Operative Technique

Linberg Technique 19288, 10

  •  The patient is placed in the supine position. 
  •  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.

 Menendez Technique

  •  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.

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