- See: Axillary Approach to the Shoulder - Indications: - most often used for Bankhart repairs for anterior shoulder dislocations; - Positioning: beach chair w/ full access to posterior aspect of shoulder;
- Incision: - incision is placed in major axillary skin fold; - skin incision begins in the axilla and is centered over pectoralis major tendon (usually no longer than 6 cm); - if incision needs to be extended, extend it toward coracoid; - cephalic vein marks the location of the deltopectoral interval; - split in deltopectoral interval continues along medial aspect of cephalic vein down the clavipectoral fascia; - the cephalic vein proceeds superiorly over the coracoid... - Deep Exposure: - elevate deep surface of deltoid; - laterally this will enter into subacromial bursa; - tip of the coracoid and the conjoined tendon (short head of biceps and the coraco-brachialis) is identified; - clavipectoral fascia is differentiated easily from the deeper tissues, because it will not move with internal and external rotation; - next the Charnley type retractors are inserted; - blades are placed deep to the deltoid and the conjoined tendon; - inner limb of the Balfour should be just caudal to the coracoid tip; - Preparation for Subscapularis Transection: - identify the anterior humeral circumflex vessels (three sisters); - identify the axillary nerve at the inferior aspect of subscapularis as it courses toward quadrangular space; - here the nerve is joined by posterior humeral circumflex vessels; - before an incision is made in the subscapularis, the arm should be externally rotated to avoid damage to axillary nerve and circumflex vessels; - finally, prior to incision, insert two or three tagging sutures just medial to the proposed line of transection, which will facilitate retraction; - Subscapularis Transection: - enter glenohumeral joint over superior border of subscapularis and slightly lateral to biciptal groove; - a vertical incision is made thru the subscapularis tendon and capsule which follows a Joker elevator, which has been inserted from above and which is aligned with the articular margin; - 1 cm of capsule and tendon is left attached to the lesser tuberosity to facilitate subscapularis closure; - inferior margi of the muscle is left intact, as is AHCA, which will help protext the axillary nerve; - Articular Exposure: ------------------------------
