A posterosuperior approach to the shoulder
Piet M. Rozing, MD, PhD, Leiden, The Netherlands
An approach for a better surgical exposure of the
posterior part the glenoid and the rotator cuff is presented
as an alternative for the long deltopectoral incision that
might be considered in specially selected cases. In
shoulder arthroplasty, it can be used for bone grafting to
reorient the glenoid, revision of a glenoid component, or
repair of a large rotator cuff tear. This posterosuperior
approach consists of an osteotomy of the lateral rim and
posterior corner of the acromion, with reflection of part of
the medial and posterior insertion of the deltoid muscle. A
special plate is used for stable fixation of the osteotomy.
The method has been used since 1994 for shoulder
prosthesis insertion in 79 patients. In 72 patients with
a total shoulder or hemiarthroplasty, the cuff was
attenuated or ruptured in 24 and could be repaired in 22.
Twenty-two patients underwent a bony procedure to
reorient the glenoid surface. The average correction of
the superior tilt was 7 . The external rotators are released
from the bone and reattached, which might result in
weakening of external rotation. This possible
complication could not be confirmed at follow-up. The
osteotomy healed in all but 1 patient. The fixation
material had to be removed in 13. (J Shoulder
Elbow Surg 2008;17:431-435.)
I n shoulder arthroplasty, a long deltopectoral ap-
proach sometimes does not give sufficient exposure
for preparation and bone grafting of the glenoid sur-
face, especially the posterior rim or repair of a large
degenerative cuff tear. An alternative to the deltopec-
toral approach was sought. The superior approach,
with an osteotomy of the acromion 1 cm medial to
the posterior edge of the acromion, was developed
on cadaver dissections and gave a wide exposure of
the rotator cuff and the glenoid.5 I used this in a small
series of patients, but repair of the acromion was
technically difficult and not always stable enough for
From the Department of Orthopaedics, Leiden University Medical
Center.
Reprint requests: PM Rozing, MD, PhD, Leiden University Medical
Center, Department of Orthopaedics, PO Box 9600, 2300 RC
Leiden, The Netherlands (E-mail: P.M.Rozing@lumc.nl).
Copyright ª 2008 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2008/$34.00
doi:10.1016/j.jse.2007.10.001
immediate postoperative active motion.10 The osteot-
omy of the acromion was reduced in size, and the sur-
gical approach was made less extensive. A special
plate was used for secure and easy fixation of the acro-
mial osteotomy at the end of the operation (Biomet,
Dordrecht, Netherlands).This surgical approach has
been used since 1994 in a series of shoulder replace-
ments. This report presents the surgical technique and
its complications.
MATERIALS AND METHODS
Operative technique
The patient is placed in the lateral decubitus position with
the involved shoulder upward. The entire upper extremity
and shoulder are prepared and draped. A straight saber
cut or a Z-shaped skin incision is made along the lateral
rim of the acromion, curving over the scapular spine down-
ward at the posterior side of the shoulder. The acromion and
deltoid muscle are exposed. The special acromion plate is
positioned at the lateral rim of the acromion with the flange
of the plate situated over the scapular spine. The plate is ad-
justed to the contour of the acromion, Kirschner (K) wires are
inserted, and screw holes are drilled with a cannulated drill
and tapped (Figure 1).
The deltoid muscle is split from the scapular spine distally
in line with its muscle fibers for a distance of 5 cm, starting
approximately 2 cm medial to the posterior corner of the
acromion. Sometimes, extra exposure is needed and can
be achieved by detaching the deltoid muscle medially and
subperiosteally for 1 or 2 cm from the scapular spine. At clo-
sure, it is reattached by transosseous sutures. Anteriorly, the
anterior and middle parts of the deltoid are split at the
anterolateral corner of the acromion for a distance of 2 cm.
After marking the osteotomy line, the plate and K wires
are removed, and an acromial osteotomy is performed. A tri-
angular piece of bone, including the lateral rim of the poste-
rior three-quarters of the acromion and the posterior corner
of the acromion, is turned down with the attached deltoid
muscle, exposing the rotator cuff. The maximum width of
the osteotomy of the lateral part of the acromion is approxi-
mately 2 cm at the posterior corner. In performing the
osteotomy, one tries to avoid the anterior part of the
acromion so the coracoacromial arch is not disturbed.
Medially, at the suprascapular notch close to the base of
the acromion, the interval between the muscle bellies of the
infraspinatus and supraspinatus muscles can be easily iden-
tified by palpation, and this interval is opened through the
capsule into the joint. If the incision extends too far medially
beyond the glenoid rim, the suprascapular nerve can be
endangered. The infraspinatus and part of the teres minor
muscle are detached sharply from the greater tuberosity.
431
432 Rozing
Figure 1 Positioning of the acromion plate before the osteotomy is
performed.
An alternative is to remove the tendon insertions with a small
piece of bone to facilitate and improve fixation of the tendon
at the end of the operation. The tendons of the infraspinatus
and teres minor with capsule are turned down as 1 unit, and
a retractor is placed underneath the humeral head. In addi-
tion, a humeral retractor is placed over the superior part of
the humeral head underneath the supraspinatus tendon. If
there is excessive tension in the supraspinatus tendon, its
insertion might be released from the bone for a distance of
just a few millimeters.
During the surgery, the surgeon needs to be aware of the
proximity of the axillary nerve in the quadrilateral space and
the suprascapular nerve at the suprascapular notch.11 At the
end of the surgery, the infraspinatus and teres minor tendon
are reinserted on the greater tuberosity with sutures through
the flange of the prosthesis and the bone. If a supraspinatus
tear is present, it might be transposed over the humeral head
and fixed at the superior facet of the greater tuberosity.
Closure of the acromial osteotomy is performed by rein-
serting the small K wires into the predrilled holes. The acro-
mial plate is positioned, and 2 cannulated 2.7-mm screws
are inserted. Finally, the plate is fixed with 2 or 3 small
2.7-mm cortical screws into the scapular spine (Figure 2).
The fixation is stable enough for immediate postoperative
mobilization,6 but one has to be cautious with the reattached
external rotators. For that reason, the shoulder is immobi-
lized in an abduction brace for 6 weeks. Passive shoulder
mobilization is started the first postoperative day along
with assisted exercises.
Patients
Between May 1994 and January 2001, the posterosupe-
rior approach was used to insert 79 shoulder prostheses,
including 8 glenoid revisions. There were 19 men and 60
women, with an average age of 60 years (range, 25-85
years). The mean duration of follow-up was 68 months
(range, 25-117 months). The right shoulder was involved
in 42 patients and the left in 37. The diagnosis was osteoar-
thritis in 18 shoulders, cuff tear arthropathy in 6, rheumatoid
arthritis in 54, and osteonecrosis in 1.
All patients were scored clinically and radiographically
before the operation, at 1 and 2 years postoperatively,
J Shoulder Elbow Surg
May/June 2008
Figure 2 Fixation of the acromion plate is accomplished with 2 can-
nulated lag screws and 3 cortical screws.
and after that at irregular intervals. The Hospital for Special
Surgery (HSS 100 Points,) scoring system and the Constant
score were used for clinical evaluation. The strength of
abduction was measured with a handheld dynamometer
(Microfet 2, Hoggan Health Industries Inc, Draper, UT,
USA). Manual muscle testing using the 0 to 5 grading of
power was used for measuring the strength of abduction
and external rotation. The function of the external rotators
was measured in active external rotation in 90 elevation
or in maximal elevation if it was less than 90 .
For statistical analysis, the paired and unpaired t test was
used to compare the variables of abduction, rotation, and
strength preoperatively and at follow-up. For comparison
of the categoric data of the manual muscle testing, a c2
test was used. Analysis was done with SPSS 12.0.1 software
(SPSS Inc, Chicago, IL). The statistical significance was
defined as P < .05.
RESULTS
A total shoulder prosthesis was inserted in 50 pa-
tients, a hemiarthroplasty in 22, a bipolar prosthesis
in 1, and a reverse prosthesis in 6. Of the 72 shoulders
with a total shoulder prosthesis or hemiarthroplasty,
the rotator cuff was intact in 48 and severely attenu-
ated or ruptured in 24. The rotator cuff in these shoul-
ders was reconstructed at the time of surgery by
transposition of the infraspinatus and part of the teres
minor. The repair was considered good (complete
closure) in 13 shoulders, reasonable (some tension
on the suture line or a small defect) in 9, and poor in 2.
The function of the external rotators was studied by
measuring the external rotation angle and the strength
of abduction and external rotation. The external rota-
tion angle in 0 abduction improved significantly
from 7 6 18.6 preoperatively to 18 6 15.1 post-
operatively (P < 0.001). The external rotation in 90
elevation improved from 17 6 25.5 preoperatively
to 36 6 27.7 postoperatively (P ¼ .002). There was
no statistical difference between patients with an intact
cuff preoperatively and those with an attenuated cuff
J Shoulder Elbow Surg Rozing 433
Volume 17, Number 3

(38 6 29 vs 32 6 28 ). The strength of abduction

for patients with an intact cuff, measured with a hand-
held dynamometer, increased only slightly from 47 6
21.6. N preoperatively to 56 6 18.1 N at follow-up (P
¼ .037), and for those with an attenuated cuff, to 49 6
12.5 N. Detachment of the external rotators, with or
without a bone block, caused no statistical difference
in the power of abduction at follow-up. With manual
muscle testing, the grading of power of abduction in-
creased significantly in the group with an intact cuff
as well as in the group with an attenuated cuff (P <
.000). The power of external rotation showed also
a significant increase at follow-up for patients with
an intact cuff (P ¼ .022) and with an attenuated cuff
(P ¼ .014).
Of the 72 patients with a total or hemiprosthesis,
the orientation of the glenoid, especially the inclina-
tion, was corrected in 22 shoulders by reorienting
the glenoid surface by removing the inferior part of
the glenoid. The superior tilt, measured as the angle
between a line parallel to the glenoid surface or gle-
noid component and a line through the scapular spine
on a true anteroposterior radiograph, changed in this
group from 72 6 10 preoperatively to 79 6 7
postoperatively (P ¼ .013).
The osteotomy of the acromion healed uneventfully
within 6 weeks after surgery in all but 1 patient. In this
patient, a screw hole in the flange of the plate was at
the osteotomy site, so no screw was inserted. A few
weeks later, the plate broke at the screw hole, and it
became an asymptomatic nonunion of the acromial
osteotomy. This patient was a 78-year-old woman
with a reverse prosthesis for a cuff tear arthropathy.
At the 2-year follow-up, she had only mild pain, flexion
of 100 , and abduction of 70 , and revision was not
considered. In another patient, only 1 screw was
used to fix the flange of the plate to the scapular spine.
On the radiograph taken 6 weeks after surgery, this
screw had loosened and the flange of the plate was
elevated from the scapular spine. At exploration, the
osteotomy was healed and no additional fixation
was necessary. In 2 patients, the fixation of the acro-
mial osteotomy at the end of surgery was considered
unstable because the acromion had fractured at the
side of the predrilled screw hole during the procedure.
The postoperative active mobilization was reduced,
and the osteotomy healed uneventfully.
Some patients had discomfort on top of the shoul-
der, provoked by their clothes or lying on the shoulder.
On examination, the discomfort was at the palpable,
subcutaneous position of the screw head and the
edge of the plate at the posterior corner of the acro-
mion. Because of this, the plate was removed in
13 patients (Figure 3). One complication was related
to weakness of the posterior deltoid because of a trac-
tion injury to the axillary nerve. This neurapraxia was
confirmed with electromyelography and recovered.
Figure 3 Loosening of the screw after healing of the osteotomy.
Detachment of the reattached external rotators did
not occur based on clinical examination.
DISCUSSION
In shoulder arthroplasty, the deltopectoral or
extended deltopectoral approaches are sometimes in-
sufficient to deal with all the pathology to be treated.
Because of this, Redfern et al9 proposed an enlarged
deltopectoral approach. They performed an osteot-
omy of the clavicle to detach the anterior part of the
deltoid muscle and released the coracoacromial liga-
ment. MacKenzie7 reported the use of Neviaser’s an-
terosuperior approach for total shoulder replacement
to provide optimum visualization of the glenoid sur-
face. A similar technique as described in this article
was published by Baulot et al3 for insertion of a reverse
prosthesis, but the osteotomy involves the whole lat-
eral rim of the acromion and violates the coracoacro-
mial arch anteriorly. A more posterior approach, as
used in this study, avoids any damage to the coracoa-
cromial arch and preserves the anterosuperior fibrous
complex of the cuff,2 which stabilizes the humeral
head and may prevent anterosuperior migration of
the head, as seen in the rheumatoid shoulder.
With the posterior approach, an internal rotation
contracture can still be corrected by a soft tissue re-
lease, especially a subperiosteal release of the subsca-
pularis muscle can easily be performed at the time of
surgery to improve external rotation. By not sectioning
the subscapularis tendon, abduction and external
rotation exercises can be started immediately in the
postoperative period. In patients with thinning or tear-
ing of the supraspinatus tendon, the capsulotendinous
flap of the infraspinatus and teres minor can be
434 Rozing
Figure 4 Radiographs shows a (A) dislocated glenoid fracture and (B) a shoulder after surgical reconstruction.
transposed superiorly to close the defect and improve
stabilization of the humeral head.10
The osteotomy of the acromion and fixation of the
fragment with the described plate is not performed
in patients in whom the acromion is very thin and
eroded by direct contact with the humeral head. A
posterosuperior approach can still be used in those
cases, but the osteotomy line is just 5 mm from the
free edge of the acromion. After surgery, the deltoid,
with a small piece of bone, is sutured back to the acro-
mion.4 An alternative to the posterosuperior approach
is the posterolateral2 or superolateral approach,1
which I use in cases where a wide exposure of the an-
terosuperior part of the cuff is less important or bony
reconstruction of the glenoid is less extensive. In shoul-
ders in which a good view on the glenoid is manda-
tory, the described posterosuperior approach, with
an osteotomy of the lateral rim and posterior corner
of the acromion, gives a wide exposure of the rotator
cuff and the glenoid and bony reconstruction of the
glenoid can easily be performed. It is also useful in
converting a painful hemiarthroplasty to a total, espe-
cially when a monobloc humeral component was
used. The posterior approach, as described by Nor-
wood et al8 and Wirth et al,12 is less suited for shoul-
der arthroplasty.
The described posterosuperior approach is not for
routine total shoulder arthroplasty, because the
surgery is more extensive than with the deltopectoral
approach. The main indication is total shoulder arthro-
J Shoulder Elbow Surg
May/June 2008
plasty combined with procedures in which good
exposure and unlimited access to the glenoid is man-
datory, such as bone grafting of the glenoid, revision
of a glenoid component, insertion of a glenoid compo-
nent in a painful hemiarthroplasty, or a cuff repair at
the time of arthroplasty with or without an additional
transfer of the teres major or latissimus dorsi, or
both. During the last few years, this approach has
also been used for other diagnoses. It is an excellent
surgical approach for reconstruction of a large, post-
traumatic, avulsion tear of the rotator cuff involving
the superior part of the subscapularis, the supraspina-
tus, and the infraspinatus in young patients. With this
approach, one has a good view of the whole rotator
cuff, and repair can easily be performed. Another
indication is anatomic reduction and fixation of
displaced glenoid fractures (Figure 4).
A drawback of this approach is the potential weak-
ening of the external rotators of the shoulder due to the
transecting of the tendons of the 2 important external
rotator muscles. Although this could not be substanti-
ated in this study, it may be that the improvement in
strength after surgery is less than that with a deltopec-
toral approach. This was not studied and is not
reported here.
In conclusion, the posterosuperior approach gives
wide exposure of the rotator cuff and glenoid. This
approach is indicated in total shoulder arthroplasty
with bony reconstruction of the glenoid or repair of
a ruptured cuff. It is also the preferred approach for
J Shoulder Elbow Surg
Volume 17, Number 3
massive, posttraumatic cuff tears in younger patients
and reduction and internal fixation of displaced, intra-
articular glenoid fractures. Fixation of the osteotomy
with a small plate provides stability for immediate
active postoperative mobilization.
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