Shoulder Arthroplasty (Total / Reverse)
Right [left] glenohumeral [osteoarthritis / rotator cuff arthropathy / irreparable rotator cuff tear / proximal humerus fracture / avascular necrosis], end-stage, not responsive to conservative management
Same
Right [left] [total / reverse total] shoulder arthroplasty, [implant manufacturer/model]
[***, MD/DO]
[Resident/PA name]
General endotracheal with interscalene nerve block
The patient is a [age]-year-old [male / female] with end-stage glenohumeral [osteoarthritis / rotator cuff arthropathy] presenting with refractory shoulder pain and functional limitation. Conservative management has been exhausted.
[For anatomic TSA: the rotator cuff is intact and functional. Glenohumeral osteoarthritis is the primary indication.]
[For RSA: the rotator cuff is irreparably torn / deficient, precluding anatomic total shoulder replacement. Reverse configuration chosen to restore deltoid-driven elevation independent of rotator cuff integrity.]
Risks including infection, instability, implant loosening, axillary nerve injury, rotator cuff failure, stiffness, and need for revision were discussed. Informed consent was obtained.
The glenohumeral joint demonstrated complete articular cartilage loss with eburnated humeral head and [posterior / concentric] glenoid wear. Glenoid version was [neutral / [X]° retroversion] on preoperative imaging. The subscapularis was [intact / repairable / irreparable]. [For TSA: the rotator cuff was intact / had a [repairable] partial/full-thickness tear.] [For RSA: the rotator cuff was [absent / irreparably torn / deficient].] The axillary nerve was protected at the inferior margin of the subscapularis[, its location confirmed by palpation]. Implants: [manufacturer/model, glenoid component/baseplate size X, glenosphere [X] mm (RSA), humeral stem size X, humeral head [X] mm / liner size X].
The patient was positioned in the beach chair position. The shoulder was prepped and draped. A deltopectoral approach was used. The deltopectoral interval was developed; the cephalic vein was identified and protected, retracted [medially / laterally].
The axillary nerve was protected at the inferior margin of the subscapularis throughout the procedure[, its location confirmed by palpation].
The subscapularis was released by [lesser tuberosity osteotomy / tendon takedown at the musculotendinous junction]. The anterior capsule was excised. The humeral head was delivered into the wound.
[TOTAL SHOULDER (ANATOMIC):]
The humeral head was resected at the anatomic neck at approximately [135°] inclination (neck-shaft angle) and [20–30°] of retroversion referenced to the forearm transepicondylar axis, using the intramedullary guide. The canal was broached sequentially to size [X]. The glenoid was prepared with central drilling and sequential reaming. A [keeled / pegged / hybrid cage] polyethylene glenoid component was [cemented / press-fit with cementless central peg] at [neutral / corrected] version. The humeral stem was [press-fit / cemented]. A trial reduction confirmed stability, appropriate head offset, and no impingement through functional range of motion.
[REVERSE TOTAL SHOULDER (RSA):]
The glenoid was reamed and the baseplate was fixed with a central [peg / screw] and [X] peripheral [locking / compression] screws, seated flush on the reamed glenoid with no rocking. A [36 / 40]-mm glenosphere was assembled and impacted onto the baseplate. The humeral canal was broached to size [X]. A humeral tray and polyethylene liner were assembled. Trial reduction confirmed stable range of motion, appropriate deltoid tension, and no impingement in adduction/internal rotation. Final implants were impacted.
[For anatomic TSA: The subscapularis was repaired through bone tunnels [/ with heavy non-absorbable suture]. Repair integrity was confirmed through passive range of motion.]
[For RSA: The subscapularis was [repaired with heavy suture / not repaired — repair was deferred given concern for external rotation restriction].]
The wound was irrigated. The deltopectoral interval was approximated. Skin was closed with [3-0 Monocryl].
None
Humeral head sent to pathology [if indicated]
[X] mL
None
The patient was taken to the PACU in a shoulder immobilizer. [For TSA: pendulum exercises at 24 hours; sling for 4–6 weeks per protocol.] [For RSA: immediate gentle passive ROM; sling for 4–6 weeks per protocol.] Physical therapy began on postoperative day 1.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left glenohumeral ***, end-stage
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left [total / reverse total] shoulder arthroplasty, *** implant
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General + interscalene block
INDICATIONS: .PTAGE-year-old .PTSEX with end-stage glenohumeral ***, failed conservative treatment. [TSA: cuff intact and functional.] [RSA: irreparable cuff deficiency.] Consent obtained.
FINDINGS: Cartilage loss, eburnate ***. Glenoid version ***. Subscapularis ***. Cuff ***. Axillary nerve protected [palpated]. Implants: ***.
PROCEDURE:
Beach chair. Deltopectoral approach. Cephalic vein preserved. Axillary nerve protected at the inferior subscapularis margin [palpated]. Subscapularis released via ***. Anterior capsule excised. Humeral head delivered. [TSA: Humeral cut at *** inclination, *** retroversion relative to forearm axis. Canal broached to size ***. Glenoid reamed, *** polyethylene component cemented/press-fit at *** version.] [RSA: Glenoid reamed. Baseplate fixed with central peg + *** peripheral screws, flush, no rocking. *** mm glenosphere assembled. Canal broached ***. Humeral tray and poly liner assembled. Deltoid tension appropriate; no impingement.] Trials: stable, appropriate offset/tension. Final implants seated. [Subscapularis repaired through bone tunnels with *** suture. / Subscapularis not repaired.] Wound irrigated. Closed 3-0 Monocryl.
EBL: *** mL
COMPLICATIONS: None
DISPOSITION: Immobilizer. PT POD 1. Sling *** weeks.
Signed: .ME, .MYDEGREE
.TODAYVariants
Hemiarthroplasty — humeral head replacement
Humeral head replacement without glenoid component. Indications: isolated humeral head AVN with preserved glenoid cartilage, or selected fracture presentations in patients where RSA is not appropriate. If hemiarthroplasty is performed for fracture: greater and lesser tuberosities are repaired to the prosthetic stem with heavy non-absorbable suture in cerclage and horizontal configuration, restoring rotator cuff footprints. A stemmed prosthesis is required for fracture — stemless designs are NOT appropriate for fracture hemiarthroplasty (stem required for rotational stability and tuberosity reattachment).
Revision shoulder arthroplasty
Reporting selection is determined by the number of components exchanged, not the complexity of dissection. Indications include glenoid loosening, humeral stem loosening, periprosthetic fracture, instability, infection (second-stage reimplantation), and rotator cuff failure requiring conversion from anatomic TSA to RSA. Increased-service reporting may be appropriate for unusually complex revisions when operative time and specific challenges are documented. Intraoperative cultures are recommended for all revision cases to screen for Cutibacterium acnes, which requires a culture hold of at least 10–14 days.
Charting Tips
- Document humeral cut parameters separately: inclination (neck-shaft angle, approximately 135°) and retroversion (approximately 20–30° referenced to the forearm transepicondylar axis). Inclination and retroversion are distinct anatomic parameters — confusing them produces an inaccurate operative note. Correct documentation: 'humeral head resected at [135°] inclination with [25°] retroversion referenced to the forearm axis.'
- Document axillary nerve protection. The axillary nerve runs inferior to the subscapularis in the quadrangular space and is at risk during subscapularis takedown, inferior capsular release, and humeral head delivery. In a primary case it is protected by an inferior retractor and by palpation rather than formally dissected out, so document what was actually done: 'the axillary nerve was protected at the inferior margin of the subscapularis (palpated).' Reserve 'identified' for cases where the nerve was truly visualized, such as revision or distorted anatomy.
- Document glenoid component fixation details. For standard all-poly cemented glenoid: central drill depth, peg/keel seating, cement pressurization, and that no rocking occurred. For RSA baseplate: number of peripheral screws and that baseplate seated flush with no rocking on intraoperative testing — baseplate micromotion leads to catastrophic early loosening.
- Document subscapularis repair details for anatomic TSA. Repair method (lesser tuberosity osteotomy vs. tendon repair), suture type and number, and that repair held through passive range of motion testing. For RSA, document whether subscapularis was repaired or not and the rationale — subscapularis repair after RSA may limit external rotation and is a deliberate surgical decision, not an omission.
- Document stability testing through functional arc. For TSA, test anterior stability at 90° abduction/external rotation AND posterior stability with posteriorly directed load at 90° forward flexion — posterior instability is the more common post-TSA failure mode. For RSA, document that no impingement position (adduction/internal rotation against glenoid neck) was identified and that the arm elevated to at least [X]° without subluxation.
Documentation & Reimbursement Considerations
- Report Shoulder Arthroplasty (Total / Reverse) as the primary service when it is the definitive operation performed.
- Document the configuration (anatomic vs. reverse), implant manufacturer, model, and component sizes. Indication must support the configuration chosen: anatomic TSA requires an intact, functional rotator cuff; RSA is indicated for rotator cuff deficiency, cuff tear arthropathy, or cases where the cuff cannot support anatomic TSA.
- Indications include humeral head AVN with preserved glenoid cartilage, and selected fracture presentations.
- Either revision code also accounts for allograft use when needed.
- 90-day global period. Related unplanned return-to-the-operating-room reporting does not reset the global period.