GLENOID EXPOSURE & RETRACTOR PLACEMENT: GETTING IT RIGHT

Abstract

1. Introduction

   • The most difficult part of shoulder replacement

   • Important steps

     1. Anaesthesia and patient position

     2. Soft-tissue releases

     3. Humeral bone removal

     4. Retractor placement

2. Anaesthesia and Patient Position

   • Need full paralysis

   • Patient must be positioned laterally enough so that the scapula is unsupported

   • Arm is draped free so that it can be manoeuvred to find the position of optimal glenoid visualisation – usually this is slight extension, external rotation, and GH elevation to 45 – 60°

3. Soft-tissue Releases

   • Humeral side – make sure that the rotator interval is incised all the way to the glenoid margin and that the inferior capsule is released past the six o’clock position

   • Glenoid

     1. Circumferential labral excision

     2. Circumferential capsular release

     3. Check for biceps glide

4. Humeral Bone Removal

   • Remove all osteophytes – inferior, anterior, and posterior

   • Make sure humeral osteotomy is through anatomic neck so that there is minimal bone protruding beyond the humeral cuff reflection

5. Retractor Placement

   • Retractors needed

     1. Ring retractor (e.g., Fukuda) – both small and large

     2. Other types of humeral head retractors (e.g., Carter Rowe)

     3. Reverse Homan x2

     4. Single prong Bankart retractor

     5. Large flat retractor (e.g., Darrach)

   • Placement

     1. Fukuda or Carter Rowe retractor – within the joint, levering on the posterior glenoid to displace humeral head posteriorly

     2. Large Darrach – on anterior neck of scapula retracting subscapularis

     3. Single prong Bankart or reverse Homan – superior glenoid under biceps anchor

     4. Reverse Homan – inferior glenoid. Not always necessary.