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C. DUMONTIER*,** - A. SAUTET* - A. APOIL*
* Hôpital Saint-Antoine - F-75571 Paris Cedex 12
** Institut de la Main - Groupe de l'Épaule - Clinique Jouvenet - F-75116 Paris
In 1953, Paul Dautry and Jean Gosset proposed surgical debridement for all rotator cuff lesions. They had been disheartened by the continual failure of sutures under tension in soft tissue, particularly in the rotator cuff; and their experience in general surgery had persuaded them that it was possible to obtain controlled healing. The procedure took the form of resection back into healthy and bleeding tissue of the rotator cuff, combined with resection of the tendon of long head of biceps. The healing process was controlled by abduction of the shoulder in a plaster cast, and the tissues were "mobilised" during healing by exercise physiotherapy, which was started immediately. A classical deltopectoral approach was used for the entire procedure (Augereau 1988a). The younger generation of surgeons might find this technique a little archaic, but it gave excellent results, and was adopted by other authors (Augereau 1988a, Judet 1986). Our results with small tears support the more recent studies by Burkhart, demonstrating that anterior and posterior repair of the rotator cuff can give excellent functional results (Burkhart 1997). However, when reviewing our results, we found that in large rotator cuff tears the quality of the result deteriorated over time. We therefore felt that it was essential that large rotator cuff tears should be closed tightly (Apoil 1985, Augereau 1988b). We found that it was more logical, and easier, to achieve this by approaching the glenohumeral joint via a superior route, preserving the subscapularis, which is often the only muscle left intact (Nobuhara 1994; Gerber 1991). A further consideration was that rotator cuff tears, particularly the larger ones, are usually a result of trophic disturbances (Nobuhara 1994; Fukuda 1994). We had learnt never to suture necrotic or poorly vascularised tissue under tension. We therefore wanted to develop a local procedure for cuff repair that would bring well-vascularised and innervated tissue into the defect; this led to our deltoid flap procedure (Apoil 1985).
The superolateral approach was developed in response to the requirements listed above; its many advantages have made it our standard access to the shoulder.
Originally we positioned the patient supine with a pad between the medial border of the scapula and the spine, both to thrust the shoulder upwards and outwards and to fix the scapula as much as possible during surgery, so as to make it easier to work on the glenoid. Nowadays, we use either this position or a beach-chair position, with no particular preference. If the scapula has to be included in the operative field, the patient could be positioned lying on his or her side, but in this case an assistant would be required to pull on the arm. Whatever position is chosen, the upper limb must be draped completely free so that it can be mobilised during the procedure. The main surface markings - the lateral border, anterolateral corner and anterior border of the acromion, together with the acromioclavicular joint - are drawn on the skin before the incision is made (Fig. 1a, 1b). It is sometimes difficult to palpate the acromioclavicular joint, especially when the patient is obese. It may be easier to locate and mark the joint indirectly, by palpating its posterior border. This always lies immediately in front of the palpable depression inside the angle formed by the acromion laterally and posteriorly, and the clavicle anteriorly.
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| Figure 1 : a-b) Skin markings for the superolateral approach. Right shoulder. The surgeon should mark the acromion, especially the anterior margin and anterolateral corner; the acromioclavicular joint; and the coracoid process. | |
The skin incision starts at the anterior border of the acromioclavicular joint and follows the anterior border of the acromion, keeping over rather than in front of it. When the incision reaches the anterolateral border of the acromion, it is angled to follow the line of the arm for a distance of 3 to 4 cm (Fig. 1a, 1c).
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| Figure 1 : a-c) The incision is made directly over the anterior margin of the acromion and extends beyond the acromioclavicular joint for a distance of only 1 cm. Distally, it curves slightly to follow the line of the arm for a distance of 3 to 4 cm. | |
When first using this approach, it can be helpful to separate the subcutaneous layer from the superficial deltoid fascia over a distance of a few millimetres, to make it easier to identify the position of the muscle incision (Fig. 2).
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| Figure 2 : When starting to use this approach, it is useful to detach the skin edges for 2-3 mm so that the deltoid can be clearly identified, particularly its superficial fascia, which must be preserved. |
Incision of the deltoid must be done very carefully, to ensure that the muscle can be reattached correctly at the end of surgery. As the deltoid has no tendinous insertion on the acromion, an incision must be made on the acromion at a distance of 1-2 mm from its anterior margin, so that a solid sheet of periosteum can be detached en bloc with the fibres of deltoid. The muscle incision is routed exactly in line with the skin incision; it is easier to make the incision using cutting diathermy (Fig. 3a, 3b). At the lateral border of the acromion, the muscle should be split to separate the anterolateral part (Fick Zone II) from the middle part (Fick Zone III) of the deltoid (Comtet 1970). The subdeltoid space is identified distally to the acromion; it is located by placing two Farabeuf angle retractors on the edges of the muscle. The subdeltoid bursa is immediately exposed, and, going back towards the acromion, the acromial insertion of the coracoacromial ligament can be identified medially.
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| Figure 3 : a) The muscle incision follows exactly the same line as the skin incision. It runs over the anterior margin of the acromion. From the acromion, it is continued distally in the deep layers down to the subacromial-subdeltoid bursa, so that the exact thickness of deltoid can be measured. b) If a deltoid flap is required, the muscle incision will already have released two of the three sides of the flap. The anterior margin is started at the acromioclavicular joint, and continued distally for 2-3 cm only, to protect any anterior blood supply to the flap by the acromial branch of the thoracoacromial artery. |
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The risk of damaging the axillary nerve, which lies on the deep surface of the deltoid, is only theoretical: We have done more than 800 procedures using this approach, and have never to our knowledge had any iatrogenic axillary nerve damage. Bryan (1986) found that the nerve passes at least 5 cm from the lateral border of the acromion and that it tends to adhere to the underside of the muscle. However, it would be prudent not to try to descend any lower than the metaphysis.
We have adopted the practice of not immediately resecting the coracoacromial ligament; we free it up to its insertion on the coracoid (Fig. 4a, 4b, 4c). By mobilising the arm, it is then possible to examine the area where the coracoacromial arch impinges on the cuff, and to try to relate the clinical findings to the situation discovered during surgery. If the rotator cuff tear appears to be reparable, the ligament will be resected; the fact that it has already been freed up will facilitate haemostasis of the acromial branch of the thoracoacromial artery, which might otherwise retract underneath the deltoid. Conversely, if the rotator cuff appears to be irreparable, the coracoacromial ligament would be preserved. In fact, in cases of irreparable rotator cuff tears, we now tend to insert a bipolar prosthesis, and it is important to increase the retentive capacity of the subacromial arch in order to stabilise the implant. Preservation of the coracoacromial ligament will provide an anterior buttress for the prosthesis.
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| Figure 4 : a) Access to a rotator cuff tear by the superolateral approach. The deltoid has been detached from the anterior surface of the acromion to the acromioclavicular joint, and split along the line of the arm for a distance of 3-4 cm. The coracoacromial ligament is preserved during the first stage, while the cuff is investigated and the possibility of repair is assessed. Ligament acromio-coracoidien = Coracoacromial ligament Acromio-claviculaire = Acromioclavicular joint b) This photograph shows a cuff tear, which can be seen in the depth of the wound. The coracoacromial ligament has been freed up as far as its insertion on the coracoid process. The anterior margin of the acromion is clearly visible, as is the insertion, on the front of the clavicle, of the anterior deltoid, which is always left intact. c) Same details, view during surgery. |
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The muscle edges are held by a self-retaining retractor, and an acromioplasty is performed if the cuff is torn. In a classical acromioplasty, all the anteroinferior part of the acromion is removed; we extend the osteotomy to the underside of the acromioclavicular joint, which needs to be flat to accommodate the flap. We use Liston bone-cutting forceps to resect the anterior cortex of the acromion for a distance of 2-3 mm, so that we can determine the thickness of the acromioplasty. This exposes the full height of the acromion, and a chisel can be used directly on the cancellous bone without risk of slipping. The subacromial-subdeltoid bursa is incised or excised depending on the surgeon's preference: We always excise it at least as far as the edges of the tear. The supraspinatus lies immediately below, in the line of the approach (Fig. 5). The rotator interval, the superior half of subscapularis and the biceps tendon can be accessed by externally rotating the arm, while internal rotation gives access to the infraspinatus and the superior half of the teres minor. The humeral head may be dislocated from the glenoid cavity by pulling on the arm, which facilitates any procedures that may be needed on the tendons of the cuff, the superior margin of the glenoid and the coracohumeral ligament. In rotator cuff tears, it is easy to locate the supraspinatus tendon proximally, where it may be retracted above the glenoid. When retracted, the infraspinatus tendon sticks to the undersurface of the acromion; it is easier to identify it during the acromioplasty stage. Mersilene® or Ethibond® tag sutures should be passed through the tendons of the cuff in order to mobilise them; pulling on these sutures provides good access for first debriding the edges of the tear and then preparing the flap sutures (Fig. 6). All the classical surgical procedures on the rotator cuff can be performed by rotating the arm; what is done will depend on the lesion pattern and on the individual surgeon's preference (Fig. 7).
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| Figure 5 : Once the coracoacromial ligament has been resected and an anterior inferior acromioplasty performed, the viability of the cuff is assessed. We always resect the edges of the cuff back into bleeding tissue. The arm is rotated to allow access first to the anterior part and then to the posterior part of the cuff. | Figure 6 : Necrotic edges have to be debrided when preparing the cuff. A suture is passed through each tendon to mobilise it without causing damage. |
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| Figure 7 : Suture of a rotator cuff tear by the superolateral approach. Very good exposure has been obtained. Suturing is easier, as it can be done in the direction of the fibres and face-on. | Figure 8 : Postoperative immobilisation in a shoulder splint. Active exercises are started the day after surgery. Most patients are able to work in a sitting position after three weeks. |
During closure, if the deltoid has not been used as a flap, it is reattached either to the tough fibrous covering of the acromion or by means of transosseous sutures. As far as we know, we have not had any cases where there have been complications related to the deltoid becoming disinserted. The slight curve of the incision means that the skin can be closed with a continuous suture. The scar is situated on the top of the shoulder, and is therefore generally not very visible; it is usually felt to be cosmetically satisfactory. The shoulder can be immobilised in a sling and swathe, as the deltoid suturing is sufficiently strong, but this is not recommended if a deltoid flap has been used. However, we remain convinced of the benefit of immediate active exercise physiotherapy starting from a position of abduction, and patients are usually immobilised in a plaster cast or shoulder splint for 5 to 6 weeks (Fig. 8). This position also decreases any postoperative tension on the tissues, and, we hope, also reduces postoperative pain, which may be severe in this type of surgery.
SUPEROLATERAL APPROACH
The approach was originally described for deltoid flap procedures, and we were delighted with its ease of use, with the quality of exposure obtained, and with the uneventful postoperative course in our patients. We have, therefore, extended its indications to include practically all surgical procedures on the rotator cuff, and the insertion of prostheses.
1. Cuff repair
The degree of cuff exposure provided makes it possible to perform any procedures that may be necessary (Fig. 7). However, this approach cannot (or rather, to our way of thinking, should not) be used for subscapularis surgery. If an attempt is made to mobilise the entire muscle, there will be a considerable risk of axillary nerve violation. If it is found at surgery that the subscapularis needs to be mobilised, then a deltopectoral incision may be added to the superolateral one. We have never had any skin-related complications with this procedure; however, the scars are unsightly.
2. Deltoid flap
The deltoid flap is raised from the anterolateral part of the deltoid (equivalent to Fick Zone II) or from the anterior fascicle of the middle deltoid (Comtet 1970). Two of the three edges of the rectangular flap will already have been freed up by the incision (Dumontier 1992). After the edges of the cuff have been debrided, the third side of the flap is produced by an incision starting at the acromioclavicular joint and continuing for a distance of just 2 to 3 cm (Figs. 3b and 9a, 9b), in order to limit any risk of damage to branches of the thoracoacromial artery which form part of the blood supply to the anterior margin of the flap (Rothman 1965). A more detailed description of this procedure and the results obtained appears in another article in this journal.
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| Figure 9 : a) Two of the three edges of the flap are released when the approach is made. The third edge is dissected starting at the acromioclavicular joint and continuing for 2-3 cm. Forceps grasp the anterior and posterior medial corners of the flap, which will be sutured to the stumps of the supraspinatus and infraspinatus. For this photograph, the anterior dissection has been continued further than the usual 2-3 cm. b) Once the flap has been freed up, it is swung into the defect in the rotator cuff. The anterior edge, which is the most fragile, is sutured first, followed by the medial and, finally, the posterior edge. |
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At the end of the procedure, once the flap has been put into position, it is not possible to bring the remaining edges of deltoid together (Fig. 10). We tack the anterior margin to the fibrous acromioclavicular tissue in order to prevent the deltoid fascicle from becoming detached.
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| Figure 10 : When the deltoid flap is in place it completely closes medium and large tears of the rotator cuff. It is not possible to reapproximate the fibres of the deltoid for closure. |
3. Fractures of the proximal end of the humerus
The superolateral approach has been found to be particularly useful in epiphyseal fractures of the proximal end of the humerus. With this approach it is possible to examine the fragment of the greater tuberosity of the humerus posteriorly and the fragment of the lesser tuberosity anteriorly. It is perfectly possible to use screw or suture fixation on these fragments, or to lift a humeral head which has been impacted in valgus. There is only one limitation, but it is a crucial one: the fracture line must not extend into the metaphysis or the diaphysis, which cannot be accessed by this route. This approach is therefore not suitable for internal fixation using plates. The main technical problem is that as the repair progresses, the surgeon's view of the field will become increasingly restricted. Care should therefore be taken when suturing the tuberosities or fragments which have split off the bone, to work gradually back towards the incision, starting with the fragments farthest from it.
If a humeral arthroplasty is required, the fractured tuberosities are held apart by tag sutures, which can be used for frgment manipulation. The humeral head is removed from the wound and used as a graft to facilitate union of the tuberosities. The medullary cavity is easy to prepare since the surgeon will have a face-on view of the canal. However, it is difficult to check the height of the prosthesis, as the implant hides the landmarks on the shaft when it is put into position. The surgeon will have to be guided by the medial calcar of the humerus, which will often have been preserved, and by the tension obtained after reduction of the tuberosities. The main problem with this approach is the risk of positioning the prosthesis in varus, with resultant lowering of the implant and the tuberosities. When driving the implant home, it is difficult to judge when the tuberosities have been fully reduced and the prosthesis is in the correct position. So, again, it is recommended that the tuberosities should be attached, sequentially and separately, to the shaft and to the prosthesis. In fractures, especially when a prosthetic implant is used, the limb should not be immobilised in abduction, as there would be a risk of the head being dislocated inferiorly while the deltoid has not yet recovered from the reflex inhibition caused by the trauma of surgery.
4. Total arthroplasty
The superolateral approach also has a number of advantages in total arthroplasty.
- The cutting guide for the humeral head is fitted onto a readily accessible humerus, which should reduce the risk of malpositioning. The surgeon will find it much easier to control any retroversion and/or posterior translation required, and it is not necessary to force the arm into extension and external rotation, as in the deltopectoral approach. Revision surgery, particularly the removal of cement, are made easier. Removal of posterior osteophytes is more straightforward, although inferior osteophytes are harder to remove. A Kerisson laminectomy rongeur will have to be used. Persistent limited abduction of the arm throughout the procedure usually suggests that there are still some inferior osteophytes, which will need to be excised. The rest of the humeral preparation is straightforward; surgeons should refer to the instructions that come with whatever prosthesis is being used.- With this approach, it is very easy to prepare the glenoid, since the surgeon will have a face-on view. A two-pronged blunt retractor is placed on the lower margin of the glenoid cavity to depress the proximal humerus. This exposes the whole of the glenoid cavity, and generally means that the implant bed can be prepared very thoroughly. When embedding the glenoid component, it is easier to check that anteversion is correct. Removal of extraneous cement, particularly posteriorly, is easier than with the deltopectoral approach. Escape of cement inferiorly can be prevented by keeping the blunt retractor on the lower margin of the cavity during cementing.
- This approach allows total arthroplasty to be combined with cuff repair, possibly by a deltoid flap. Our experience goes back to 1985, and the results obtained have been satisfactory.
If the surgeon wishes to use a superolateral approach when there is an intact cuff, the supraspinatus and at least half of the infraspinatus will have to be lifted in order to provide adequate access to the glenoid and the humerus. In order to do this, the rotator cuff tendons may be resected about 1 cm from their insertions on the humerus, making it possible to lift a flap of cuff which is easily resutured at the end of the procedure (Fig. 11). In more than 40 cases where a prosthesis has been inserted using this route, we have only had two instances of suture failure. The method should not be used in apparently healthy cuffs of rheumatoid patients. In practice, when dividing the supraspinatus and infraspinatus, the conjoined muscle fibres of the infraspinatus and the teres minor are preserved, to allow sound reinsertion.
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| Figure 11 :Superior decompression: cuff flap pattern. When the cuff is intact, a flap of cuff muscles, consisting of the supraspinatus and at least half the infraspinatus, has to be elevated to allow access to the joint after decompression and debridement, which in our normal practice includes acromioplasty and resection of the coracoacromial ligament. |
If the surgeon wishes to preserve the cuff, this approach also makes it possible to elevate the insertions of the supraspinatus and infraspinatus tendons en bloc, together with a fragment of the greater tuberosity of the humerus, through the rotator interval. The interval can be used as a portal through which a 15 mm bone chisel can be slipped, posterior to the biceps tendon, to detach a bone fragment of sufficient size to permit sound reinsertion; the cuff muscles themselves are left intact.
The principal advantage of the superior approaches is that the subscapularis can be preserved intact. Anterior stabilisation of the humeral head is crucial (Loehr 1994, Burkhart 1994). We feel that it is essential to preserve the anterior restraint provided by the subscapularis, as anterior instability causes poor results after rotator cuff repair or shoulder arthroplasty. Apart from one patient who had a Charcot joint, we have not experienced any prosthetic instability after insertion using this approach. Retraction of the subscapularis is a limitation to the use of the superolateral approach. However, in our experience, this condition is encountered only very occasionally. Any limitation of external rotation observed preoperatively is almost always caused by osteophytes, especially inferior ones, and disappears after the outgrowths have been resected. If the subscapularis is retracted, it is possible to perform a Z-lengthening from a superolateral approach; however, it is a difficult procedure to perform.
Many approaches have been described for shoulder surgery, each with its own advantages and drawbacks: This article is concerned only with the superior approaches. All the sagittal approaches with horizontal section of the deltoid, such as the Codman sabre-cut incision or the approach proposed by Judet, have been abandoned. The equivalent approaches which involved resection of the acromion (Moseley, McLaughlin), have also been discontinued because of frequent complications (Judet 1968, Patte 1986). Several superior approaches involving a transverse osteotomy of the acromion, and differing only in the more or less anterior positioning of the incision, have been proposed. These are the posterosuperior approach of Cadenat-Debeyre, the transacromial approach of McLaughlin, the Kessel approach, and the transacromioclavicular approach (Cadenat 1981, Kessel 1977, Patte 1986, Bauer 1988). We feel that they all suffer from the disadvantage of causing considerable morbidity, without contributing any real benefits. In any case, they are used only very occasionally. The major anterior dissection proposed by Patte, where the transverse incision ran into the acromioclavicular joint, and which also included resection of the lateral quarter of the clavicle, has been abandoned (Patte 1988). It offered very good exposure, but the periosteal flaps were very fragile, and if they failed, the humeral head was no longer held in position; if the cuff was not sound, the head could migrate upwards underneath the skin. Two other superior approaches are similar to the proposed superolateral approach and may be used as alternatives: The anterosuperior approach proposed by Neer (1972) is a straight line, running more along the line of the arm, which facilitates closure. However, as with the superolateral approach, the anterior part of the middle deltoid has to be detached before an acromioplasty can be performed. The shape of the incision means that it gives less good a survey of the posterior part of the cuff, which is generally the most difficult part to repair. Finally, it is not possible to perform a satisfactory deltoid flap procedure using this approach. We therefore do not use it, preferring to use a deltopectoral approach if an anterior procedure is required, or, otherwise, a superolateral approach. The other superior approach is that proposed by Gschwend, who returned to the pattern proposed by Kessel, replacing the osteotomy of the acromion with a continuous trapezius-and-deltoid detachment (Bauer 1988). The trapezius-deltoid unit is released medially and laterally from the acromion and taken down with osteoperiosteal flaps, to maintain the continuity of the two muscles. This approach does not provide any greater exposure of the tendon area of the cuff than does the superolateral approach, and we feel that its only advantage is that it makes it possible to work on the supraspinatus. We have found that the supraspinatus tendon is accessible by the superolateral route; in the rare cases where it is not accessible, it will usually be found to have degenerated completely, and any attempts at repair would be futile.
The superolateral approach was originally described for deltoid flap procedures, but has been found to be very useful in all types of cuff surgery, in fractures of the proximal end of the humerus, and in shoulder arthroplasty. We feel that its principal advantage is that the subscapularis is preserved intact; this muscle is crucial to shoulder dynamics, and is often the only muscle left intact in major rotator cuff tears. We use the superolateral approach routinely in all cases of rotator cuff tears other than full-thickness tears of the subscapularis. It is also our standard approach in fractures of the proximal end of the humerus, whether or not a prosthesis is to be inserted; with the express proviso that no part of the fracture line must be below the epiphysis. We feel that any fractures extending into the shaft are a formal indication for the deltopectoral approach.
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REFERENCES
Apoil A, Augereau B. Le lambeau de deltoïde dans la réparation des larges pertes de substance de la coiffe des rotateurs. Chirurgie 1985; 111:287-290. |