OT notes · Orthopaedics

Shoulder arthroplasty (anatomic, reverse or hemiarthroplasty)

Usual anaesthesia
General anaesthesia, often with a brachial plexus block for post-operative pain
Position
Beach chair, head on a headrest, medial border of scapula free of the table
Setting
elective

Operative note template for anatomic total, reverse total and hemi shoulder arthroplasty through the deltopectoral approach, with a filled example for an anatomic total shoulder arthroplasty for primary osteoarthritis with an intact rotator cuff.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • infection of the prosthesis
  • loosening of the glenoid or humeral component
  • instability or dislocation
  • subscapularis repair failure
  • axillary nerve injury
  • fracture of the humerus or glenoid during surgery
  • persistent pain and stiffness
  • for reverse arthroplasty: scapular notching and acromial fracture

Pre-operative details for this operation

  1. DiagnosisPrimary osteoarthritisInflammatory arthritisCuff tear arthropathyFour-part / head-splitting fractureOsteonecrosis of the humeral head
  2. SideRightLeft
  3. Rotator cuff statusIntactIrreparable tear / non-functionalon examination and MRI / USG; decides anatomic vs reverse
  4. Glenoid wear and versionon CT; posterior erosion, planned correction (eccentric reaming, graft, augment)
  5. Implant plannedAnatomic totalReverse totalHemiarthroplastysystem and sizes available, augments and bone graft set
  6. Pre-op range of motion and axillary nerve functiondeltoid power and sensation over the regimental badge area

Anaesthesia and position

  1. AnaesthesiaGeneralGeneral with brachial plexus block
  2. PositionBeach chairhead secured without neck hyperextension or tilt; bony points padded; arm free for adduction and extension
  3. Skin preparationantiseptic; axilla covered with occlusive drape

Operative findings

  1. Humeral headcartilage loss, osteophytes (especially inferior), avascular changes
  2. Glenoidwear pattern, posterior erosion, bone defects, labrum
  3. Rotator cuffsubscapularis, supraspinatus, infraspinatus: intact / torn / thin
  4. Long head of bicepsnormal / frayed / ruptured
  5. Synovial fluidamount and appearance
  6. Stability with trialsposterior translation about 50 percent of glenoid width with re-centring (anatomic); 2 to 3 mm gapping (reverse)

Procedure (steps)

  1. Deltopectoral incisionlength; from coracoid towards deltoid insertion
  2. Cephalic veinRetracted laterally with deltoidRetracted medially
  3. Clavipectoral fascia incised, subdeltoid and subacromial releases
  4. Axillary nerve identified and protectedpalpated on the front of subscapularis
  5. Biceps tendonTenotomyTenodesisLeft intact
  6. Subscapularis managementTenotomy about 1 cm medial to lesser tuberosityPeel off boneLesser tuberosity osteotomystay sutures placed
  7. Rotator interval opened, inferior capsule releasedat least to 6 o'clock, staying on bone
  8. Head dislocated, humeral canal opened and hand-reamedentry at base of cuff footprint; final reamer size
  9. Humeral head osteotomycutting guide or free-hand; retroversion in degrees (usually 30); cuff protected
  10. Humerus broachedbroach size, retroversion checked
  11. Glenoid exposure and preparationall four rims seen; labrum and cartilage removed; centring hole; reaming; version correction if any
  12. Glenoid componentCemented peggedCemented keeledIngrowth postReverse baseplate with screws and glenospheresize; for reverse: inferior placement, 0 to 10 degrees inferior tilt, screw lengths
  13. Trial reductionhead or bearing size and thickness, stability, range of motion
  14. Final humeral componentPress-fit stemCemented stemStemlessstem size, head diameter and height / polyethylene bearing
  15. Tuberosity fixation (fracture cases)heavy sutures around the stem

Closure, drains and dressing

  1. Subscapularis and rotator interval repairRepairedNot repaired (reverse)suture type and technique
  2. Irrigationsaline volume
  3. DrainClosed suction drainNone
  4. Subcutaneous tissue and skinsuture used
  5. Dressing and slingSlingShoulder immobiliser
  6. Distal neurovascular status at endradial pulse, hand colour

Specimens and implants

  1. Humeral stemmake, size, batch/lot, sticker pasted
  2. Humeral head or reverse bearingdiameter, thickness, batch/lot, sticker pasted
  3. Glenoid component / baseplate, glenosphere and screwssize, batch/lot, sticker pasted
  4. Bone cementtype and batch, if used
  5. Humeral headDiscarded as human anatomical wasteUsed as bone graftSent for HPE

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Distal neurovascular observationradial pulse, finger movement, deltoid area sensation once block wears off
  2. Slingfull time for 6 weeks; pillow behind elbow when lying down
  3. Exercisespassive forward elevation to 90 degrees and passive external rotation to neutral only
  4. Drainrecord output; plan for removal
  5. Analgesiablock, then oral analgesics
  6. Antibioticsdrug and number of post-op doses, if any
  7. Check X-rayAP and axillary views of the shoulder
  8. Follow-upwound check; full passive motion by 6 to 12 weeks; isometric strengthening from 10 weeks

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. P.D., 66 years, primary osteoarthritis of the left shoulder with pain at night and loss of rotation for 3 years, intact rotator cuff on MRI, mild posterior glenoid wear on CT.

Case details

Date: 14/05/2026. Elective left anatomic total shoulder arthroplasty. OT 1.

In OT 08:50. Incision 09:35. Closure completed 11:40. Out of OT 12:00.

Surgeon: Dr A. (consultant, orthopaedics). Assistant: Dr B. (3rd-year resident). Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Indication: end-stage glenohumeral osteoarthritis, rotator cuff intact on MRI, not relieved by 1 year of physiotherapy and analgesics.

CT: mild posterior glenoid wear, correctable by eccentric reaming. Axillary nerve intact pre-op.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient, son present. Instability, nerve injury and loosening explained.

Left shoulder marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 09:15.

Anaesthesia and position

General anaesthesia with left brachial plexus block by anaesthetist for post-op pain.

Beach chair position, head fixed on headrest in neutral, bony points padded, medial border of scapula free of the table.

Parts painted with chlorhexidine-alcohol and draped. Axilla sealed off with occlusive drape.

Procedure

Deltopectoral incision about 12 cm. Cephalic vein retracted laterally with deltoid. Clavipectoral fascia incised. Subdeltoid, subacromial and subcoracoid releases done.

Axillary nerve palpated on the front of subscapularis and protected throughout.

Long head of biceps frayed: tenotomy done.

Subscapularis divided 1 cm medial to the lesser tuberosity; two stay sutures placed. Rotator interval opened. Clear synovial fluid.

Inferior capsule released from the humerus to the 6 o'clock position, staying on bone. Inferior head osteophytes removed.

Findings: humeral head with full-thickness cartilage loss and a large inferior osteophyte. Glenoid with mild posterior wear. Supraspinatus and infraspinatus intact.

Head dislocated. Canal opened with a burr at the base of the cuff footprint and hand-reamed to size 10. Head cut with the cutting guide at 30 degrees of retroversion. Canal broached to size 10.

Glenoid exposed with posterior retractor; all four rims seen. Labrum and remaining cartilage removed. Centring hole made; anterior rim reamed eccentrically to correct version. Pegged glenoid trial seated flat without rocking.

Glenoid dried after pulsed lavage; cement pressurised into the peg holes with a syringe. Pegged glenoid size M cemented and held till the cement set.

Trial head 46 x 16 mm: posterior translation about half the glenoid width with re-centring. Final press-fit stem size 10 and head 46 x 16 mm inserted after drying the taper. Joint reduced.

Closure

Subscapularis tendon repaired end to end with heavy non-absorbable sutures.

Wound irrigated with normal saline. Closed suction drain placed. Subcutaneous tissue with polyglactin 910 (Vicryl) 2-0, skin with poliglecaprone (Monocryl) 4-0 subcuticular.

Dressing and shoulder sling. Radial pulse present, fingers pink.

Specimens and implants

Humeral stem size 10, humeral head 46 x 16 mm, pegged glenoid size M, one packet of bone cement. Make, batch and serial numbers recorded; stickers pasted on the implant page.

Resected humeral head discarded as human anatomical waste. No specimen sent for HPE.

End of procedure

Estimated blood loss 300 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 78/min, BP 132/80 mmHg.

Post-op orders

Radial pulse and finger movement hourly for 6 hours. Check deltoid area sensation once block wears off.

Sling full time for 6 weeks. Pillow behind the elbow when lying down.

Passive forward elevation up to 90 degrees and passive external rotation up to neutral only, taught by physiotherapist.

Drain output charting. Check X-ray left shoulder AP and axillary views on POD 1.

Planned discharge POD 1. Wound check at 2 weeks.

Signature

Dr B., JR-3, Orthopaedics, for Dr A. Reg. no. ________. 14/05/2026, 12:10.

Must document for this operation

  • Rotator cuff status seen at surgery. It justifies the choice of an anatomic or reverse implant, and a later cuff failure is judged against it.
  • How the subscapularis was taken down and how it was repaired. Subscapularis failure after anatomic arthroplasty cannot be salvaged easily, and a revision surgeon needs to know the technique used.
  • Humeral retroversion and glenoid version correction. Malposition causes instability and early wear, and these angles are checked if the shoulder dislocates.
  • Implant make, sizes, head or bearing size, cement batch, with stickers. Needed for revision planning and implant recall.
  • Axillary nerve identified and protected. If deltoid weakness is found after surgery, the note shows the nerve was seen and guarded.
  • The allowed range of motion and sling duration. The physiotherapist follows these limits to protect the subscapularis repair.

Common mistakes in these notes

  • Writing 'TSR done' without stating whether it was anatomic, reverse or hemiarthroplasty.
  • No mention of the subscapularis repair.
  • Leaving out glenoid wear and how it was corrected.
  • Implant stickers not pasted or head size left out.
  • Post-op orders that say only 'physiotherapy' with no range-of-motion limits.

Indian practice and paperwork

  • Record the batch and serial number of each component and the cement in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • A resected humeral head not sent for HPE is human anatomical waste and goes in the yellow bag. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Azar FM, Beaty JH, eds. Campbell's Core Orthopaedic Procedures. 2nd ed. Elsevier; 2024, Technique 7, Total shoulder arthroplasty; Technique 8, Reverse total shoulder arthroplasty (Throckmorton TW), pp. 25-32.
  • Saghieh S, et al., eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 76, Total shoulder replacement (Al-Taki M); Ch 79, Hemiarthroplasty of shoulder (Shamseddeen A), pp. 275-277; 285-287.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; recommended for total joint replacement; redose after 4 h; duration under 24 h. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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