Download Standard procedure for shoulder reconstruction The patient is

Standard procedure for shoulder reconstruction
The patient is placed in a lateral decubitus position and a saber shaped skin incision
over the shoulder is made. Additional horizontal skin incision over the upper trapezius
exposes the trapezius and deltoid muscles at their attachments to the acromion, clavicle,
and spine of the scapula. The insertions of the trapezius into the clavicle and spine of
the scapula are released, without disturbing its attachment to the acromion. The
acromion with trapezius attachment was osteotomied to be a muscle-bone graft. The
deltoid is released from the lateral third of the clavicle, acromion and the lateral half of
the spine of the scapula.
Posteriorly, the LD tendon is taken off its insertion on the humerus and dissected
proximally enough to reach the distal insertion site of the infraspinatus, taking care not
to injure the thoracodorsal artery, veins, and nerve.
Anteriorly, the clavicular portion of the pectoralis major is explored and elevated from
the clavicle, with care taken to avoid injury to the neurovascular pedicles. The released
clavicular portion of the pectoralis major is turned and placed over the anterior deltoid
muscle. It is then sutured over the deltoid and other structures to the lateral aspect of the
clavicle(Figure 1).
Next with the arm in 100 degrees of abduction, the acromial fragment with its trapezius
insertion is transferred and fixed to the humerus as distally as possible, using a 4.5-mmdiameter screw. The released tendon of the LD muscle is sutured under tension to the
insertion of the infraspinatus muscle in 90 degrees of external rotation. The deltoid is
then sutured over the trapezius, and the skin is closed over two suction drains (Figure
1). The trapezius transfer was done in all 8 cases, the LD to the infraspinatus transfer in
6, and the pectoralis transfer in 6 cases.
Elbow Reconstruction
Steindler Procedure
Steindler procedure was the first choice for reconstruction of elbow flexion as long as
the power strength of the forearm muscles was strong enough to transfer. Steindler
procedure was done in the first stage as a part of two stage operation in two cases. The
incision begins posterior to the medial epicondyle of the humerus and is then directed
proximally and anteriorly for 7.5 cm over the distal upper arm. The incision curves
distally over the anterior forearm for 10 cm, following the outline of the pronator teres
muscle. The common origin of the pronator and wrist flexor muscles is dissected from
above downward and then detached with a fragment of bone from the medial
epicondyle using an osteotome, and the muscles are gently retracted while their nerve
supply is protected from injury. With the elbow acutely flexed to 130 degrees, the bone
fragment and muscle origin can be advanced 5 to 7 cm proximally, where the bone
fragment is fixed to the anterior humerus with a screw and additional anchoring sutures.
LD Transfer
The basic technique for LD harvest described by Zancolli was used when the LD was
chosen for elbow flexion reconstruction[17]. After the muscle is harvested, the
coracoid process is exposed, and in the distal antecubital fossa the biceps tendon
exposed. Both edges of the LD muscle are sutured to each other, and the muscle is
shaped into a tubed muscle flap and passed underneath the tunnel. The authors prefer
to suture the fascial origin of the muscle not to the biceps brachii tendon but to the
radius as distal as possible, because the muscle moment arm is greater when it is
attached as far from the joint center as possible. The tension when suturing the
proximal origin of LD muscle to the coracoid process is correct when the shoulder is
in full adduction and the elbow is in 100 degrees of flexion. LD transfer for elbow
flexion was done in 2 patients.
Pectoralis Major Transfer
We followed Wahegaonkar's technique for the pectoralis major transfer[15]. A long
curvilinear incision is first made from the seventh sternocostal joint to up to two
fingerbreadths inferior to the clavicle. The incision continues laterally to the coracoid
process, then distally along the anteromedial aspect of the arm to the level of the axilla
with the forearm held in neutral position. With the acromion and entire pectoralis major
exposed, the entire mass of the pectoralis major muscle then is detached from its origin
along the medial half of the clavicle and its sternocostal border (Figure 2). With the use
of both sharp and blunt techniques, the muscle is elevated with a wide strip of attached
anterior rectus abdominis fascia. While elevating the pectoralis major from the chest
wall and underlying Pectoralis minor, meticulous care must be taken to preserve its
neurovascular pedicles. After detaching the humeral insertion of the muscle, the entire
muscle mass is then rotated 90 degrees on its two neurovascular pedicles(Figure 3). The
origins of the clavicular and sternocostal heads with attached anterior rectus abdominis
sheath are rolled into a tube and directed down the arm through an anterior
subcutaneous tunnel, exiting through the second incision. The rectus fascial tube is
sutured to the biceps tendon, taking care not to kink the neurovascular pedicle. The
humeral attachment of the muscle is now directed cephalad and sutured securely to the
anterior aspect of the acromion with suture anchors, under correct tension with 1000 of
elbow flexion (Figure 4). The final position of the transplanted pectoralis major is colinear with the anatomic origin and insertion of the biceps brachii. The pectoralis major
transfer for elbow flexion was done in three cases, in which simultaneous
transfer(Along with Steindler’s procedure) was done in one case.
Post-operative management
Following shoulder reconstruction, the shoulder is held in 600 of flexion and 1000 of
abduction and in neutral rotation. We employ a prefabricated orthoplastic air plane
splint tailor made for the patient. This position is maintained for a period of eight
weeks. During this period, isometric exercise of the transferred muscles in the splint
was encouraged. After the end of the eighth week, active shoulder motion was
commenced and the fixed splint position of abduction was decreased 300 by each week.
Following elbow reconstruction, the elbow is held in 1000 of flexion and with the wrist
in flexion in Steindler's procedure, and without the wrist immobilization in pectoralis
major or latissimus dorsi transfer, for six weeks. For this period, isometric elbow
flexion was encouraged and active range of elbow motion was started at the end of the
sixth week.