Extended Neviaser-MacKenzie Anterosuperior Approach for Proximal Humeral Fractures
Authors: M Webb, L Funk, A Marshall
References: SICOT, 2005
The deltopectoral approach is the standard approach for operative management of fractures of the proximal humerus. Mackenzie described an anterosuperior approach to the shoulder to optimise insertion of the components for a total shoulder replacement, which he attributed to Neviaser. This approach has recently been popularised for the Copeland resurfacing and Delta reverse-geometry prostheses. Using a modification of this approach we describe it`s use in a group of patients requiring either internal fixation or hemiarthroplasty for proximal humeral fracture and the effect of this approach on the postoperative function on the axillary nerve and deltoid muscle
METHODS: A longitudinal incision starting posterior to the anterior tip of the acromion running distally down the deltoid is made. The raphe between the anterior middle deltoid is split in the line of the fibres distally. The axillary neve is identified and protected. For hemiarthroplasty, the incision can be extended proximally and an anterior acomioplasty performed. No deep closure is required, unless part of the acromioplasty.
Using this approach, we have performed 25 internal fixations of the proximal humerus and 19 stemmed arthroplasties for humeral head fractures.
At an average of 3 months postoperatively, all patients underwent specific axillary nerve and deltoid function assessment using both clinical examination and conduction studies involving seperate needle EMG assesment of the anterior, middle and posterior deltoid bundles.
RESULTS: There have been no cases of partial or complete axillary nerve palsy, clinically and on deltoid EMG studies.There were no cases of superficial or deep infection and no scars have been revised.
CONCLUSION: The extended Nevasier-Mackenzie approach provides a more direct approach to the fracture, particularly the greater tuberosity fragment, humeral head and rotator cuff than the deltopectoral approach. The lateral cortex is better exposed for application of a lateral plate. Other than the axillary nerve other surrounding neurovascular structures are at less risk than a deltopectoral approach. Despite this risk, our study including deltoid EMG`s have shown that this approach can be performed without injury to the axillary nerve.