl 1):178–90.CrossRefGoogle Scholar
  56. 56.
    Harman M, Frankle M, Vasey M, Banks S. Initial glenoid component fixation in ‘reverse’ total shoulder arthroplasty: a biomechanical evaluation. J Shoulder Elb Surg. 2005;14(1 Suppl S):162S–7S.CrossRefGoogle Scholar
  57. 57.
    Cuff D, Pupello D, Virani N, Levy J, Frankle M. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint Surg Am. 2008;90:1244–51.CrossRefGoogle Scholar
  58. 58.
    Boileau P, Moineau G, Roussanne Y, O’Shea K. Bony increased-offset reversed shoulder arthroplasty minimizing scapular impingement while maximizing glenoid fixation. Clin Orthop Relat Res. 2011;469:2558–67.CrossRefGoogle Scholar
  59. 59.
    Sirveaux F, Favard L, Oudet D, Huguet D, Lautman S. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive and non repairable cuff rupture. In: Walch G, Boileau P, Mole D, editors. 2000 Shoulder prostheses: two to ten year follow-up. Montpellier: Sauramps Medical; 2001. p. 247–52.Google Scholar
  60. 60.
    Boulahia A, Edwards TB, Walch G, Baratta RV. Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear. Orthopedics. 2002;25:129–33.PubMedGoogle Scholar
  61. 61.
    Costantini O, Choi DS, Kontaxis A, Gulotta LV. The effects of progressive lateralization of the joint center of rotation of reverse total shoulder implants. J Shoulder Elb Surg. 2015;24(7):1120–8. Scholar
  62. 62.
    Greiner S, Schmidt C, König C, Perka C, Herrmann S. Lateralized reverse shoulder arthroplasty maintains rotational function of the remaining rotator cuff. Clin Orthop Relat Res. 2013;471(3):940–6. Scholar
  63. 63.
    de Wilde LF, Poncet D, Middernacht B, Ekelund A. Prosthetic overhang is the most effective way to prevent scapular conflict in a reverse total shoulder prosthesis. Acta Orthop. 2010;81(6):719–26. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Stefano Gumina
    • 1
    Email author
  • Kamal I. Bohsali
    • 2
  • Michael A. Wirth
    • 3
  1. 1.Department of Orthopaedics and TraumatologySapienza University of RomeRomeItaly
  2. 2.BOSMJacksonvilleUSA
  3. 3.Orthopaedic SurgeryUniversity of Texas HSC-San AntonioSan AntonioUSA

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