There are a few basic open approaches that can be used for shoulder surgery. Selecting the appropriate approach can help facilitate operative goals.
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 )
Operating room setup:
Usually performed in the semi-sitting (Beach chair) or supine position
Can be performed with patient in lateral position but may be more uncomfortable for surgeon
May use a commercial head holder or positioning device to assist with positioning (▶ Fig. 3.2 ):
These can improve access to posterior shoulder for portal placement
They help maintain cervical spine in neutral alignment
They can assist with dislocation of the humeral head during arthroplasty.
A more upright position can lead to a flatter surgeon hand position during arthroscopy procedures
A more supine position can assist with dislocation of the humeral head
The beach chair position may be associated with a slightly higher risk of cerebral hypoperfusion
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:
Need adequate exposure to the deep interval
Develop an interval between the medial aspect of the deltoid and the lateral aspect of the pectoralis:
May be easier to identify closer to clavicle
Will usually find the cephalic vein in a fat stripe directly over the interval.
Releasing the vein proximally and distally will help mobilize it and prevent tethering at the proximal and distal ends:
The vein may be deep in the interval
Can be absent in cases of prior surgery
In cases of scar or tethering it may be beneficial to move vein medially to prevent iatrogenic laceration from deltoid retraction.
Once the interval has been developed, the pectoralis can be elevated off the underlying fascia to further develop the space (▶ Fig. 3.5 ):
This will expose the coracoid and the conjoint tendon coursing distally
The coracoacromial (CA) ligament should also be visualized or palpated
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 ).
The clavipectoral fascia can be incised lateral to the muscle of the short head of the biceps:
Take care not to plunge to deep to avoid subscapularis injury
Preserve the CA ligament at the top of the release
May release some of the upper border of the pectoralis in tight shoulders.
Once the clavipectoral fascia is incised, the subcoracoid space can be dissected bluntly, exposing the subscapularis:
The subdeltoid space can be developed by dissecting under the CA ligament, but above the rotator cuff
Once the subdeltoid space is identified proximally and distally, the remainder of the deltoid can be mobilized off the humeral head and bursa:
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
The humeral branch of the posterior circumflex is often at the same level as the axillary nerve and can bleed briskly if not coagulated.
The surgeon can use a self-retaining retractor (Kolbel) if desired:
One blade under the conjoined tendon and one blade under the deltoid (▶ Fig. 3.7 )
Excessive retraction can injure the musculocutaneous nerve.
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
If more medial exposure to the plexus or vessels is needed, the surgeon can perform a coracoid osteotomy or conjoint tendon tenotomy.
A bursectomy can improve visualization
The bicipital groove is usually easily identified and can serve as a landmark during surgical dissection:
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
As the biceps approaches the interval, it turns medially to enter the joint.
The upper rolled border of the subscapularis can usually be palpated in the rotator interval
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”
Depending on the procedure, different steps can be undertaken at this point
Access into the glenohumeral joint can be facilitated through opening the rotator interval or through the subscapularis (▶ Fig. 3.8 ):
The rotator interval can be excised to allow better access into joint and identification of structures.
Subscapularis management can be variable (▶ Fig. 3.9 ):
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.
i. Elevation of entire subscapularis off the bone starting at the bicipital groove.
i. Can be used for open Bankart repair, coracoid transfer, or anterior glenoid fracture fixation.
Tenotomy medial to the tuberosity:
i. Side-to-side tendon repair performed to close.
L-shaped inferior tenotomy.
Once the joint is opened, any further capsular releases or intra-articular work can be performed.