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Uses
Any anterior shoulder
surgery, e.g.
› Capsular shift &
dislocation procedures
› Proximal humerus
fracture work
› Shoulder arthroplasty
› Long head of biceps
repair
› Subscapularis repair
Uses
This approach is preferred for shoulder
arthroplasty and for plate-and-screw
fixation of proximal humeral fractures
because it affords greater visualization
than does the lateral approach.
Incision
Length: 10-15 cm (depending
on the procedure and build
of patient).
Extent: From coracoid
process running along the
deltopectoral groove
towards the deltoid insertion.
Expose deltopectoral groove.
› The cephalic vein and the
coracoid are landmarks to the
interval.
Exposure of deltopectoral groove
and cephalic vein
Identify the cephalic vein and preserve it during dissection. › Failure to preserve cephalic
vein = post-surgical arm edema.
Retract the cephalic vein laterally or medially, and open along the groove. › Failure to find this plane =
difficulty in dissection of deltoid
possible denervation of anterior portion of deltoid.
Laterally reflect the anterior part of
deltoid to expose the underlying
coracoid process and joint capsule.
Identification of the tuberosities and
the humeral head fragments
Expose the subscapularis tendon and the tendon of long head of biceps. › The long head of
biceps serves as a landmark to separate the greater and lesser tuberosities.
Distally, expose the pectoralis major.
Pearl:
If a wider exposure is necessary, place
ethibond stay sutures (c.3) into the
medial aspect of the last centimeter of
the subscapuaris tendon, and partially
divide it laterally to this.
External rotation of the shoulder during
subscapularis release moves the
dissection away from the axillary nerve
and decreases tension on the nerve.
Care should be taken to isolate and ligate the anterior humeral circumflex artery, along with, if necessary, its two venae communicantes at the distal margin of the subscapularis tendon during the exposure.
To maintain the blood supply to the humeral head, surgical dissection should not extend to the inferior margin of the subscapularis.
A cuff of muscle must be maintained to protect the anterior humeral circumflex vessels.
Likewise, by releasing the subscapularis medial to its tendinous insertion, the arcuate artery is not sacrificed at the point at which it enters the humeral head along the lateral border of the bicipital groove.
Pitfall:
The musculocutaneous nerve enters the
coracobrachialis muscle as close as 2.5
cm distal to the tip of coracoid.
› Retractors placed under the conjoint tendon
can cause neuropraxia; therefore vigorous
retraction must be avoided.
If more extensive exposure is required,
pre drill the coracoid and remove the tip
with an osteotome.
Structures at risk
Superiorly: Acromial branch of thoracoacromial artery:› Lies in the medial aspect of coracoacromial
ligament.
Inferiorly: Musculocutaneous nerve:› Comes out and enters the biceps approx. 5 cm distal
to the coracoid.
› Usually not cut, but can be retracted and damaged with the retraction.
› Dissection medial to the conjoint tendon should be avoided because it places the musculocutaneous nerve at risk.
Structures at risk
Axillary nerve:
› The axillary nerve should be palpated as it passes
inferior to the subscapularis and the inferior capsule,
and it should be protected throughout the
procedure.
› A retractor placed below the subscapularis and the
capsule puts this nerve in grave danger.
Cephalic vein:
› Can also be damaged if not identified and
protected as the deltopectoral groove is being
developed.
Tricks
Find the deltopectoral groove and take
whichever vein seems easiest (typically
laterally).
The coracoid is the best landmark for the
short head of biceps; split the fascia in
that direction, which will get you into the
interval between the 2 heads.
Tricks
Put a stay suture in the subscapularis
prior to cutting it free from the humeral
head so that it does not retract out of
the way.
Feel the shoulder joint and the glenoid
edge prior to doing the capsulotomy, so
you can place it correctly for whatever
procedure you are attempting to do.
› This is especially important when attempting
to do instability procedures.
Extension
When a greater exposure of the lateral
humeral shaft is needed, less than one
fifth of the anterior deltoid insertion can
be released.
Distal extension may be accomplished
via the anterolateral approach to the
humerus.
Recommended