EXCISION OF THE SHOULDER-JOINT 
BY 
A. R. SHANDS, M.D. 
WASHINGTON, D. C. 
From the 
Transactions of the Southern Surgical and Gynecological Association 
1899 EXCISION OF THE SHOULDER-JOINT. 
By A. B. Shands, M.D., 
Washington, I). C. 
The rarest of all joints that the surgeon is called upon to 
treat is the shoulder-joint. Especially is this the case as re- 
gards tuberculous disease. Dr. James K. Young, of the 
University of Pennsylvania, reports that in 2292 cases of 
orthopaedic affections treated in the Orthopaedic Department 
of the Hospital of the University of Pennsylvania there were 
only two cases of this affection. The present writer, having 
become especially interested in the subject of excision of the 
shoulder, on account of the rare case herein to be reported 
somewhat in detail, has looked up the literature on the sub- 
ject so far as possible, and has been able to find the report of 
but very few cases. The text-books dispose of the subject 
in a very few words; all, however, agree that excision for 
relief of extensive osteitis of the head of the humerus is fully 
justified by the excellent results obtained functionally as well 
as the complete cure of the disease. 
Excision of the shoulder should never be done as a routine 
practice, as a natural cure under a conservative treatment is 
the most desirable; for even with an absolutely ankylosed 
joint the patient has an exceedingly useful arm, chiefly on 
account of the free motion of the scapula, to which the head 
of the humerus may be firmly attached by bony union. In 
either case in the vast majority of cases almost every motion 
can be effected except an overhead one, since the arm cannot 
be raised above the shoulder. 
Excision of the shoulder in gunshot injuries is now well 
recognized as an operation of great value, a fact well demon- 
strated in our recent wars. In gunshot injuries there is 
seldom any necessity for the removal of more than the head 
of the humerus; the same is true in ununited fractures of the 
neck of the humerus as well as in disease, for it is extremely EXCISION OF THE SHOULDER-JOINT. 
2 
rare that more than the head of the bone is involved in an 
osteitis. The writer has been unable to find the report of 
any case of excision of the shoulder in which more than the 
head and neck has been removed. This fact is especially in- 
teresting in connection with the case here reported, in which 
seven and one-half inches of the humerus, with the head, had 
to be excised to remove all of the diseased bone, leaving the 
patient a very useful arm. Regarding the technique of ex- 
cision of the shoulder, the writer will quote from Bradford 
and Lovett’s excellent book on orthopaedic surgery, as follows: 
“ The longitudinal incision is in general the most useful. 
The periosteum is divided with a bone knife inserted along 
the inner border of the bicipital groove. The arm is rotated 
both outward and inward, and the periosteum and muscular 
attachments are removed as they appear. The head can be 
removed with the keyhole or chain saw, removing as much 
of the bone as is diseased. The operation is performed sub- 
periosteally, and the head of the bone is thrown out of the 
wound aud sawed off. In after-treatment very good fixation 
can be obtained by bandaging the arm to the side with a thick 
pad between the body and the inner side of the arm. Plaster- 
of-Paris dressing around the chest and arm affords the best 
fixation; and after the need of complete fixation is passed a 
sling answers every purpose. Passive motion should be be- 
gun as soon after the operation as possible, if it is desired to 
obtain a movable joint; but the surgeon in that way runs the 
risk of making a flail-joint, inasmuch as but little of the liga- 
mentous structure has been preserved. Ankylosis of the 
shoulder is of comparatively slight importance in comparison 
to obtaining a stable joint, on account of the mobility which 
the shoulder-blade possesses, so that passive motion should 
not be begun too early, and in many cases should not be 
undertaken at all.” 
Miss R., aged thirty years. Personal history good, with 
the exception of the trouble with the left shoulder. Patient 
is a well-developed young woman, five feet five inches tall, and 
usually weighs about one hundred and twenty pounds, and is 
of a decided brunette type. She has always been strong and 
hearty, with the exception above noted. She is one of a large A. B. SHANDS. 
3 
family, nine children, the youngest nine years old, all healthy 
except one sister, who died recently of consumption at the 
age of thirty-two years. Father and mother are living and 
enjoying good health. At the age of five years the patient 
received a severe injury in the left shoulder, which, in a few 
days following the injury, began to swell and soon developed 
a purulent synovitis. A large quantity of pus was evacuated 
from the joint, suppuration with a profuse discharge con- 
tinued for several years, but finally ceased, and all sinuses 
closed. When between eight and nine years old abscesses 
began to form one after another over the shoulder, in the 
axilla, and along the anterior aspect of the arm to within a 
few inches of the elbow. Sinuses at the seat of these abscesses 
continued to discharge for several years. Then for about 
nine years the sinuses remained closed, but during this period 
the patient says she was never free from pain. At the end 
of this time another crop of abscesses began to appear, which 
were incised one after another, leaving discharging sinuses 
which existed at the time she came under my charge in Janu- 
ary, 1899. During this period of twenty-five years this 
patient had received the most conservative treatment, the 
abscesses being simply incised as they appeared. Many 
small pieces of necrotic bone came away. Upon examination 
I found the general condition of the patient good, all of the 
vital organs being in normal condition. There were six or 
eight sinuses situated chiefly on the anterior aspect of the 
shoulder and arm, extending nearly to the elbow-joint, all dis- 
charging a thick, creamy, foul-smelling pus. Dead bone was 
detected with the probe at the bottom of each sinus. 
Operative measures were advised and accepted. On January 
18, 1899, a free longitudinal incision was made about three 
inches long, and an attempt was made with chisel and curette 
to remove the dead bone ; but before proceeding very far 
there was discovered a large sequestrum enveloped in newly- 
formed bone with numerous sinuses extending through it. 
The diseased bone was so extensive that it was impossible to 
remove it all without doing an excision, and as this radical 
procedure bad not been anticipated or advised it was post- 
poned to gain the consent of the patient. 4 
EXCISION OF THE SHOULDER-JOINT. 
Consent having been obtained to do whatever I thought 
best, on April 19th I excised seven and one-half inches of 
the humerus through a longitudinal incision extending from 
the acromion process about nine inches down the anterior 
aspect of the humerus. All of the periosteum was dissected 
back from the humerus, which was sawed off seven and one- 
half inches from the glenoid cavity and about one-quarter 
inch below the lowest bony sinus, which is shown in photo- 
graph No. 1. 
The structure through which the long incision was made 
consisted of a mass of cicatricial and fibrous tissues, all of 
the muscular fibres having degenerated as a result of this 
old inflammatory and suppurative process. The head of 
the humerus was thoroughly diseased and firmly ankvlosed 
with the glenoid cavity. After disarticulating the head of the 
bone the glenoid cavity was thoroughly curetted, which re- 
moved all of the diseased bone. The hemorrhage was pro- 
fuse ; many ligatures and hot water were freely used. A 
counter drainage was made in the axilla and a drainage-tube 
was inserted. The long anterior incision was closed with 
interrupted sutures of silkworm-gut after inserting a drain- 
age-tube extending the entire length of the wound, with free 
openings at either end. The wound healed firmly in about 
four weeks, and has remained so up to the present time, about 
nine months. After applying antiseptic dressings the arm 
was bandaged firmly to the side and held in a fixed position 
by means of plaster-of-Paris bandages. There was little or 
no shock following the operation, and the patient made a 
rapid and uneventful recovery. 
The tissues above the proximal end of the humerus have 
contracted several inches ; considerable bone has formed from 
the periosteum, which was left in ; this has stiffened the arm 
considerably and gives the patient a very useful arm. 
Photograph No. 2 shows a sequestrum of bone surrounded 
by a reparative shell of bone newly formed from the uninjured 
periosteum. The sequestrum evidently represents the result 
of the original disease in the shaft of the humerus twenty- 
five years ago. FIg. 1. 
Fig. 2.