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Anterior Approach to Shoulder

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Positioning and Draping:

  • supine or beach chair;
  • small soft bolster is placed beneath the shoulder blades to protract the shoulder;
  • head is stabilized to prevent hyperextension and subsequent brachial plexus palsy;
  • place patient in a beach chair position w/ torso flexed 45 deg and the knees flexed to 30 deg;
    • in the beach chair position, ensure that the patient is firmly fastened to prevent sliding;
  • move patient to the edge of the table (operative side), and use a McConnel positioner to prevent the patient from failing off the table;
    • positioning is optimal when the scapula hangs over the edge of the table;
  • place a folded towel under the spine and ipsilateral scapula;
  • it is helpful to drape the should w/ a large Ioband sheet w/ a hole cut in the middle;
    • several Iobrand strips (2-3 inches in width) are also helpful;
      • consider the Mconnel Shoulder Positioner;

Instruments:

Superficial Dissection:


Deep Dissection:

  • clavipectoral fascial incision:
    • once the deltopectoral interval has been fully developed, the clavipectoral fascia is exposed (which is most prominent lateral to coracoid muscles);
    • clavipectoral fascia is differentiated from the deeper tissues, because it will not move with internal and external rotation;
    • tip of the coracoid and the conjoined tendon (short head of biceps and the coraco-brachialis) is identified;
    • clavipectoral fascia is then divided vertically just lateral to the conjoined tendon, up to coracoacromial ligament, exposing subscapularis tendon & lesser tuberosity.
      • proximally, the fascia is divided at a point just lateral to the coracoid;
      • the incision is carried distally to the level of the anterior circumflex;
      • these vessels mark the level of the subscapularis tendon;
  • identification of the musculocutaneous nerve:
    • musculocutaneous nerve can usually be palpated on deep surface of coracobrachialis;
    • nerve enters posterior of coracobrachialis about 5 cm distal to coracoid tip but can be as close as 1 to 2 cm;
  • identification of the axillary nerve
  • retraction:
    • often a "Charnley type" of self retaining retractor is inserted underneath the deltoid medially and the coracobrachialis laterally;
  • coraco-acromial ligament:
    • in patients w/ traumatic arthritis or DJD, the shoulders may be tight and therefore, the ligament can be
      partially incised for better exposure of the upper portion of the subscapularis;
    • in patients w/ rheumatoid arthritis or cuff tear arthropathy, excision of the CA ligament may destabilize the shoulder arthroplasty;

Transection of the Subscapularis:

  • subscapularis tendon and the underlying joint capsule are divided approximately 1 cm medial to the lesser tuberosity;
  • medial retraction of the tendon and capsule will expose the glenoid;

Caspsular Transection:

  • external rotation of the humerus affords better capsular exposure and relaxes the nerve;
  • insert a blunt retractor inferiorly to protect the axillary nerve, insert two single pronged skin hooks to elevate the capsule superiorly and place it under tension;
  • vertically transect the capsule at a point midway between the lesser trochanter and the edgle of the glenoid;
  • carry this vertical capsular incision superiorly into the rotator interval, which converts the capsular incision into a T (since the rotator interval lies in a horizontal direction);
  • at the end of the case, the superior and inferior capsular capsular flaps are closed (and shortened) in order to shift the inferior capsule in a superior direction;
  • the vertical portion of the incision is closed anatomically (so that there will be no loss of external rotation);

Distal Exposure:

  • lower part of shaft is exposed by incising brachialis longitudinally along lateral border of biceps;
  • lowest part of the front of the shaft can be approached between brachioradialis which is retracted laterally and brachialis which is retracted medially