Approach

Fig. 3.1

Beach chair position

The head is secured in a Mayfield headrest or any commercial beach chair attachment and the back elevated at 40 to horizontal.

The opposite arm, legs, and other prominences are padded and secured.

The knees should be slightly bent (30°) in order to prevent neuropraxia by stretching the sciatic nerve.

Any available arm holders may be helpful.

Staphylococcus aureus, S. epidermidis, and Propionibacterium acnes are the bacterial species most implicated in infection after shoulder arthroplasty [3]. These germs are present in hair follicles; consequently the focus in draping is to exclude the axilla and the upper part of the shoulder [4].

Chlorhexidine solution is thought to be the best antiseptic agent for preoperative skin preparation [5].

The deltopectoral incision begins inferior to the clavicle and lateral to coracoid tip, toward deltoid insertion (Fig. 3.2). The incision should be done enough large in order to reduce retraction force, thereby decreasing the incidence of tension neuropraxia [6].

../images/429740_1_En_3_Chapter/429740_1_En_3_Fig2_HTML.png — Fig. 3.2

Deltopectoral incision: inferior to the clavicle and lateral to coracoid tip, toward deltoid insertion

Then, the cephalic vein is exposed (Fig. 3.3) and it can be retracted laterally or medially.

../images/429740_1_En_3_Chapter/429740_1_En_3_Fig3_HTML.png — Fig. 3.3

Exposure of the cephalic vein

In most cases, the vein is retracted laterally because it is usually more adherent to the deltoid, and in this way the deltoid’s venous drainage is preserved. If medially, the tributary vessels of the cephalic vein are ligated and coagulated as needed [7]. If the cephalic vein is not visible, look for a fat strip which may overlie the vein.

Together with the cephalic vein, the deltoid muscle is retracted laterally, while the pectoralis major medially (Fig. 3.4).

../images/429740_1_En_3_Chapter/429740_1_En_3_Fig4_HTML.jpg — Fig. 3.4

Deltoid muscle is retracted laterally, while the pectoralis major medially

Superior part (1–3 cm) of the pectoralis major tendon may be released to achieve better exposure of the inferior portion of the subscapularis tendon and better mobility of the humerus. It should be very careful in positioning of the retractors, because putting them inside the deltoid risk the axillary nerve lesion.

The clavipectoral fascia should be incised lateral to the conjoint tendon, start proximal to the coracoacromial ligament, and continue distally to the inferior aspect of the subscapularis tendon. The coracoacromial ligament does not need to be excised, and its preservation prevents anterosuperior humeral subluxation of the humeral head [8]. At this point it is important to identify the musculocutaneous nerve, which is localized deep to the conjoint tendon. It enters posterior to coracobrachialis, but the distance from the coracoid can vary from 1 to 5 cm (Fig. 3.5).

../images/429740_1_En_3_Chapter/429740_1_En_3_Fig5_HTML.jpg — Fig. 3.5

Identification of musculocutaneous nerve and circumflex nerve

The next step is the identification of the long head of the biceps, which will help in locating the insertion of the subscapularis. The long biceps tendon is located immediately above the insertion of the pectoralis major, which joins the lateral lip of the intertubercular groove [2]. The biceps tendon is tenotomized (Fig. 3.6) below the subscapularis, tagged with a stay stitch, and left for the subsequent tenodesis to the superior border of the pectoralis major tendon at the end of the procedure [7]. Anterior humeral circumflex vessels along the inferior third of the subscapularis tendon are ligated or coagulated.