Anterior incision: begins from the middle third of the clavicle, extending to the anterior edge of the armpit, and then along the medial border of the biceps. See photo at right.18
The clavicle and pectoralis major is divided.
The neurovascular bundle is dissected out down to the end of the skin incision. The side branches of the vessels are ligated. Nerve branches are conserved as much as possible.
A circular flap incision is made on the arm.
The deltoid is transected at its attachments to the clavicle, acromion, and scapular spine. The long and short heads of the triceps are transected at their insertions.
The humerus is transected at its surgical neck. The patient is turned to the prone position.
Posterior incision: starts at the clavicle and continues posteriorly along the scapula until it meets the anterior incision. See photo at right.
The trapezius is removed medially, the teres major and long head of the triceps are resected, and the scapula is removed.
The limb is fixed to the anterior surface of the thorax and the biceps sutured to the anterior intercostal muscles and rib periosteum, while the triceps is similarly sutured posteriorly.
Drainage tubes are placed to prevent hematoma.
The patient is placed in the lateral decubitus position, with affected shoulder facing up.
A longitudinal posterior incision is begun over the posterior aspect of the scapula. The previous biopsy site is ellipsed.
The incision is extended proximally over the posterior portion of the shoulder, then distally over the anterior aspect of the shoulder into the deltopectoral groove.
Skin flaps are raised and the subcutaneous tissue and fascia are dissected through.
The tip of the scapula is identified. Muscular attachments are severed first laterally then medially with a cutting stapler device. The subscapularis muscle will be taken with the specimen. The scapula is retracted off the chest wall.
The dissection is continued into the axilla and neurovascular bundle identified.
The posterior deltoid is taken down, infraspinatus, supraspinatus, and joint capsule are incised. The amount of muscle removed depends on the extent of muscular involvement.
The humeral head is dislocated from the glenoid.
The clavicle is dissected subperiostially medial to the AC joint, and the clavicle is osteotomized with an oscillating saw.
The scapula is removed.
The humerus is osteotomized blow the humeral head in order to accommodate an angled proximal humeral prosthesis.
Placement of humeral prosthesis: The humerus is reamed to a diameter of 10mm.
Antibiotic impregnated poly-methylmethacrylate cement is injected into the humeral canal. The humeral stem is inserted, placed in 40 degrees of retroversion, and held in place until the cement hardens.
Placement of scapular prosthesis: The scapular component is secured to the surrounding musculature with interrupted sutures.
The prosthetic humeral head is snapped into the constrained liner of the prosthetic scapular glenoid cavity.
The muscle and fascia are closed. Certain cases require the use of an orthobiologic patch (see photo at right) to seal incomplete areas of fascia.
Latissimus dorsi muscle flaps may also be used for improved soft tissue coverage.
The skin is closed.
Drainage tubes are inserted and the patient is placed in a shoulder immobilizer.
Estimated blood loss has been 1.5-4 L in our experience.