Patent Publication Number: US-2012041563-A1

Title: Resurfacing implant for a humeral head

Description:
CLAIM FOR PRIORITY 
     This application is a division of application Ser. No. 11/525,629, filed Sep. 25, 2006, itself a division of application Ser. No. 10/917,266, filed Aug. 11, 2004. Applicant claims, under 35 U.S.C. §120, the priority benefit of the filing dates of applications Ser. Nos. 10/917,266 and 11/525,629, and, as set forth in application Ser. No. 10/917,266, the priority benefit under 35 U.S.C. §119(e), of: 1) the filing date of Aug. 11, 2003 of U.S. Provisional Application No. 60/494,289, 2) the filing date of Oct. 8, 2003 of U.S. Provisional Application No. 60/509,655, 3) the filing date of Oct. 16, 2003 of U.S. Provisional Application No. 60/511,805, 4) the filing date of Nov. 19, 2003 of U.S. Provisional Application No. 60/523,401, 5) the filing date of Jun. 15, 2004 of U.S. Provisional Application No. 60/579,893 and 6) the filing date of Jul. 2, 2004 of U.S. Provisional Application No. 60/585,033, the entire contents of each of the above-identified applications being, and hereby are, incorporated by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates to methods, instrumentation, and implants for orthopaedic surgery and, more specifically, to rotator cuff sparing procedures and associated devices for shoulder replacement surgery. 
     2. Discussion of Related Art 
     Orthopaedic surgeons perform joint replacement surgery for patients who suffer pain and physical limitations caused by joint surfaces that have been damaged by degenerative, traumatic, or other pathologic processes. The functional outcome from these joint replacement surgeries is directly related to the degree of morbidity associated with the surgical method and the ability of the method to best restore the natural anatomy and biomechanics of the joint. Orthopaedic surgeons are continually searching for ways to improve outcomes for joint replacement surgery by developing methods of less invasive surgery to limit surgical morbidity and by developing novel methods and implants to better restore the native joint anatomy. 
     Conventional shoulder replacement surgery has several limitations. It requires an extensive exposure that irreversibly damages the rotator cuff and still fails to gain sufficient joint access to properly restore the native anatomic relationships of both the humeral head and glenoid surfaces. Also, there remain issues with glenoid implant fixation and early loosening. 
     Conventional methods utilize a large anterior deltopectoral exposure. The anterior humeral circumflex blood vessels are typically ligated and the anterior (subscapularis) musculotendinous unit is transected. The shoulder must then be completely dislocated both anteriorly and posteriorly to prepare the humeral and glenoid joint surfaces. This can cause excessive traction on the arm which has resulted in injury to the nerves of the brachial plexus (Lynch N M, Cofield R H, Silbert P L, et al., Neurologic complications after total shoulder arthroplasty. J Shoulder Elbow Surg 1996;5(1): 53-61.). 
     With regards to shoulder replacement surgery, all conventional methods require surgical transection of a rotator cuff tendon to gain sufficient exposure of the joint surfaces of the shoulder (See U.S. Pat. No. 4,550,450, entitled, “Total Shoulder Prosthesis System”, the entire contents of which are incorporated herein by reference). After the joint surfaces are replaced, the rotator cuff tendon must be surgically repaired with suture material. This tenuous repair necessitates an obligatory period of approximately six weeks for the rotator cuff tendon to heal before advanced shoulder rehabilitation can be performed. This surgical transection and subsequent repair, as well as the delay in rehabilitation, hold significant consequences for the functional outcome of the shoulder replacement including permanent weakness and decreased range of motion (Miller S L et al., “Loss of subscapularus function after total shoulder replacement: A seldom recognized problem”, J Shoulder Elbow Surg. 2003 January-February; 12(1): 29-34). 
     Additionally, despite the extensive exposure, conventional methods for shoulder replacement surgery still fail to properly restore the native anatomic relationships of the joint surfaces of the shoulder. Conventional methods prepare the humeral surfaces of the shoulder joint by referencing off the intramedullary axis of the humeral shaft. This poses great difficulty for the surgeon since the intramedullary axis has an inconsistent relationship to the humeral surface. The humeral joint surface also possesses a complex anatomy with significant variability which cannot be entirely restored with conventional methods and implants. There exists much variability in the humeral head neck-shaft angle, posterior and medial offset, version (rotation), height, thickness, and radius of curvature. (Boileau P, Walch G, “The Three-Dimensional Geometry of the Proximal Humerus”, J Bone Joint Surg Br 1997; 79B: 857-865; Iannotti J P, et al., “The Normal Glenohumeral Relationships. An Anatomic Study of One Hundred and Forty Shoulders”, J Bone Joint Surg 1992; 74A(4): 491-500; McPherson E J, et al. “Anthropometric Study of Normal Glenohumeral Relationships”, J Shoulder Elbow Surg 1997; 6:105-112; Soslowsky L J, et al. “Articular geometry of the glenohumeral joint”, Clin Orthop 1992;285:181-190). The failure to restore the native anatomic relationships and biomechanics to the shoulder joint has proven to result in a significantly lesser functional and durable outcome (Williams G R, et al. “The effect of articular malposition and shoulder arthroplasty on glenohumeral translations, range of motion, and subacromial impingement”, J Shoulder Elbow Surg. 2001; 10(5):399-409). 
     Conventional methods of shoulder replacement surgery also have difficulty gaining access to the glenoid joint surface. The glenoid surface of the shoulder joint is best prepared by working along an axis perpendicular to its surface. Because the humeral head sits in the way, this is a nearly impossible task with conventional methods. The humeral head has to be partially removed, the subscapularis (anterior shoulder rotator cuff muscle) transected, and the proximal humerus dislocated to even get close to working along this axis. Because of this difficulty, a majority of orthopaedic surgeons still choose not to replace the glenoid surface despite clinically proven results of improved pain relief and function for shoulder replacement surgery when both the humeral and glenoid surfaces are replaced. (Boyd A D, Thomas W H, Scott R D, et al. “Total shoulder arthoplasty versus hemiarthroplasty—indications for glenoid resurfacing”, J of Arthroplasty 1990;5(4):329-336: Gartsman G M, Roddey T S, Hammerman S M. J Bone Joint Surg 2000;82A(1):26-34; Edwards T B, Kadakia N R, Boulahia A, et al., “A comparison of hemiarthoplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: Results of a multicenter study”, J Shoulder Elbow Surg 2003; 12(3):207-13; Orfaly R M, Rockwood C A, Esenyel C Z, et al., “A prospective functional outcome study of shoulder arthoplasty for osteoarthritis with an intact rotator cuff”, J Shoulder Elbow Surg 2003;12(3):214-21.) 
     Despite improved results of conventional methods when both the humerus and glenoid surfaces are replaced, there still remains limitations with regard to glenoid fixation and early glenoid implant loosening (Boileau P, Avidor C, Krishnan S G, et al., “Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study”, J Shoulder Elbow Surg 2002;11(4):351-9). Both, cemented polyethylene and metal backed glenoid components are used in conventional methods. The cemented implant never incorporates with the glenoid bone and with time, the cement-bone interface eventually fails and the implant comes loose. Conversely, the metal-backed glenoid prosthesis has an unacceptable rate of early loosening, at least 20% in one study. However, if the metal-backed implant can remain rigidly fixed to the bone for a sufficient period of time, the bone of the glenoid will eventually adhere to the metal-backed surface and long-term studies have revealed little evidence for late clinical loosening in these cases. Failure of the metal-backed glenoid implant appears to be related to the limitations in achieving sufficiently rigid and durable initial fixation. 
     While performing shoulder replacement surgery for arthritis, associated rotator cuff tears are sometimes discovered and should be repaired when possible. If a less invasive surgical approach is employed to perform the shoulder replacement surgery, a less invasive method of rotator cuff repair that is compatible with the method shoulder replacement surgery must be available to simultaneously address these associated rotator cuff tears. 
     BRIEF SUMMARY OF THE INVENTION 
     One aspect of the present invention regards a method for shoulder replacement surgery. Utilizing the method of the present invention, a portal is created along a central axis of a neck of a proximal humerus that is associated with a shoulder of a patient. An implant is subsequently implanted into the shoulder of the patient, however a component of that implant is not passed through the portal. The rotator cuff is spared in the process. 
     One advantage provided by the above mentioned aspect of the present invention is that it allows determination of a central axis in the proximal humerus which allows simple and less invasive perpendicular access to the humeral and glenoid joint surfaces. An additional advantage is it offers a simple and reliable means of restoring the native anatomy and biomechanical relationships, allowing for an improved functional and durable outcome. 
     A further advantage is that it spares the rotator cuff tendons and allows for a quicker and more functional recovery. 
     Another aspect of the present invention regards a humeral implant with one component that is removably attached to a second component. 
     Another aspect of the present invention provides a glenoid implant. The glenoid implant includes an ingrowth shell, a wear-resistant surface that is removably attached to the ingrowth shell. An advantage is that the ingrowth shell provides novel geometry and superior fixation to the glenoid. 
     An additional aspect of the invention regards a transhumeral portal sleeve with a bullet shaped guide that has a central and a peripheral longitudinal cannulation. An advantage is that it safely creates a working portal along the central axis of the proximal humerus. 
     In another aspect of the present invention, there is provided a transhumeral humeral reamer that has a working head and a removably attached transhumeral shaft with a diameter of from 0.1 to 5 cm. 
     Another aspect of the present invention regards a transhumeral glenoid reamer with a working head and a removably attached transhumeral shaft that has a diameter of from 0.1 to 5 cm. 
     In another aspect, a transhumeral protective sheath is provided that is a tube of material with a diameter of from 0.1 to 5 cm. 
     Another aspect of the invention regards a glenoid surface protective guard that has a protective surface and a removably attached handle. 
     In another aspect, a humeral head surface protective guard is provided that has a protective surface and a removably attached handle. 
     An additional aspect of the invention regards a glenoid sizer and centering hole guide that has a surface that contacts the glenoid of a shoulder and a removably attached handle. 
     In another aspect, a drill guide with a guiding surface and a removably attached handle is provided. The guiding surface has a centering hole and is available in sizes equivalent to the respective glenoid implants. 
     In another aspect, the invention regards a transhumeral glenoid drill with a working surface and a removably attached shaft. 
     In another aspect, a transhumeral burr is provided. The transhumeral burr has a high speed working burr surface and a removably attached shaft. 
     An additional aspect of the invention regards a glenoid keel punch with a working head and a removably attached shaft. The working head has a keel shape and cutting teeth. 
     In another aspect, a transhumeral irrigation and suction catheter is provided. The catheter is a semi-rigid plastic tubing removably attached to either a fluid pump or a suction device. 
     In another aspect, a transhumeral cementation device is provided that has a semi-rigid catheter removably attached to a head. 
     An additional aspect provides a transhumeral glenoid impactor with a dome-shaped head and a removably attached shaft. 
     Another aspect of the invention regards a transhumeral screw driver with a working head and a removably attached shaft. 
     In another aspect, the present invention provides a rotator interval retractor with a first blade dimensioned to interact with a supraspinatus and a second blade dimensioned to interact with a subscapularis. 
     Another aspect of the invention regards a glenohumeral joint with a transhumeral portal along a central axis of a neck of a proximal humerus as well as an implant. 
     Further advantages as well as details of the present invention ensue from the following description of a preferred embodiment represented in the drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a schematic of a patient positioned with fluoroscopy C-arm unit that may be used in conjunction with the present inventions; 
         FIGS. 2   a  and  b  are plan views of an embodiment of a rotator interval retractor with specialized supraspinatus and subscapularis blades ( FIG. 2   b ) in accordance with the present invention; 
         FIG. 3   a  is a perspective view of an embodiment of a transhumeral portal drill guide and protective sleeve in accordance with the present invention. 
         FIG. 3   b  is a top plan view of the transhumeral portal drill guide of  FIG. 3   a;    
         FIG. 3   c  is a side plan view of the protective sleeve of the transhumeral portal drill guide and sleeve of  FIG. 3   a  in accordance with the present invention; 
         FIG. 4   a  is a schematic of an embodiment of an insertion procedure of a proximal humeral guide pin and measurement of humeral head depth after placement of a second guide pin in accordance with the present invention; 
         FIG. 4   b  is a schematic of the insertion of  FIG. 4   a  using an optional embodiment of a radiolucent guide attachment to assist with a guide pin insertion procedure in accordance with the present invention; 
         FIG. 5  is a schematic of an embodiment of a drilling procedure for forming an embodiment of a transhumeral portal in accordance with the present invention; 
         FIG. 6  is a schematic of a preliminary cut of a humeral head joint surface during an embodiment of a surgical procedure in accordance with the present invention; 
         FIG. 7   a  is a schematic showing a possible way of preparing the humeral head with a transhumeral humeral head reamer in preparation for a conventional proximal humeral implant during an embodiment of a surgical procedure in accordance the present invention; 
         FIG. 7   b  is a schematic showing a possible way of preparing the humeral head with a novel transhumeral humeral reamer in preparation for a novel proximal humeral implant during an embodiment of a surgical procedure in accordance with the present invention; 
         FIG. 7   c  is a perspective view of an embodiment of a novel transhumeral humeral reamer head to be used in an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 7   d  is a perspective view of an embodiment of a glenoid protective cap to be used in an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 8   a  is a schematic showing a possible way of drilling a glenoid centering hole and placing a transhumeral glenoid guide wire with a glenoid sizing and centering guide which can be used for both a left and a right shoulder for a conventional proximal humeral implant in an embodiment of a surgical procedure in accordance with the present invention; 
         FIG. 8   b  is a schematic showing a possible way of drilling a glenoid centering hole and placing a transhumeral glenoid guide wire with a glenoid sizing and centering guide which can be used for both a right and a left shoulder for a novel proximal humeral implant during an embodiment of a surgical procedure in accordance with the present invention; 
         FIG. 8   c  is a perspective view of an embodiment of a head of a glenoid sizing and centering guide in accordance with the present invention; 
         FIG. 9   a  is a schematic of a way of preparing a glenoid with a cannulated transhumeral glenoid reamer for a conventional proximal implant during an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 9   b  is a schematic of a way of preparing a glenoid with a cannulated transhumeral glenoid reamer for a novel proximal humeral implant during an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 10   a  is a schematic of a way of preparing a glenoid with a transhumeral glenoid keel/peg drill and a glenoid peg or keel guide for a conventional proximal humeral implant during an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 10   b  is a perspective view of a peg or keel guide for a conventional glenoid implant to be used in an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 10   c  is a schematic of a way of preparing a glenoid with a transhumeral keel/peg glenoid drill and a glenoid peg or keel guide for a novel proximal humeral implant during an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 11   a  is a schematic of a way of preparing a glenoid to accept a conventional keel glenoid implant with a transhumeral burr for a conventional proximal humeral implant during an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 11   b  is a schematic of a way of preparing a glenoid to accept a conventional keel glenoid implant with a transhumeral burr for a novel proximal humeral implant during an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 12   a  is a schematic of a way of preparing a glenoid to accept a conventional keel glenoid implant with a transhumeral keel punch for a conventional proximal humeral implant to be used in an embodiment of a surgical procedure in accordance with the present invention; 
         FIG. 12   b  is a schematic of a way of preparing a glenoid to accept a conventional keel glenoid implant with a transhumeral keel punch for a novel proximal humeral implant to be used in an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 13   a  is a schematic a way of utilizing an embodiment of a transhumeral cementation catheter and glenoid cement pressurizer for a conventional proximal humeral implant to be used during a surgical procedure in accordance with the present invention; 
         FIG. 13   b  is a perspective view of an embodiment of a modular glenoid cement pressurizer tip for a keel implant and a catheter in accordance with the procedure shown in  FIG. 13   a;    
         FIG. 13   c  is an exploded view of an embodiment of a glenoid cement pressurizer tip of  FIGS. 13   a  and  b  in accordance with the present invention; 
         FIG. 13   d  is an exploded view of an embodiment of a glenoid cement pressurizer tip for a peg implant of  FIGS. 13   a  and  c , in accordance with the present invention; 
         FIG. 13   e  is a schematic of a way of utilizing an embodiment of a transhumeral cementation catheter and glenoid cement pressurizer for a novel proximal humeral implant to be used during a surgical procedure in accordance with the present invention; 
         FIG. 14   a  is a schematic of a way of utilizing an embodiment of a transhumeral glenoid impactor for a conventional humeral implant during a surgical procedure of the present invention; 
         FIG. 14   b  is a schematic of a way of utilizing an embodiment of a transhumeral glenoid impactor for a novel humeral implant during a surgical procedure of the present invention; 
         FIG. 15   a  is an exploded view of a humeral implant in accordance with the present invention; 
         FIG. 15   b  is a bottom plan view of a humeral implant in accordance with the present invention; 
         FIG. 16  is a schematic of an embodiment of a humeral surface implant, Example A, in accordance with the present invention; 
         FIG. 17   a  is schematic of an embodiment of a humeral surface implant, Example B, in accordance with the present invention; 
         FIG. 17   b  is a perspective view of an embodiment of a stem with inner cement channels in accordance with the present invention; 
         FIG. 17   c  is an perspective view of an embodiment of a endcap of the novel transhumeral stem of  FIG. 17   b  in accordance with the present invention; 
         FIG. 18   a  is a schematic of a way of removing an embodiment of a humeral surface implant, Step 1, Example B, during an embodiment of a surgical procedure in accordance with the present invention; 
         FIG. 18   b  is a schematic of a way of performing Step 2 of removing an embodiment of a humeral surface implant of  FIG. 18   a  during an embodiment of a surgical procedure in accordance with the present invention; 
         FIG. 19   a  is a schematic of inserting an embodiment of a humeral surface implant, Example C in accordance with the present invention; 
         FIG. 19   b  is a perspective view of a stem of an embodiment of a humeral implant of  FIG. 19   a  that is inflatable in accordance with the present invention; 
         FIG. 20   a  is a schematic a way of inserting a multiple peg glenoid surface to be used in an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 20   b  is a side plan view of a glenoid peg to be used in during a surgical technique in accordance with the present invention; 
         FIG. 20   c  is a perspective view of a multiple peg glenoid guide of  FIG. 20   a  in accordance with the present invention; 
         FIG. 21  is a side perspective view of an embodiment of a novel transhumeral glenoid reamer in accordance with the present invention; 
         FIG. 22  is a schematic of a way of utilizing a novel glenoid reamer in an embodiment of a surgical technique in accordance with the present invention; 
         FIG. 23   a  is a perspective view of an embodiment of a shell component of a novel glenoid implant in accordance with the present invention; 
         FIG. 23   b  is a bottom plan view of a shell component of a novel glenoid implant of  FIG. 23   a;    
         FIG. 24   a  is a schematic of a way of drilling screw holes into a glenoid utilizing a glenoid drill guide sleeve and glenoid screw guide sleeve in an embodiment of a surgical technique of the present invention; 
         FIG. 24   b  is an exploded view of the glenoid drill guide sleeve interfit with the glenoid screw guide sleeve of  FIG. 24   a;    
         FIG. 25   a  is a schematic of a way of utilizing a glenoid screw guide sleeve and transhumeral screwdriver in accordance with an embodiment of a surgical technique of the present invention; 
         FIG. 25   b  is an exploded view of the glenoid screw guide sleeve of  FIG. 25   a;    
         FIG. 26   a  is a schematic of utilizing a transhumeral impactor to secure a novel wear-resistant glenoid surface into an ingrowth shell of the novel glenoid implant in accordance with an embodiment of the present invention; 
         FIG. 26   b  is an exploded view of the novel glenoid implant of  FIG. 26   a;    
         FIG. 27   a  is a side view of an embodiment of a novel glenoid implant in accordance with the present invention; 
         FIG. 27   b  is a top plan view of an embodiment of a novel wear-resistant surface the novel glenoid implant of  FIG. 27   a;    
         FIG. 27   c  is a bottom plan view of an embodiment of the novel wear-resistant surface of novel glenoid implant of  FIGS. 27   a  and  b.    
         FIG. 28   a  is a perspective view of an embodiment of an insertional guide in accordance with the present invention; 
         FIG. 28   b  is a perspective view of an embodiment of a flexible inner trocar of an embodiment of an insertion guide in accordance with the present invention; 
         FIG. 29  is a perspective view of an embodiment of a suture pin of the present invention; 
         FIG. 30  is a schematic of a way of performing an embodiment of a surgical technique using the insertion guide of  FIGS. 28-29  to bore into a greater tuberosity of a proximal humerus in accordance with the present invention; 
         FIG. 31  is a schematic of a way of performing an embodiment of a surgical technique using the insertion guide of  FIGS. 28-29  to advance the suture-pin device through the greater tuberosity of the proximal humerus and leading edge of a rotator cuff tendon in accordance with the present invention; 
         FIG. 32  is a schematic of a way of performing an embodiment of a surgical technique using a pin director to guide the pin out from the shoulder in accordance with the present invention; 
         FIG. 33  is a schematic of a way of performing an embodiment of a surgical technique and tying the passed suture of the suture pin device after removing the pin component in accordance with the present invention. 
     
    
    
     DETAILED DESCRIPTION OF THE DRAWINGS AND THE PRESENTLY PREFERRED EMBODIMENTS 
     The present invention relates to methods, instrumentation, and implants for performing rotator cuff sparing shoulder replacement surgery. Both, total shoulder arthroplasty, where both the humeral and glenoid joint surfaces are replaced, and shoulder hemiarthroplasty, where only the humeral joint surface is replaced, can be performed as indicated. The present invention utilizes among other things: a novel surgical exposure including an optional method of arthroscopic anterior contracture release, posterior capsular tightening, osteophyte resection, and glenoid soft-tissue clearance; two limited incisions, a transhumeral portal and a deep rotator cuff sparing exposure; novel transhumeral instrumentation with modular working components, protective guides, sleeves, sheaths, and retractors; conventional or novel implants, and an associated method of rotator cuff repair. 
     Utilizing the method of the present invention, a portal is created along a central axis of a neck of a proximal humerus that is associated with a shoulder of a patient. This portal provides superior perpendicular access to both the humeral and glenoid joint surfaces in a less invasive manner to allow more anatomic replacement surgery to occur. The axis of the humeral head and the axis of the glenoid have a sufficiently consistent natural relationship such that simple positioning of the arm can allow a surgeon to easily align the central axis perpendicular to the humeral head with the axis perpendicular to the glenoid. Research has shown that there exists a natural relationship between the orientation of the humeral and glenoid surfaces (DeWilde, L F, et al., “Glenohumeral Relationship in the Transverse Plane of the Body”, J Shoulder Elbow Surg 2003; 12(3):260-267). Therefore, I have determined that with consistent positioning of the arm, these axes will be co-linear. 
     Accordingly, the present invention provides a reliable way of reestablishing the proper orientation of the humeral and glenoid joint surfaces without the associated surgical morbidity of conventional methods, i.e., a large exposure, dislocation of the humerus, or transection of the rotator cuff, as will be described below. Note that in the description to follow there will be mention made of transhumeral instruments. Such transhumeral instruments include transhumeral proximal humerus and glenoid reamers, drills, burrs, guides, protective guards, sheaths, sleeves, cementation tools, glenoid peg and keel punches, and glenoid implant insertor and impactor. 
     Shown in  FIGS. 4   a - b ,  5 ,  6 ,  7   a - b ,  8   a - b ,  9   a - b ,  10   a - c ,  11   a - b ,  12   a - b ,  13   a ,  13   e ,  14   a - b ,  16 ,  17   a ,  18   a - b ,  19   a ,  20   a ,  22 ,  24   a ,  25   a , and  26   a , is a possible medical procedure according to the present invention. Preoperatively, two orthogonal radiographic images should be taken including a Grashey anteroposterior view with the patient&#39;s shoulder held in neutral rotation to slight external rotation and an axiliary lateral view. Next, two-dimensional transparencies with representations of different sizes of the humeral and glenoid implants/templates are placed over the x-rays to evaluate the patient&#39;s bony anatomy and estimate the size of the implants to be used. From these radiographic images, preoperative measurements can be taken of the humeral head diameter and depth, the humeral neck angle, glenoid size and version, and the amount of scapular bone available to fix the implants to be used in the surgical procedure. A preoperative CT scan of the shoulder can also be useful when plain radiographs do not offer sufficient detail. 
     After interscalene regional block and general anesthesia are administered by the anesthesiologist, the patient  1  is positioned in a sitting position with a beach chair positioner  3  as shown in  FIG. 1 . Prior to prepping and draping the patient  1 , a fluoroscopic C-arm machine  7  is positioned accordingly to the patient  1  to obtain a Grashey anteroposterior radiographic view and a modified axiliary lateral view using rotation of the shoulder and slight repositioning of the fluoroscopic machine  7 . After the fluoroscopic views are confirmed, the fluoroscopic machine  7  is backed away from the patient  1  and the shoulder and upper extremity are prepped and draped in sterile fashion. 
     Initially, an optional arthroscopic procedure may be performed using conventional arthroscopic tools to release the anterior capsular contractures, tighten the posterior capsule, resect osteophytes, and clear the glenoid soft-tissue for exposure. The procedure is begun by placing an arthroscope in the shoulder joint through a standard posterior portal and making an anterior rotator interval passage under needle localization. Standard diagnostic arthroscopy is performed and the posterosuperior, superior, and anterior labrum are excised or ablated; the biceps tendon may be released from the superior glenoid; and the anterior and anteroinferior ligamentous and capsular attachments are released from the glenoid. Then an accessory posterior passage is made under needle localization and an arthroscopic burr is inserted to remove the inferior humeral neck osteophytes. From the same accessory posterior passage, the posterior, posteroinferior and inferior labrum are excised or ablated and the posteroinferior and inferior ligamentous and capsular attachments to the glenoid are released from 7 O&#39;clock anteriorly on a right shoulder of 5 O&#39;clock anteriorly on a left shoulder. Gentle manipulation of the shoulder can also be performed if necessary to complete the soft-tissue release. Any posterior capsular redundancy can be addressed by techniques of capsular plication (tightening with arthroscopic sutures). 
     After the optional arthroscopic procedure is performed, an anterosuperior passage is formed to expose the glenohumeral joint. In particular, an anterosuperior incision is made either obliquely running over the anterolateral border of the acromion over the tip of the coracoid or longitudinally from just inferior to the clavicle running between the coracoid and the AC joint distally. Deep dissection is continued through the deltopectoral interval or a limited muscular split running in line with the deltoid muscle fibers. The clavipectoral fascia is incised, the coracoacromial ligament is released from the coracoid, and the subdeltoid and subacromial adhesions are released. Bony and soft-tissue subacromial decompression and distal clavicle excision should be performed if secondary conditions of impingement, rotator cuff tears, or acromioclavcular joint arthritis are present. The anterior circumflex blood vessels are ligated only as needed. The rotator interval is opened completely around both sides of the coracoid and distally into the biceps sheath. The supraspinatus and subscapularis muscles are bluntly released from the glenoid superior and anterior surfaces, respectively. A biceps tenodesis may be performed by simply sewing it to the tissue of the biceps sheath and excising the intraarticular portion of the tendon. At this point, a novel rotator interval retractor  5  with specialized supraspinatus  2  and subscapularis  4  blades is inserted ( FIG. 2   a - b ). The blades connect to separate arms of a self-retaining device which allow it to hold open the interval between the supraspinatus and the subscapularis rotator cuff musculotendinous units. 
     If necessary, a second rotator interval can be made by splitting the subscapularis in line with its fibers. 
     Note that the anterosuperior passage described above and below can be performed without the aid of the previously described arthroscopic procedure. If the arthroscopic procedure is not performed, joint capsular contractures are released, posterior capsule is tightened (if needed), osteophytes are resected, and the soft-tissue surrounding the glenoid is excised as described above using open rather than arthroscopic instruments. 
     The surgical method next involves creating a transhumeral portal  30 . The transhumeral portal  30  is a cylindrical-like tunnel that is parallel to the neck of the humerus from the anterolateral bony cortex of the proximal humerus through the center of the humeral head. Creation of the transhumeral portal  30  first involves obtaining an anteroposterior view of the proximal humerus via the fluoroscopic C-arm machine  7  shown in  FIG. 1 . The shoulder is externally rotated between 20 and 40 degrees relative to the plane of the fluoroscope  7  to achieve a view perpendicular to the neck of the humerus. A free radioopaque guide pin is placed over the anterior shoulder along the axis of the humerus neck. By using fluoroscopy, a guide pin in that position defines a line to be used as a guideline that is marked/drawn along the anterior skin. A second small anterosuperior incision is made longitudinally, 1 centimeter lateral to the biceps tendon centered on the point of intersection with the drawn guideline marking the humeral neck axis. This second incision lies just inferolateral to the first. Via the second anterosuperior path, the deep deltoid muscle is split bluntly along its fibers to protect the motor branch of the axillary nerve and the transhumeral portal drill guide  14  and protective sleeve  15  ( FIGS. 3   a - c ) are inserted down to the anterolateral cortex of the humerus, approximately 1 cm lateral to the biceps groove. Using intraoperative fluoroscopy, a small guide pin  16  is inserted through the transhumeral portal drill guide  14  and sleeve  15  from the anterolateral humeral cortex along the central axis of the humeral neck into the center of the articular surface of the humeral head ( FIG. 4   a ). Anteroposterior and modified axillary lateral fluoroscopic images are taken to confirm proper positioning of the guide pin  16 . The guide pin  16  is repositioned as necessary until the pin runs centrally through the humeral neck and head on all fluoroscopic views. 
     Note, a specialized transhumeral portal drill guide  14  may be used to help direct the guide pin  16  into the center of the humeral head  20  ( FIG. 4   a ). The transhumeral portal drill guide  14  is a bullet shaped object with multiple longitudinal cannulations to direct guide  16 , 18 . It fits into a protective sleeve  15  which has a handle  6  that is inserted into the second anterosuperior passage to the anterolateral cortex of the proximal humerus  20 . The sleeve  15  and guide  14  protect the surrounding soft-tissue and axillary nerve from harm. There is a radiolucent guide attachment  21  which rigidly connects to the handle  6  of the protective sleeve  15  of the transhumeral portal drill guide  14 . The radiolucent guide attachment  21  has a radiolucent arm  23  which runs parallel with the cannulations  10 , 12  in the transhumeral portal guide  14  and connects to a radiolucent tip  25  which can be any suitable shape, for example, hemispheric ( FIG. 4   b ). Once the guide is assembled, the central cannulation  12  of the transhumeral portal guide  14  will direct a guide pin  16  to the center of the hemispheric tip  25 . The arm  23  of the guide attachment  21  is sufficiently long to allow significant adjustments in length to accommodate variations in size of the proximal humerus. After the tip  25  of the transhumeral portal drill guide  14  is placed on the humeral surface through the first anterosuperior passage, the radiolucent arm  23  containing a radiopaque reference line can also be aligned with the central axis of the neck of the proximal humerus  20  under fluoroscopy to assist in directing the guide pin  16  to the center of the humeral  20  surface. 
     The guide pin  16  is advanced through the transhumeral drill guide  14  and protective sleeve  15  such that it travels toward the glenohumeral joint  9 , along the central axis of the neck of the humerus and perpendicular to the humeral  20  joint surface. The guide pin  16  is advanced such that the tip of the pin stops right at the humeral  20  joint surface. A second pin  18  of equal length is inserted through one of the peripheral holes  10  in the transhumeral portal drill guide  14  and sleeve  15  until it stops at the lateral humeral cortex. Measuring the difference in exposed length between the pins  16 ,  18  closely estimates the length of the transhumeral portal  30 . This measurement assists the surgeon in creating and using the transhumeral portal  30  more safely as well as providing the size of the modular stem  98  used for the proximal humeral implant  94 . Then, the second guide pin  18  is advanced into the bone until it reaches the level of the anatomic neck  13  of the humerus. Measuring the difference in exposed length between the pins  16 ,  18  provides an accurate measurement of the humeral head  20  depth ( FIG. 4   a - b ). Using the actual humeral depth measured by the difference between the pins  16 ,  18  and that measured on the fluoroscopic screen, the actual humeral head diameter can be determined from measurements on the fluoroscopic screen. These measurements help in selecting the proper size transhumeral humeral reamers and final humeral implant later in the procedure. 
     Based on the actual measured transhumeral portal  30  length, the transhumeral portal  30  is created by drilling with an approximately 1 centimeter diameter or less cannulated drill bit  26  through the transhumeral portal protective sleeve  15  over the first guide pin  16  from the anterolateral humeral cortex and into the joint ( FIG. 5 ). The transhumeral portal  30  defines an opening of any suitable shape (such as circular, square, triangular, etc.), having a diameter with a range of 0.1 to 5 cm, more preferably, a range of 0.1 to 1 cm, and most preferably, a range of 0.5 to 1.0 cm. The first guide pin  16  is removed along with the cannulated drill bit  26  and the second guide pin  18  may remain as a guide for later humeral head resection. 
     With the formation of the transhumeral portal  30 , the humeral  20  and glenoid  22  surfaces can be prepared as explained hereafter. Note that the order of preparing either the humeral  20  or glenoid  22  surfaces may be altered depending on the proximal humeral  20  bone quality. If there are concerns about the quality of the proximal humeral  20  bone, the humeral  20  surface can be prepared last, after the glenoid  22 , to avoid weakening the proximal humeral bone  20  and jeopardizing the integrity of the transhumeral portal  30 . Also, if hemiarthroplasty is indicated, the humeral  20  surface may solely be prepared and replaced. 
     Assuming that it is determined to prepare the humeral  20  surface first, the articular surface of the humeral head  20  may either be resected and replaced to the level of the anatomic neck  13  for the insertion of a conventional proximal humeral implant, or merely resected and replaced to the level of the subchondral bone for the insertion of a novel proximal humeral implant  94 . To insert a conventional humeral implant in accordance with the present invention, a preliminary humeral head  20  cut can be made to improve visualization and expedite resection. From the anterosuperior passage previously formed, a long oscillating saw  28  is used to safely resect a limited portion of the humeral head  20  joint surface perpendicular to the portal ( FIG. 6 ). 
     A transhumeral protective sheath  38  used during the procedure of the present invention is then threaded or press-fit into the transhumeral portal  30  through the second anterosuperior passage using the transhumeral portal drill guide protective sleeve  15  to safely direct it. It is inserted to the level of the anatomic neck  13  of the proximal humerus  20  in preparation for a conventional humeral implant or to the level of the humeral  20  joint surface for a novel humeral implant  94  ( FIG. 7   a ). An embodiment of the transhumeral protective sheath  38  of the present invention provides protection for the bone within which the transhumeral portal sits. The transhumeral sheath  38  is a tube of such shape, inner and outer diameter, and thickness such that it interfits securely within the transhumeral portal  30  along the central axis of the neck of the humerus  20 , allows easy passage and use of all transhumeral instruments and sleeves while protecting the remaining bone of the proximal humerus  20  from harm. The transhumeral sheath  38  may be metal, plastic, or other semi-rigid, wear-resistant material and may be slid or threaded into the transhumeral portal. 
     Next, a transhumeral reamer shaft  34  is placed through the protective sheath  38  and assembled in the joint with the appropriately sized modular humeral reamer head  36  inserted through the anterosuperior passage ( FIGS. 7   a - d ). A novel transhumeral humeral reamer  32 , in one embodiment of the present invention, includes a reaming surface  36  and a transhumeral shaft  34 . The transhumeral reamer  32  is designed so that the shaft  34  interfits securely within the transhumeral portal  30 , and more specifically, within the transhumeral protective sheath  38  within the transhumeral portal  30 , such that there is no shaking or toggling while the reamer is being used. Therefore the diameter of the shaft  34  is from 0.1 to 5 cm and slightly smaller than the inner diameter of the transhumeral protective sheath  38  through which it traverses. For a conventional humeral prosthesis, a flat reaming head surface  36  with sizes similar to the diameter of the humerus and surgical neck are used. The flat reamer removes bone of the humeral head down to the level of the anatomic neck  13  of the humerus. For a novel humeral implant  94 , a hemispherically shaped reaming surface  37 , sized similarly to a novel humeral surface  96  implant component is used, having similar depth and radius of curvature ( FIG. 7   c ). The hemispherically shaped reaming surface  37  removes a minimal amount of bone. The amount of bone removed is roughly equivalent to the thickness of the humeral surface  96  component of the implant  94 . 
     A protective guard  40  may be placed over the glenoid through the anterosuperior passage during reaming ( FIG. 7   d ). The protective guard  40  is introduced through the first anterosuperior passage by a handle  44 . In one embodiment of the present invention, the guard  40  is shaped like the glenoid and is available in small, medium and large sizes. The guard is made of a solid metal surface with an elevated peripheral edge that fits over the glenoid surface. The guard has a thickness of about 0.1 to 2 mm. The handle  44  is removable and can be attached to the guard at different positions to allow it to be inserted from variable angles through the anterosuperior passage. 
     After the guard  40  is in place, the orthopaedic surgeon grasps the protective sheath  38  and pulls the running reamer  32  back onto the humeral head until it cuts to the level of the anatomic neck  13  for a conventional humeral implant ( FIG. 7   a ). Live fluoroscopy may be used to assist with making the cut and insuring that the reamer stays parallel to the second guide pin  18  and stops before its tip. The bone debris from the cutting is removed with thorough irrigation from the anterosuperior passage. Any remaining humeral osteophytes may be removed with a small rongeur from the anterosuperior passage. 
     To insert a novel proximal humeral implant  94 , the transhumeral protective sheath  38  and reamer shaft  34  are inserted as described above ( FIGS. 7   a - d ). Alternatively, the appropriate size novel modular humeral reamer head  37  is inserted through the anterosuperior passage into the joint and assembled with the transhumeral shaft  34 . A protective guard  40  may be placed over the glenoid  22  through the anterosuperior passage during reaming. Again, the orthopaedic surgeon grasps the protective sheath  38  and pulls the running reamer  32  back onto the humeral head until the novel humeral reamer has removed just enough bone to restore the proper humeral head dimensions ( FIG. 7   b ). Openings  39  in the reamer head can help the surgeon determine the proper amount of reaming. Also, live fluoroscopy may be used to assist with making the cut and insuring that the reamer  32  stays parallel to the second guide pin  18  and stops at the appropriate level. The bone debris from the cutting is removed with thorough irrigation and suction from the anterosuperior passage. Any remaining humeral osteophytes may be removed with a small rongeur from the anterosuperior passage. 
     After the reamer  32  has prepared the humeral head, either for a conventional or a novel proximal humeral implant  94 , the glenoid  22  of the shoulder joint can then be prepared for the placement of a conventional glenoid implant  115  ( FIG. 8   a ). Any remaining soft-tissue obstructing the glenoid surface  22  should be excised. The humerus is abducted, rotated, and laterally distracted to direct the transhumeral portal  30  such that its path lies perpendicular to and centered on the glenoid surface  22 . A glenoid sizing and centering hole guide  46  is placed from the anterosuperior passage ( FIGS. 8   a - c ). In another embodiment of the present invention, a glenoid sizer and centering hole guide  46  includes a working surface  52  and a handle  53 . The guide  46  is shaped and sized according to the shape and size of the glenoid  22  to be prepared. The working surface  52  is inserted through the first anterosuperior passage by its handle  53 . The handle  53  is removable and can be attached to the working surface  52  at different positions  56  to allow it to be inserted from variable angles through the anterosuperior passage. The working surface  52  is approximately 0.1 to 10 mm thick and flat and has as central hole  54 . 
     Utilizing the appropriately sized glenoid sizing and centering guide  46 , a transhumeral guide wire  50  is inserted into the transhumeral portal  30  through the transhumeral protective sheath  38  to drill a centering hole in the glenoid surface  22  regardless of whether a conventional or novel humeral implant is being inserted ( FIGS. 8   a - b ). After the centering hole has been started, the guide wire  50  is backed up to allow the removal of the glenoid sizing and centering guide  46 . A cannulated flat or hemispherical humeral head guard  64 , followed by a cannulated glenoid surface cutting reamer head  60 , is inserted through the anterosuperior passage and the guidewire  50  is advanced through cannulations in both instruments back into the centering hole in the glenoid. 
     In another embodiment of the present invention, a humeral head surface protective guard  64  may be used ( FIGS. 9   a - b ). This protective guard  64  includes a protective metal surface which is flat or hemispheric in shape corresponding to the prepared end of the proximal humerus for a conventional or novel humeral implant, respectively. The protective guard  64  is inserted via the first anterosuperior passage and fits over the humeral surface  20  and the shaft  62  of the transhumeral glenoid reamer  58 . The shaft  62  of the transhumeral glenoid reamer  58 , described below, passes through a central cannulation of the guard  64  to prepare the glenoid  22 . The humeral head surface protective guard  64  is sized according to need, such as small, medium, and large. The guard  64  is approximately 0.1 to 2.0 mm thick. Optionally, the guard  64  may be used with a handle. 
     The present invention also provides a transhumeral glenoid reamer  58  ( FIGS. 9   a - b ,  21 ,  22 ,  23   a - b ). The glenoid reamer  58  has a shaft  62  and a working head  60 . The shaft  62  is designed to interfit securely within the transhumeral portal  30 , and more specifically, within the transhumeral protective sheath  38  within the transhumeral portal  30 , such that there is no shaking or toggling of the shaft  62  within the transhumeral portal  30  while the transhumeral glenoid reamer  58  is in use. Therefore, the outer diameter of the shaft  62  is approximately 0.1 to 5 cm, and slightly less than the inner diameter of the transhumeral protective sheath  38  within which the shaft  62  is used. The working glenoid reamer heads  60 ,  61  and the shaft  62  are cannulated to fit over a central glenoid guide wire  50 . There is also a non-cannulated reamer head with a leading central peg which can fit into a central glenoid hole and allow some redirection of the reamer as necessary. 
     For a conventional glenoid implant  115  (shown in  FIG. 14   a ), a nearly flat, slightly convex, reaming head surface  60  is used with sizes being similar to that of a glenoid. The radius of curvature of the reamer surface matches that of the non-articular side of the conventional glenoid implant. The flat reaming head  60  removes a minimal thickness of bone. The same flat reaming head  60  as used for a conventional glenoid implant  115  may also be used before inserting the multiple pegged glenoid implant  117 . 
     For a novel glenoid implant  118 , the glenoid reamer head  61  includes a peripherally flat, less aggressive surface  116  and a centrally raised surface  114  which has a more aggressive reaming surface ( FIGS. 23   a - b ). The centrally raised surface  114  may be a convex dome, a square, triangle, pyramid, or any other shape that matches the protruding surface of the novel glenoid implant  118  to be implanted within the glenoid, as described below. The peripheral glenoid reaming surface  116  removes a minimal amount of bone from the peripheral surface of the glenoid to just correct the version (orientation) of the glenoid surface. In one embodiment, the central reaming surface  114  removes a spherically shaped area of bone such that a central concave glenoid surface is created which fits an ingrowth shell component  120  of a novel glenoid implant  118  in accordance with the present invention. The concavity is slightly undersized to allow a pressfit of the ingrowth shell  120 . 
     To prepare the glenoid  22  for a conventional prosthesis  115 , the cannulated transhumeral glenoid reamer shaft  62  is positioned over the guidewire  50  and through the transhumeral protective sheath  38  from the second anterosuperior passage. The transhumeral reamer shaft  62  is assembled in the shoulder joint with its glenoid surface cutting reamer head  60  and the reamer  58  is advanced along the guidewire  50  removing as little bone as possible to correct the profile of the worn glenoid  22  and create the proper radius of curvature on the surface to match that of the non-articular surface of the conventional glenoid implant  115 . The guide wire  50  must be inserted initially in the proper orientation to direct the cut appropriately. There is also an optional glenoid cutting surface head with a central peg that can be used without the guidewire  50  and can be inserted directly into the glenoid centering hole while the surgeon runs the transhumeral glenoid reamer  58  ( FIGS. 9   a, b ). The bone debris from the cutting is removed with thorough irrigation from the anterosuperior passage. Any remaining glenoid osteophytes may be removed with a small rongeur from the anterosuperior passage. 
     The glenoid  22  can be prepared for implantation of either a conventional pegged or keeled glenoid implant  115 , a multiple peg glenoid implant  117  ( FIG. 20   b ), or a novel glenoid implant  118 . In the case of implanting a conventional peg or keel glenoid implant  115 , the appropriately sized (according to the previously used glenoid sizer and centering hole guide) peg glenoid or keel guide  68  is inserted through the anterosuperior passage and centered by placing its peg  72  into the previously created glenoid centering hole ( FIG. 10   a ). The transhumeral glenoid drill  66  is placed through the transhumeral protective sheath  38  within the transhumeral portal  30  from the second anterosuperior passage. In one embodiment of the present invention, a glenoid keel drill guide  68  has a working surface  69  and a handle  70 . The working surface  69  is introduced via the first anterosuperior passage by its handle  70 . The handle  70  is removable and can be attached to the guide  68  at different positions to allow it to be inserted from variable angles through the an anterosuperior passage. This drill guide  68  is shaped and sized similarly to the glenoid sizing and centering hole guide  46 , discussed above. The working surface  69  of the guide  68  has a central peg  72  that fits into a centering hole in the glenoid bone. The drill guide  68  for the conventional keel glenoid implant has two converging holes, one superior and one inferior, directed toward each other to direct a transhumeral glenoid drill  66  to cut a keel shape into the glenoid bone ( FIG. 10   b ). 
     The previously mentioned glenoid peg drill guide  68  has a working surface  69  and a handle  70 . The working surface  69  is inserted through the first anterosuperior passage by its handle  70 . The handle  70  is removable and can be attached to the guide surface  69  at different positions to allow it to be inserted from variable angles through the anterosuperior passage. This drill guide  68  is sized and shaped similarly to the glenoid sizing and centering hole guide  46 , discussed above. The working surface  69  of the guide  68  has a central peg  72  that fits into a centering hole in the glenoid bone. The working surface is approximately 0.1 to 5 mm thick and has peripheral holes in parallel configuration to drill holes with a transhumeral glenoid drill  66  for pegs in a glenoid. 
     In one embodiment, the above-mentioned transhumeral keel/peg glenoid drill  66  has a working surface  67  and a removably attached transhumeral shaft  65 . The working surface  67  is a drill bit (or tip) for drilling holes in the glenoid for keels or pegs of the conventional glenoid implant  115 . The drill bit  67  (or tip) is larger for drilling holes for a keel or a peg than a bit used for drilling holes for screws. 
     To further prepare the glenoid surface for a conventional glenoid implant, the humerus is positioned and translated such that the transhumeral keel/glenoid drill  66  is maintained perpendicular to the glenoid peg/keel guide surface  69 . With the glenoid drill introduced through the transhumeral protective sheath  38  of the transhumeral portal  30  and the glenoid drill guide  68  positioned from the first anterosuperior passage, holes are drilled into the glenoid ( FIGS. 10   a - c ). To prepare the glenoid to accept a keel glenoid implant, the transhumeral burr  74  is inserted into the transhumeral portal  30  through the transhumeral protective sheath  38  and used to connect the drilled holes in the glenoid  22  surface ( FIGS. 11   a - b ). 
     In one embodiment, the transhumeral burr  74  has a transhumeral shaft  75  removably attached to a high speed burr tip  73  with different sizes used for cutting holes in a glenoid  22 , particularly for a keel. 
     A modular keel punch  76  is used to finish the glenoid keel cut. In an embodiment, where a glenoid keel punch  76  is used, the keel punch  76  has a working surface  77  and a removably attached transhumeral shaft  78  ( FIGS. 12   a - b ). The working surface  77  (also referred to as a punch head) is inserted through the first anterosuperior passage and the shaft  78  is introduced through the second anterosuperior passage and the transhumeral protective sheath  38 . The shaft  78  is assembled with the working surface  77  in the glenohumeral joint. The working surface  77  is a head shaped like a keel with cutting teeth to cut a keel shape into a glenoid surface  22 . The punch  76  is struck with a hammer to complete the keel shaped cut into the glenoid ( FIGS. 12   a - b ). 
     The humeral head and glenoid trial implants are inserted through the anterosuperior passage and the rotator interval retractor  5  ( FIG. 2 ) is temporarily removed. There are different humeral trial implants that can be used, one for the conventional implant and one for a novel implant. In either case, both can mate with trial modular stems through the transhumeral portal. If there is not sufficient bone available to stabilize the conventional humeral trial with a transhumeral trial stem or the humeral surface is too far offset from the intramedullary axis of the humeral shaft to accurately trial, the intramedullary canal of the humerus can be prepared and fitted with a conventional intramedullary stem trial using conventional techniques and instruments from the anterosuperior passage. Because the rotator cuff has not been transected, it is much simpler to determine the proper size implant required to restore the normal musculotendinous length and tension in the rotator cuff and thus, more accurately, restore the native anatomical dimensions of the joint. Fluoroscopy can also be used to judge proper implant size. 
     Next, the glenoid  22  is prepared to affix its conventional implant  115  using transhumeral cementation tools  80  ( FIGS. 13   a - e ). A transhumeral irrigation and suction catheter is inserted into the transhumeral portal  30  through the novel transhumeral protective sheath  38  and used to irrigate and suck the prepared glenoid  22  holes dry. A transhumeral irrigation and suction catheter is used in yet another embodiment of the present invention. The irrigation and suction catheter includes semi-rigid tubing that is inserted through the second anterosuperior passage and the transhumeral protective sheath  38  in the transhumeral portal  30  in order to irrigate or suction the prepared glenoid surface. The catheter attaches to both, a fluid pump and suction tubing, and may be easily switched between the two with a stopcock-like device. 
     The peg or keel holes are temporarily packed with thrombin soaked gel pads or epinephrine soaked gauze using a novel transhumeral forceps device. The transhumeral irrigation and suction catheter is used again to clean and dry the holes and a transhumeral cementation catheter  84  is inserted through the transhumeral portal  30  and protective sheath  38  to place the cement. 
     Note that the above-described transhumeral cementation tool  80  includes a keel glenoid or peg glenoid cement pressurizer head  86  and a cementation catheter  84 . The transhumeral cementation catheter  84  includes semi-rigid tubing which connects to a conventional cement gun  104  to deliver cement to the site of implant fixation to bone. The head  86  includes a keel glenoid or peg glenoid cement pressurizer tip  82  that is cannulated and fits into a respective keel or peg-shaped prepared hole in the glenoid surface to dispense cementation material under pressure into that hole in the glenoid surface  22 . The pressure heads  86  are shaped similar to a glenoid implant with a smaller keel or single peg. The radius of curvature of the periphery of the tip  82  matches that of the reamed bony glenoid surface  22  to help seal the hole during cement insertion. These heads  86  are inserted through the first anterosuperior passage by their handles  88  and are attached to the transhumeral cementation catheter  84  within the glenohumeral joint  9  to pressurize the cement in the glenoid  22  holes. The handle  88  is removable and can be attached to the head  86  at different positions to allow it to be inserted from variable angles through the anterosuperior passage. The cementation head  86  limits the escape of cementation material from the hole and allows pressure to build up which forces the cement deep into the interstices of the trabecular bone to allow improved fixation. A cement pressurizer tip  82  may be inserted into the joint through the anterosuperior passage and assembled with the transhumeral cementation catheter  84 . There are different pressurizer tips  82  to match either the pegged or keeled glenoid. The conventional glenoid implant  115  is inserted through the anterosuperior passage, is seated and held in place until the cement dries with a modular transhumeral glenoid impactor  90 . Excess cement is removed and the joint is irrigated. 
     The transhumeral glenoid impactor  90  includes a transhumeral shaft  92  which removably attaches to a working head  91 . The working head  91  has a convex surface that approximates the radius of curvature of the articular surface of the glenoid implant. The shaft  92  is introduced through transhumeral protective sheath  38  within the transhumeral portal  30 . The working head  91  is introduced through the first anterosuperior passage and mated with the transhumeral shaft  92 . Force can then be applied to the handle  89  of the impactor  90  to seat the glenoid implant  115 . 
     In accordance with an embodiment of the present invention, a multiple peg glenoid implant  117  ( FIGS. 20   a - c ) or a novel modular ingrowth glenoid implant  118  ( FIGS. 26   a - b ,  25   a - c ) can also be inserted. 
     After the glenoid surface  22  has been reamed by a glenoid reamer  58  as described previously, the multiple glenoid pegs  117  can be introduced with a novel multiple peg guide  72  through the anterosuperior passage and inserted into the prepared surface of the glenoid  22  using a transhumeral insertor device  79  ( FIG. 20   a ). In another embodiment, a multiple peg glenoid insertor  79  and insertor guide  72  are used. The multiple peg glenoid insertor guide  72  includes a handle  73  and a guiding surface  71 . The guiding surface  71  is sized and shaped as the glenoid peg drill guide surface  69  discussed above. The guide  72  is introduced via the first anterosuperior passage and holds multiple pegs  117  to be inserted into the glenoid  22 . The guiding surface  71  of the guide  72  controls the depth and location of insertion of the multiple pegs  117 . 
     The multiple peg glenoid insertor  79  is inserted via the second anterosuperior passage and through the transhumeral protective sheath  38  in the transhumeral portal  30 . It is used to engage the pegs  117  located within the multiple peg insertor guide working surface  71  and then drives them into the glenoid  22  one at a time. The insertor  79  stops when it hits the guide surface  71  to control the depth of peg  117  insertion. Drilling pilot holes through a separate guide with a special transhumeral drill can precede this step. The guide surface  71 , preloaded with the implant pegs  117 , controls the position, direction and depth of peg  117  insertion. The guide surface  71  has a protruding centering peg which fits into the centering hole of the glenoid to help center and position the guide surface  7 . 
     After the multiple peg prosthesis is implanted, trialing of a conventional or novel humeral implant can be performed as described previously. 
     Alternatively, a novel ingrowth glenoid implant  118  can be implanted after reaming the glenoid with a novel transhumeral glenoid reamer  57  as described previously. The novel modular ingrowth glenoid implant  118  has an ingrowth shell  120  and modular wear-resistant articulating surface  122  ( FIGS. 23   a - b ;  26   a - b ,  27   a - c ). 
     The ingrowth shell  120  of the glenoid implant  118  is a cannulated shallow shell with a protruding surface  119  that sits within the concavity of the reamed glenoid surface. The protruding surface is surrounded by a flat outer surface  121  (or brim). The protruding surface  119  may be any shape such as a square, pyramid, hemispheric, triangular or any other suitable shape. The protruding surface  119  protrudes into the glenoid  22  to a specified depth. The depth is such that it is enough for the ingrowth shell  120  to be securely seated within the glenoid  22  and for the wear-resistant surface  122  to fit therein (as described below) and yet not so deep that a large amount of subchrondral bone must be reamed from the glenoid  22 . Preferably, the shape of the previously described novel glenoid reamer  57  is the same as the shape of the protruding surface  119  of the ingrowth shell  120  such that there will be a secure fit when the ingrowth shell  120  is seated within the glenoid  22 . As the ingrowth shell  120  is pressed into the glenoid, the flat surface (or annular brim)  121  of the ingrowth shell  120  also makes contact with the peripheral glenoid surface  22 , and in fact, provides a stopping point of insertion. The ingrowth shell  120  is made of suitable material, examples of which include, but are not limited to metal, tantalum, porous metal, trabecular metal, ceramic materials, and titanium. The protruding surface  119  and the annular brim  121  of the shell  120  may also maintain a surface of a bony ingrowth material, as described in connection with the humeral implant below. The ingrowth material promotes bone growth and adhesion of the shell to the glenoid surface. The ingrowth shell  120  has a thickness of 0.1 to 10 mm, preferably from 0.1 to 2 mm. The ingrowth shell  120  has holes for fixation. These holes may be central  124  and peripheral  126  and may further be smooth, threaded or a combination thereof. In one embodiment, a shell has a central hole  124  and multiple peripheral holes  126 , for example three peripheral holes  126 . The central hole  124  is preferably smooth and the peripheral holes  126  are preferably threaded. 
     After reaming, the ingrowth shell  120  is inserted through the anterosuperior passage and impacted into the concavity (which matches the shape of the reamer head  61  and that of the protruding surface  119  of the ingrowth shell  120  to be implanted) of the reamed glenoid with a transhumeral impacting device  90 . The concavity is slightly undersized to obtain a tight fit upon impaction. The ingrowth glenoid shell  120  is then fixed to the glenoid  22  using screws  133 ,  135 . In one embodiment, a central compression screw  133  is first used to compress the ingrowth shell into the concavity created in the glenoid and affix the ingrowth shell  120  to the glenoid and then fixed angle peripheral screws  135  are used to lock the ingrowth shell into place ( FIGS. 25   a - b ,  26   a - b ). 
     The transhumeral glenoid drill  49  is used along with a transhumeral glenoid drill sleeve  48  ( FIGS. 24   a - b ) to make the holes for the glenoid screws  133 ,  135 . The transhumeral glenoid drill sleeve  48  fits into a transhumeral glenoid screw sleeve  128  which fits into the protective transhumeral sheath  38  in the transhumeral portal  30 . The drill sleeve  48  mates with the holes  124 ,  126  in the ingrowth shell component  120  of the novel glenoid implant  118  to direct the drill  49  in the proper orientation. The shaft of the transhumeral glenoid drill  49  just fits within the inner diameter of the transhumeral glenoid drill sleeve  48  and has visible markings on it that allow one to measure the depth of the hole off the distant edge of the transhumeral drill sleeve  48  ( FIGS. 24   a - b ). The drill  49  is advanced until the far cortex of the glenoid and scapula is reached. At which point, the surgeon reads the mark on the drill at the level of the glenoid drill guide sleeve  48 . Approximately 5 mm is added to the screw length to determine the length of the screw used. The drill  49  is then advanced through the far cortex to complete the screw hole in the glenoid  22 . 
     In one embodiment of the present invention, a novel transhumeral screwdriver  130  and transhumeral glenoid screw guide sleeve  128  are used to place the above described screws  133 ,  135 . After drilling, the surgeon removes the inner transhumeral glenoid drill guide sleeve  48  and the transhumeral screwdriver  130  is inserted through the previously positioned transhumeral glenoid screw guide sleeve  48 . The screwdriver shaft  130  fits snugly within a transhumeral glenoid screwdriver guide sleeve  128 . The screwdriver  130  is then advanced to place a screw  133 ,  135  through a hole  124  or  126  of the ingrowth shell  120  of a novel glenoid implant  118  into the drilled glenoid bone  22 . As briefly described above, a central screw  133  is first inserted through a central smooth hole  124  in the glenoid shell  120  to initially compress the ingrowth shell  120  firmly into the glenoid surface  22 . The glenoid ingrowth shell  120  is then locked into place by at least one peripheral screw  135 , preferably three ( FIGS. 25   a - b ,  26   a - b ). For example if three peripheral screws are utilized, one is placed anterosuperiorly, one is placed posterosuperiorly, and one is placed inferiorly. The threads of the screws  135  engage the threading of the peripheral holes  126  in the glenoid ingrowth shell  120  as well as the drilled outer cortical surface of the glenoid  22  and scapula. The peripheral holes  126  of the shell  120  direct the screws  135  into a fixed divergent pattern. 
     After the glenoid ingrowth shell  120  is well fixed, the modular wear-resistant glenoid surface  122  is inserted through the anterosuperior passage and impacted into the shell  120  with a transhumeral glenoid impactor  90  ( FIGS. 14   a - b ,  26   a - b ) as described previously. 
     The wear-resistant surface  122  of the glenoid implant  118  has a convex surface which mates with the concave side of the protruding surface  119  of the ingrowth shell  120  and forms the articulating surface of the glenoid implant  118 . The protruding surface  119  of the ingrowth shell  120  is of thin dimension such that it simultaneously provides 1) fixation to the glenoid bone; 2) an ingrowth surface; 3) provides a support surface for the wear-resistant surface  122 ; and 4) a recessed coupling device which maximizes the thickness of the wear-resistant surface  122  for durability while still maintaining proper anatomic glenohumeral surface relationships. The wear-resistant surface  122  may include, but is not limited to polyethylene, plastic, ceramic material, metals, and magnetic materials. At a minimum, the wear-resistant surface  122  has a thickness of 0.1 o 15 mm, preferably 4 to 7 mm, if composed of currently available forms of polyethylene, protruding above the glenoid bony surface and flat outer surface (or annular brim)  121  of the ingrowth shell  120 . It may have variable thickness along its dimension to correct version of glenoid. The wear-resistant surface  122  of the glenoid implant 118, which is approximately pear shaped, has both a superior-inferior dimension and an anterior-posterior dimension. The superior-inferior axis has a suitable range of from about 20 to 60 mm, preferably from about 30 to 48 mm. The anterior-posterior axis defines an upper half and a lower half The lower half anterior-posterior axis has a range of about 15 to 50 mm, preferably from about 21 to 35 mm. The upper half has a range of from about 10 to 50, preferably 18 to 33 mm. The ratio of the upper half to the lower half is approximately 0.8 to 1.0. The ratio of the lower half of the anterior-posterior axis to the superior-interior axis is approximately 0.7 to 1.0, whereas the ratio of the upper half of the anterior-posterior axis to the superior-inferior axis is approximately 0.6 to 1.0. In addition, the radius of curvature of the superior-inferior axis of the glenoid surface is greater than the coronal radius of curvature of the humeral surface of the humeral implant with which the glenoid implant articulates. The anterior-posterior radius of curvature of the glenoid surface is larger than the axial radius of curvature of the humeral surface. It may have variable thickness along its dimension to correct version of glenoid. 
     To prepare the humerus for a conventional humeral implant, the humerus is adducted and extended to line up the axis of the intramedullary canal with the first anterosuperior passage. With the self-retaining rotator interval retractor  5  in place, the humeral canal is prepared using conventional instruments, trials are used to determine the proper fit and size of the implants, and the proper conventional humeral implant with an intramedullary stem is either cemented or press-fit into the proximal humerus  20  in accordance with the present. 
     For the novel humeral implant  94 , the humerus does not require special positioning. After humeral trialing, the novel humeral stem  98  is placed in the transhumeral portal  30  from either the first or second anterosuperior passages and the novel modular head  96  is inserted through the anterosuperior passage. The two components  96 ,  98  are then mated together. 
     The novel humeral implant  94  in accordance with the present invention is modular and includes a humeral surface  96  component, a roughly hemispheric shaped surface with a short central mating device  100 , and a transhumeral stem  98  which fills the transhumeral portal  30  ( FIG. 15   a - b ). Alternatively, a novel humeral surface implant that includes only a humeral surface  96 , with no stem  98  may be used when warranted. Preferably, however, a novel humeral implant  94  with two components  96 ,  98  is used. The two components, the humeral surface  96  and stem  98 , are removably attached to one another. The humeral surface  96  has a coronal radius of curvature and an axial radius of curvature. The humeral surface can be spherical in shape. Preferably the humeral surface can be more anatomic being spherical, with equal coronal and axial radii of curvature, in the center and elliptical, with larger coronal than axial radii of curvature, at the periphery. A suitable range for the coronal radius of curvature is from 10 to 50 mm, preferably from 19 to 28 mm, with approximately 81% of all men having a coronal radius of curvature ranging from 23-28 mm, and 79% of all women having coronal radius of curvature ranging from 19-22 mm. A suitable range for the axial radius of curvature of the humeral surface of the implant is from 10 to 50 mm, preferably from 18 to 26 mm. The humeral surface  96  of the implant  94  also has a depth and thickness. A suitable range for the depth of the humeral implant  94  is from 5 to 40 mm, preferably from 15 to 24 mm, and the depth is the same in both the coronal and axial planes. The humeral surface  96  thickness has a range of from 0.1 to 5 mm, preferably from 1 to 3 mm. The ratio of the depth to the coronal radius of curvature is approximately 0.7 to 0.9. See Table 1. 
     
       
         
           
               
             
               
                 TABLE 1  
               
             
            
               
                   
               
               
                 Table 1 shows suitable and preferred ranges of radius of curvature 
               
               
                 and depth for the humeral surface of the humeral implant. 
               
            
           
           
               
               
               
            
               
                   
                 Radius of 
                 Depth (mm) 
               
            
           
           
               
               
               
               
               
            
               
                   
                 curvature (mm) 
                 15-17 
                 18-20 
                 21-24 
               
               
                   
                   
               
            
           
           
               
               
               
               
               
            
               
                   
                 19-20 
                 10 
                 3 
                 2 
               
               
                   
                 21-22 
                 7 
                 18 
                 3 
               
               
                   
                 23-24 
                 0 
                 9 
                 18 
               
               
                   
                 25-26 
                 0 
                 8 
                 14 
               
               
                   
                 27-28 
                 0 
                 0 
                 4 
               
               
                   
                   
               
               
                   
                 (See Iannotti J P, Gabriel J P, Schneck S L, et al. The normal glenohumeral relationships: an anatomical study of one hundred and forty shoulders. J Bone Joint Surg 1992; 74A(4): 491-500.) 
               
            
           
         
       
     
     The humeral surface  96  of the humeral implant  94  may be spherically shaped or more of an elliptical shape which better approximates the anatomy of a natural humeral head. The humeral surface  96  may be made of a variety of materials including, but not limited to cobalt-chrome alloys, ceramic materials, metals, and magnetic materials. It is contemplated that the humeral surface may also have fins, spikes or other protuberances  96   a  on its concave, non-articular surface to enhance rotational stability. Additionally, the concave, non-articular surface may also contain a bony ingrowth material. A bony ingrowth material allows the bone to which the implant is attached to grow into the implant and aids in attaining long-lasting fixation of the implant. These ingrowth materials include, but are not limited to autologous and allograft osteoprogenitor cells and tissues, bone-morphogenic proteins, hydroxyapapite coating, trabecular metal, porous metal coating, and tantalum. It is contemplated that the surface of the humeral surface component  96  of the implant  94  that articulates with the glenoid or the glenoid implant, is smooth with a low coefficient of friction. 
     The stem  98  of the modular humeral implant  94  is sized to fit within the transhumeral portal  30  located along the central axis of the neck of the humerus. By fitting, it is meant that the stem  98  fits in a tight manner and is stable in that location. As it is contemplated that the transhumeral portal  30  has a diameter of from 0.1 to 5 cm, the diameter of the stem  98  is also from 0.1 to 5 cm, and is dimensioned to fit within the transhumeral portal  30 . The stem  98  may be composed of any suitable materials including, but not limited to titanium, stainless steel, cobalt-chrome alloy. The stem  98  may be smooth, textured, or threaded. Smooth glass bead blast finishes are another possibility. Threads may be uniform or may vary in width along the length of the stem. Further, the shape of the stem  98  is intended to accommodate the shape of the transhumeral portal  30 , therefore it may be round, square, triangular, or any other geometric shape that may comprise the transhumeral portal  30 . The main body of the stem  98  has a consistent cross-sectional shape and size along its straight longitudinal axis. Therefore, unlike conventional humeral implant stems, which are tapered and bowed to fit within the dimensions of the metaphysis and diaphysis of the humerus, the stem  98  of the present invention maintains a uniform diameter and is linear from end to end. As such, the stem is dimensioned to sit within the epiphyseal and metaphyseal portions of the humerus. As described for the humeral surface  96 , the stem  98  may also contain fins or spikes to aid rotational stability, and it may also possess a bony ingrowth material surface, as described above. 
     The stem  98  may be of varying lengths, a suitable range of which is from about 4 to 7 cm. The preferred length is dimensioned to extend from the lateral cortex of the humerus to the center of a humeral head. It is intended that this stem  98  be introduced into the transhumeral portal  30  via the second anterosuperior incision and advanced through the transhumeral portal  30  to a position that is suitable for mating with the humeral surface  96  which is inserted via the anterosuperior incision, described above. If appropriate, the stem  98  may also be inserted from the articular surface of the proximal humerus through the first anterosuperior passage. 
     The humeral surface  96  and stem  98  of the humeral implant  94  connect to one another via a mating site  100 . The humeral surface  96  and stem  98  are joined within the glenohumeral joint space. They may be press fit, screwed together, or joined by morse taper, as well as any other suitable locking mechanism. It is possible for the male or female counterpart to be on either the stem  98  or the humeral surface  96 , so long as one male counterpart and one female counterpart are present in the humeral implant  94 . 
     The humeral surface  96  component is inserted through the anterosuperior passage and mated with its stem  98  placed through the transhumeral portal  30 . The humeral surface  96  and modular stem  98  implant can be cemented or press-fit to the prepared humeral surface and there are many possible variations of the implant  94 . Examples A, B, and C are various embodiments of a humeral implant  94  in accordance with the present invention. Example A includes a hemisphere shaped humeral surface  96  and a threaded transhumeral stem  98  ( FIG. 16 ). The humeral surface  96  component is inserted through the anterosuperior passage and is either cemented or press-fit onto the humeral surface  20  and then impacted on the prepared humeral surface against the glenoid  22 . The hemisphere shaped surface  96  is rotationally stabilized with a rod inserted into a hole at a peripheral edge of the hemisphere shaped surface  96  while the threaded humeral stem  98  is advanced through the protective sleeve  15  from the transhumeral portal guide  14  and up the transhumeral portal  30  to engage with the non-articular side of the hemisphere shaped humeral surface  96 . The threaded stem  98  has a double pitch with finer pitched but deeper cancellous threads that engage and fill the transhumeral portal  30  and slightly wider pitched more shallow threads on the narrower diameter tip which engages the humeral surface  96  component so as to secure the humeral surface  96  component. Should it be necessary, removal of the Example A implant  94  is conducted by recreating both anterosuperior passages, inserting a driver for the threaded stem  98  through the second anterosuperior passage, inserting a stabilizing rod into a peripheral edge of the humeral surface  96  component from the first anterosuperior passage and backing out the stem through the protective sleeve  15  from the transhumeral portal guide  14 . The humeral surface  96  component is then removed by sawing across the base of the humeral surface  96  component at the anatomic neck of the humerus with a power or Gigli saw. 
     Example B includes a similar humeral surface  96  component and a cemented transhumeral stem  98  ( FIGS. 17   a - c ). Again, the humeral surface component  96  is inserted through the anterosuperior passage, is either cemented or press-fit onto the prepared humeral surface  20  and impacted on the prepared humeral surface  20  against the glenoid  22 . Another transhumeral stem  98  which possesses the male end of a morse taper is inserted into the female end on the non-articular side of the humeral surface component  96  and impacted against the glenoid. This stem  98  may be press-fit or cemented to the bony transhumeral portal. An endcap  106  is threaded into the non-articular side of the stem  98  to assist with later removal of the humeral surface implant  94 . To fix with cement, a cementation catheter  84  is assembled to an opening in the endcap  106  and cement is injected through the cannulated transhumeral stem  98  exiting holes  99  at its articular end. The cement is injected until it becomes visible around the non-articular end of the stem  98 . Should it be necessary, removal of the Example B implant is conducted by recreating the anterosuperior passages, removing the endcap with a T-handled wrench, threading the removal shaft  111  into the stem  98 , drilling out the cement-implant interface with a coring reamer  110  over the stem  98  and disimpacting the stem  98  from the humeral surface component  96  with a disimpaction sleeve  112  ( FIGS. 18   a - b ). The humeral surface component  96  is removed by sawing across the base of the humeral surface component  96  at the anatomic neck of the humerus with a power or Gigli saw. 
     Example C includes a similar humeral surface  96  component and an inflatable transhumeral stem  98  ( FIGS. 19   a - b ) similar to technology used in the FIXION™ IM Nail (See “A New Expandable Implant for the Repair of Long Bone Fractures”, Sinha, Anjoy M. D. et al, published in www.Healthfocus.com). Again, the humeral surface component  96  is inserted through the anterosuperior passage and either cemented or press-fit, and further impacted on the prepared humeral surface  20  against the glenoid  22 . Another transhumeral stem  98  which possesses the male end of a morse taper is inserted into the female end on the non-articular side of the humeral surface  96  component and impacted against the glenoid  22 . The inflatable stem  98  is an expandable tube that is reinforced with longitudinal bars and has a one-way valve system on the end that doesn&#39;t mate with the humeral surface component. Once positioned, the stem  98  is inflated or expanded from its collapsed position with a specialized saline pump to fill the stem  98 , within the transhumeral portal  30 , and gain purchase. The stem  98  can be removed by deflating it with the same pump and disimpacting the stem  98  from the humeral surface  96  component with a disimpaction sleeve  112  The humeral surface component  96  is removed by sawing across the base of the humeral surface  96  component at the anatomic neck of the humerus with a power or Gigli saw. 
     After the prosthetic implants, either humeral or glenoid, novel or conventional, are inserted as described above, the soft-tissue tension is evaluated, and the wounds are copiously irrigated, the deep passages, subcutaneous tissue and skin are closed with sutures. 
     In yet another embodiment, the present invention is a glenohumeral joint with a transhumeral portal  30  along the central axis of the neck of the humerus and at least one implant. The implant may be a humeral implant  94 , a glenoid implant  118  or both. The implants may be conventional implant or novel  94 ,  118  described herein. 
     In an alternative embodiment of the present invention, there is provided a method of repairing a rotator cuff tear as shown in  FIGS. 28-33 . This procedure may be utilized in conjunction with the above described method of shoulder replacement or it may be used as a stand-alone procedure. In this method standard positioning and techniques for arthroscopic or open rotator cuff exposure are employed. If performed in conjunction with the previously described methods of shoulder replacement surgery, the anterosuperior passages may be used. If performed in isolation, an open deltoid split or arthroscopic subacromial exposure used for rotator cuff repair is performed in standard fashion. A small longitudinal stab is made through the skin and superficial deltoid fascia approximately 5-12 cm below the level of the anterolateral edge of the acromion. 
     In one embodiment of the rotator cuff repair method, an insertional guide  134  is inserted with a protective inner sheath  137  ( FIGS. 28   a - b ). The insertional guide  134  includes a cannulated handle  134 A and a cannulated tip  148 . The cannulated tip  148  is an elongated rigid tube with a sharp trocar tip  150 . The diameter of the rigid tube and trocar tip  150  is slightly larger than that of the leading flexible pin  140  of suture pin device  141  adjacent its sharp leading end  154  ( FIG. 29 ) described below, and is approximately 1.0 to 5.0 mm. An inner protective sheath  137  may be used with the insertional guide  134  ( FIG. 28   b ). The inner protective sheath  137  screws into the handle  134 A of the insertional guide  134 . The inner protective sheath  137  has a handle  138  that acts as a stop and prevents the inner protective sheath  137  from extending further into the insertional guide  134  than the level of the protective sheath handle  138 . The inner sheath  137  has a blunt end  139  that extends beyond the level of the sharp trocar  150  of the insertional guide  134 , providing a non-sharp surface with which to enter the tissue. When the surgeon is prepared to use the sharp trocar tip  150  of the insertional guide  134 , the inner protective sheath  137  is removed by unscrewing the handle  138  and sliding it out of the insertional guide  134 . Optionally, an outer protective sheath may be used that extends over the tip of the insertional guide  134  and provides a blunt end as well. In this embodiment, the outer protective sheath has a longitudinal split so that it may be peeled off of the insertional guide when the surgeon is ready to use the sharp trocar tip  150  of the insertional guide  134 . The bore tip  150  is extended into the lateral humeral  20  cortex under direct or arthroscopic visualization ( FIG. 30 ). An arthroscopic retractor  136  may assist the process. Directed by an insertional guide  134 , a flexible pin  140  is advanced by a drill through the greater tuberosity of the proximal humerus to exit into an anteromedial supraspinatus rotator cuff footprint. The next step is to reduce the torn edge of the supraspinatus tendon with a soft tissue grasper  138 A. The flexible pin  140  is advanced through the cuff ( FIG. 31 ) and out through the superior soft-tissue and the skin  143  using a pin director  142  as needed ( FIG. 32 ). The suture-pin device  141  may pass through the acromion or deltoid as necessary. These steps, namely, advancing the suture pin through the greater tuberosity of the humerus, the supraspinatus rotator cuff tendon and out of the shoulder through the superior soft tissue and the skin  143 , are done, as described, in a single pass. The drill is switched to a suture-pin leading tip and the flexible pin component  140  is removed from the body. The pin  140  is cut from the suture  144 . The above steps may be repeated as often as necessary to provide sufficient sutures  144  to secure the torn rotator cuff. For the arthroscopic technique, a tying cannula  146  is then inserted for tensioning and securing suture  144  ( FIG. 33 ). The sutures  144  are retrieved and passed in modified Mason-Allen fashion if desired, using free needles (open technique) or an arthroscopic suture passing device. The sutures  144  are tied and the tying steps are repeated. The repair may be reinforced with lateral suture anchors as needed before or after tying the transosseous sutures  144  ( FIG. 33 ). 
     The suture-pin device  141  comprises two components, a leading flexible pin  140  and a swedged on suture  144 . The suture  144  is preferably a durable size #2 suture  144 . The pin  140  has a sharp slightly larger diameter trocar tip  154  on its leading end. The remaining pin  140  has a diameter closer to that of the suture  144 . The pin  140  is sufficiently long to enter the anterolateral surface of the shoulder, pass through the proximal humerus, rotator cuff, and exit the superior surface of the shoulder with both its leading and trailing ends are exposed. The suture  144  is of similar length. 
     It is therefore intended that the foregoing detailed description be regarded as illustrative rather than limiting, and that it be understood that it is the following claims, including all equivalents, that are intended to define the spirit and scope of this invention.