Top 10 Tips for Glenoid Exposure

    Dr. Gerald Williams offers his advice for achieving good glenoid exposure in a total shoulder arthroplasty.

    Good glenoid exposure is the most difficult part of a total shoulder arthroplasty – and the most important.

    Gerald R. Williams, Jr., MD, from The Rothman Institute in Philadelphia, Pennsylvania, recently shared his top 10 tips for achieving good glenoid exposure, most of which, he says, he “learned through the school of hard knocks.”

    In the style of David Letterman’s nightly top 10 list, Dr. Williams started at 10 and worked his way up to his number 1 tip:

    10. Tilt the table away from the side of the operation, particularly in patients with glenoid wear.

    9. Have more than one type and more than one set of retractors available in the operating room.

    8. Remove humeral osteophytes before attempting glenoid exposure. Reducing the size of the humerus is one of the most important ways of improving glenoid exposure, Dr. Williams said.

    7. Make the humeral cut at or near the supraspinatus – even 5 mm of extra humeral length can make exposure of the glenoid difficult in some patients.

    6. In general, the humerus should be in neutral or slight external rotation. Dr. Williams has found that extreme positions make glenoid exposure more difficult.

    5. Retractors are typically placed in front of the scapula, between the humerus and the glenoid, and posterior superiorly to move the deltoid out of the way. Some patients may need additional retractors.

    4. A laminar spreader opens up the joint, allowing for posterior glenohumeral joint exposure. Dr. Williams credited Dr. Joseph Iannotti with this innovation.

    3. Maximum humeral capsular release is important and is done early in the procedure. Release to the 6 o’clock position is insufficient, Dr. Williams said; the release must go past 6 o’clock for good glenoid exposure.

    2. Excise or release the anteroinferior capsule. In patients with osteoarthritis, Dr. Williams excises the capsule from the base of the coracoid to the 6 o’clock position.

    1. Release the posteroinferior capsule for the last bit of posterior displacement, which Dr. Williams said is helpful in exposure. Be careful, though, with patients who have superior subluxation.