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Introduction
  • Overview
    • Not frequently used due to the development of arthroscopy
    • Provides exposure to the coracoacromial ligament and supraspinatus tendon
  • Indications
    • Rotator cuff repair
    • Repair of the long head of the biceps
    • Acromioclavicular joint decompression
    • Anterior shoulder decompression
 
Internervous plane & Applied Anatomy
  • Internervous plane
    • None (deltoid split proximally to the axillary nerve)
  • Applied anatomy
    • The deltoid is difficult to repair back to the acromion; limited detachment is recommended.
 
Preparation  
  • Anesthesia
    • general
    • brachial plexus block (interscalene)
  • Position
    • beach chair
  • Tourniquet
    • none
 
Approach
  • Incision
    • An incision is made along the anterolateral edge of the shoulder, generally starting at the coracoid.
  • Superficial dissection
    • The superficial fascia is encountered and incised
    • Superficial vessels are numerous; attention must be paid to these to facilitate visualization
    • The deltoid is then sharply released from the acromion or clavicle, depending on area of surgical need
      • This should be limited, as deltoid repair is often difficult
    • The acromial branch of the thoracoacromial artery must be ligated when encountered deep to the deltoid, near the acromioclavicular joint
  • Deep dissection
    • The coracoacromial ligament is then released from the acromion
      • The ligament can be excised by releasing it from the coracoid as well
    • The subacromial bursa is now seen and can be excised to reveal rotator cuff pathology
 



Dangers
  • Axillary nerve 
    • This nerve runs transversely across the surface of the deltoid muscle approximately 7 cm distal to the acromion
  • Acromial branch of the thoracoacromial artery
    • Runs directly under the deltoid muscle
 
 

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