Shoulder Arthroplasty Instrument Set: Replacement Tools

Ask a shoulder surgeon what makes a replacement go badly and the answer is rarely the implant. It is exposure. The glenoid sits deep, faces away from the incision, and is guarded by a humeral head that does not want to move. If the retractors on the tray cannot get that head out of the way and hold it there, every later step — reaming, peg drilling, cementing, trialling — becomes slower and less accurate.

That is why a well-built shoulder arthroplasty tray is mostly a retraction tray. The implant company brings its own cutting guides, reamers and trials on loan. The hospital’s reusable set has to deliver everything else: the approach, the soft-tissue handling, the head and glenoid exposure, bone work around the proximal humerus, and a secure closure of subscapularis or the lesser tuberosity.

Below is how we break that set down for hospitals and distributors, what each instrument does at each stage, and what to check when you buy.

Which Operation Is the Tray For?

Three procedures share most of the same base tray:

• Anatomic total shoulder arthroplasty (TSA) — humeral head replaced, glenoid resurfaced with a polyethylene component. Requires an intact rotator cuff. Glenoid exposure is the critical step.
• Reverse total shoulder arthroplasty (RSA) — ball placed on the glenoid (glenosphere on a baseplate), socket on the humerus. Used for cuff-deficient shoulders, cuff tear arthropathy and many proximal humerus fractures in older patients. The baseplate is fixed with screws, so drills and a depth gauge matter more.
• Hemiarthroplasty — humeral side only. Less glenoid work, but fracture cases add tuberosity repair, which needs heavy suture handling and often bone-tunnel instruments.

Most units run all three through the deltopectoral approach: an incision from the coracoid toward the deltoid insertion, developing the interval between deltoid and pectoralis major with the cephalic vein usually taken laterally with the deltoid. Some surgeons use an anterosuperior approach for reverse shoulders. The retractor selection changes a little between them, so it is worth asking which approach the unit prefers before finalising a set list.

Exposure and Superficial Retraction

The opening is standard general-surgery work: a No. 3 or No. 4 scalpel handle with No. 10 and No. 15 blades, toothed Adson and heavier DeBakey or Ferris-Smith dissecting forceps, curved Mayo and Metzenbaum scissors, and a supply of artery forceps for the perforators crossing the deltopectoral interval.

Once the interval is open, the self-retaining retractor goes in. Choices vary by preference:

• Gelpi or Weitlaner retractors for the skin and subcutaneous layer — compact and quick, but they only hold the superficial tissues. See our Weitlaner vs Gelpi comparison for blade depths.
• Dedicated shoulder self-retaining retractors (a Kölbel-type frame or two-arm designs with interchangeable deep blades) that hold deltoid laterally and the conjoint tendon medially. These free an assistant for the deep work.
• Deltoid retractors — broad, curved hand-held blades that hook under the deltoid. A Richardson or Browne-pattern deltoid retractor is common on the tray.

Medially, the conjoint tendon (short head of biceps and coracobrachialis) needs gentle retraction because the musculocutaneous nerve enters it a few centimetres below the coracoid. A blunt, smooth retractor is preferred here — never a sharp rake.

Subscapularis Management

The subscapularis covers the front of the joint and has to be released to dislocate the humeral head. Three techniques are in use, and each puts slightly different demands on the tray:

Stay sutures are placed in the tendon edge before release. Small, light clamps such as mosquito forceps hold them out of the field, and a pair of towel clips at the drape edge keeps the bundle organised. Whichever technique is used, closure later needs a robust needle holder — a 20 cm Mayo-Hegar with tungsten carbide inserts is the usual choice for heavy braided sutures.

Humeral Head Retraction — the Make-or-Break Step

After subscapularis release and capsular work, the arm is externally rotated and extended to dislocate the head anteriorly. A bone hook or a Darrach elevator under the anatomical neck helps deliver it. The head is then cut — usually with a powered oscillating saw following the implant system’s cutting guide or a freehand line along the anatomical neck.

For the glenoid stage the cut humerus must be pushed posteriorly and held. This is the job of the humeral head retractor, and it is the instrument most often missing or wrongly sized on hospital trays.

• Fukuda ring retractor — a ring-ended blade that sits on the posterior glenoid rim and levers the proximal humerus backwards. Supplied in small and large sizes; the large one is needed in big or stiff shoulders. Because it levers against the glenoid rim, the ring edge must be smooth to avoid scoring cartilage or bone stock.
• Posterior glenoid / “bone-spike” retractors — narrow, curved blades with a pointed tip that anchors on the posterior glenoid neck, pushing the humerus away. Useful in tight shoulders where the ring will not seat.
• Cobra retractors — broad, curved blades with a tapered tip that some surgeons prefer to the Fukuda for posterior displacement, particularly when the ring will not sit cleanly on a worn posterior rim.

Glenoid Exposure Around the Rim

With the humerus held back, the rim of the glenoid has to be cleared and circled with retractors so the face can be seen square on. A typical arrangement uses:

• Single-prong anterior glenoid (Bankart-type) retractor on the anterior glenoid neck, retracting subscapularis and the anterior capsule.
• Reverse Hohmann retractors — one at the superior glenoid under the biceps origin, one inferiorly. Our Hohmann retractor guide covers tip widths and the difference between standard and reverse patterns.
• Large flat (Darrach-type) retractor on the anterior scapular neck when more medial clearance is needed.

The inferior retractor sits near the axillary nerve, which runs just below the inferior capsule. Inferior capsular release is done under direct vision with the nerve protected, and the retractor used there should have a rounded, blunt tip.

Once exposed, the labrum and remaining capsule are excised with a long-handled No. 15 blade, curved Mayo scissors and a pituitary or fine bone rongeur. Osteophytes on the rim are removed with a narrow osteotome or a double-action rongeur. The glenoid is then sized and reamed using the implant company’s guides and reamers — these are system-specific and come in the loan kit.

Bone Work on the Humeral Side

The humeral canal is prepared with the implant system’s starter awls, broaches and trials. But a reusable tray still needs general bone instruments around that work:

• Bone rongeurs — a Leksell-type double-action rongeur and a smaller single-action pattern to trim osteophytes from the humeral neck.
• Osteotomes — straight Lambotte patterns in 10, 15 and 20 mm for osteophytes and for LTO.
• Curettes — for cleaning cysts in the glenoid vault and the humeral head bed.
• Mallet — a solid stainless or nylon-faced mallet of roughly 500–700 g for osteotomes and for impacting trials and components. See our bone impactor and mallet guide for head weights.
• Bone holding forceps — to steady the LTO fragment or a fractured tuberosity while it is fixed.

In fracture hemiarthroplasty and reverse shoulders for fracture, the greater and lesser tuberosities have to be reattached around the stem. That adds heavy non-absorbable suture work, bone awls for drill holes, and a suture passer or large curved needle.

A Reference Set List

This is a practical baseline we use when quoting a reusable shoulder arthroplasty instruments tray. It excludes powered equipment and all implant-specific instrumentation.

Units doing a high proportion of reverse shoulders for fracture should add a second bone awl, a heavy suture passer and an extra needle holder. Units with a lot of revision work will want longer osteotomes and a thin flexible osteotome set, which is beyond this baseline.

Sizing the tray to the patients you actually see

A single tray rarely fits every shoulder. Small-framed patients and many Asian populations have a shallower, narrower glenoid, and a large Fukuda ring can sit on the coracoid instead of the posterior rim. Large, muscular or stiff post-traumatic shoulders need the opposite: longer deltoid blades, the large Fukuda, and a heavier Darrach. When we build shoulder arthroplasty instruments sets for a new unit, we ask for two numbers first — the share of reverse versus anatomic cases, and the share of fracture work — and then the typical patient build. Those three answers decide whether one tray is enough or whether a small supplementary pack of alternative retractor sizes pays for itself.

A practical approach is to keep the core tray fixed and hold the size variants (small Fukuda, extra-long deltoid, narrow glenoid retractor) as a separately wrapped peel pack. That keeps tray weight within reprocessing limits and stops rarely used shoulder arthroplasty instruments from travelling through the washer on every case.

What the Hospital Tray Does Not Include

Be clear about this when writing a tender specification. The following almost always come from the implant manufacturer, as a loan or consignment kit matched to their components:

• Humeral cutting guides and resection jigs
• Canal starter awls, broaches and humeral trials
• Glenoid sizers, centring guides, reamers and peg/keel drill guides
• Baseplate drills, screw depth gauges and glenosphere trials (reverse systems)
• Implant-specific impactors and insertion handles

Fizza Surgical manufactures the reusable base tray — retractors, bone instruments, soft-tissue and closure instruments — not implant-specific guides or trials. Mixing generic instruments into a loaner kit’s workflow is not recommended; the implant manufacturer’s instructions define which instruments are validated with their components. Our loaner instrument set management guide explains how to receive, check and reprocess those loan kits alongside your own trays.

Material and Finish Considerations

Most of the tray is AISI 410 or 420 martensitic stainless, hardened for edges and springs. Retractor blades benefit from a satin finish to cut light reflection deep in the wound. Two points deserve attention:

The Fukuda ring and posterior glenoid retractors take high bending loads. They are levers against bone with an assistant pulling hard. A blade that is too thin will bend permanently after a few months. Ask for the blade thickness and test a sample by hand before accepting a batch.

Osteotomes and the mallet see impact. Osteotome edges should be hardened and ground, with handles that do not mushroom. Nylon-faced mallets reduce chipping of osteotome handles but are heavier for the same head size.

Cleaning and Inspection Points

Shoulder trays come back heavily soiled with bone debris and blood. Rongeur jaws, the hinge of the double-action rongeur, the ring of the Fukuda retractor and cannulated awls all trap debris. Pre-soak or enzymatic treatment before washer-disinfection, and open every hinged instrument fully. Brush the rongeur box joints and inspect them under magnification.

At each check, look at:

• Retractor tips — bent or burred tips scar cartilage and should be repaired or replaced.
• Osteotome edges — chips and rolled edges mean resharpening.
• Rongeur jaw alignment — the jaws should meet evenly along their length.
• Needle holder TC inserts — worn serrations let heavy needles rotate.

For the wider orthopaedic context, see our total knee replacement instrument set and hip replacement instrument set guides, or browse our full range of bone surgery instruments. If your unit also does arthroscopic shoulder work, the arthroscopy instrument set guide covers that separate tray.