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  • Overview
    • This approach can be a fairly extensile exposure, allowing access to the anterior, medial, and lateral aspects of the shoulder.
    • Can be extended distally to incorporate the anterior approach to the humerus
  • Indications
    • shoulder arthroplasty
    • proximal humerus fractures (especially 3 and 4 part fractures)
    • reconstruction of recurrent dislocations
    • long head of the biceps injury
    • septic glenohumeral joint
Internervous plane
  • Beach chair position or supine with an ipsilateral scapular bump

  • Incision
    • an incision is made following the line of the deltopectoral groove
      • In obese patients, this may be difficult to palpate; the incision starts at the coracoid process, which is usually more easily palpable
    • a 10-15 cm incision is usually utilized, but is sized according to surgical need and size of patient
  • Superficial dissection
    • attention must be paid to superficial skin vessels, as these can bleed significantly
    • the deltopectoral fascia is encountered first ; the cephalic vein is surrounded in a layer of fat and is used to identify the interval
    • the cephalic vein can be mobilized either medially or laterally, depending on patient factors and surgeon preference.
    • fibers of the deltoid are retracted laterally and the pectoralis major is retracted medially
  • Deep dissection
    • the short head of the biceps and coracobrachialis arise from the coracoid process and are retracted medially.
      • The musculocutaneous nerve enters the biceps 5-8cm distal to the coracoid process; retraction of the conjoint tendon must be done with care.
    • the fascia on the lateral side of the conjoint tendon is incised to reveal the subscapularis
      • External rotation puts the subscapularis fibers on stretch
    • the subscapularis may be released from its insertion on the lesser tuberosity through the tendon or via an osteotomy
    • the capsule is then incised (as needed) to enter the joint

  • Musculocutaneous nerve 
    • renters medial side of biceps muscle 5-8 cm distal to coracoid (stay lateral)
    • can have neurapraxia if retraction is too vigorous
  • Cephalic vein
    • should be preserved if possible; if injured, can ligate
    • Helpful to be preserved as anatomical landmark in case of revision cases needing same approach
  • Axillary nerve
    • at risk with release of subscapularis tendon (runs distal and medial to) or with incision of teres major tendon or latissimus dorsi tendon (runs proximal to)
  • Anterior circumflex humeral artery 
    • runs anteriorly around the proximal humerus cephalad to pectoralis major tendon

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