49 Superior Approach to the Shoulder

10.1055/b-0039-167698

49 Superior Approach to the Shoulder

Victor A. Olujimi, Paul J. Cagle Jr., and Evan L. Flatow

Abstract

The deltopectoral approach is a commonly used surgical approach when performing shoulder arthroplasty. The superior approach can be used as an alternative approach when implanting a reverse total shoulder arthroplasty. This approach can be especially useful in cases with proximal migration of the humeral head. Our technique, instrumentation details, and key points to consider will be outlined.

49.1 Goals of Procedure

Present an alternative surgical exposure for shoulder arthroplasty that maintains adequate exposure of the humeral head and visualization of the glenoid.
Techniques to guide dissection and protection of the deltoid and axillary nerve.
Demonstrate how, via this approach, to accurately place both the humeral and the glenoid components in a reverse total shoulder arthroplasty.
- A superior approach may be used for standard/anatomic and reverse total shoulder arthroplasty based on surgeon preference or to accommodate for a prior incision or specific patient requirement.
- The approach is thought to allow improved “straight on” visualization of the glenoid surface.

49.2 Advantages

Direct visualization of the glenoid surface.
Minimal or partial release of the subscapularis.
Decreases risk of injury to the cephalic vein.
Avoids retractor traction on anterior deltoid.
Lower rate of instability and dislocations.
Allows for prior incision to be used for a patient who had previously undergone an approach through the deltoid.

49.3 Indications

Total shoulder arthroplasty, both standard/anatomic and reverse.
Shoulder arthroplasty for proximal humerus fractures.
Reverse total shoulder for rotator cuff arthropathy.
Open reduction and internal fixation for proximal humerus fractures.
Open rotator cuff repair.

49.4 Contraindications (Relative)

Poor preoperative range of motion.
Shoulder dysplasia.
Extensive osteophyte formation.
Axillary nerve injury.

49.5 Preoperative Preparation

49.5.1 Imaging

X-rays

Anteroposterior (AP), true AP of the glenohumeral joint, scapular Y, and axillary views.

CT Scan and MRI (Noncontrast)

Allows for evaluation of glenoid version, bone stock, and rotator cuff muscle–tendon unit integrity.
Evaluation of osteophyte size and location:
1. Extensive osteophyte formation along the inferior humeral head may be difficult to visualize and address from the superior approach.
2. If there is any suspicion for infection, preoperative labs should be obtained:
  - Complete blood count (CBC).
  - Erythrocyte sedimentation rate (ESR).
  - C-reactive protein (CRP).
3. If there is high suspicion clinically with inconclusive laboratory findings, then proceed to perform an arthrocentesis or arthroscopic biopsy sent for the following:
  - Cell count.
  - Gram stain.
  - Culture (aerobe and anaerobe): cultures should be held for at least 14 days to allow adequate culture time for Propionibacterium acnes.

Instruments (Fig. 49.1)

Positioning:
1. Anesthesia: general or laryngeal mask airway.
2. Preoperative regional anesthesia via an interscalene injection or catheter is used adjunctively for pain management.
3. Patient is placed in a semi-beach-chair position (~ 45 degrees of hip flexion and 30 degrees of knee flexion):
  - The head is secured in a padded holder with the neck in a neutral position.
4. The operative arm is secured in a pneumatic arm holder ( Fig. 49.2 ).
  
  Important: Take the operative arm through the range of motion to ensure unimpeded motion especially adduction and extension.
  - The contralateral arm is secured across the body or with a well-padded arm holder.
  - Venodynes (sequential compression devices) are placed on the calves to decrease the incidence of deep venous thrombosis.
5. Prep and drape:
  - The authors’ preference is for a chlorhexidine scrub, followed by chlorhexidine prep.
  - Drape as medial on the scapula as possible.
  - Use of a bump placed under the scapula may direct the glenoid surface forward and assist in visualization.

**Fig. 49.1** Example of instruments used for shoulder arthroplasty.

**Fig. 49.2** Attachable limb positioner can be used to assist with holding and manipulating the shoulder throughout the procedure.

49.6 Operative Technique

49.6.1 Incision

Mark any prior incisions and determine the utility of the planned incision or if a separate surgical approach is necessary.
Standard landmarks are outlined on the shoulder:
1. The anterior, lateral, and posterior borders of the acromion, the acromioclavicular joint, the clavicle, and the coracoid process.
Anterosuperior incision ( Fig. 49.3 ):
1. Vertical incision marked a few centimeters above the anterolateral edge of the acromion extending distally along the anterolateral edge of the acromion for 4 to 6 cm. Important: keep incision relatively parallel to a standard deltopectoral incision.

**Fig. 49.3** Location of incision over anterolateral acromion.

49.6.2 Exposure

Anterosuperior Approach

Superficial exposure:
1. Subcutaneous skin flaps are raised using sharp dissection or electrocautery.
2. Deltoid fascia is visualized and the raphe between the anterior and middle head of deltoid is identified. Important: Anterolateral acromion can be used to help identify the interval.
3. A stay stitch is placed with nonabsorbable suture along the distal extent of the raphe between the anterior and middle head of the deltoid (about 3.5 cm distal to greater tuberosity) to prevent distal propagation potentially injuring the axillary nerve ( Fig. 49.4 ).
4. Starting a few millimeters posterior to the anterolateral edge of the acromion, incise the raphe with electrocautery along the interval extending distally for 3 to 4 cm (Video 49.2).
5. Extend incision a few millimeters posterior to the anterolateral edge of acromion incorporating the coracoacromial ligament into the release:
  - Provides stout tissue for final repair of deltoid, which allows for distal clavicle excision as well ( Fig. 49.5 ).
6. Continue release of subacromial, further releasing the coracoacromial ligament with the anterior deltoid.