Surgical Approaches to the Shoulder‌‌‌

 

 

Summary

There are a few basic open approaches that can be used for shoulder surgery. Selecting the appropriate approach can help facilitate operative goals.

Keywords: Shoulder, approach, surgical technique, deltopectoral

 

General introduction

As comfort increases with arthroscopic techniques, less shoulder surgery is being performed through open approaches

Important to understand anatomy and open approaches to the shoulder.

 

Deltopectoral approach

One of the more common anterior approaches to the shoulder

Wide utility for a variety of different procedures

Internervous plane between the pectoralis major (medial and lateral pectoral nerves) and the deltoid (axillary nerve)

Exposes the coracoid, subscapularis, anterior humerus, biceps, and glenoid

Can be used as an extensile approach and combined with an anterolateral approach to the humerus (▶Fig. 3.1)

 

Fig. 3.1 Incision for a deltopectoral approach to the shoulder. Incision is starting at the coracoid and extending toward the pectoralis insertion on the humerus.

 

 

 

Operating room setup:

Usually performed in the semi-sitting (Beach chair) or supine position

Can be performed with patient in lateral position but may be more uncomfortable for surgeon

May use a commercial head holder or positioning device to assist with positioning (▶Fig. 3.2):

These can improve access to posterior shoulder for portal placement

They help maintain cervical spine in neutral alignment

They can assist with dislocation of the humeral head during arthroplasty.

A more upright position can lead to a flatter surgeon hand position during

arthroscopy procedures

A more supine position can assist with dislocation of the humeral head

The beach chair position may be associated with a slightly higher risk of cerebral hypoperfusion

A padded Mayo stand or arm holder can also be useful in providing control and assisting with position of the distal extremity.

Incision and dissection:

Need adequate exposure to the deep interval

 

Fig. 3.2 Operating room setup in the beach chair position. Note neutral position of the cervical

spine, easy access to the posterior shoulder, and pneumatic arm holder.

 

 

 

Skin incision usually placed referencing the coracoid superiorly and the insertion of the pectoralis distally (▶Fig. 3.3 and ▶Fig. 3.4)

Develop an interval between the medial aspect of the deltoid and the lateral aspect of the pectoralis:

May be easier to identify closer to clavicle

Will usually find the cephalic vein in a fat stripe directly over the interval.

Releasing the vein proximally and distally will help mobilize it and prevent tethering at the proximal and distal ends:

The vein may be deep in the interval

Can be absent in cases of prior surgery

In cases of scar or tethering it may be beneficial to move vein medially to

prevent iatrogenic laceration from deltoid retraction.

Once the interval has been developed, the pectoralis can be elevated off the

underlying fascia to further develop the space (▶Fig. 3.5):

This will expose the coracoid and the conjoint tendon coursing distally

The coracoacromial (CA) ligament should also be visualized or palpated

One can also develop the plane between the humeral shaft and the deltoid at the lateral aspect of the humerus at the level of the pectoralis insertion (▶Fig. 3.6).

The clavipectoral fascia can be incised lateral to the muscle of the short head of the biceps:

Take care not to plunge to deep to avoid subscapularis injury

Preserve the CA ligament at the top of the release

May release some of the upper border of the pectoralis in tight shoulders.

 

Fig. 3.3 Subcutaneous dissection for the deltopectoral approach.

 

 

 

Fig. 3.4 The coracoid is visualized at the superior aspect of the wound. It is easier to distinguish the differing orientation of the pectoralis major and deltoid fibers at this level.

 

 

 

Fig. 3.5 Notice the interval between deltoid and pectoralis major. In this patient, the cephalic vein is deep in the interval and not visible.

 

 

 

Once the clavipectoral fascia is incised, the subcoracoid space can be dissected bluntly, exposing the subscapularis:

The axillary nerve can be felt at the inferior aspect of the subscapularis when palpating medially.

 

Fig. 3.6 Distal retractor placed around the humeral shaft retracting the deltoid laterally. This exposes the pectoralis insertion. The proximal humerus is still obscured by the overlying deltoid.

 

 

 

The subdeltoid space can be developed by dissecting under the CA ligament,

but above the rotator cuff

Once the subdeltoid space is identified proximally and distally, the remainder of the deltoid can be mobilized off the humeral head and bursa:

The axillary nerve lies on the deep surface of the deltoid, and the surgeon should be careful not to violate the deep fascia of the deltoid

The humeral branch of the posterior circumflex is often at the same level

as the axillary nerve and can bleed briskly if not coagulated.

The surgeon can use a self-retaining retractor (Kolbel) if desired:

One blade under the conjoined tendon and one blade under the deltoid (▶Fig. 3.7)

Excessive retraction can injure the musculocutaneous nerve.

In rare cases of severe scarring or poor access, an anteromedial appro-

ach reflecting the clavicular origin of the deltoid can be performed. Meticulous reattachment of the deltoid is important to maintain continued functionality

If more medial exposure to the plexus or vessels is needed, the surgeon can perform a coracoid osteotomy or conjoint tendon tenotomy.

Deep dissection:

A bursectomy can improve visualization

 

Fig. 3.7 Musculocutaneous nerve seen entering the coracobrachialis when exposing the medial side of the conjoined tendon. This particular patient is undergoing a pectoralis transfer for subscapularis insufficiency.

 

 

 

The bicipital groove is usually easily identified and can serve as a landmark

during surgical dissection:

The long head of the biceps sits in the bicipital groove and can be traced from the upper border of the pectoralis up to the rotator interval

As the biceps approaches the interval, it turns medially to enter the joint.

The upper rolled border of the subscapularis can usually be palpated in the rotator interval

The inferior border of the subscapularis can be identified by the presence of the anterior circumflex artery and its two venae comitantes, often referred to as the “three sisters”

Depending on the procedure, different steps can be undertaken at this point

Access into the glenohumeral joint can be facilitated through opening the rotator interval or through the subscapularis (▶Fig. 3.8):

The rotator interval can be excised to allow better access into joint and

identification of structures.

 

Fig. 3.8 Proximal humerus exposure for an anatomic total shoulder arthroplasty. One blade of the self-retaining retractor is behind the conjoined tendon, and the other behind the deltoid. A Browne retractor is retracting the deltoid superiorly. A blunt

Hohmann is protecting the axillary nerve. The subscapularis has been peeled off the lesser tuberosity and tagged for later repair. Notice the proximal humeral osteophytes.

 

 

 

Subscapularis management can be variable (▶Fig. 3.9):

Lesser tuberosity osteotomy:

A small piece of bone is removed from the lesser tuberosity along with the subscapularis to preserve Sharpey’s fibers as well as facilitate direct bony healing when the subscapularis is reattached.

Subscapularis peel:

Elevation of entire subscapularis off the bone starting at the bicipital

groove.

glenoid fracture fixation.

e. L-shaped inferior tenotomy.

Subscapularis split:

Can be used for open Bankart repair, coracoid transfer, or anterior

Tenotomy medial to the tuberosity:

Side-to-side tendon repair performed to close.

Once the joint is opened, any further capsular releases or intra-articular work can be performed.

 

Fig. 3.9 Diagram showing incision lines for subscapularis management. (a) Subscapularis tenotomy. (b) Subscapularis split. (c) Subscapularis peel. (d) Inferior subscapularis takedown.‌

 

 

 

Deltoid splitting approach

Can be used for rotator cuff repair, proximal humeral fracture fixation, and shoulder arthroplasty

Axillary nerve is described as being 5 cm from the lateral edge of the acromion, but it can be closer in smaller patients

Incision can be made off the anterolateral corner of the acromion, either in the direction of Langer’s lines or the deltoid fibers

 

The acromial attachment of the deltoid can be left intact or reflected off the anterior acromion‌‌

If distal exposure is needed, the axillary nerve can be palpated and the dissection continued below the nerve. Alternately the nerve can be exposed.

 

Approach to the acromioclavicular (AC) joint

Can be used for resection of the distal clavicle or AC joint reconstruction

Any approach to the AC joint should preserve the thick deltotrapezial tissue for closure at the end of the case

The skin incision can be in line with the AC joint along Langer’s lines or parallel to the clavicle (▶Fig. 3.10)

Once skin is divided, full-thickness flaps are elevated off the anterior and posterior surfaces of the AC joint (▶Fig. 3.11)

Once the desired procedure is performed, the flaps are repaired to each other or through drill holes.

 

Posterior approaches to the shoulder

Can be used in treatment of posterior instability, glenoid osteotomy, oncological surgery, scapular neck fractures, open suprascapular nerve decompression, or posterior fracture dislocations

 

Fig. 3.10 Open approach for reconstruction of an

acromioclavicular joint dislocation. The skin incision paralleled Langer’s lines and skin flaps were developed to expose medially and laterally. Notice musculoperiosteal flaps elevated in line with clavicle.

 

 

 

Fig. 3.11 The musculoperiosteal flaps should be full thickness to allow for closure at the end of the procedure.

 

 

 

A more extensive Judet approach to the posterior shoulder can be used for scapular body fractures

Easiest to position patient in lateral decubitus or prone

Skin incision can be along the scapular spine or vertical:

Vertical incision can be made along the soft spot of the joint posteriorly, similar to an arthroscopic portal, or just medial

A laterally placed incision may make access to joint difficult.

Once the deltoid is identified it can be split in line with its fibers or elevated off the scapular spine:

The deltoid fibers tend to be oriented in a more horizontal fashion

posteriorly.

If the deltoid is split, the axillary nerve can be found exiting from the quadrilateral space at the level of the teres minor

The deep fascia enveloping the infraspinatus and teres minor can be identified

The interval between these two muscles can be developed bluntly toward their insertion on the greater tuberosity

Once the two muscles are reflected, the posterior capsule of the joint can be identified and incised as needed

For scapular body fractures, a Judet approach can provide extensile exposure:

The incision starts at the spine of the scapula and curves down along the medial edge of the scapular body (▶Fig. 3.12)

The skin and all subcutaneous tissue are elevated as one large flap

The glenohumeral joint and scapular neck can be accessed in a similar method as described above

In addition, this approach will allow plating of the medial border of the scapula.

 

Fig. 3.12 Line signifying skin incision for posterior Judet approach to the scapula. Once through the subcutaneous tissue, the posterior deltoid can be reflected to reveal the insertion of the teres minor and infraspinatus on the proximal humerus.

 

 

 

Suggested Readings

Chalmers PN, Van Thiel GS, Trenhaile SW. Surgical exposures of the shoulder. J Am Acad Orthop Surg 2016;24(4):250–25810.5435/JAAOS-D-14-00342

Hoppenfeld S; de Boer P, Buckley R. Surgical Exposures in orthopaedics: the anatomic approach. Chapter 1: The Shoulder. Lippincott Williams and Wilkins; 2009

Zlotolow DA, Catalano LW, Barron OA, Glickel SZ. Surgical exposures of the humerus. J Am Acad Orthop Surg 2006;1