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Home , Acromioplasty, Deltoid muscle, Deltoid tuberosity, Hand, Rotator cuff

Loss of the deltoid after operations: An operative disaster

Gordon I. Groh, MD, Michael Simoni, MD, Paolo Rolla, MD, and Charles A Rockwood, MD, Denver, Colo., Rio de Janeiro, Brazil, Varese, Italy, and San Antonio, Texas

A series of 36 patients who hod a postoperative loss of the anterior or anterior lateral after shoulder operations (i.e., acromioplasties, anterior shoulder reconstructions, or procedures) was referred to the senior author. Three patients lost the function of their deltoid after an injury to the axillary , and 33 patients lost deltoid function after loss of the origin of the deltoid from the and . All patients were significantly disabled. All patients were dissatisfied with the result of the previous operation, and eight patients experienced painful anterior or anterior/superior dislocation of the glenohumeral . Treatment was nonspecific and supportive. The authors conclude that loss of anterior deltoid function secondary to denervation or detachment results in irrevocable and impairment of function. Careful attention to the surgical technique of deltoid reattachment and protection of the are essential to the prevention of dire consequences to shoulder function. (J SHOULDER ELBOWSURG 1994;3:243-53)

The deltoid, especially the anterior deltoid, is iatrogenic injury to the deltoid during shoulder a most important, unique, and irreplaceable operations, motor vehicle plexus injuries, and muscle of the shoulder. In the normal shoulder gunshot wounds." These iatrogenic injuries will the deltoid provides 50% of the power for el• serve as the focus of this report. evation of the in the scapular plene." 20 However, patients with massive de• MATERIAL AND METHODS fects can exhibit full overhead elevation of the Thirty-six patients with deltoid deficiencies glenohumeral joint, especially after a rehabil• were referred to the senior author (CAR.) for itation program.* Injury to the deltoid is poorly evaluation after having undergone a previous tolerated; even injury confined to the anterior operative shoulder procedure. The average deltoid alone may preclude any overhead ac• age of the patients was 55 years (range 25 to tivity·t 77 years). Fourteen women and 22 men were With the introduction of vaccine, poliomyelitis studied. Twenty-three patients presented with as a cause of deltoid loss is rarely seen. Deltoid right shoulder complaints, and 13 patients pre• loss is now most commonly seen as a result of sented with left shoulder complaints (Table I). The patients had undergone an average of 2.1 operative procedures (range one to four) *References 6, 9, 21,25, 26, 29, 34, 40-42. before the referral. Fourteen patients had un• tReferences 2, 3, 5, 10·13,21,30,32,34. dergone one previous procedure, nine patients had undergone two, seven patients had under• From the Shoulder Service, Department of Orthopaedic Sur• gone three, andsix patients had undergone four gery, University 01 Texas Health Science Center, San An• tonio. previous surgical procedures. Previous opera• Reprint requests: Gordon I. Groh, MD, Department of Or• tive procedures are listed in Table II. The last thopaedic Surgery, University of Colorodo Health Science operative procedure had been performed for Center,4701 E. 9th Ave., Campus Box E203, Denver, CO the group an average of 28 months before 80262. being evaluated (range 3 to 162 months). Copyright © 1994 by Journal of Shoulder and Surgery Boord of Trustees. . The location of the previous incision was de• 1058-2746/94/$3.00 + 0 32/1154382 termined for all patients. Twenty patients had

243 244 Groh et a I. J. Shoulder Elbow Surg. July/August 1994

Table I Patient data

Previous Incision Extent of deltoid Patient Age (yr), sex operation type spilt/detachment Deltoid repair

1 64, F Hemiarthroplasty Deltopectoral Anterior detachment Deltotrapezial 2 41, F Bristow Axillary Anterior detachment Deltotrapezial fascia 3 75, F Revision total Deltopectoral Anterior detachment Deltotrapezial shoulder fascia 4 77, F Total shoulder Deltopectoral None None

5 56, M Hemiarthroplasty Deltopectoral None None

6 55, M Inferior acromioplasty Deltoid Split of 3 cm Deltotrapezial splitting fascia 7 76, M Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial splitting fascia

8 41,M Inferior acromioplasty Deltoid Deltoid split 5 cm Deltotrapezial and RTC repair splitting fascia 9 64, F Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial ond RTC repair splitting fascia 10 64, M Inferior acromioplasty Deltoid Deltoid split 5 cm Deltotrapezial and RTC repair splitting fascia 11 34, M Inferior acromioplasty Deltoid Deltoid split 3 cm Deltotrapezial and distal clavicle splitting fascia excision 12 68, M Inferior acromioplasty Deltoid Deltoid split 3 cm Deltotrapezial and RTC repair splitting fascia 13 45, M Inferior acromioplasty Deltoid Deltoid split 2 cm Deltotrapezial and splitting fascia tenodesis 14 71, F Inferior acromioplasty Deltoid Deltoid split 5 cm Deltotrapezial and RTC repair splitting fascia 15 40, M Revision total Deltopectoral None None shoulder 16 32, F Revision total Deltopectoral Detachment of ante• Deltotrapezial shoulder rior deltoid fascia 17 64, M Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial and RTC repair splitting fascia 18 63, M Inferior acromioplasty Deltoid Deltoid split 3 cm Deltotrapezial and RTC repair splitting fascia 19 77, F Hemiarthroplasty Deltopectoral Detachment of ante• Deltotrapezial rior deltoid fascia 20 77, M Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial and RTC repair splitting fascia 21 25, M Magnuson-Stack Axillary Detachment of ante• Deltotrapezial rior deltoid fascia 22 60, M Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial and RTC repair splitting fascia 23 71, M Inferior acromioplasty Deltoid Deltoid split 3 cm Deltotrapezial and RTC repair splitting fascia 24 68, F Total shoulder Deltopectoral Detachment of ante• Deltotrapezial rior deltoid fascia

M, Male; F, female; RTC, rotator cuff. 'Degrees of forward elevation, external rotation, and internal rotation to the spinous process. fFunctional result; see text and Table III. 1. Shoulder Elbow Surg. Groh et 01. 245 Volume 3, Number 4

Table I Cont'd - Cause of Coexisting Location of dehold shoulder Range of Adlvltles of deltoid loss loss problems motion- Pain dally IIvlngt

- Anter ior Failure of None 20/S0/ Ll Yes Poor repa ir Anterior Failure of Multidirectional 140/0/TS Yes Good repa ir instabi lity Anterior Failure of None 30/15/l5 Yes Poor repa ir Anterior, lat- Denervatian None 0/30/lateral No Poor eral, and posterior Anterior, lat- Denervation None 0/45/1ateral Yes Poor eral, and hip posterior Anterior Failure of Rotator cuff in- 35/15/l4 Yes Poor repa ir sufficiency Anterior, lat- Denervotion Rotator cuff in- 0/10/l5 Yes Poor eral, and sufficiency posterior Anterior and Failure of None 60/20//Ll Yes Poor lateral repa ir Anterior Failure of Rotator cuff in- 30/30/TS No Poor repa ir sufficiency Anterior Failure af Rotator cuff in- 15/15/l5 No Poor repa ir suffic iency lateral Fail ure of None 140/40/T7 No Good repoir

Anterior, lateral Failure of None 40/15/T12 No Poor repa ir Anterior Failure of Rotator cuff in- 30/75/T12 Yes Poor repa ir sufficiency

Anterior Failure of None 70/S0/Sa- Yes Fair repair crum Anterior Failure of None 75/25/Ll Yes Poor repair Anterior and Failure of None 15/60/T10 Yes Poor lateral repair Anterior Failure of Rotator cuff in- 15/45/laterol Yes Poor repa ir sufficiency hip Anterior Failure of Rotator cuff in- 65/25/loterol Yes Fair repa ir sufficiency hip Anterior Failure of None 75/15/loterol Yes Fair repa ir hip Anterior and Failure of Rotator cuff in- 10/25/Tl2 Yes Poor loterol repa ir suffic iency Anterior Failure of None 155/30/Ll No Good repa ir Anterior and Failure af None 20125/Ll Yes Poor lateral repair Anterior and Failure of None 10/0/l5 No Paor lateral repa ir Anter ior Failure of None 45/45/Ll Yes Poor repa ir

Cont'd 246 Groh et 01. J. Shoulder Elbow Surg. July/August 1994

Table I Patient data (Cont'd)

Previous Incision Extent of deltoid Patient Age (yr), sex operation type splitI detachment Deltoid repair

25 48, M Total shoulder Deltopectoral Detachment of ante- Deltotrapezial rior deltoid fascia 26 35, M Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial and RTC repair splitting fascia 27 73, F Hemiarthoplasty Deltopectoral Detachment of ante- Deltotrapezial rior deltoid fascia 28 66, F Hemiarthroplasty Deltopectoral Detachment of ante- Deltotrapezial rior delto id fascia 29 52,M Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial and RTC repair splitting fascia 30 31,M Open reduction and Deltopectoral Detachment of ante- Deltotrapezial rior deltoid fascia 31 61, M Total shoulder Deltopectoral Detachment of ante- Deltotrapezial rior deltoid fascia 32 25,M Inferior acromioplasty Deltoid Deltoid split 5 cm Deltotrapezial and biceps splitting fascia tenodesis 33 56, M Inferior acromioplasty Deltoid Deltoid split 3 cm Deltotrapezial and RTC repair splitting fascia 34 50, F Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial and RTC repair splitting fascia 35 69, F Inferior acromioplasty Deltoid Deltoid split 4 cm Deltotrapezial and RTC repair splitting fascia 36 26, M Bristow Axillary Detachment of ante- Deltotrapezial rior deltoid fascia

Table II Previous operative procedures The location of the deltoid loss was distrib• uted as follows: 25 patients had loss of the an• Type of procedure Total = 36 terior deltoid, seven patients had loss of the an• AcromioplastyI cuff repair 15 terior and lateral deltoid, three patients had loss Hemiarthroplasty 5 of the anterior, lateral, and posterior deltoid, Acromioplasty 2 and one patient had loss of the lateral deltoid. Total shoulder arthroplasty 4 Revision of total shoulder 3 The etiology of the deltoid loss was determined arthroplasty to be detachment of the deltoid in 33 patients. Internal fixation of prox imal Three patients suffered complete denervation of fracture the deltoid. Of the three patients who had de• Bristow procedure 2 nervation of the deltoid, one patient had under• Magnuson-Stack procedure 1 Acromioplasty and biceps 2 gone a hemiarthroplasty and another a total tenodesis shoulder arthroplasty, both through a deltopec• Acromioplasty and distal clav• toral incision. The remaining patient suffered icle excision denervation of the deltoid through a deltoid• splitting incision for acromioplasty (Table I). The remaining 32 patients had detachment of the an approach through an anterosuperior inci• deltoid after undergoing the procedures sion (deltoid-splitting) along the lateral border through the incisions listed in Table I. of the acromion. In 13 patients the incision was In addition to loss of the deltoid, 15 (42%) a long deltopectoral approach. Three patients patients had coexisting shoulder problems that had an anterior axillary incision. In 20 patients were believed to be symptomatic. Twelve pa• a distal split of the deltoid was performed tients demonstrated continued signs of an in• (Table I). In 13 patients a portion of the deltoid sufficient and degenerative rotator cuff, two pa• was released during the initial operative pro• tients had multidirectional instability of their cedure. In three patients there was neither split• shoulder, and one patient had continued an• ting nor release of any of the deltoid fibers. terior instability after an initial traumatic event. 1. Shoulder Elbow Surg. Groh et al. 247 Volume 3, Number 4

Table I Cont'd Cause of Coexisting Location of deltoid shoulder Range of Activities of deltoid loss loss problems motion· Pain dally IIvlngt

Anterior Failure of None 75/25/T11 No Fair repair Anterior Failure of Instobility 60/5/L4 Yes Poor repair Anterior Failure of None 10/25/L5 Yes Poor repair Anterior Failure of None 60/30/Ll No Fair repair Anterior and Failure of Rotator cuff in- 35/50/TlO Yes Poor lateral repair sufficiency Anterior Failure of None aO/0/L5 Yes Fair repair Anterior Failure of None 35/35/L5 Yes Poor repair Anterior Failure of None 125/35/Tl2 No Good repair

Anterior Failure of Rotator cuff in- 25/5/Lateral Yes Poor repair sufficiency hip Anterior Failure of Rotator cuff in- 30/0/Lateral No Poor repair sufficiency hip Anterior Failure of Rotator cuff in- 30/65/Lateral No Poor repair sufficiency hip Anterior Failure of Multidirectional 170/40/T12 No Good repair instability

Function of the involved shoulder was deter• Table III Activities of daily living mined for various activities of daily living. All 1. Button blouse or shirt patients were questioned as to their ability to 2. Put arm into coat sleeve perform 15 tasks (Table III). A score of 15 was 3. Place behind head considered excellent, 13 to 14 was good, 10 to 4. Drink from glass or mug 12 was rated as fair, and below nine as poor. 5. Lift 10 pounds to shoulder height 6. Lift 10 pounds above shoulder height RESULTS 7. Comb and brush a. Brush teeth Range of motion was measured for all pa• 9. Apply deodorant to opposite side tients. Forward elevation averaged 52° (range 10. Carry a 10-pound suitcase 0° to 170°, Figure 1). External rotation measured 11. Carry a 25-pound suitcase 30° (range - 10° to 80°), and mean internal ro• 12. Carry a 50-pound suitcase tation was to the spinous process of the fourth 13. Throw underhand 10 yards 14. Throw overhand 30 yards lumbar vertebrae (range lateral hip to spinous 15. Throw overhand greater than 30 yards process of the seventh thoracic vertebrae). Eight patients had anterior subluxation of the gleno• humeral joint with forward elevation (Figure 2). Twenty-two (60%) of the 36 patients had con• Function for the 36 patients was determined tinued pain in the affected shoulder. Of the 21 by their ability to accomplish 15 tasks of daily patients with no coexisting shoulder problems, living. No patient scored an excellent result. In 13 had pain, whereas seven reported no pain. five patients the result was rated as good, in six Seven of the patients with rotator cuff defects patients the result was rated as fair, and in 25 had pain, whereas five reported no pain. One patients the result was rated as poor. The dis• patient with multidirectional instability com• tribution of functional results with regard to co• plained of pain at the last examination, whereas existing problems revealed that the result of one did not. The only patient with ongoing an• three of the 21 patients with no coexisting shoul• terior instability complained of pain. der problems was rated as good, the result of 248 Groh at 01. J. Shoulder Elbow Surg. July/August 1994

Figure 1 Patient with detachment of right anterior deltoid after acro• mioplasty and rotator cuff repa ir. A, Maximal forward elevat ion. B, Lo• cation of incision.

DISCUSSION five as fair, and the result of 13 as poor. Of the The deltoid arises from the anterior and su• 12 patients with symptomatic degenerative ro• perior surface of the lateral third of the clavicle, tator cuff defects, 11 patients hod a poor result, from the lateral margin and adjoining upper whereas only one result was rated as fair. The surface of the acromion, and from the crest of results of two patients with multidirectional in• the spine of the . The deltoid is multi• stability were rated as good. pennate; the middle port of the muscle rece ives The distribution of functional results with re• four or five that descend from the ac• gard to corresponding loss of the deltoid re• romion. The clavicular and scapular ports of the vealed one good result in the patient with on muscle converge to be inserted, together with isolated lateral deltoid loss. All three patients the acromial port, into the of with loss of the anterior, lateral, and posterior the humerus. IS The deltoid is innervated by the deltoid were rated as poor. Similarly, all seven axillary nerve. The axillary nerve arises from of the patients with loss of the anterior and lat• the fifth and sixth cervical and is formed eral deltoid were rated as poor. Of the 25 pa• from the terminal branch of the tients with loss of the anterior deltoid alone, the of the . It crosses from medial to results of four patients were rated as good, six lateral along the anterior surface of the sub• as fa ir, and 15 as poor. The overage age of the scapularis muscle. At the inferior border of the patients with a rating of good was 30 years, as subscapularis the nerve travels posteriorly un• compared with the remainder of the group who der the inferior capsule of the glenohumeral hod on average age of 60 years (p < 0.01) . joint. In many instances the axillary nerve gives Only three (8.4%) patients of the 36 thought the off two branches that supply the inferior aspect function of the shoulder was satisfactory. All of the capsule of the . At this point patients (100%) were dissatisfied with the result the axillary nerve joins with the posterior hu• of the previous surgery. meral circumflex , and together they exit J. Shoulder Elbow Surg. Groh et 01. 249 Volume 3, Number 4

Figure 2 Axillary lateral radiographs. A, Patient with anterior detachment of deltoid and anterior subluxation with forward elevation after total shoul• der arthroplasty. B, Patient with anterior detachment 01 deltoid and anterior subluxation with forward elevation after hemiarthroplasty.

Figure 3 Appearance of shoulder alter denervation of entire deltoid. Hemiarthroplasty was performed through extended anterior deltopectoral approach. through the , where the ax• plies the lateral deltoid and then the anterior illary nerve splits into two majortrunks. The pos • deltoid." 10.24 terior trunk gives off branches to the teres minor Most anterior surgical approaches to the and posterior deltoid and terminates as the su• shoulder are performed either through a limited perior lateral cutaneous nerve of the arm. The deltoid muscle split or through the deltopectoral anterior trunk passes anteriorly around the hu• interval.* The relationship of the axillary nerve merus and lies approximately 5 em distal to the to these approaches has been described by pre- lateral border of the acromion. The nerve lies on the deep surface of the deltoid and sup- "References 1,5, 14,21,25,27-29,31,38. 250 Groh et 01. J. Shoulder Elbow Surg. July/August 7994

Figure 5 Deltoid is repaired to and into del• totrapezial fascia, with heavy nonabsorbable, number 2 suture to ensure a reliable reattachment.

deltoid loss in three patients (Figure 3). The function of all three patients was rated as poor. The operative approach in two of these patients was deltopectoral and in the third was deltoid• 27 29 splitting. • Burkhead et 01.10 have described in Figure 4 Patient with loss of anterior deltoid after detail the tremendous variation, from specimen surgical approach with anterior approach of Henry. to specimen, in the course and position of the Maximum active forward elevation. axillary nerve. They report that previously de• scribed "safe zones" for all are sig• vious authors.* Protection of the axillary nerve nificantly smaller than previously described. For during a deltoid-splitting approach has gen• this reason the authors advocate locating the erally consisted of limiting the incision to "no axillary nerve during arthroplasty and recon• JO 27 more than 5 em" below the acromion. • Sim• structive procedures. The volar surface of the ilarly, the admonishment for protection of the index is slid along the anterior surface of axillary nerve during anterior shoulder ap• the and then rotated an• proaches has been to place the arm in adduc• teriorly to hook the axillary nerve." In cases of tion and external rotation, to place the nerve dense scarring and adhesions, a periosteal el• farther from the operative field." 31 evator may be used along the anterior surface Iniury to the axillary nerve. Laceration of the subscapularis to identify the axillary of the axillary nerve deinnervates the deltoid nerve. A retractor may then be positioned to muscle and in this report was responsible for protect the nerve during capsular releose." Because shoulder function requires elevation in the scapular plane, injury to the axillary nerve "References 1,7,8,10,21,25,27,29,38. is a catastrophic injury. In 1935 Hoes" cdvo- J. Shoulder Elbow Surg. Groh et al. 251 Volume 3, Number 4 cated transfer of the extended by a In reviewing the results of previous series of fascial graft for deltoid muscle paralysis. The rotator cuff procedures," 29. 30 . ~ . 42 it becomes procedure is accompanied by a long period of clear that a consistent subset of patients in these protection in an abduction brace and muscle reports is reported as having poor results. training for more than 1 year. It was compli• Closer scrutiny of the data reveals that an equal cated by partial or complete failure of the tra• number of patients is usually reported in the pezial transfer in a significant number of cases. complications section of the reports as having Harmon17 described anterior transplantation of detachment of the deltoid origin. Other the posterior deltoid in these cases, and ltoh" outhorsv 13. 32 have reported poor results in pa• advocated transfer of the latissimus dorsi as an tients undergoing revision rotator cuff surgery inverted pedicle graft. Although many other who have also had a detached or retracted del• procedures have also been devised for treat• toid. Indeed, in the senior author's" report of ment of this injury,* the results have been un• acromioplasty and rotator cuff debridement for predictoble.": 29. 30 Further, the transfers de• massive, irreparable rotator cuff defects, three scribed to treat this condition have typically patients were reported as having a poor result. functioned as a tenodesis, have stretched with All three patients had had previous surgery, and time, or do not have an effective range of motor all were noted, before surgery, to have lost the fiber controctobility.' orig in of their anterior deltoid. Loss of origin of the deltoid. More com• Surgical treatment of deltoid avulsion has sel• mon and problematic has been loss of deltoid dom been successful. Neer30 described 30 pa• as a result of detachment from the acromion tients who had previously had removal of 80% and clavicle after shoulder procedures. The of the acromion with resultant adhesions of the three parts of the deltoid muscle, anterior, lat• deltoid to the rotator cuff, deltoid contracture, eral, and posterior, must be considered sepa• and loss of the acromial fulcrum. Surgical cor• rately, so far as actions are concerned. The lat• rection in 20 yielded generally poor outcomes. eral deltoid is a powerful abductor of the arm, It is therefore imperative that surgical recon• but its line of pull is such that when acting alone struction does not jeopardize the deltoid. it abducts the arm in the plane of the scapula. The posterior part of the deltoid extends the arm The operative procedures for treating disease and rotates it laterally. Weakness of the pos• of the rotator cuff and acromion are similar in terior deltoid is less problematic, because the placing the deltoid origin at risk. In the ap• latissimus dorsi is a strong synergistic mus• proach to the shoulder as described by Neer/7 c1e. 12 The anterior deltoid flexes the arm and he recommends placing a suture at the inferior rotates it medially. No other effective muscle aspect of the deltoid split to prevent continued compensates for loss of this powerful shoulder splitting and potential injury to the axillary Hexor.'? nerve . Furthermore, Neer recommends that the Twenty-two of the 33 patients who suffered deltoid be repaired to the deltotrapezial fascia loss of the deltoid secondary to detachment of at the conclusion of the procedure. We are con• the anterior or anterior and lateral deltoid had cerned that repair of the heavy deltoid muscle shoulder function rated as poor. Only five pa • only to the deltotrapezius fascia is insufficient tients in this group obtained a shoulder function and may be responsible for detachment of the rating of good, and these patients were consid• anterior deltoid and subsequent shoulder erably younger than the remainder of the pa• weakness. We believe that it is important to se• tients studied. These five patients were further curely repair the deltoid back to bone with differentiated by possessing no coexisting heavy number 2 nonabsorbable suture at the shoulder problems in three, and multidirec• conclusion of the procedure (Figure 5).9.35.36,37 tional instability in the remaining two. Patients A secure repair of the deltoid to bone enables with more extensive loss of the deltoid (i.e., an• the surgeon to initiate range of motion of the terior and lateral) or coexisting shoulder prob• shoulder immediately after the operation, and lems appeared more likely to have a poor out• the authors have experienced no case of de• come (Figure 4). tachment of the anterior deltoid when employ• ing this operative technique. *References2,3,5, 11, 18, 19,23,29,30,33,39. It is clear that deinnervation or detachment of 252 Groh et 01. J. Shoulder Elbow Surg. July/August 1994 the deltoid results in a group of patients who of the axillary nerve. J SHOULDER ELBOW SURG 1992;1: have pain and poor function and who are ex• 31-6. tremely dissatisfied! Because treatment of this 11 . Coene LN, Narakas AO. Surgical management of ax• illary nerve lesions, isolated or comb ined with others catastrophe is almost certainly doomed, the infraclaviculor nerves lesions. Peripheral Nerve Repair best approach is prevention. Although posi• and Regeneration, 1986;3:47-65. tioning the arm in adduction and external ro• 12. Cofield RH. Degenerative revisions of the gle• tation may make deltopectoral approaches to nohumeral joint. In: Rockwood CA, Matsen FA,eds. The shoulder. Philadelphia: WB Saunders, 1990. the shoulder safer, we strongly recommend 13. De Orio JK, Cofield RH. Results of a second attempt at identifying the axillary nerve during anterior surgical repair of a failed initial rotator cuff repair. J Bone shoulder procedures and protecting it during Joint Surg [Am] 1984;66A:563-7. the entire procedure. Furthermore, the long an• 14. De Palma AF. Surgery of the shoulder. 3rd ed. Phila• terior deltopectoral incision described by delphia: JB Lippincott, 1983:88..,. , 28 31 15. Gardner E, Gray OJ, O'Rahilly R. . Philadel• Neer • for use in shoulder arthroplasty does phia : WB Saunders, 1967:143-4. not require release of any of the origin of the 16. 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33. Ober FR. An operation to relieve paralysis of the deltoid nique in arthroplasty of the shoulder. In: Friedman RJ, muscle. JAMA 1932;99:2182. ed . New York: Thieme Medical Publishers, 1993. 34. Rockwood CA. The role of anterior impingement to le• 39. Saha AK. Surgical rehabilitation of shoulder following sions of rotator cuff. J Bone Joint Surg [Br] 1980;62B:274. pol iomyelites in adult and children . Journa l of the Inter• 35. Rockwood CA. Shoulder function following decompres• nationa l College of Surgeons 1964;42:198. sion and irreparable cuff lesions. Orthop Trans 40. Samilson RL, Binder WF. Symptomatic full thickness tear 1984;8:92. of the rotator cuff: An analysis of 292 shoulders in 276 36. Rockwood CA. The management of pat ients with mas• pat ients. Orthop Clin North Am 1975;6:449-6. sive rotator' cuff defects by acrom ioplasty and rota tor 41. Takagishi N . Conservative treatment of the ruptures of cuff debridement. Orthop Trans 1986; 10:622. the rotator cuff. J Jpn Orthop Assoc 1978;52:781-7. 37. Rockwood CA. The technique of total shoulder arthro• 42. Wolfgang GL. Surgical repairs of tears of the rotato r cuff plasty. Instr Course Lect 1990;39:437-47 . of the shoulder : Factors influencing the result. J Bone 38. Rockwood CA, Groh GI. Surgical anatomy and tech- Joint Surg [AmjI974;56A:14-26.

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