• Self-retaining Kolbel retractor

• Hohmann retractor

• Mayo scissors

• Blunt retractor

• Periosteal elevator

• 90-degree oscillating saw blade

• Angled saw

• Chandler elevators

• Toothed grasping forceps

• Microsagittal saw

• Osteotome

• 3.2-mm drill bit

• Mayo scissors

• Single-prong self-retaining subscapularis spreader

• High-speed burr

• Fukuda retractor

• 4-mm Steinmann pin

• 2.5-mm drill bit

• Kocher clamps

• Implants

• 3.5-mm cortical or 4.0-mm malleolar screws

• Suture washers

• Drill

• An interscalene block is recommended.

• The patient is positioned in modified beach-chair position with the head elevated 40 degrees.

• Two folded towels are placed under the scapula to flatten and stabilize it.

• The arm is draped free to allow intraoperative abduction and external rotation.

• A pneumatic limb positioner (Smith & Nephew, Andover, MA) or a padded Mayo stand is used.

• An arthroscopic examination is performed.

• An oblique 5- to 7-cm incision is made from the tip of the coracoid process, extending inferiorly down the deltopectoral groove to the superior portion of the axillary fold.¹

• A standard deltopectoral approach is used. The cephalic vein is protected and gently retracted laterally with the deltoid musculature.²

• A self-retaining Kolbel retractor is placed between the pectoralis major and deltoid to maintain exposure.

• If more exposure is desired, a Hohmann retractor can be placed over the top of the coracoid while the arm is in abduction and external rotation.

• With proper coracoid exposure and the arm in external rotation and abduction, Mayo scissors are used to further expose the coracoid from its tip all the way to the base.

• The coracoacromial (CA) ligament is identified and sharply transected 1 cm laterally off its coracoid insertion.

• It is important to harvest 1 cm of this ligament so it can later be incorporated into the capsular repair to produce the bumper effect.

• To improve exposure on the medial side of the coracoid, the arm is placed in adduction and internal rotation.

• The pectoralis minor is released with an elevator.

• Care must be taken to protect the neurovascular structures inferiorly with a blunt retractor.

• The release should not continue past the tip of the coracoid in order to avoid risk to the graft blood supply.

• A periosteal elevator is used to remove excess soft tissue from the undersurface of the coracoid (Fig. 3-1A).

• Palpation to identify and protect the axillary and musculocutaneous nerves is necessary throughout the coracoid exposure.

• A 90-degree oscillating saw blade is used to create a medial-to-lateral osteotomy of the coracoid at a line just anterior to the coracoclavicular ligament insertion at the coracoid base (Fig. 3-1B).¹

• The coracoid graft should be 22-25 mm long from the tip to base.

• The osteotomy is made perpendicular to the coracoid process to avoid accidentally extending it to the glenoid articular surface.

• An angled saw is used instead of a half-inch osteotome because the saw is less likely to cause iatrogenic glenoid fracture.

• Levering on the fragment with an osteotome can assist in completing the osteotomy but should be avoided if possible to avoid splitting the fragment.

• Chandler elevators are positioned inferior and medial to the coracoid to protect vital neurovascular structures.

• The blood supply to the graft enters the coracoid at the medial aspect of the insertion of the conjoined tendon; care is taken not to disturb it while performing the osteotomy.

• After the osteotomy is made, toothed grasping forceps are used to gently hold the graft at the level of the incision and the coracohumeral ligament is released to liberate the coracoid.

• The musculocutaneous nerve is then identified and released from the posterior fascia of the conjoint tendon, just until it dives into muscle ˜4-7 cm from the coracoid tip.

• The coracoid is brought out of the incision >1-2 cm to avoid any tension on the musculocutaneous nerve.

• It is important to completely release all soft tissue adhesions on the posterior aspect of the conjoint tendon to allow ease of coracoid transfer.