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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

(i) Surgical approaches for


shoulder arthroplasty

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.

Keywords anatomy; approaches; arthroplasty; shoulder

Patient positioning and set-up


The patient is placed in the beach chair position with knees
flexed and pressure areas protected. The back support is inclined
at 30 e60 , which allows the arm to be placed in extension. At
our institution the set-up and patient positioning is the same for
both DP and AS approaches. The operation is performed with the
patient under a general anaesthetic with an interscalene block,
and intravenous antibiotics are administered at the induction of
anaesthesia. The surface anatomy of the shoulder girdle can be
marked using a sterile pen after antiseptic preparation and
draping, with the forearm and hand covered using a small sterile
drape and 400 crepe bandage.
A slim, adjustable armrest can be used to alter the position of
the upper limb during different stages of both approaches. 10e15
ml of a long-acting local anaesthetic with 1:200 000 concentration
of adrenaline is infiltrated in the line of the planned skin incision
to minimize superficial bleeding and improve visualization.
Specialized Kolbel, Gelpi and other retractors can be useful to
gain access to the glenohumeral joint while minimizing tissue

Henry B Colaco MSc FRCS(Tr&Orth) MFSTEd Senior Clinical Fellow,


Orthopaedics, Dept. of Trauma & Orthopaedics, St Georges Hospital,
St Georges University of London, London, UK. Conflict of interest:
none.
Magnus Arnander FRCS(Tr&Orth) Consultant Orthopaedic Surgeon,
St Georges Hospital, St Georges University of London, London, UK.
Conflict of interest: none.
Eyiyemi O Pearse FRCS(Tr&Orth) Consultant Orthopaedic Surgeon,
St Georges Hospital, St Georges University of London, London, UK.
Conflict of interest: none.
T Duncan Tennent FRCS(Tr&Orth) Consultant Orthopaedic Surgeon,
St Georges Hospital, St Georges University of London, London, UK.
Conflict of interest: none.

ORTHOPAEDICS AND TRAUMA 29:5

Figure 1 DP: surface anatomy and skin incision (Left shoulder).

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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

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.)

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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

The subscapularis tendon must be reflected to allow access to


the joint. There are a number of options, which will be discussed
in the following section; our preferred technique is described
here. The footprint of the subscapularis tendon is carefully
elevated using sharp dissection to peel it away from the lesser
tuberosity and a stay suture is placed in the tendon to assist
mobilization of the muscle from the subscapular fossa
(Figure 3b) This allows increased excursion of the contracted
muscle and can aid placement of glenoid guidewires. In the
arthroplasty situation the anterior capsule can be incised and
elevated en masse with subscapularis. External rotation in
adduction will deliver the humeral head articular surface into the
wound (Figure 5). Further release of inferior joint capsule from
the humeral neck, and removal of osteophytes can be performed
prior to humeral neck cut and preparation. The cut surface of the
humeral neck is protected and retracted using a curved retractor
positioned behind the posteroinferior glenoid with the humerus
internally rotated (Figure 6).
A circumferential capsulo-labral release is carefully performed
under direct vision with a #15 scalpel against the glenoid rim to
avoid thermal damage to the axillary nerve from electrocautery.
A Bristow periosteal elevator can be used to elevate subscapularis muscle belly. The glenoid articular surface can now be
prepared according to implant-specific surgical technique
(Figure 7). After insertion of implants and adequate lavage,
transosseous subscapularis repair is performed using four 2 mm
drill holes in the bicipital groove. A Mayo needle is used to
facilitate transosseous passage of three Mason-Allen tendon sutures using #2-Fiberwire or similar, which are secured in
mattress configuration, and additional sutures can be placed in
the rotator interval. The LHB can either be tenotomized or
tenodesed to the upper border of pectoralis major tendon insertion under appropriate tension.

Figure 6 DP: exposure of the glenoid.

manage subscapularis in TSA; tenotomy with tendon-to-tendon


repair, subperiosteal peel with transosseous repair, and lesser
tuberosity osteotomy (LTO) with bone-to bone healing.2e4 The
LTO technique has been popularized by Gerber et al., and
although the union rate is excellent and clinical outcomes are
superior in some studies, the rate of post-operative fatty atrophy
of subscapularis remains relatively high.5e7 Evidence of biomechanical superiority of LTO over tenotomy from cadaveric
studies is inconclusive.8,9 There is recent evidence to suggest that
LTO results in superior clinical outcomes compared to tenotomy
but a randomized controlled trial found no difference in healing
rate, fatty infiltration or clinical outcomes when comparing LTO
against subscapularis peel.3,10e12 For patients with adequate
tendon quality and excursion, tenotomy and tendon-to-tendon
repair (with or without additional rotator interval approximation) remains a valid option.2
Lafosse et al. developed a rotator interval approach for
anatomic TSA that preserves both supraspinatus and subscapularis tendons, and does not require joint dislocation. It does
however require specialized instruments, and whilst good clinical outcomes can be achieved at 2 years, humeral head undersizing, non-anatomic neck cut, and retained inferior humeral
neck osteophytes are common.13,14 Further modifications of this
technique via a deltopectoral approach have been developed,
which utilize windows or partial subscapularis take-down to
facilitate access to inferior humeral neck.15,16
The importance of subscapularis integrity in RSA remains
controversial, and differs between implant design philosophies;
when a both components are medialized, a functioning subscapularis is integral to stability, but this is less important for
lateralized designs, and may actually increase the work of the
residual rotator cuff.17

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

Figure 5 DP: delivery of the humeral head for preparation.

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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

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.

divided to expose the raphe between the anterior and middle


heads of deltoid muscle, and the muscle is split in line with the
fibres. A stay suture can be placed in deltoid 5 cm distal to the
acromial origin to prevent inadvertent extension and reduce
risk to the terminal motor branch of the axillary nerve
(Figure 8).
The exposure is extended superiorly using an osteotome to
release the acromial attachment of deltoid, coracoacromial ligament, and subacromial bursa en masse attached to a flake of
anterior acromion.18 This facilitates transosseous deltoid repair
after implant insertion using #2-Fiberwire sutures or similar,
which are secured in a simple configuration to achieve bone-tobone contact of the acromial osteotomy. The subdeltoid bursa
is divided, and the LHB is tenotomized at its origin, if present. If
intact, the subscapularis tendon insertion is preserved and the
posterior rotator cuff can be assessed by extending and internally
rotating the arm. The assistant then can deliver the humeral head
into the operative field by subluxing the head anterosuperiorly.
Large inferior osteophytes can be difficult to access and are often
removed after the humeral neck cut has been made. The

presence of significant inferior and posteroinferior humeral neck


osteophytes is a relative contra-indication to this approach. A
curved retractor placed at the inferior aspect of glenoid is used to
retract the humerus to facilitate circumferential capsular release.
The glenoid is prepared in accordance with implant-specific
technique, but care must be taken to avoid superior tilt of the
glenoid component (Figure 9).
Although exposure of the glenoid is better, and retroversion is
easier to assess, superior tilt of the glenoid component in RSA is
more common when an AS approach is used; this is associated
with scapular notching and may contribute to early glenoid
component loosening.18,19 Humeral access can also be difficult,
and while specific instruments have been developed to overcome
this, there is an increased rate of valgus positioning of stemmed
humeral components.19 The anterosuperior approach now
commonly used for RSA differs from the Codman sabre cut
transacromial approach described by Grammont.20 It also differs
from the anterosuperior approach described by Mackenzie for
anatomic TSR, which utilizes the deltoid split, but is not a
subscapularis-sparing approach (Figure 10).21

Figure 8 Anterosuperior: surface anatomy (including axillary nerve) and


skin incision (Right shoulder).

Figure 9 Anterosuperior: identify raphe between anterior and middle


deltoid muscle.

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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

REFERENCES
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2 Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after primary tendon to tendon repair in patients after replacement arthroplasty of the shoulder. J Shoulder Elbow Surg 2009 MareApr; 18:
193e6. discussion 197e8.
3 Lapner PL, Sabri E, Rakhra K, Bell K, Athwal GS. Comparison of lesser
tuberosity osteotomy to subscapularis peel in shoulder arthroplasty:
a randomized controlled trial. J Bone Joint Surg Am 2012 Dec 19; 94:
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4 Lapner PL, Sabri E, Rakhra K, Bell K, Athwal GS. Healing rates and
subscapularis fatty infiltration after lesser tuberosity osteotomy
versus subscapularis peel for exposure during shoulder arthroplasty.
J Shoulder Elbow Surg 2013 Mar; 22: 396e402.
5 Gerber C, Pennington SD, Yian EH, Pfirrmann CA, Werner CM,
Zumstein MA. Lesser tuberosity osteotomy for total shoulder
arthroplasty. Surgical technique. J Bone Joint Surg Am 2006 Sep;
88(suppl 1 Pt 2): 170e7.
6 Gerber C, Yian EH, Pfirrmann CA, Zumstein MA, Werner CM. Subscapularis muscle function and structure after total shoulder
replacement with lesser tuberosity osteotomy and repair. J Bone Joint
Surg Am 2005 Aug; 87: 1739e45.
7 Qureshi S, Hsiao A, Klug RA, Lee E, Braman J, Flatow EL. Subscapularis function after total shoulder replacement: results with
lesser tuberosity osteotomy. J Shoulder Elbow Surg 2008 JaneFeb;
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8 Fishman MP, Budge MD, Moravek Jr JE, et al. Biomechanical testing of
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9 Giuseffi SA, Wongtriratanachai P, Omae H, et al. Biomechanical
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10 Buckley T, Miller R, Nicandri G, Lewis R, Voloshin I. Analysis of subscapularis integrity and function after lesser tuberosity osteotomy
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14 Ding DY, Mahure SA, Akuoko JA, Zuckerman JD, Kwon YW. Total
shoulder arthroplasty using a subscapularis-sparing approach: a
radiographic analysis. J Shoulder Elbow Surg 2015 Jun; 24: 831e7.
15 Simovitch R, Fullick R, Zuckerman JD. Use of the subscapularis preserving technique in anatomic total shoulder arthroplasty. Bull Hosp
Jt Dis (2013) 2013; 71(suppl 2): 94e100.

Figure 10 Anterosuperior: can be extended with anterior acromial


osteotomy (this patient underwent surgery for a proximal humerus
fracture).

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

Comparison of DP and AS approaches


Deltopectoral (DP)

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

Improved humeral exposure


Reduced risk nerve injury
Deltoid preservation
Reduced risk
notching (RSA)
Anatomic TSA
Improved glenoid exposure
Reduced dislocation risk
Subscapularis
preservation











Table 1

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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

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.

ORTHOPAEDICS AND TRAUMA 29:5

19 Gillespie RJ, Garrigues GE, Chang ES, Namdari S, Williams Jr GR.


Surgical exposure for reverse total shoulder arthroplasty: differences
in approaches and outcomes. Orthop Clin North Am 2015 Jan; 46:
49e56.
20 Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff
rupture. Orthopedics 1993; 16: 65e8.
21 Mackenzie DB. The antero-superior exposure for total shoulder
replacement. Orthop Traumatol 1993; 2: 71e7.

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