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Top ten tips for glenoid exposure in shoulder arthroplasty
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M I N A R S I N
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R T H R O P L A S T Y
28 (2017) 124–127
Available online at www.sciencedirect.com
www.elsevier.com/locate/sart
Top ten tips for glenoid exposure in shoulder arthroplasty Gerald R. Williams Jr, MD⁎ Department of Orthopaedic Surgery, The Rothman Institute, Sidney Kimmel Medical College, Thomas Jefferson University, 825 Old Lancaster Rd, Suite 200, Bryn Mawr, Philadelphia, PA 19010
article info
abstract
Keywords:
Glenoid exposure is the most difficult part of total shoulder arthroplasty. This manuscript
Shoulder arthroplasty
will outline 10 tips for glenoid exposure that the author has found useful in achieving good
Technique
glenoid exposure. These include, tilting the operating table away from the surgical side,
Glenoid
having a variety of retractors available, removing all humeral osteophytes, making an
Exposure
accurate humeral cut, achieving optimal humeral positioning, ensuring proper retractor placement, utilizing a laminar spreader in select situations, achieving adequate capsular release on the humeral side, excising the anteroinferior capsule from the glenoid, and releasing the posteroinferior capsule from the glenoid. & 2017 Published by Elsevier Inc.
Total shoulder arthroplasty produces substantial decrease in pain and increase in shoulder function in patients with glenohumeral arthritis. The most difficult part of total shoulder arthroplasty is glenoid exposure. Adequate visualization requires that the surgeon be familiar with regional anatomy and comfortable working around the inferior glenoid, in proximity to the axillary nerve. Specialized instruments and retractors are available to aid this process. The integral surgical steps in shoulder arthroplasty have been described [1]. This manuscript will outline 10 tips for glenoid exposure that the author has found useful in achieving the type of glenoid exposure required for glenoid preparation and component placement. These include, in ascending order of importance: tilting the operating table away from the surgical side (10), having a variety of retractors available (9), removing all humeral osteophytes (8), making an accurate humeral cut (7), achieving optimal humeral positioning (6), ensuring proper retractor placement (5), utilizing a laminar spreader in select situations (4), achieving adequate capsular release on the humeral side (3), excising the anteroinferior capsule
⁎
Corresponding author: E-mail address: [email protected]
https://doi.org/10.1053/j.sart.2017.12.009 1045-4527/& 2017 Published by Elsevier Inc.
from the glenoid (2), and releasing the posteroinferior capsule from the glenoid (1). The scapula is suspended on the thorax at an oblique angle to the coronal plane. Moreover, in cases of posterior glenoid wear and increased glenoid retroversion, the glenoid surface faces posteroinferiorly away from the surgical field, toward the floor. This makes visualization of the posterior half of the glenoid and adequate placement of a glenoid reamer difficult. Tilting the operating table 25–30° away from the surgical side brings the glenoid surface more anteriorly and facilitates access to the glenoid surface. A bolster should be placed on the operating table on the nonoperative side to support the patient and the surgeon should confirm that the patient’s legs have remained on the table. Multiple retractors are available to facilitate glenoid exposure and the surgeon should become familiar with as many as possible. These include small and large Fukuda retractors, small and large reverse Bankart retractors, and Blunt Homan retractors (Fig. 1). All retractors should be available as part of surgical trays that are dedicated to shoulder arthroplasty so
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Figure 1 – A variety of retractors should be available to assist in glenoid exposure. These include Fukuda, Bankart, and Homan retractors. that support staff do not have to search for them when they are needed. All humeral osteophytes should be removed before osteotomizing and excising the humeral head and before glenoid exposure. This allows accurate identification of the anatomic neck of the humerus and allows for an accurate humeral cut (Fig. 2). In addition, posterior or posteroinferior humeral displacement is required for adequate glenoid exposure. Humeral osteophyte removal narrows the diameter of the humerus and facilitates sufficient humeral displacement. The humeral cut should approximate the surgical neck of the humerus. If this is done appropriately, the osteotomy surface should be within 1–2 mm of the supraspinatus insertion superiorly and 5–10 mm medial to the infraspinatus
Figure 3 – The humeral osteotomy should exit close (2 mm) to the supraspinatus insertion superiorly.
insertion posteroinferiorly (Fig. 3). This allows the bare area of the humerus to remain with the native humerus when the head is removed. In addition, it ensures that the remaining humeral metaphysis is the appropriate size and the gap between the humerus and the glenoid is optimal for glenoid exposure. The presence of even a small amount of unnecessary humeral metaphyseal bone can substantially hamper glenoid exposure.
Figure 2 – Removal of humeral head osteophytes prior to making the humeral osteotomy (A) helps identify the anatomic neck and aids glenoid exposure by narrowing the humeral head (B).
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Figure 4 – Proper placement of glenoid retractors provides for excellent glenoid exposure.
The proper positioning of the humerus to allow adequate posterior or posteroinferior humeral displacement for glenoid exposure is variable. A position of abduction, extension, and external rotation has been commonly recommended as optimal. However, this is not true in all cases. The surgeon should try multiple positions to determine which provides the best glenoid visualization. Often, posterior or posteroinferior humeral displacement is best when the arm is placed in 75–80° of elevation, slightly posterior to the coronal plane, in the amount of external rotation that allows the humeral osteotomy surface to be approximately parallel to the glenoid surface. Proper retractor replacement is an essential step in glenoid visualization. A Fukuda or other humeral head
Figure 6 – The anterior capsule is often thickened and pathologic, especially in osteoarthritis. It can be separated and isolated from the overlying subscapularis (A). Excision provides excellent glenoid exposure (B).
Figure 5 – The use of a laminar spreader allows for lateralization of the humerus and improved visualization of the posterior glenoid (Courtesy: Joseph Iannotti, MD, PhD).
retractor is placed within the joint on the posterior or posteroinferior glenoid rim to retract the humerus posteriorly or posteroinferiorly. A reverse Bankart retractor is placed anteriorly, on the neck of the scapula to retract the subscapularis and conjoined tendon of the short head of the biceps and coracobrachialis. A blunt Homan retractor or straight Bankart retractor is placed posterosuperiorly to retract the anterior deltoid. Occasionally, a Blunt Homan retractor is placed on the anteroinferior glenoid to retract the pectoralis major in larger, more muscular
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Figure 7 – The posteroinferior capsule is released from the posteroinferior margin of the glenoid. This release can be continued superiorly, along the posterior glenoid, in cases 25% or less posterior subluxation.
patients. This combination of retractor placement provides excellent glenoid visualization (Fig. 4). Care should be taken to avoid excessive force on the retractors to minimize the possibility of nerve stretch injury or muscular damage.
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The use of a laminar spreader can be extremely useful in select cases (personal communication: Joseph Iannotti, MD, PhD). When a humeral head retractor is used to lever the humerus posteriorly, the humerus actually moves both posteriorly and medially. This can obscure the posterior capsule and hinder posterior glenoid visualization, especially in cases where posterior capsulorrhaphy is required to address posterior instability. The humerus can be displaced almost straight laterally using a laminar spreader with one blade placed on the face of the humeral osteotomy and one blade placed on the base of the coracoid. This lateral displacement allows excellent exposure of the posterior portion of the joint and access to the posterior capsule (Fig. 5). Complete release of the capsule from the posterioinferior humerus is an important step for glenoid exposure. During humeral exposure and delivery, the anterior capsule is released from the humerus starting superiorly and extending inferomedially as the humerus is externally rotated. Posterior humeral displacement during glenoid exposure will not be adequate unless the humeral capsular release is continued completely around the inferior humerus, including any osteophytes, to include the posteroinferior humeral attachment. Visualization of the posteroinferior humeral capsular attachment is facilitated by slightly flexing and abducting the humerus and providing maximal external rotation. Care must be taken to protect the axillary nerve. The anterior and inferior capsule is pathologic and contracted in many cases of glenohumeral arthritis, especially osteoarthritis. This capsular contracture must be countered in order to restore motion and to provide adequate exposure of the glenoid. Although release of the anterior and inferior capsule is recommended by some surgeons, this author prefers actual excision of the anteroinferior capsule. With the humeral head retracted posteriorly and the axillary nerve retracted and protected with blunt Homan retractors, the inferior capsule is incised from lateral to medial at approximately the six o’clock position and the entire anteroinferior capsule is excised (Fig. 6). The final tip for glenoid exposure is a critical one. The capsule that remains starts at the inferior glenoid and extends posteriorly and superiorly to the biceps anchor. At minimum, the posterioinferior corner of the capsule is released from the glenoid (Fig. 7). This allows a perceptible increase in the posterior humeral translation and glenoid visualization. If preoperative posterior subluxation of more than 25% was present, the degree and posterosuperior extension of this release is limited. Although every case is different, the 10 tips mentioned above will provide excellent glenoid exposure in the vast majority of cases (Fig. 8). With adequate glenoid exposure, preparation of the glenoid and placement of the glenoid component becomes much easier and more reproducible.
r e f e re n c e
Figure 8 – Using these 10 surgical tips, adequate glenoid exposure is routinely achieved.
[1] Cofield RH. Integral surgical maneuvers in prosthetic shoulder arthroplasty. Semin Arthroplasty 1990;1:112–23.
M I N A R S I N
A
R T H R O P L A S T Y
28 (2017) 124–127
Available online at www.sciencedirect.com
www.elsevier.com/locate/sart
Top ten tips for glenoid exposure in shoulder arthroplasty Gerald R. Williams Jr, MD⁎ Department of Orthopaedic Surgery, The Rothman Institute, Sidney Kimmel Medical College, Thomas Jefferson University, 825 Old Lancaster Rd, Suite 200, Bryn Mawr, Philadelphia, PA 19010
article info
abstract
Keywords:
Glenoid exposure is the most difficult part of total shoulder arthroplasty. This manuscript
Shoulder arthroplasty
will outline 10 tips for glenoid exposure that the author has found useful in achieving good
Technique
glenoid exposure. These include, tilting the operating table away from the surgical side,
Glenoid
having a variety of retractors available, removing all humeral osteophytes, making an
Exposure
accurate humeral cut, achieving optimal humeral positioning, ensuring proper retractor placement, utilizing a laminar spreader in select situations, achieving adequate capsular release on the humeral side, excising the anteroinferior capsule from the glenoid, and releasing the posteroinferior capsule from the glenoid. & 2017 Published by Elsevier Inc.
Total shoulder arthroplasty produces substantial decrease in pain and increase in shoulder function in patients with glenohumeral arthritis. The most difficult part of total shoulder arthroplasty is glenoid exposure. Adequate visualization requires that the surgeon be familiar with regional anatomy and comfortable working around the inferior glenoid, in proximity to the axillary nerve. Specialized instruments and retractors are available to aid this process. The integral surgical steps in shoulder arthroplasty have been described [1]. This manuscript will outline 10 tips for glenoid exposure that the author has found useful in achieving the type of glenoid exposure required for glenoid preparation and component placement. These include, in ascending order of importance: tilting the operating table away from the surgical side (10), having a variety of retractors available (9), removing all humeral osteophytes (8), making an accurate humeral cut (7), achieving optimal humeral positioning (6), ensuring proper retractor placement (5), utilizing a laminar spreader in select situations (4), achieving adequate capsular release on the humeral side (3), excising the anteroinferior capsule
⁎
Corresponding author: E-mail address: [email protected]
https://doi.org/10.1053/j.sart.2017.12.009 1045-4527/& 2017 Published by Elsevier Inc.
from the glenoid (2), and releasing the posteroinferior capsule from the glenoid (1). The scapula is suspended on the thorax at an oblique angle to the coronal plane. Moreover, in cases of posterior glenoid wear and increased glenoid retroversion, the glenoid surface faces posteroinferiorly away from the surgical field, toward the floor. This makes visualization of the posterior half of the glenoid and adequate placement of a glenoid reamer difficult. Tilting the operating table 25–30° away from the surgical side brings the glenoid surface more anteriorly and facilitates access to the glenoid surface. A bolster should be placed on the operating table on the nonoperative side to support the patient and the surgeon should confirm that the patient’s legs have remained on the table. Multiple retractors are available to facilitate glenoid exposure and the surgeon should become familiar with as many as possible. These include small and large Fukuda retractors, small and large reverse Bankart retractors, and Blunt Homan retractors (Fig. 1). All retractors should be available as part of surgical trays that are dedicated to shoulder arthroplasty so
SE
M I N A R S I N
AR
T H R O P L A S T Y
28 (2017) 124–127
125
Figure 1 – A variety of retractors should be available to assist in glenoid exposure. These include Fukuda, Bankart, and Homan retractors. that support staff do not have to search for them when they are needed. All humeral osteophytes should be removed before osteotomizing and excising the humeral head and before glenoid exposure. This allows accurate identification of the anatomic neck of the humerus and allows for an accurate humeral cut (Fig. 2). In addition, posterior or posteroinferior humeral displacement is required for adequate glenoid exposure. Humeral osteophyte removal narrows the diameter of the humerus and facilitates sufficient humeral displacement. The humeral cut should approximate the surgical neck of the humerus. If this is done appropriately, the osteotomy surface should be within 1–2 mm of the supraspinatus insertion superiorly and 5–10 mm medial to the infraspinatus
Figure 3 – The humeral osteotomy should exit close (2 mm) to the supraspinatus insertion superiorly.
insertion posteroinferiorly (Fig. 3). This allows the bare area of the humerus to remain with the native humerus when the head is removed. In addition, it ensures that the remaining humeral metaphysis is the appropriate size and the gap between the humerus and the glenoid is optimal for glenoid exposure. The presence of even a small amount of unnecessary humeral metaphyseal bone can substantially hamper glenoid exposure.
Figure 2 – Removal of humeral head osteophytes prior to making the humeral osteotomy (A) helps identify the anatomic neck and aids glenoid exposure by narrowing the humeral head (B).
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Figure 4 – Proper placement of glenoid retractors provides for excellent glenoid exposure.
The proper positioning of the humerus to allow adequate posterior or posteroinferior humeral displacement for glenoid exposure is variable. A position of abduction, extension, and external rotation has been commonly recommended as optimal. However, this is not true in all cases. The surgeon should try multiple positions to determine which provides the best glenoid visualization. Often, posterior or posteroinferior humeral displacement is best when the arm is placed in 75–80° of elevation, slightly posterior to the coronal plane, in the amount of external rotation that allows the humeral osteotomy surface to be approximately parallel to the glenoid surface. Proper retractor replacement is an essential step in glenoid visualization. A Fukuda or other humeral head
Figure 6 – The anterior capsule is often thickened and pathologic, especially in osteoarthritis. It can be separated and isolated from the overlying subscapularis (A). Excision provides excellent glenoid exposure (B).
Figure 5 – The use of a laminar spreader allows for lateralization of the humerus and improved visualization of the posterior glenoid (Courtesy: Joseph Iannotti, MD, PhD).
retractor is placed within the joint on the posterior or posteroinferior glenoid rim to retract the humerus posteriorly or posteroinferiorly. A reverse Bankart retractor is placed anteriorly, on the neck of the scapula to retract the subscapularis and conjoined tendon of the short head of the biceps and coracobrachialis. A blunt Homan retractor or straight Bankart retractor is placed posterosuperiorly to retract the anterior deltoid. Occasionally, a Blunt Homan retractor is placed on the anteroinferior glenoid to retract the pectoralis major in larger, more muscular
SE
M I N A R S I N
AR
T H R O P L A S T Y
Figure 7 – The posteroinferior capsule is released from the posteroinferior margin of the glenoid. This release can be continued superiorly, along the posterior glenoid, in cases 25% or less posterior subluxation.
patients. This combination of retractor placement provides excellent glenoid visualization (Fig. 4). Care should be taken to avoid excessive force on the retractors to minimize the possibility of nerve stretch injury or muscular damage.
28 (2017) 124–127
127
The use of a laminar spreader can be extremely useful in select cases (personal communication: Joseph Iannotti, MD, PhD). When a humeral head retractor is used to lever the humerus posteriorly, the humerus actually moves both posteriorly and medially. This can obscure the posterior capsule and hinder posterior glenoid visualization, especially in cases where posterior capsulorrhaphy is required to address posterior instability. The humerus can be displaced almost straight laterally using a laminar spreader with one blade placed on the face of the humeral osteotomy and one blade placed on the base of the coracoid. This lateral displacement allows excellent exposure of the posterior portion of the joint and access to the posterior capsule (Fig. 5). Complete release of the capsule from the posterioinferior humerus is an important step for glenoid exposure. During humeral exposure and delivery, the anterior capsule is released from the humerus starting superiorly and extending inferomedially as the humerus is externally rotated. Posterior humeral displacement during glenoid exposure will not be adequate unless the humeral capsular release is continued completely around the inferior humerus, including any osteophytes, to include the posteroinferior humeral attachment. Visualization of the posteroinferior humeral capsular attachment is facilitated by slightly flexing and abducting the humerus and providing maximal external rotation. Care must be taken to protect the axillary nerve. The anterior and inferior capsule is pathologic and contracted in many cases of glenohumeral arthritis, especially osteoarthritis. This capsular contracture must be countered in order to restore motion and to provide adequate exposure of the glenoid. Although release of the anterior and inferior capsule is recommended by some surgeons, this author prefers actual excision of the anteroinferior capsule. With the humeral head retracted posteriorly and the axillary nerve retracted and protected with blunt Homan retractors, the inferior capsule is incised from lateral to medial at approximately the six o’clock position and the entire anteroinferior capsule is excised (Fig. 6). The final tip for glenoid exposure is a critical one. The capsule that remains starts at the inferior glenoid and extends posteriorly and superiorly to the biceps anchor. At minimum, the posterioinferior corner of the capsule is released from the glenoid (Fig. 7). This allows a perceptible increase in the posterior humeral translation and glenoid visualization. If preoperative posterior subluxation of more than 25% was present, the degree and posterosuperior extension of this release is limited. Although every case is different, the 10 tips mentioned above will provide excellent glenoid exposure in the vast majority of cases (Fig. 8). With adequate glenoid exposure, preparation of the glenoid and placement of the glenoid component becomes much easier and more reproducible.
r e f e re n c e
Figure 8 – Using these 10 surgical tips, adequate glenoid exposure is routinely achieved.
[1] Cofield RH. Integral surgical maneuvers in prosthetic shoulder arthroplasty. Semin Arthroplasty 1990;1:112–23.