**5. Alternate approaches**

If the deltoid was peeled subperiosteally off the acromion, it must be repaired using a large-diameter, non-absorbable suture in a transosseous fashion. Many large-diameter suture needles are strong enough to pass through the acromion without using a power drill; however, if the bone is hard, a drill may be used [44]. The suture should be passed through the deltoid with sufficient purchase to ensure that the suture does not pull through the muscle. If the acromial osteotomy was utilized, suture should be passed around the fleck of the acromion with sufficient purchase in the deltoid to again prevent pulling through the suture within the substance of the deltoid.

Once the deltoid has been adequately repaired to the acromion, the deltoid raphe should be sutured with a 0 vicryl or polydioxanone (PDS) suture in a running whipstitch or figure-of-eight interupted fashion. Care should again be taken to avoid suturing below the previously placed stay suture to avoid damaging the axillary nerve. With the raphe closed, the subcutaneous layer may be closed with an absorbable 2-0 suture and the skin with a nylon, running monocryl or other method of skin closure. A dry dressing or an incisional vacuum should be placed over the wound and the arm placed into a sling with abduction pillow prior to awakening the patient.

The anterosuperior approach provides several advantages to the deltopectoral approach. Perhaps, the greatest of these is the subscapularis sparing nature of the approach. Though originally Mackenzie described the approach with a subscapularis tenotomy, modern-day surgeons have typically modified this approach to spare the subscapularis. Utilizing a subscapularis tenotomy with adequate repair, Miller et al. showed, both clinically and functionally, that the subscapularis was deficient following shoulder arthroplasty in a majority of cases [45]. Jackson et al. showed high re-rupture rates following repair of a tenotomy using ultrasound and then showed that it was associated with decreased function [46]. Furthermore, early literature has shown that subscapularis-deficient shoulders have higher rates of instabil-

The anterosuperior lateral approach is also superior in terms of exposure to the posterior structures of the shoulder, including the posterior glenoid and the rotator cuff. This exposure may be particularly useful for three- or four-part proximal humerus fractures where the greater tuberosity fragment attached to the rotator cuff is pulled posterior and superior [44]. The exposure of the glenoid via the anterosuperior approach is, historically, felt to be superior to that of the deltopectoral approach. It allows for visualization of the entire glenoid and for better sagittal positioning of the glenoid component. Furthermore, it allows for easier preparation of the glenoid, particularly in obese patients and in cases where the glenoid may be retroverted.

Despite having superior exposure of the glenoid as a whole, exposure of the inferior aspect of the glenoid is more difficult via the anterosuperior approach. As such, it is more difficult to provide sufficient inferior tilt of the glenoid component which may lead to scapular notching and subsequent failure of the glenoid component [35, 48, 49]. Furthermore, the presence of inferior osteophytes is a relative contraindication to this approach due to the extreme difficulty in accessing and removing these osteophytes. In addition, there is a theoretical disadvantage

ity [36], though other studies have shown no significant difference [47].

**4.7. Advantages**

78 Advances in Shoulder Surgery

**4.8. Disadvantages**

The deltopectoral and anterosuperior approaches are by and large the most commonly used approaches for shoulder arthroplasty; however, there are other approaches to the glenohumeral joint which have been described in the literature. Lafosse et al. described an approach for anatomic total shoulder arthroplasty that spares all of the rotator-cuff tendons and is performed through the rotator interval [50]. The approach mimics that of the anterosuperior approach in that the deltoid is split in line with its fibers in the raphe between the anterior and middle portions of the deltoids. Again, similar to the anterosuperior approach, the authors had difficulty removing the inferior osteophytes as well as performing an anatomic humeral neck cut and sizing of the humeral head. Two-year follow-up data from this approach do show promising results, though no comparison was made to the deltopectoral approach.

Bellamy et al. performed a cadaveric study analyzing more minimally invasive approaches to the subscapularis including a partial tenotomy and a subscapularis split [51]. In this study, they measured the average area of the glenoid and the humerus that they could visualize through each of these approaches. They found that all of these approaches had adequate exposure of the glenoid; however, the split provided poor exposure of the humerus for humeral-based procedures, while the partial tenotomy provided sufficient exposure.

Gagey et al. presented the results of 53 patients who underwent anatomic total shoulder arthroplasty over a 6-year span via a posterolateral approach [52]. This approach begins with the patient in the lateral decubitus position and a posterior incision is made and carried down between the raphe of the posterior and middle portions of the deltoid. The bursa is then released to identify the tendons of the external rotators. The tendons are then removed via an osteotomy of the greater tuberosity. This allows for exposure to the glenohumeral joint. The osteotomy is then repaired in a manner similar to the lesser tuberosity osteotomy described in the deltopectoral section. Adequate exposure was achieved for placement of shoulder arthroplasty components; however, the authors did note two cases of posterior deltoid atrophy that was unexplained. Brodsky described a modified approach that utilizes the internervous interval between the infraspinatus and the teres minor which allows for preservation of the external rotators [53]. However, no literature exists, which shows that this interval would be feasible for use with shoulder arthroplasty.

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A cadaveric study in England compared these three alternative approaches and they found that the posterior approach to the glenohumeral joint provided significantly improved exposure compared to a subscapularis-splitting approach or an approach through the rotator interval [54]. They also measured the average force of retraction on the rotator cuff utilizing these approaches and found that significantly more force was placed on the rotator cuff by retractors in the subscapularis-splitting approach. Before any of these approaches will supplant the deltopectoral or anterosuperior approaches, more research needs to be performed to ensure that good outcomes with minimal morbidity can be achieved through these approaches.
