Anterior Deltopectoral Approach Research Articles

Extended deltopectoral approach for revision total elbow arthroplasty requiring humeral allograft-prosthetic composites in patients with severely compromised proximal humerus bone stock

Severe humeral bone loss in the setting of failed total elbow arthroplasty (TEA) poses a particularly challenging reconstructive problem. The objective of this study was to review the rationale, indications, contraindications, and detailed surgical technique for using an extended anterior deltopectoral approach to perform a revision TEA when substantially long allografts are required in the presence of severely compromised proximal humerus bone stock. The authors developed this exposure and reconstructive strategy for failed elbow arthroplasties where the remaining segment of proximal humerus is extremely short, which makes adequate plate fixation of an allograft-prosthetic composite (APC) to the native bone extremely challenging. From an anterior deltopectoral approach, it is possible to use dedicated long, precontoured proximal humerus locking plates to maximize fixation in any remaining proximal humerus. This exposure still makes it possible to provide adequate access to the coupling mechanism of the humeral and ulnar components for implantation of a linked elbow arthroplasty. This exposure also allows for adequate judgment of humeral length and rotation. Crucial steps in the surgery include extending the dissection past the elbow flexion crease such that one can obtain circumferential exposure of the distal humerus. It is also important to couple the humeral and ulnar components prior to committing to the length of the APC. Special attention must be paid to gauge appropriate APC rotation and length for proper soft tissue tension. When performing fixation of the proximal humeral plate, screw purchase must be maximized in both the remaining native proximal humerus and the APC. Compression across the allograft-host interface is paramount for healing to occur. An extended anterior deltopectoral approach to perform a revision TEA when very long APCs are required is a viable option to restore humeral bone stock and regain humeral stem fixation in the setting of failed TEA with extensive humeral bone loss.

Outcomes of shoulder hemiarthroplasty in non-salvageable proximal humerus fracture: A prospective study

Background: Proximal humerus fractures are 5% of all fractures and 80% of all humerus fractures in elderly. Arthroplasty is generally reserved for comminuted Neer”s 3 or 4 part fractures, head split fractures or fracture with significant underlying arthritic changes. The aim of the study is to analyse clinical, radiological and functional outcome of shoulder hemiarthroplasty in non-salvageable proximal humerus fracture.Materials and Methods: This prospective study was carried out in 20 cases of non-salvageable proximal humerus fracture aged above 50 years irrespective of sex. Standard Modular cemented prosthesis were used in all 20 patients. The study was conducted for a period of 15 months and cases were followed up for a period of 6 months.Results: The average age of patient was 62 years with 12 female and 8 were male. Anterior Deltopectoral approach was used as the standard approach for hemiarthroplasty. Modular Hemiarthroplasty prosthesis was inserted with cement. 13 of the 20 patients has shown good results. The range of movement in all 17 patients are satisfactory except for 3 who had poor results but had satisfactory relief of pain. In 3 patients the greater tuberocity failed to unite.Conclusion: Outcome of Hemiarthroplasty is quite satisfactory in elderly if done for fresh traumatic non salvageable proximal humerus fracture without involvement of glenoid and without any unrepairable major rotator cuff injury. Hemiarthroplasty if done within 2 weeks gives better results as there will be less adhesion of soft tissue thus soft tissue repair and their reattachment can be done meticulously. Hemiarthroplasty shoulder done for non-salvageable proximal humerus fractures will provide better stability, early mobilization, lesser stiffness and satisfactory range of motion (ROM) in elderly.

A prospective study of functional outcome in displaced fractures of the proximal humerus managed surgically

Background: The aim of the study is to evaluate the functional outcome of displaced fractures of the proximal humerus managed surgically.Methods: A prospective analysis of the functional outcome of 20 cases under surgically managed displaced proximal humeral fractures were undertaken in our hospital. The indications of the surgery were displacement to more than 1 cm and angulation of more than 45°. The patients were operated by the standard anterior deltopectoral approach, deltoid splitting or percutaneous procedure depending upon the type of fracture and bone quality. Results: The mean age of the patients was 44 years. The mode of injury was fall at ground level in 10(50%) patients, road traffic accident in 6(30%) patients, fall from height in 3(15%) patients, fall due to epilepsy in 1(5%) patients. Based on Neer’s sytem 10 patients (50%) had two part fractures, 5(25%) patients had 3 part fractures and 5(25%) had four part fractures. Greater Tuberosity fractures were the predominant type in 2 part fracture. Patients underwent the surgery on an average of 7.95 days after injury. The mean follow-up period in this study was 12.2 months. Conclusion: Displaced proximal humeral fractures when treated surgically produce less pain, less stiffness and greater range of motion. Earlier the surgery better are the results. Results are better with fractures than with fracture dislocations. Results are best when operative method results in stable fixation that allows early passive mobilization. Functional outcome of 2 part fractures is better than 3 part and 4 part fractures.

Periprosthetic humeral fractures: from osteosynthesis to prosthetic replacement

Stabilization of the humeral shaft and the restoration of shoulder function dependent on the osseous integrity of the prosthetic stem component. In cases of astable prosthesis stem, an isolated plate osteosynthesis is possible. Prosthesis stem replacement is indicated in cases of aloose stem. With sufficient bone stock of the proximal humeral segment, achange to ashorter humeral shaft component with subsequent plate fixation of the fracture is possible. If the bone stock is poor, conversion to along revision stem is necessary. Inoperability of the patient due to serious comorbidities. Advanced age and low demands on shoulder function are relative contraindications for complex prosthesis replacements. Plate osteosynthesis can be done through an anterior or posterior approach, stem replacement only from anterior deltopectoral approach. When changing humeral shaft components, the loose shaft and all cement residues are removed, the fracture is reduced and, if possible, ashorter shaft is implanted with subsequent plate osteosynthesis of the fracture. When changing to along revision stem, additional osteosynthesis with cerclages wires is usually sufficient. In case of poor bone stock, an additive autologous or allogenic bone grafting can be performed. An instable anatomical prosthesis with poor shoulder function may require conversion to an inverse prosthesis. In cases of an isolated plate osteosynthesis with an otherwise stable prosthesis, immediate active rehabilitation of the upper limb is advocated. When aprosthesis replacement and conversion to an inverse prosthesis is performed the shoulder is immobilized in 30°abduction for 6weeks. Passive and after 3weeks active-assistive shoulder movement up to 90°abduction and flexion is allowed. In 40patients with aperiprosthetic humeral fracture, an isolated plate osteosynthesis was performed in 30cases and aprosthesis replacement in 10cases. Complications included 3infections and 3temporary radial nerve palsies. Revisions due to pseudarthrosis were necessary in 2cases.

Mid-term results of minimally invasive deltoid-split versus standard open deltopectoral approach for PHILOS™ (proximal humeral internal locking system) osteosynthesis in proximal humeral fractures.

Only a few reports compare the mid- and long-term outcome of the minimally invasive deltoid split (MIDS) with the classic anterior deltopectoral (DP) approach for osteosynthesis in proximal humeral fractures. This study compared the mid-term functional and the radiological results in patients with proximal humeral fractures undergoing osteosynthesis with the proximal humeral internal locking system (PHILOS™). All patients undergoing osteosynthesis between 2008 and 2015 were clinically and radiologically examined with a minimal follow-up period of 1year. Functional outcomes were analyzed using the DASH- and Constant Shoulder Scores (CSS). Radiological results were analyzed using a newly developed score. Thirty-nine patients underwent PHILOS™ osteosynthesis with the MIDS and twenty-three with the DP approach. Follow-up time was 41 months in the MIDS group and 62 months in the DP group, respectively. The median CSS was similar with 79 points in the MIDS group and 82 points in the DP group (p = 0.17). The MIDS group showed a significant lower power measurement in the CSS. In four-part fractures, a substantially lower CSS in absolute numbers in the MIDS group was detected. The median DASH score was 26.7 points in the MIDS group and 25.8 points in the DP group (p = 0.48). There was no difference in the radiological score. More patients with partial avascular necrosis (AVN) were found in the MIDS group, most with three- and four-part fractures. However, this was not statistically significant. Morbidity was similar between groups. The results of the two surgical approaches are statistically comparable. Some differences such as a lower power measurement in the MIDS group, a higher partial AVN frequency and more plate removals are observed. In four-part fractures, the CSS was lower in the MIDS compared to the DP cohort. The MIDS technique might not be a solution for all fracture types, and the surgeon should be careful to analyze the morphology of the fracture before deciding upon the approach. Four-part fractures might be better treated with a DP approach.

The bra strap incision in the open Latarjet procedure

BackgroundThe anterior deltopectoral approach is the standard approach for performing the open Latarjet procedure. Through the use of a more medial and vertical skin incision, the scar can be cosmetically covered by the bra strap in women. We call this incision the bra strap incision.The intention of this study was (1) to elaborate if the bra strap incision is considered beneficial by female patients, (2) to find reproducible landmarks to indicate how the bra strap incision has to be oriented, and (3) to evaluate preliminary clinical results of patients in whom the bra strap incision was used.MethodsIn 18 patients with a mean follow-up of 21 (range, 12–31) months treated with an open Latarjet procedure through the bra strap incision, the clinical results (scar satisfaction, Constant and Murley score [CMS], and subjective shoulder value [SSV]) were retrospectively analyzed.To assess the typical course of the bra strap, anatomical landmarks were assessed in 100 consecutive female patients as the distance from the bra strap center to (1) the tip of the coracoid process, (2) the superior end of the anterior axillary fold, and (3) the acromioclavicular joint.ResultsAll (18 of 18) patients stated that they would prefer the bra strap incision if the same procedure had to be performed on the opposite shoulder; 16 women were satisfied with the scar. The mean CMS was 83 (range 64–96) points and the mean SSV was 85 (range, 60–100) %.The mean distances from the bra strap center to the acromioclavicular joint, coracoid tip, and axillary fold were 28 (range, 5–60) mm, 15 (range, 2–17) mm, and 30 (range, 2–55) mm.No combination of distance measures and demographic variable revealed a linear relationship.ConclusionThis analysis shows that the bra strap incision appears to be highly welcomed by female patients and does not compromise the clinical outcome, when compared to previously published data. However, even though the typical location of the bra strap can be determined, the large variations in the distances make it more preferable to preoperatively mark the incision for optimal placement.Trial registrationThe study is approved by the Ethical Committee Zurich. (Cantonal Ethical Committee number: ZH-Nr.2017–00891).

A prospective study on functional and radiological outcome of proximal humeral fractures treated with locking compression plates

Fractures of proximal humerus account for about 4 to 5% of all fractures. It is the third most common fracture after hip fracture and colles fracture in elderly patients. In this study we have analysed 20 cases of proximal humeral fractures treated surgically using (PHILOS) proximal humerus locking compression plates admitted at Department of Orthopaedics and Traumatology, Government Kilpauk Medical College and Hospital, Chennai from April 2013 to November 2013. The aim of the study was to analyze the functional and radiological outcome and to assess the complications of proximal humeral fractures treated using locking compression plates. Patients with proximal humerus fractures, who are skeletally mature and age more than 18 years satisfying Neer s criteria for operative displacement were selected. The patients were operated by the standard anterior deltopectoral approach or deltoid splitting approach using proximal humerus locking plates. All the patients were reviewed at two weeks interval, for first three months and later every month, Radiological evaluation of fracture union was observed by serial X rays. Constant and Murley’s score was used to assess the functional outcome of our patients. The average constant score in our study with 20 patients was 82.4. Finally we concluded that displaced proximal humeral fractures when treated surgically produce greater range of movements (ROM), less pain and less stiffness.

Anterior Deltopectoral Approach for Axillary Nerve Neurotisation

To report outcome of axillary nerve neurotisation for brachial plexus injury through the anterior deltopectoral approach. Nine men aged 20 to 52 (mean, 27.8) years with brachial plexus injury underwent axillary nerve neurotisation through the anterior deltopectoral approach. Three of the patients had complete avulsion of C5-T1 nerve roots. The remaining 6 patients had brachial plexus injury of C5-C6 nerve roots, with associated subluxation of the glenohumeral joint, atrophy of the supraspinatus, deltoid and elbow flexors. They had no active shoulder abduction, external rotation, and elbow flexion. The pectoralis major and minor were cut and/or retracted to expose the underlying infraclavicular plexus. The axillary nerve was identified with respect to the available donor nerves (long head of triceps branch, thoracodorsal nerve, and medial pectoral nerve). In addition to the axillary nerve neurotisation, each patient had a spinal accessory nerve transferred to the suprascapular nerve for better shoulder animation. Patients were followed up for 24 to 30 (mean, 26) months. In the 3 patients with C5-T1 nerve root injuries, the mean active abduction and external rotation were 63 and 20 degrees, respectively, whereas the mean abduction strength was M3 (motion against gravity). In the 6 patients with C5-C6 nerve root injuries, the mean active abduction and external rotation were 133 and 65 degrees, respectively, whereas the strength of the deltoids and triceps was M5 (normal) in all. In 4 patients with the pectoralis major cut and repaired, the muscle regained normal strength. The anterior deltopectoral approach enabled easy access to all available donor nerves for axillary nerve neurotisation and achieved good outcomes.

Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries

Combined neurotization of both axillary and suprascapular nerves in shoulder reanimation has been widely accepted in brachial plexus injuries, and the functional outcome is much superior to single nerve transfer. This study describes the surgical anatomy for axillary nerve relative to the available donor nerves and emphasize the salient technical aspects of anterior deltopectoral approach in brachial plexus injuries. Fifteen patients with brachial plexus injury who had axillary nerve neurotizations were evaluated. Five patients had complete avulsion, 9 patients had C5, six patients had brachial plexus injury pattern, and one patient had combined axillary and suprascapular nerve injury. The long head of triceps branch was the donor in C5,6 injuries; nerve to brachialis in combined nerve injury and intercostals for C5-T1 avulsion injuries. All these donors were identified through the anterior approach, and the nerve transfer was done. The recovery of deltoid was found excellent (M5) in C5,6 brachial plexus injuries with an average of 134.4° abduction at follow up of average 34.6 months. The shoulder recovery was good with 130° abduction in a case of combined axillary and suprascapular nerve injury. The deltoid recovery was good (M3) in C5-T1 avulsion injuries patients with an average of 64° shoulder abduction at follow up of 35 months. We believe that anterior approach is simple and easy for all axillary nerve transfers in brachial plexus injuries.

Long Head of the Triceps Branch Transfer to Axillary Nerve in C5, C6 Brachial Plexus Injuries

Shoulder abduction is a very complex movement and quite important for upper limb function, as more distal functions depend on a stable shoulder, especially in C5, C6 brachial plexus injuries. Various studies in the literature have emphasized the importance of improved functional outcome and shoulder reanimation with concomitant neurotization of suprascapular nerve and axillary nerve in C5, C6 brachial plexus injuries. A number of approaches to axillary nerve transfer in brachial plexus injuries have been reported. The author describes an innovative anterior deltopectoral approach for axillary nerve transfers in five patients with C5, C6 brachial plexus injuries. The spinal accessory nerve was neurotized with the suprascapular nerve through a transverse supraclavicular incision. The axillary nerve and the long head of the triceps branch were identified through the anterior deltopectoral approach and neurotized at the posterior cord level. This approach gives easy access to other donors such as the medial pectoral, thoracodorsal, and median and ulnar nerves. Oberlin's transfer was also performed for elbow flexion by extending the deltopectoral incision. The regained shoulder active abduction (M5) averaged 120 degrees and active external rotation averaged 65 degrees at the final follow-up of 26 months (average). This anterior deltopectoral approach is an excellent alternative for axillary nerve transfer in brachial plexus injuries and produces results comparable with those of other approaches. All brachial plexus surgeons must understand the anatomy and the relationship of the axillary nerve to the surrounding structures. Therapeutic, V.

Minimal Invasive PHILOS(®)-Plate Osteosynthesis in Proximal Humeral Fractures.

The anterior delto-pectoral approach is the standard approach for the fixation of proximal humeral fractures with the PHILOS(®)-Plate system. However, this approach can impair the vascular supply and can increase avascular necrosis. The objective of this study was to evaluate the results and complexity of surgery of proximal humeral fractures with a minimal invasive (MIPO) approach. All PHILOS(®)-plate osteosynthesis operated between Januray 2003 and June 2006 were evaluated prospectively. A minimal invasive antero-lateral deltasplit-approach was performed in all two to four fragment instable fractures meeting the indication for osteosynthesis according to Neer. An open approach (ORIF) was chosen in all other fractures mainly dislocated fractures and particularly in fractures with major subcapital displacement. A cohort of 68 patients suffered a proximal humerus fracture and qualified for a minimal invasive approach with a PHILOS(®)-plate osteosynthesis. Of these 68 patients, 41 were locally resident. Eight patients refused a follow-up, two patients were in constant care, and two patients died; 29 patients (71%) (20 females, 9 males) could be documented entirely with a median age of 64 years. The median operation time amounted to 75 min with a fluoroscopic time of 160 s. The median Constant score was 78 after 12 months. All fractures healed in adequate time. One patient showed a lesion of the ventral part of the axillary nerve. No patient suffered an avascular necrosis. The minimal invasive PHILOS(®) plate osteosynthesis through an antero-lateral delta-split approach proved to be an elegant procedure for selected fractures of the proximal humerus with a low morbidity and good functional outcome.

Early results of treatment of proximal humerus fractures with the PHILOS locking plate

The aim of this study was to evaluate early results of proximal humerus fractures treated with the PHILOS locking plate. Proximal humerus fractures of 22 patients (13 males, 9 females; mean age 57 years; range 35 to 83 years) were treated with the PHILOS locking plate. According to the Neer classification, 13 patients had comminuted fractures, four patients had valgus impact injuries, two patients had fracture-dislocations, and three patients had fractures involving the proximal 1/3 of the humerus. The fractures were reduced by the transdeltoid lateral approach (n=8) using minimally invasive surgery, and by the anterior deltopectoral approach (n=14) using open surgery. Passive and active exercises were initiated on the second postoperative day and after 4 to 6 weeks, respectively. The results were assessed using the Constant-Murley shoulder scoring system. The mean follow up was 14 months (range 12 to 19 months). Radiographically, union was observed in 20 patients at the end of 10 weeks. In one patient, time to union was 16 weeks. One patient underwent autogenous bone grafting because of nonunion after 16 weeks. The mean Constant-Murley score was 75.5 (range 51 to 93). There was no significant difference between Constant-Murley scores of patients undergoing the transdeltoid lateral and anterior deltopectoral approaches (p>0.05). Plate fixation was associated with minimal varus deformity in two patients, and subacromial impingement in one patient. Implant failure did not occur. Reflex sympathetic dystrophy and avascular necrosis were observed in two patients, respectively. Fixation with the PHILOS plate is a near-ideal technique with a high union rate in the treatment of proximal humeral fractures.

A wide and versatile combined surgical approach to the shoulder

Complex injuries and conditions of the shoulder may necessitate wide exposure during the operative procedure. The commonly used approach today is a wide anterior deltopectoral approach with extensive detachment of the deltoid muscle, leading to muscle damage, which may result in difficult postoperative rehabilitation and deteriorated function. We describe a simple combined approach that consists of a deltopectoral approach in conjunction with a subcutaneously performed lateral deltoid split with a single skin incision. We believe this surgical technique provides another useful tool to achieve wide and versatile exposure of the shoulder without jeopardizing the function of either the deltoid muscle or axillary nerve.

Treatment of locked posterior fracture-dislocations of the shoulder by total shoulder arthroplasty

Total shoulder arthroplasty is indicated in the treatment of locked posterior fracture-dislocations of the shoulder where there is extensive damage to the articular surfaces of the humerus and glenoid. This report reviews the surgical technique, postoperative rehabilitation program, and functional results of seven shoulders in five patients who had locked posterior dislocations of the shoulder. Activities involving overhead positioning of the arm and heavy lifting continued to be challenging for this group of patients. The American Shoulder and Elbow Surgeons' Shoulder Score improved from 20.1 before surgery to 55.6 after surgery (p = 0.018). The extrication of the posteriorly dislocated humeral head may be difficult from an anterior deltopectoral approach. The authors describe the use of a secondary posterior incision facilitating the extrication of the humeral head. In this series total shoulder arthroplasty reliably decreased the patients' level of pain, improved their range of motion, and significantly improved their level of function.

Surgical management of scapular fractures

Scapula fractures are rare and historically have been treated effectively with nonsurgical methods. There is a paucity of literature and limited practical experience regarding surgical indications and intervention for this entity. The indications for surgical intervention are still unclear but are becoming better defined. The operative approaches are refined and include either a standard anterior deltopectoral approach or a posterior approach. The latter involves detachment of the deltoid from the spine of the scapula and development of the interval between the infraspinatus and teres minor muscles. Accurate reduction of the articular surface is crucial, and internal fixation should be varied in relation to the size and location of the fracture fragments. The stability of the fixation should allow for early or slightly delayed motion in order to allow soft tissue, musculotendinous, and capsule healing.