Tips for Preventing and Managing Complications of TSA

    Despite efforts to prevent them, complications of total shoulder arthroplasty (TSA) – instability, stiffness, loosening, fracture, cuff tear, infection, and neurovascular injury – do occur.

    How can the risk of these postoperative complications be minimized? Richard Friedman, MD, FRCSC, shared his recommendations for preventing and managing complications of TSA at ICJR’s annual Shoulder Course in Las Vegas.

    Prevention of Anterior Instability

    • Ensurer proper humeral version
    • Secure the subscapularis repair
    • Avoid excessive glenoid anteversion

    Management of Anterior Instability

    • Repair the subscapularis; early detection is important to avoid difficulty with mobilization and fixation
    • Revise the humeral stem if there is inappropriate humeral version
    • Exchange humeral head with retroversion
    • Revise the glenoid with corrected version

    Prevention of Posterior Instability

    • Ensure proper humeral version
    • Identify and tighten a lax or redundant posterior capsule by imbricating it
    • Avoid excessive glenoid retroversion

    Management of Posterior Instability

    • Perform a posterior capsular shift
    • Revise the humeral stem
    • Exchange humeral head with retroversion
    • Revise glenoid with corrected version

    Prevention of Anterosuperior Instability

    • Avoid excessive acromioplasty
    • Retain the coracoacromial ligament
    • Repair the remaining rotator cuff tendons
    • Adjust thickness of head height to balance anterior and posterior tissues
    • Recognize preoperative and perform a reverse total shoulder arthroplasty

    Management of Anterosuperior Instability

    • Reconstruct the coracoacromial ligament with a fascia lata graft (historical interest only)
    • Revise to reverse total shoulder arthroplasty

    Prevention of Limited Range of Motion

    • Remove humeral and glenoid osteophytes
    • Complete the capsular release
    • Lengthen the subscapularis (30° external rotation)
    • Avoid oversized humeral head; adjust head height accordingly

    Management of Limited Range of Motion

    • Prescribe aggressive physical therapy
    • Manipulate under anesthesia
    • Perform arthroscopic capsular release
    • Perform open capsular release
    • Revise humeral head (most cases)

    Prevention of Glenoid Loosening

    • Strive for 100% congruency between component and bone
    • Use modern cement technique
    • Protect/repair the rotator cuff
    • Avoid in rotator cuff deficiency

    Management of Glenoid Loosening

    • Revise glenoid component
    • Convert to hemiarthroplasty
    • Convert to reverse total shoulder arthroplasty

    Prevention of Humeral Loosening

    • Ensure proper alignment and version
    • Ensure adequate press fit
    • Use modern cement technique for deficient bone to ensure good fixation

    Management of Humeral Loosening

    • Revise the humeral component

    Prevention of Humeral Fracture

    • Ensure adequate exposure
    • Avoid eccentric or excessive reaming
    • Use hand reaming in osteopenic bone
    • Avoid “orthopaedic” impaction; tap gently

    Management of Humeral Fracture

    • Use a coaptation splint for a nondisplaced fracture
    • Perform open reduction and internal fixation with cable wires if needed
    • Revise with a long-stem component that is 2.5 times the diameter at the level of the fracture for adequate fixation of the distal fragment

    Prevention of Impingement/Cuff Tears

    • Protect the rotator cuff during surgery
    • Keep the humeral head 5-10 mm above the tuberosity ; anything less may cause impingement, while anything more puts overstretch on the cuff, causing pain, stiffening, cuff rupture
    • Avoid large components to prevent overhang in any direction
    • Avoid overstuffing the joint

    Management of Impingement/Cuff Tears

    • Perform open/arthroscopic subacromial decompression
    • Perform an open rotator cuff repair
    • Revise to a reverse total shoulder arthroplasty

    Prevention of Infection

    • Check for adequate nutritional status (albumin, total lymphocyte count, serum transferrin)
    • Prescribe preoperative scrubs with chlorhexdine
    • Administer prophylactic antibiotics
    • Maintain strict sterile technique

    Management of Infection

    • Perform aggressive early debridement
    • Exchange primary prosthesis (not commonly done)
    • Perform resection arthroplasty with cement spacer and delayed reimplantation

    Prevention of Neurovascular Injury

    • Document preoperative neurovascular function (key point)
    • Ensure adequate exposure
    • Be aware of the location of the musculocutaneous and axillary nerves

    Management of Neurovascular Injury

    • Observe the patient
    • Explore and repair/grafting

    Dr. Friedman’s presentation can be found here.