A NEW INCISION FOR ARTH= 
RECTOMY, RESECTION AND FOR 
REDUCTION OF IRREDUCIBLE 
DISLOCATION OF THE 
JOINT. 
BY 
N. SENN, M.D., Ph.D., LL.D. 
OP CHICAGO. 
FROM 
THE PHILADELPHIA MEDICAL JOURNAL, 
1898. [Reprinted from T*he Philadelphia Medical Journal, January 1,1898.] 
A NEW INCISION FOR ARTHRECTOMY, RESECTION, 
AND FOR REDUCTION OF IRREDUCIBLE DISLO- 
CATION OF THE SHOULDER-JOINT. 
N. SENN, M.D., Ph.D., LL.D., 
Professor of Surgery in Rush Medical College ; Professor of Surgery in Chicago 
Polyclinic; Attending Surgeon Presbyterian Hospital; 
Surgeon-in-Chief St. Joseph’s Hospital. 
The modern operations for tuberculosis of joints re- 
quiring arthrectomy or resection are characterized by 
thorough removal of the diseased tissue through in- 
cisions which afford free access to the joint, and that 
do not inflict unnecessary damage to important mus- 
cles, vessels and nerves. The ultimate success of such 
operations depends largely upon the thoroughness with 
which they are performed, the care exercised in the 
preservation of healthy tissue, and the prevention of 
injury to important structures involved at the site of 
operation. The incisions which are being devised for 
resection of the different joints have these two objects 
in view, and the recent improvements in the surgery of 
joints are largely due to a more perfect technic in 
performing the operations. The success that has at- 
tended the open method in the reduction of irreducible 
dislocations has added a new impulse to this depart- 
ment of surgery. Attempts to reduce old dislocations 
of the shoulder-joint have, in the hands of the most 
careful and competent surgeons, frequently terminated 
in disaster, so that the surgeon of to-day has learned 
caution, and is more inclined to remove the obstacles to 
reduction by a safe and clean dissection than by brute 
force. 
The object of this paper is to describe a new incision 2 
for exposing the shoulder-joint for different indications, 
but before doing so it may be of interest to mention the 
many different incisions which have been devised from 
the time the first excision of the shoulder-joint was made 
until the present time. A retrospective view of this 
kind is of interest in showing what progress surgery 
has made during the present century. 
Boucher removed parts of the shoulder-joint for gun- 
shot wounds in 1753, and Thomas opened the joint for 
the extraction of necrosed bone in 1740. The first 
authenticated case of resection of the shoulder-joint was 
performed by Ch. White and not by Bent, as stated 
by Treves in his work on “ Operative Surgery,” vol. i, 
p. 647. White (Cases of Surgery, vol. i,) performed the 
operation in 1768; Bent, of Newcastle, in 1771, three 
years later. White’s patient was a boy of 14, who was 
the subject of acute suppurative inflammation of the 
shoulder-joint, terminating in the formation of an ex- 
tensive abscess, which had discharged itself externally. 
The description of the operation, given by Mr. White 
himself, is interesting : 
“I began my incision at that’orifice, which was situated 
just below the processus acromion, and carried it down to the 
middle of the humerus, by which all the subjacent bone was 
brought into view, then took hold of the patient’s elbow and 
easily forced the upper head of the humerus out of its 
socket, and brought it so entirely out of the wound, that I 
readily grasped the whole head in my left hand, and held it 
there till I had sawn it off with a common amputation saw, 
having first applied a pasteboard card betwixt the bone and 
the skin. I had taken the precaution of placing an assistant, 
on whom I could depend, with a compress just above the 
clavicle, to stop the circulation in the artery, if I should have 
the misfortune to cut or lacerate it; but no accident of any 
kind happened, and the patient did not lose more than two 
ounces of blood; only a small artery, which partly surrounds 
the joint, being wounded, which was easily secured.” 
The patient made a good recovery, and four months 
later left the infirmary completely cured, the functional 
result being excellent. Sequestration of the sawed sur- 3 
face of the humerus delayed the healing of the wound. 
Mr. White’s example was followed by Bent in 1771 and 
by Mr. Orred, of Chester, in 1778. It appears, from the 
accounts we have of these operations, that the disease 
for which they were performed was really caries of the 
shoulder-joint, and that the patients retained limbs 
which, if not perfect, were at least extremely useful. 
Notwithstanding this encouragement to extend the 
practice, it seems to have been afterward treated in 
England with entire neglect. 
In France, Moreau the elder performed the opera- 
tion successfully in 1786, and the army surgeons, par- 
ticularly Banus, Percy, and Larrey, frequently resorted 
to it on account of recent gunshot wounds, instead of 
removing the limb. In Scotland the operation was 
revived by Mr. Syme in 1820, and was later performed 
by Babington, Liston, Baddely, Fergusson, Lawrence, 
Hunt, Coote, Hutchinson, Erichsen, Birkett, Stubbs, 
Blackman, and others. In Germany the first resection 
of the shoulder-joint was made by Lentin in 1771, and 
he was followed by Wutzer, Fricke, Jager, Blasius, 
Textor, Dietz, Heyfelder, Langenbeck, Esmarch,Wilms, 
and Bartels. 
The variety of incisions that have been devised for 
exposing the shoulder-joint with a view of resecting the 
head of the humerus is something remarkable. White’s 
original incision was a straight one, extending from the 
acromion process downward through the center of the 
deltoid muscle. The same incision was practised by 
Virgarrus. The incisions of Larrey, Kern, Chassaignac, 
and Jager are only slight modifications of White’s in- 
cision. Baudens commenced his incision just below 
the coracoid process of the scapula and carried the knife 
along the groove between the pectoralis major and del- 
toid muscles to the groove for the biceps muscle. If 
this incision did not afford the necessary room for the 4 
removal of the diseased head of the humerus, he en- 
larged the wound by making two small transverse cuts 
(but only through the muscles), in a forward direction 
at each end of the vertical incision. Langenbeck’s 
incision extends from the anterior border of the acro- 
mion process near the clavicular junction in a vertical 
direction downward through the deltoid muscle and is 
the incision that has usually been selected for resection 
of the shoulder-joint. Baudens’ incision was somewhat 
modified by Malgaigne and Robert. Frank and Ried 
joined the upper end of the anterior vertical incision 
by a short transverse cut extending beneath the acro- 
mion process. Bouzairies joined two oblique incisions 
in the figure of the letter V, making a flap including 
the deltoid muscle with its base directed upward. 
Bent made a long incision from the joint downward in 
the furrow between the pectoralis major and deltoid 
muscles; and as this did not afford enough room, he 
made two short transverse cuts, one meeting the upper 
end of the long cut dividing the clavicular attachment 
of the deltoid muscle, the lower the humeral insertion 
of the pectoralis major, making thus a quadrangular 
flap with its base directed toward the body. Bell, 
Morel, and Guepratte made a semilunar incision with 
its base directed upward. Wattmann carried the knife 
from the posterior margin of the acromion process along 
the border of the deltoid to its insertion, and joined it 
by another incision extending from the tip ol the cor- 
acoid process to the same point, making in this way a 
triangular flap which included the deltoid muscle. Sa- 
batier’s flap-incisions are the same, only the space in- 
cluded by the incision is smaller. The elder Moreau 
made a quadrangular flap with its base directed down- 
ward, while a similar flap, with its base in an opposite 
direction, was advised by Manne, Percy, the younger 
Moreau, Textor, and Jager. Syme made a perpendicu- 5 
lar incision from the acromion through the middle of 
the deltoid, nearly to its point of insertion, and then 
another one upward and backward, from the lower ex- 
tremity of the former, so as to divide the external part 
of the muscle. 
“ The flap thus formed being dissected off, the joint will be 
brought into view, and the capsular ligament, if still remain- 
ing, having been divided, the finger of the surgeon may be 
passed around the head of the bone, so as to feel the attach- 
ments of the spinati and scapular muscles, which can then 
be readily divided by introducing the scalpel first on the one 
side and then on the other. After this, the elbow being 
pulled across the fore part of the chest, the head of the hu- 
merus will be protruded, and may then be easily sawed off, 
while grasped in the operator’s left hand.” 
Albanese makes a posterior incision in the shape of 
an inverted L, commencing at the spine of the scapula, 
at the junction of this with the acromion process, ex- 
tending from above downward and forward to the head 
of the humerus, from where it is directed forward, ter- 
minating at the tuberculum majus. The muscles are 
separated with the periosteum, and through the wound 
the head of the humerus is removed. It is claimed 
that this incision has the advantage over other posterior 
incisions that it does not endanger the circumflex nerve. 
Ollier’s incision extends from the outer border of the 
coracoid process of the scapula in the direction of the 
fibers of the deltoid muscle obliquely outward and 
downward, a distance of four or five inches, to the shaft 
of the humerus, and is called the anterior oblique 
incision. Kocher’s posterior curved incision is com- 
menced over the acromio-clavicular joint, extends over 
the shoulder-joint to the middle of the crista scapulae, 
and is continued in a curved direction downward to the 
posterior fold of the axillary space. In Kocher’s opera- 
tion the acromion process is temporarily detached to 
furnish better access to the joint. Bardenheuer’s in- 6 
cision passes directly over the acromion process, which 
is divided in the same line and temporarily detached. 
The incision that I have devised has this great 
advantage over Bardenhener’s that the scar result- 
ing from the operation is well protected by the 
prominence formed by the shoulder-joint, and at the 
Fig. 1.—External semilunar incision exposing the deltoid muscle. 
same time secures free access to every part of the 
shoulder-joint and its immediate vicinity. The ex- 
ternal incision is made so as to form an oval cutane- 
ous flap, which is turned upward, exposing the upper 
half of the deltoid muscle. It is commenced over 
the coracoid process, and is carried downward and 
outward in a gentle curve as far as the middle of the 7 
deltoid muscle, when it is continued in a similar curve 
upward and backward as far as the posterior border of 
the axillary space on the same level where it was com- 
menced, that is, a point opposite the coracoid. The 
semilunar flap is next dissected up as far as the base of 
the acromion process and reflected. The acromion 
process is detached with a saw, and turned downward, 
with the deltoid muscle attached (Fig. 2). The capsule 
Fig. 2.—-Exposure of shoulder-joint after temporary detachment of acromion 
process which with the attached deltoid is turned inward. (1) Glenoid cavity. 
(2) Head of humerus. (3) Acromion process. 
of the joint is now freely exposed. If the operation is 
performed for an irreducible dislocation of the shoulder- 
joint, the head of the humerus can now be located, the 
cause of resistance to reduction is sought for and re- 
moved, tfr corrected when the reduction can be accora- plished by direct means, or by direct measures and 
manipulation. If the operation has for its object the 
removal of diseased tissue, the capsule is opened and 
the interior of the joint subjected to a careful examina- 
tion, to determine the extent of the operation. If the 
disease is limited to the soft structures, a complete ar- 
Fig. 3.—Free exposure of glenoid cavity and capsule of joint after resection of 
head of humerus. 
threctomy can be performed without sacrificing any 
portion of the bony constituents of the joint by dis- 
locating the head of the humerus in different directions 
for the purpose of rendering the entire capsule accessible 
to the dissecting forceps, knife, and scissors. If the 
head of the humerus is sufficiently diseased to indicate 
a typical resection, it should be removed as a prelimi- 
nary step to the subsequent arthrectomy. The glenoid 9 
cavity is readily accessible, and should be dealt with in 
accordance with the pathologic conditions present. After 
the removal of all diseased tissue, and proper prepara- 
tion of the wound, the acromion process is replaced and 
Fig. 4.—Operation completed. Cutaneous flap sutured. Through-tubular 
drainage. 
held in position by two or three strong catgut sutures. 
Silver wire is seldom required in suturing a temporarily 
detached bony prominence in operations upon the dif- 
ferent joints. The catgut sutures hold the fragment 10 
long enough in place for bony union to occur. I very 
rarely drill the bone-ends, as the sutures gain a suffi- 
ciently strong hold by including the periosteum and 
the paraperiosteal structures. In operating upon the 
shoulder-joint for disease, through-tubular or capillary 
drainage should be established and continued for two 
or three days. The divided portion of the deltoid 
muscle is sutured separately with catgut, when the cuta- 
neous flap is brought down in position and sutured in 
the usual manner. 
In operations for irreducible dislocation, drainage is 
not required and primary healing of the deep and 
superficial wounds should be aimed at by careful su- 
turing. After applying a copious hygroscopic aseptic 
dressing, the arm should be immobilized against the 
side of the chest with a few turns of the plaster-of-Paris 
bandage. The operation as described, undertaken for 
the reduction of an irreducible dislocation, arthrectomy 
or resection for disease of the joint, does not involve any 
of the important tendons, muscles, vessels or nerves, and 
for this reason a good functional result may be confi- 
dently expected. The Philadelphia Medical Journal 
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