Bailie D S, Moseley B, Lowe W R
Baylor Sports Medicine Institute, Baylor College of Medicine, USA.
J Shoulder Elbow Surg. 1999 Jul-Aug;8(4):307-13. doi: 10.1016/s1058-2746(99)90151-9.
The purposes of this study were to evaluate anatomically various surgical intervals to the posterior shoulder and to determine the effects of varying arm positions and anterior-inferior capsular shift (AICS) on the relation of the posterior neurovascular structures to fixed bony landmarks. Fourteen cadaveric shoulders were dissected. The posterior surgical anatomy was defined, and the distances from fixed bony landmarks to neurovascular and musculotendinous structures were determined with digital calipers. Measurements were made with the arm in various positions and repeated after AICS. The most direct anatomic approach to the posterior shoulder was through a deltoid split in the raphe from the posterolateral corner of the acromion (PLCA), followed by an infraspinatus (IS) splitting incision. The IS/teres minor interval was at the inferior aspect of the glenoid rim and was difficult to locate in all specimens. The distance to the axillary nerve from the PLCA averaged 65 mm and decreased by an average of 14 mm (22%) with abduction and by 19 mm (29%) with extension. The posterior humeral circumflex artery was located along the humeral neck and was vulnerable to injury during lateral capsular dissection. The suprascapular nerve had multiple branches to the IS with most penetrating the muscle at its inferior portion. The closest branch to the glenoid rim was an average of 20 mm medial from it. No branch entered at the level of the IS raphe. The anatomic relations of the suprascapular nerve were unchanged after AICS. On the basis of this study, surgical exposure of the posterior shoulder with a deltoid split from the PLCA, followed by an IS split, appears to be anatomically safe. The arm position should be in neutral rotation, especially if previous anterior capsular procedures have been performed, which can alter the posterior neurovascular anatomic relations.
本研究的目的是从解剖学角度评估至肩关节后方的不同手术间隙，并确定不同的手臂位置及前下关节囊移位（AICS）对后方神经血管结构与固定骨性标志之间关系的影响。对14具尸体肩部进行了解剖。明确了后方手术解剖结构，并用数字卡尺测量了从固定骨性标志到神经血管及肌肉肌腱结构的距离。在手臂处于不同位置时进行测量，并在AICS后重复测量。至肩关节后方最直接的解剖入路是从肩峰后外侧角（PLCA）沿中缝劈开三角肌，随后作冈下肌（IS）劈开切口。IS/小圆肌间隙位于关节盂边缘下方，在所有标本中均难以定位。从PLCA到腋神经的平均距离为65 mm，外展时平均减少14 mm（22%），伸展时平均减少19 mm（29%）。旋肱后动脉沿肱骨干颈走行，在外侧关节囊剥离时易受损伤。肩胛上神经有多个分支至冈下肌，多数分支在其下部穿透该肌。距关节盂边缘最近的分支平均在其内侧20 mm处。没有分支在冈下肌中缝水平进入。AICS后肩胛上神经的解剖关系未改变。基于本研究，经PLCA劈开三角肌，随后劈开冈下肌来进行肩关节后方手术显露，在解剖学上似乎是安全的。手臂应处于中立旋转位，尤其是在先前已进行过前方关节囊手术的情况下，因为这可能会改变后方神经血管的解剖关系。
