CHAPTER 19 Surgical Approach and Handling of the Tuberosities
SURGICAL APPROACH
When performing shoulder arthroplasty for fracture, operating room setup, anesthesia, patient positioning, surgical site preparation, and sterile draping (Chapters 3 and 4) are essentially the same as for nonfracture cases, with a few exceptions. Draping of the patient differs slightly in fracture cases in which use of the fracture jig for prosthetic positioning is planned, in that the stockinet covers only the forearm so that the elbow and humeral epicondyles are easily accessible to use as reference points in judging prosthetic retroversion. When use of the fracture jig is planned, the epicondyles are palpated and marked with a surgical marking pen (Fig. 19-1).
A standard deltopectoral approach is used for exposure just as in arthroplasty cases performed for chronic conditions. The skin incision starts at the tip of the coracoid process and extends distally and laterally approximately 10 to 15 cm, depending on the size of the patient. A needle tip electrocautery is used for deep dissection throughout the procedure to minimize hemorrhage. The interval between the deltoid and pectoralis major is identified by locating the cephalic vein. Once the cephalic vein is identified, it is retracted laterally with the deltoid muscle. The superior centimeter of the pectoralis major tendon is divided with the electrocautery to further enhance exposure. A self-retaining deltopectoral retractor is placed to maintain exposure during the procedure. The conjoined tendon is identified and traced to its insertion on the coracoid process. The tip of a Hohmann-type retractor is placed behind the base of the coracoid process to provide proximal retraction. With the arm abducted and externally rotated, the apex formed by the insertion of the coracoacromial ligament and the conjoined tendon onto the coracoid process is identified. The conjoined tendon is retracted medially to expose the proximal humeral fracture (Fig. 19-2).
