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damage, but with adequate care both approaches can be performed using Trethowan bone levers, Travers, and Hohmann
retractors.
Deltopectoral approach
Henry B Colaco
The skin incision extends from the level of the coracoid process
along the deltopectoral interval (Figure 1). Meticulous haemostasis is performed throughout using Gillies forceps and a finger
switch monopolar pencil diathermy. The subcutaneous fat is
divided to expose the deltopectoral interval where the cephalic
vein lies within a streak of fatty tissue (Figure 2a). The vein is
preserved, protected and mobilized laterally with the deltoid,
after ligation or electrocautery to medial branches (Figure 2b).
Care must be taken with placement and tension of self-retaining
retractors to avoid damage to the vein. If the vein is taken
medially, there are more branches to ligate or cauterize, but less
pressure is exerted on it by retractors and the vein is further from
the active surgical field. After incising the clavipectoral fascia,
the surgeon can perform a blunt finger sweep of the subacromial
and subdeltoid bursae with the shoulder held in abduction to detension the deltoid muscle. The musculocutaneous nerve enters
the muscular portion of the conjoint tendon to supply coracobrachialis 3e8 cm distal to the coracoid tip. Avoid placing the
conjoint tendon under excessive tension with a retractor to
minimize risk of injury to the nerve.
If present, the long head of biceps (LHB) can be palpated and
identified in the bicipital groove, located between the tuberosities
of the proximal humerus (Figure 3a). After incising the bicipital
sheath, the LHB can be traced proximally to locate the rotator
interval, and enter the glenohumeral joint. At this stage, the LHB
can be tenotomized close to its origin and if a tenodesis is
planned, a #1 vicryl stay suture can be placed at the planned
level and used for later repair. With the arm in external rotation,
the upper and lower borders of subscapularis can be clearly
defined. The three sisters (anterior circumflex humeral artery
and two venae comitantes) overlying the inferior border can now
be ligated or cauterized. The axillary nerve runs inferior to the
lower border subscapularis before exiting posteriorly through the
quadrilateral space (Figure 4), and should be identified either by
palpation or more formal dissection, and protected.
Magnus Arnander
Eyiyemi O Pearse
T Duncan Tennentf
Abstract
Shoulder arthroplasty is most commonly performed via a deltopectoral
(DP) or anterosuperior (AS) approach, and several modifications of
each have been described. Both approaches can be used for resurfacing,
stemless and stemmed hemiarthroplasty, anatomic total shoulder arthroplasty (TSA), and reverse shoulder arthroplasty (RSA). This article aims to
give a practical guide to performing both approaches, and a summary of
the related evidence.
281
Figure 2 DP: (a). deltopectoral interval and cephalic vein. (b). development of deltopectoral interval to expose coracoid and conjoint tendon.
Figure 3 DP: (a). identification of long head of biceps. (b). subscapularis detachment using a peel technique.
Figure 4 Location of important neurovascular structures around the humerus (a). Posterior. (b). Anterior. (Reproduced with permission from Wolters
Kluwer Heath: Zlotolow DA, Catalano LW 3rd, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am Acad Orthop Surg. 2006 Dec; 14(13):754e65.)
282
Subscapularis
Healing rates and clinical outcomes following repair of a subscapularis tenotomy performed to allow anatomic TSA vary in
the literature. Post-operative subscapularis insufficiency is common, with one study reporting a 7/15 (47%) failure rate detected
by ultrasound at 6 months, although this did not correlate with
clinical assessment.1 There are three common strategies to
Anterosuperior approach
This approach is used more commonly for reverse shoulder
arthroplasty in the setting of rotator cuff arthropathy, as the
supraspinatus tendon is absent. The skin incision extends
laterally from the acromioclavicular joint to approximately 5 cm
distal to the lateral edge of the acromion. Alternatively, a sabre
incision can be used and a large skin flap mobilized laterally.
Meticulous haemostasis is performed, subcutaneous fat is
283
Figure 7 Stemless TSA via DP approach. (a). Pre-operative AP X-ray (note inferior humeral head and superior glenoid osteophytes). (b). Pre-operative axial
X-ray. (c). Post-operative AP X-ray. (d). Post-operative axial X-ray.
284
REFERENCES
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Jt Dis (2013) 2013; 71(suppl 2): 94e100.
Summary
The overall number of both anatomic TSA and RSAs being performed is rising. As techniques and implants are refined and
outcomes improve, there may be a trend towards further indications and a lower threshold for arthroplasty. The
subscapular-sparing AS approach is a good alternative for RSA,
however the DP interval remains the workhorse utility
approach to the glenohumeral joint for arthroplasty (Table 1).
Careful consideration must be given to the management of subscapularis if this is used. In both approaches the neurovascular
structures are in close proximity and are potentially at risk.
Although the reported rate of damage is low the surgeon must
appreciate the anatomy when undertaking shoulder arthroplasty
by whichever technique is chosen.
A
Anterosuperior
(AS)
Internervous plane
Intermuscular plane
Axillary/L Pectoral
Deltoid/Pec. major
Dangers
Axillary N
Musculoskeletal N
Ant. Circumflex
vessels
Axillary/Axillary
Anterior/Middle
Deltoid
Axillary N
Table 1
285
16 Savoie 3rd FH, Charles R, Casselton J, OBrien MJ, Hurt 3rd JA. The
subscapularis-sparing approach in humeral head replacement.
J Shoulder Elbow Surg 2015 Apr; 24: 606e12.
17 Routman HD. The role of subscapularis repair in reverse total shoulder arthroplasty. Bull Hosp Jt Dis (2013) 2013; 71(suppl 2): 108e12.
18 Mol
e D, Wein F, D
ezaly C, Valenti P, Sirveaux F. Surgical technique: the
anterosuperior approach for reverse shoulder arthroplasty. Clin
Orthop Relat Res 2011 Sep; 469: 2461e8.
286