Implant and fixation options

Anatomic total shoulder arthroplasty (aTSA) is the reference standard for primary glenohumeral osteoarthritis with an intact cuff; reverse total shoulder arthroplasty (rTSA) is now the most frequently implanted construct overall in the UK. Most current systems are convertible platforms, sharing a humeral stem between anatomic and reverse configurations. Stemless anatomic implants and, in narrow indications, resurfacing and hemiarthroplasty complete the range.

Component vocabulary. Humeral side: stemmed (standard, short or stemless), with a neck-shaft angle that may be anatomic or, in reverse, 135 to 155 degrees, and an inlay or onlay tray. Glenoid side: in anatomic, a pegged or keeled polyethylene (or hybrid) component; in reverse, a metal baseplate with a central post or screw plus peripheral locking screws, carrying a glenosphere (commonly 36 to 42 mm, with eccentric and lateralised options). Augmented (half- or full-wedge) baseplates and bone grafting (BIO-RSA) address glenoid wear.

Note. rTSA baseplate fixation uses a central post or screw with peripheral locking screws; augmented baseplates, BIO-RSA and patient-specific components address glenoid bone loss. Confirm current ODEP construct ratings before selection.

Total elbow arthroplasty (TEA) is most established for inflammatory arthropathy and for selected distal humeral fractures and their sequelae in lower-demand patients. Implants are linked (semi-constrained) or unlinked, and most are cemented with an anterior humeral flange. Distal humeral hemiarthroplasty is an alternative for unreconstructable fractures with intact columns.

Note. Newer linked and convertible designs have not yet matched the long-term survivorship data of the Coonrad-Morrey, which remains the benchmark.

Most proximal humeral fractures are managed non-operatively. When surgery is indicated, the main reconstructive options are locking-plate ORIF and angle-stable intramedullary nailing for reconstructable patterns, with arthroplasty reserved for unreconstructable head fractures, head-split patterns and selected elderly patients.

Note. Suture-only and minimally invasive techniques are used for selected lower-demand patients.

Many humeral shaft fractures unite with functional bracing. Surgery is indicated for open injuries, vascular injury, polytrauma, floating elbow, certain fracture patterns, failure of bracing and some radial nerve presentations. The principal options are plate ORIF and intramedullary nailing.

Note. Approach-related morbidity and radial nerve handling differ between plate and nail and inform the choice.

Intra-articular (AO/OTA type 13-C) distal humeral fractures are treated by dual-column locking-plate ORIF, usually through an olecranon osteotomy. Total elbow arthroplasty or distal humeral hemiarthroplasty is an alternative for unreconstructable fractures in selected, typically older or inflammatory, patients.

Note. The olecranon osteotomy used for exposure is itself fixed by tension-band wiring or a plate (see olecranon).

Olecranon fractures are largely operative because of the displacing pull of triceps. Fixation is selected on fracture pattern, comminution and patient demand: simple transverse fractures suit tension-band wiring, while comminuted, oblique and Monteggia-associated patterns favour a precontoured locking plate.

Most clavicle fractures are managed non-operatively. Fixation is considered for displaced or shortened midshaft fractures, open injuries, skin compromise, and unstable lateral-third fractures with coracoclavicular ligament disruption. Plating is the usual construct, by a superior or anterior approach, with intramedullary devices and dedicated distal-clavicle plates as alternatives.

Note. Distal-clavicle and acromioclavicular problems overlap; see also the AC joint section for hook plates and coracoclavicular suspensory fixation.

Anterior instability is the commonest pattern. Soft-tissue (arthroscopic Bankart) repair with suture anchors is the workhorse where bone loss is low; significant glenoid bone loss or failed soft-tissue repair shifts management to bony reconstruction (Latarjet or free bone block). Engaging Hill-Sachs lesions may be addressed with remplissage. Posterior and multidirectional patterns have their own algorithms.

Note. Suture-button and all-suture coracoid fixation is increasingly used in place of screws to reduce implant-related revision; weigh graft union against hardware profile.

Low-grade AC injuries (Rockwood I-II) are managed non-operatively. High-grade injuries (types III-VI, with type III individualised) may be reconstructed. Acute injuries can heal with a stabilising construct, whereas chronic instability generally needs a biological or synthetic ligament reconstruction.

Note. Loss of reduction and hardware complications differ between constructs; chronic reconstructions augment biology rather than rely on fixation alone.

Reparable full-thickness cuff tears are most often repaired arthroscopically with suture anchors in a single-row or, more commonly, a double-row / transosseous-equivalent (suture-bridge) construct. Anchor bodies may be hard (titanium, PEEK or biocomposite) screw-in, or all-suture; constructs may be knotted or knotless. Irreparable tears are addressed with augmentation, superior capsular reconstruction, tendon transfer or reverse arthroplasty.

Anchor body materials. Titanium (strongest, MRI artefact); PEEK (non-absorbable polymer, radiolucent); PLLA; biocomposite (PLGA with B-TCP or calcium sulfate, osteoconductive and intended to be replaced by bone); all-suture (a UHMWPE or polyester sleeve that balls up under cortex, smallest bone footprint, smallest drill hole). High-strength sutures and tapes (for example FiberWire, FiberTape, ULTRABRAID, ORTHOCORD, MaxBraid, Hi-Fi) carry the repair.

Note. Healing rates fall with tear size, age and tissue quality; construct choice is one of several factors in outcome.

Tenodesis of the long head of biceps is performed for symptomatic tendinopathy, instability, SLAP pathology in older patients and as an adjunct to cuff repair. Fixation can be suprapectoral or subpectoral and uses an interference screw, a cortical button, a suture anchor or a soft-tissue technique. Tenotomy is a simpler alternative where cramping and a Popeye deformity are acceptable.