Many general orthopaedic surgeons avoid placement of a glenoid component during shoulder replacement surgery or have problems with glenoid exposure. The following pictures demonstrate the way we perform the exposure using Darrach retractors, 3 or 4 Homan retractors and 2 Gelbi retractors. The key to glenoid exposure is the release of the inferior capsule at the neck of the humerus. This is performed by external rotation of the proximal humerus as the subscapularis is sequentially released at the inferior aspect. This movement moves the axillary nerve away from the surgical field. By releasing the inferior capsule the humeral head can be displaced posteriorly for glenoid exposure.
It is important NOT to do an aggressive humeral cut to facilitate glenoid exposure because the loss of proximal humeral bone cannot be corrected and will lead to shoulder instability.
It is important to recognize that depending on the size of the patient, musculature and stiffness exposure can be challenging even if the necessary steps were taken for adequate soft tissue release. In that case although most shoulder surgeons do not admit it, bone resection from the lesser tuberosity while the humerus is dislocated posteriorly is necessary. This humeral bone resection should be just enough for drilling and reaming the glenoid and again the bone preservation should be kept in mind.
In addition, if the surgery is done on older patients (usually in their 70s or 80s) with osteopenic bone or rheumatoid disease then it might be necessary to keep the trial humeral component in the humeral canal to avoid humeral fracture during the retraction for exposure of the glenoid.
Of note, the release of the rotator cuff interval from a lateral to medial direction to the coracoid and conjoined tendon but not pass the coracoid/conjoined tendon can help with visualization at the anterior superior aspect of the glenoid.
The following pictures demonstrate the exposure and final implantation of an all poly-ethylene glenoid component and press fit humeral stem.
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| Exposure of humeral head |
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| Exposure of the glenoid |
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| Drilling the hole for the central peg |
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| Drilled peripheral peg holes |
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Implanted glenoid component
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| Insertion of 6 humeral Fiberwire sutures to the lesser tuberosity for repair of the subscapularis |
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| Insertion of press fit humeral component and head |
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| Postoperative Grashey view (sling metal adjustor superimposed - xray taken in the postanesthesia care unit) |
