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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

(i) Surgical approaches for shoulder arthroplasty

Henry B Colac o 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 arthro- plasty (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 4 00 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 Colac o MSc FRCS(Tr&Orth) MFSTEd Senior Clinical Fellow, Orthopaedics, Dept. of Trauma & Orthopaedics, St George’s Hospital, St George’s University of London, London, UK. Conflict of interest:

none.

Magnus Arnander FRCS(Tr&Orth) Consultant Orthopaedic Surgeon, St George’s Hospital, St George’s University of London, London, UK. Conflict of interest: none.

Eyiyemi O Pearse FRCS(Tr&Orth) Consultant Orthopaedic Surgeon, St George’s Hospital, St George’s University of London, London, UK. Conflict of interest: none.

T Duncan Tennent FRCS(Tr&Orth) Consultant Orthopaedic Surgeon, St George’s Hospital, St George’s University of London, London, UK. Conflict of interest: none.

damage, but with adequate care both approaches can be per- formed using Trethowan bone levers, Travers, and Hohmann retractors.

Deltopectoral approach

The skin incision extends from the level of the coracoid process along the deltopectoral interval (Figure 1). Meticulous haemo- stasis 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 de- tension the deltoid muscle. The musculocutaneous nerve enters the muscular portion of the conjoint tendon to supply coraco- brachialis 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.

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY (i) Surgical approaches for shoulder arthroplasty Henry B Colac o Magnus Arnander EyiyemiORTHOPAEDICS AND TRAUMA 29:5 281 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-0-71" src="pdf-obj-0-71.jpg">

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

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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY Figure 2 DP: ( a ). deltopectoral interval and cephalic vein. ( bORTHOPAEDICS AND TRAUMA 29:5 282 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-1-4" src="pdf-obj-1-4.jpg">

Figure 2 DP: (a). deltopectoral interval and cephalic vein. (b). development of deltopectoral interval to expose coracoid and conjoint tendon.

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY Figure 2 DP: ( a ). deltopectoral interval and cephalic vein. ( bORTHOPAEDICS AND TRAUMA 29:5 282 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-1-13" src="pdf-obj-1-13.jpg">

Figure 3 DP: (a). identification of long head of biceps. (b). subscapularis detachment using a peel technique.

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY Figure 2 DP: ( a ). deltopectoral interval and cephalic vein. ( bORTHOPAEDICS AND TRAUMA 29:5 282 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-1-22" src="pdf-obj-1-22.jpg">

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 sub- scapularis 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 su- tures 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 inser- tion under appropriate tension.

Subscapularis Healing rates and clinical outcomes following repair of a sub- scapularis tenotomy performed to allow anatomic TSA vary in the literature. Post-operative subscapularis insufficiency is com- mon, 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

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY The subscapularis tendon must be reflected to allow access to the joint. ThereORTHOPAEDICS AND TRAUMA 29:5 283 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-2-21" src="pdf-obj-2-21.jpg">

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

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY The subscapularis tendon must be reflected to allow access to the joint. ThereORTHOPAEDICS AND TRAUMA 29:5 283 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-2-26" src="pdf-obj-2-26.jpg">

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. 2 e 4 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. 5 e 7 Evidence of biome- chanical 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. 3,10 e 12 For patients with adequate tendon quality and excursion, tenotomy and tendon-to-tendon repair (with or without additional rotator interval approxima- tion) remains a valid option. 2 Lafosse et al. developed a rotator interval approach for anatomic TSA that preserves both supraspinatus and sub- scapularis tendons, and does not require joint dislocation. It does however require specialized instruments, and whilst good clin- ical outcomes can be achieved at 2 years, humeral head under- sizing, 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 sub- scapularis is integral to stability, but this is less important for lateralized designs, and may actually increase the work of the residual rotator cuff. 17

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

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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY Figure 7 Stemless TSA via DP approach. ( a ). Pre-operative AP X-rayORTHOPAEDICS AND TRAUMA 29:5 284 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-3-4" src="pdf-obj-3-4.jpg">

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 liga- ment, 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-to- bone 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

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY Figure 7 Stemless TSA via DP approach. ( a ). Pre-operative AP X-rayORTHOPAEDICS AND TRAUMA 29:5 284 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-3-38" src="pdf-obj-3-38.jpg">

Figure 8 Anterosuperior: surface anatomy (including axillary nerve) and skin incision (Right shoulder).

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY Figure 7 Stemless TSA via DP approach. ( a ). Pre-operative AP X-rayORTHOPAEDICS AND TRAUMA 29:5 284 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-3-43" src="pdf-obj-3-43.jpg">

Figure 9 Anterosuperior: identify raphe between anterior and middle deltoid muscle.

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MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY

MINI-SYMPOSIUM: SHOULDER ARTHROPLASTY Figure 10 Anterosuperior: can be extended with anterior acromial osteotomy (this patient underwentJackson JD, Cil A, Smith J, Steinmann SP. Integrity and function of the subscapularis after total shoulder arthroplasty. J Shoulder Elbow Surg 2010 Oct; 19: 1085 e 90 . 2 Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after pri- mary tendon to tendon repair in patients after replacement arthro- plasty of the shoulder. J Shoulder Elbow Surg 2009 Mar e Apr; 18: 193 e 6. discussion 197 e 8 . 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: 2239 e 46 . 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: 396 e 402 . 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) : 170 e 7 . 6 Gerber C, Yian EH, Pfirrmann CA, Zumstein MA, Werner CM. Sub- scapularis muscle function and structure after total shoulder replacement with lesser tuberosity osteotomy and repair. J Bone Joint Surg Am 2005 Aug; 87: 1739 e 45 . 7 Qureshi S, Hsiao A, Klug RA, Lee E, Braman J, Flatow EL. Sub- scapularis function after total shoulder replacement: results with lesser tuberosity osteotomy. J Shoulder Elbow Surg 2008 Jan e Feb; 17: 68 e 72 . 8 Fishman MP, Budge MD, Moravek Jr JE, et al. Biomechanical testing of small versus large lesser tuberosity osteotomies: effect on gap for- mation and ultimate failure load. J Shoulder Elbow Surg 2014 Apr; 23: 470 e 6 . 9 Giuseffi SA, Wongtriratanachai P, Omae H, et al. Biomechanical comparison of lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty. J Shoulder Elbow Surg 2012 Aug; 21: 1087 e 95 . 10 Buckley T, Miller R, Nicandri G, Lewis R, Voloshin I. Analysis of sub- scapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures. J Shoulder Elbow Surg 2014 Sep; 23: 1309 e 17 . 11 Scalise JJ, Ciccone J, Iannotti JP. Clinical, radiographic, and ultraso- nographic comparison of subscapularis tenotomy and lesser tuber- osity osteotomy for total shoulder arthroplasty. J Bone Joint Surg Am 2010 Jul 7; 92: 1627 e 34 . 12 Jandhyala S, Unnithan A, Hughes S, Hong T. Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder replace- ment: a comparison of patient outcomes. J Shoulder Elbow Surg 2011 Oct; 20: 1102 e 7 . 13 Lafosse L, Schnaser E, Haag M, Gobezie R. Primary total shoulder arthroplasty performed entirely thru the rotator interval: technique and minimum two-year outcomes. J Shoulder Elbow Surg 2009 Nov e Dec; 18: 864 e 73 . 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: 831 e 7 . 15 Simovitch R, Fullick R, Zuckerman JD. Use of the subscapularis pre- serving technique in anatomic total shoulder arthroplasty. Bull Hosp Jt Dis (2013) 2013; 71 (suppl 2) : 94 e 100 . ORTHOPAEDICS AND TRAUMA 29:5 285 2015 Elsevier Ltd. All rights reserved. " id="pdf-obj-4-4" src="pdf-obj-4-4.jpg">

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 per- formed is rising. As techniques and implants are refined and outcomes improve, there may be a trend towards further in- dications 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 sub- scapularis 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

Axillary/L Pectoral Axillary/Axillary

Intermuscular plane

Deltoid/Pec. major Anterior/Middle Deltoid

Dangers

Axillary N

Axillary N

 

Musculoskeletal N

Ant. Circumflex

vessels

 

Improved humeral exposure

þ

Reduced risk nerve injury

þ

Deltoid preservation

þ

Reduced risk

þ

notching (RSA) Anatomic TSA

þ

Improved glenoid exposure

þ

Reduced dislocation risk

þ

Subscapularis preservation

þ

Table 1

REFERENCES

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