Amirthanayagam Tressa D, Amis Andrew A, Reilly Peter, Emery Roger J H
Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, UK.
Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, UK; Faculty of Engineering, Department of Mechanical Engineering, Imperial College, London, UK.
J Shoulder Elbow Surg. 2017 Mar;26(3):512-520. doi: 10.1016/j.jse.2016.08.011. Epub 2016 Oct 10.
The deltopectoral approach for total shoulder arthroplasty can result in subscapularis dysfunction. In addition, glenoid wear is more prevalent posteriorly, a region difficult to access with this approach. We propose a posterior approach for access in total shoulder arthroplasty that uses the internervous interval between the infraspinatus and teres minor. This study compares this internervous posterior approach with other rotator cuff-sparing techniques, namely, the subscapularis-splitting and rotator interval approaches.
The 3 approaches were performed on 12 fresh frozen cadavers. The degree of circumferential access to the glenohumeral joint, the force exerted on the rotator cuff, the proximity of neurovascular structures, and the depth of the incisions were measured, and digital photographs of the approaches in different arm positions were analyzed.
The posterior approach permits direct linear access to 60% of the humeral and 59% of the glenoid joint circumference compared with 39% and 42% for the subscapularis-splitting approach and 37% and 28% for the rotator interval approach. The mean force of retraction on the rotator cuff was 2.76 (standard deviation [SD], 1.10) N with the posterior approach, 2.72 (SD, 1.22) N with the rotator interval, and 4.75 (SD, 2.56) N with the subscapularis-splitting approach. From the digital photographs and depth measurements, the estimated volumetric access available for instrumentation during surgery was comparable for the 3 approaches.
The internervous posterior approach provides greater access to the shoulder joint while minimizing damage to the rotator cuff.
全肩关节置换术的三角肌胸大肌入路可能导致肩胛下肌功能障碍。此外，关节盂磨损在后方更为普遍，而该入路难以到达该区域。我们提出一种全肩关节置换术的后方入路，该入路利用冈下肌和小圆肌之间的神经间隙。本研究将这种神经间隙后方入路与其他保留肩袖技术，即肩胛下肌劈开入路和旋转间隙入路进行比较。
对12具新鲜冷冻尸体进行这3种入路操作。测量了对盂肱关节的圆周暴露程度、对肩袖施加的力、神经血管结构的接近程度以及切口深度，并分析了不同手臂位置下入路的数码照片。
后方入路可直接线性暴露60%的肱骨和59%的关节盂圆周，肩胛下肌劈开入路分别为39%和42%，旋转间隙入路分别为37%和28%。后方入路对肩袖的平均牵拉力量为2.76（标准差[SD]，1.10）N，旋转间隙入路为2.72（SD，1.22）N，肩胛下肌劈开入路为4.75（SD，2.56）N。从数码照片和深度测量来看，手术中器械可用的估计容积暴露在这3种入路中相当。
神经间隙后方入路能更好地暴露肩关节，同时将对肩袖的损伤降至最低。
