Fig. 1 Radiograph of a reverse total shoulder arthroplasty.
Courtesy of Sumant G. Krishnan, MD


Published 6/1/2008
Peter Pollack

A superior approach for reverse TSAs

Early outcomes show high satisfaction, low complications

Reverse total shoulder arthroplasty (TSA) has gained acceptance for complex shoulder conditions, yet the proper surgical approach remains controversial. Support for using a superior approach was presented at the 6th Biennial AAOS/American Shoulder and Elbow Surgeons (ASES) Meeting by Sumant G. Krishnan, MD.

His retrospective review of the results of 100 primary reverse TSAs (Fig. 1) performed using a superior approach found that early results demonstrated successful outcomes with relatively few complications, especially with regard to postoperative instability and hematoma formation.

The research team from the Shoulder Service at the Carrell Clinic (Dallas, Texas) included Dr. Krishnan, Kenneth C. Lin, MD, and Wayne Z. Burkhead Jr, MD. They conducted a retrospective review of the first 100 consecutive reverse TSAs using a superior approach performed by two surgeons at a single institution. Patients ranged in age from 70 years to 85 years (mean: 73 years old). None of the surgeries were revision arthroplasties.

Before the TSA, the mean preoperative ASES score was 45; it increased to 74 (p<0.05) after surgery. active anterior elevation improved from a mean of 60 degrees before surgery to 128 degrees after surgery (>p<0.05). pain levels decreased from 8.1 preoperative to 0.9 postoperative (scale: 0 [no pain] to 10). overall patient satisfaction was determined to be 9.4 (scale: 0 to 10 [completely satisfied]).>

Overall, complications occurred in only 10 patients (10 percent) and included the following:

  • 5 hematomas, none of which required drainage
  • 2 acromial stress fractures treated nonsurgically
  • 1 infection treated with successful component retention
  • No episodes of instability
  • No complications related to deltoid function or healing

The avoidance of instability was a noted difference when compared to deltopectoral approaches for reverse TSA, which have historically demonstrated much higher incidences of postoperative instability. Although a theoretical concern is that the superior approach must detach and repair the deltoid (the primary muscle responsible for reverse TSA function), this series had no deltoid-related problems.

These early results of reverse TSA through a superior approach demonstrated successful outcomes with relatively fewer complications and no deltoid problems, but Dr. Krishnan cautioned that long-term follow-up is necessary to determine the durability of these implants and outcomes.

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Peter Pollack is a staff writer for AAOS Now. He can be contacted at