3 Surgical Approaches to the Shoulder

Nickolas G. Garbis and Diana Zhu

Summary

There are a few basic open approaches that can be used for shoulder surgery. Selecting the appropriate approach can help facilitate operative goals.

Shoulder – approach – surgical technique – deltopectoral

3 Surgical Approaches to the Shoulder

I. General introduction

As comfort increases with arthroscopic techniques, less shoulder surgery is being performed through open approaches
Important to understand anatomy and open approaches to the shoulder.

II. Deltopectoral approach

One of the more common anterior approaches to the shoulder
Wide utility for a variety of different procedures
Internervous plane between the pectoralis major (medial and lateral pectoral nerves) and the deltoid (axillary nerve)
Exposes the coracoid, subscapularis, anterior humerus, biceps, and glenoid
Can be used as an extensile approach and combined with an anterolateral approach to the humerus (▶ Fig. 3.1 )

Fig. 3.1 Incision for a deltopectoral approach to the shoulder. Incision is starting at the coracoid and extending toward the pectoralis insertion on the humerus.
Operating room setup:
1. Usually performed in the semi-sitting (Beach chair) or supine position
2. Can be performed with patient in lateral position but may be more uncomfortable for surgeon
3. May use a commercial head holder or positioning device to assist with positioning (▶ Fig. 3.2 ):
  1. These can improve access to posterior shoulder for portal placement
  2. They help maintain cervical spine in neutral alignment
  3. They can assist with dislocation of the humeral head during arthroplasty.
4. A more upright position can lead to a flatter surgeon hand position during arthroscopy procedures
5. A more supine position can assist with dislocation of the humeral head
6. The beach chair position may be associated with a slightly higher risk of cerebral hypoperfusion
7. A padded Mayo stand or arm holder can also be useful in providing control and assisting with position of the distal extremity.
Incision and dissection:
1. Need adequate exposure to the deep interval
  
  Fig. 3.2 Operating room setup in the beach chair position. Note neutral position of the cervical spine, easy access to the posterior shoulder, and pneumatic arm holder.
2. Skin incision usually placed referencing the coracoid superiorly and the insertion of the pectoralis distally (▶ Fig. 3.3 and ▶ Fig. 3.4 )
3. Develop an interval between the medial aspect of the deltoid and the lateral aspect of the pectoralis:
  1. May be easier to identify closer to clavicle
  2. Will usually find the cephalic vein in a fat stripe directly over the interval.
4. Releasing the vein proximally and distally will help mobilize it and prevent tethering at the proximal and distal ends:
  1. The vein may be deep in the interval
  2. Can be absent in cases of prior surgery
  3. In cases of scar or tethering it may be beneficial to move vein medially to prevent iatrogenic laceration from deltoid retraction.
5. Once the interval has been developed, the pectoralis can be elevated off the underlying fascia to further develop the space (▶ Fig. 3.5 ):
  1. This will expose the coracoid and the conjoint tendon coursing distally
  2. The coracoacromial (CA) ligament should also be visualized or palpated
  3. One can also develop the plane between the humeral shaft and the deltoid at the lateral aspect of the humerus at the level of the pectoralis insertion (▶ Fig. 3.6 ).
6. The clavipectoral fascia can be incised lateral to the muscle of the short head of the biceps:
  1. Take care not to plunge to deep to avoid subscapularis injury
  2. Preserve the CA ligament at the top of the release
  3. May release some of the upper border of the pectoralis in tight shoulders.
    
    Fig. 3.3 Subcutaneous dissection for the deltopectoral approach.
    
    Fig. 3.4 The coracoid is visualized at the superior aspect of the wound. It is easier to distinguish the differing orientation of the pectoralis major and deltoid fibers at this level.
    
    Fig. 3.5 Notice the interval between deltoid and pectoralis major. In this patient, the cephalic vein is deep in the interval and not visible.
7. Once the clavipectoral fascia is incised, the subcoracoid space can be dissected bluntly, exposing the subscapularis:
  1. The axillary nerve can be felt at the inferior aspect of the subscapularis when palpating medially.
    
    Fig. 3.6 Distal retractor placed around the humeral shaft retracting the deltoid laterally. This exposes the pectoralis insertion. The proximal humerus is still obscured by the overlying deltoid.
8. The subdeltoid space can be developed by dissecting under the CA ligament, but above the rotator cuff
9. Once the subdeltoid space is identified proximally and distally, the remainder of the deltoid can be mobilized off the humeral head and bursa:
  1. The axillary nerve lies on the deep surface of the deltoid, and the surgeon should be careful not to violate the deep fascia of the deltoid
  2. The humeral branch of the posterior circumflex is often at the same level as the axillary nerve and can bleed briskly if not coagulated.
10. The surgeon can use a self-retaining retractor (Kolbel) if desired:
  1. One blade under the conjoined tendon and one blade under the deltoid (▶ Fig. 3.7 )
  2. Excessive retraction can injure the musculocutaneous nerve.
11. In rare cases of severe scarring or poor access, an anteromedial approach reflecting the clavicular origin of the deltoid can be performed. Meticulous reattachment of the deltoid is important to maintain continued functionality
12. If more medial exposure to the plexus or vessels is needed, the surgeon can perform a coracoid osteotomy or conjoint tendon tenotomy.
Deep dissection:
1. A bursectomy can improve visualization
  
  Fig. 3.7 Musculocutaneous nerve seen entering the coracobrachialis when exposing the medial side of the conjoined tendon. This particular patient is undergoing a pectoralis transfer for subscapularis insufficiency.
2. The bicipital groove is usually easily identified and can serve as a landmark during surgical dissection:
  1. The long head of the biceps sits in the bicipital groove and can be traced from the upper border of the pectoralis up to the rotator interval
  2. As the biceps approaches the interval, it turns medially to enter the joint.
3. The upper rolled border of the subscapularis can usually be palpated in the rotator interval
4. The inferior border of the subscapularis can be identified by the presence of the anterior circumflex artery and its two venae comitantes, often referred to as the “three sisters”
5. Depending on the procedure, different steps can be undertaken at this point
6. Access into the glenohumeral joint can be facilitated through opening the rotator interval or through the subscapularis (▶ Fig. 3.8 ):
  1. The rotator interval can be excised to allow better access into joint and identification of structures.
    
    Fig. 3.8 Proximal humerus exposure for an anatomic total shoulder arthroplasty. One blade of the self-retaining retractor is behind the conjoined tendon, and the other behind the deltoid. A Browne retractor is retracting the deltoid superiorly. A blunt Hohmann is protecting the axillary nerve. The subscapularis has been peeled off the lesser tuberosity and tagged for later repair. Notice the proximal humeral osteophytes.
7. Subscapularis management can be variable (▶ Fig. 3.9 ):
  1. Lesser tuberosity osteotomy:
    - i. A small piece of bone is removed from the lesser tuberosity along with the subscapularis to preserve Sharpey’s fibers as well as facilitate direct bony healing when the subscapularis is reattached.
  2. Subscapularis peel:
    - i. Elevation of entire subscapularis off the bone starting at the bicipital groove.
  3. Subscapularis split:
    - i. Can be used for open Bankart repair, coracoid transfer, or anterior glenoid fracture fixation.
  4. Tenotomy medial to the tuberosity:
    - i. Side-to-side tendon repair performed to close.
  5. L-shaped inferior tenotomy.
8. Once the joint is opened, any further capsular releases or intra-articular work can be performed.
  
  Fig. 3.9 Diagram showing incision lines for subscapularis management. (a) Subscapularis tenotomy. (b) Subscapularis split. (c) Subscapularis peel. (d) Inferior subscapularis takedown.