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Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Radiographic evaluation (x-ray and MRI)

  • Asess for combined labral lesions
  • asess for glenoid-based, humeral-based, or combined bone loss on dedicated radiographic views or three-dimensional CT scan, with or without subtraction sequences.

2

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Room setup and Equipment

  • beach chair or standard OR table for lateral decubitus position

2

Patient Positioning

  • place in beach chair position
  • pad any prominences of the extremities
  • position the head and neck in neutral alignment
  • ensure the entire scapula is free from the edge of the table place the arm
  • supervises appropriate surgical prep and draping of the field.
G

Deltopectoral Approach

1

Make an incision

  • make the skin incision from the tip of the coracoid extending 4to 5 cm toward the axillary crease
  • take the cephalic vein laterally and ligate the large medial branch

2

Place retractors

3

Dissect down to the deltopectoral interval

4

Perform deltopectoral interval dissection

  • place a self retractor to maintain exposure
  • dissect the interval between the deltoid and the pectoralis major using Mayo scissors
  • abduct and externally rotate the arm
  • place a hohmann retractor on top of the base of the coracoid
H

Harvesting of Coracoid Process

1

Soft tissue dissection around the coracoid

  • maintain the arm in abduction and external rotation to tension the coracoacromial ligament
  • Transect the CA ligament approximately 1 cm from its attachment on the coracoid
  • using a ruler make a mark a minimum 2 cm from the tip of the coracoid
  • partially incise at the same time the coracohumeral ligament lying deep to the coracoacromial ligament
  • free the upper lateral aspect of the superior conjoint tendon
  • adduct and internally rotate the arm to allow exposure of the medial side of the coracoid process
  • release the pec minor from the attachment with electrocautery
  • do not go past the tip of the coracoid to prevent injury to the blood supply
  • use a periosteal elevator to remove any soft tissue from the undersurface of the coracoid
  • this will allow visualization of the “knee” of the corocoid
  • this is the site of the osteotomy
I

Osteotomy and Coracoid Graft Preparation

1

Perform the osteotomy

  • use a 90 degree oscillating saw to make an osteotomy from medial to lateral
  • avoid compromise of the coracoclavicular ligaments at the coracoid base
  • abduct and externally rotate the arm again
  • grasp the coracoid with toothed forceps

2

Release the coracoid

  • remove any remnants of the coracohumeral ligament
  • Perform gentle dissection medial to the conjoint tendon to allow sufficient mobilization, while avoiding iatrogenic injury to the musculocutaneous nerve
  • place the coracoid at the inferior aspect of the wound
  • remove any soft tissue from the coracoid

3

Decorticate the coracoid

  • use an oscillating saw to decorticate the coracoid to expose cancellous bone
  • place an osteotome beneath the coracoid to protect the skin

4

Drill holes

  • place the drill template on the coracoid
  • drill two holes using a 3.2 mm drill
  • place the holes in the central axis of the coracoid about 1 cm apart

5

Position the arm

  • externally rotate the arm keep the elbow by the side

6

Expose the subscapularis

  • release for about 5 cm using mayo scissors
  • push the coracoid beneath the pectoralis major
  • this exposes the subscapularis muscle
J

Subscapularis Split and Capsulotomy

1

Identify the margins of the subscapularis

  • identify the superior and inferior margins of the subscapularis

2

Identify the location of the subscapularis split

  • the location for the subscapularis split is at the junction of its superior two thirds and inferior one third

3

Perform the split

  • use cautery to create the split
  • complete the split using a knife
  • open perpendicular to the plane of the muscle fibers
  • push a small swab into the subscapularis fossa in the superomedial direction
  • place a hohmann retractor on the swab in the subscapularis fossa
  • use a curved retractor on the inferior part of the subscapularis.
  • extend the lateral part of the split with scalpel to the lesser tuberosity

4

Place pin

  • hammer a Steinmann pin into the superior scapular neck as high as possible to increase superior exposure

5

Place hohman retracted

  • replace the medial hohmann retractor with link retractor
  • place this as medial as possible on the scapula neck
  • place a small retractor inferiorly between the capsule on the inferior neck and inferior part of the subscapularis
  • the anteroinferior part of the glenoid should now be easily visualized.

6

Expose the glenoid

  • incise the anteroinferior labrum and periosteum with a knife
  • expose the glenoid 2 cm medially from 5 o’clock to 2 o’clock in a right shoulder (a vertical distance of 2 to 3 cm)
  • place a self retractor to increase exposure of the glenoid

7

Elevate flap

  • use an osteotome to elevate the labral-periosteal flap from lateral to media
  • place a hohmman retractor
K

Anterior Inferior Glenoid Preparation and Graft Insertion

1

Expose the anterior glenoid

  • use a rongeur to expose the anterior inferior glenoid
  • use a oscillating saw to decorticate the anteroinferior surface of the glenoid

2

Create a flap surface to place the graft

  • use a 3.2 mm drill (or 2.5 mm for 3.5 mm screw) the inferior hole in the glenoid
  • this is at the 5 o`clock position parallel to the plane of the glenoid and sufficiently medial that the coracoid will not overhang the glenoid

3

Drill the anterior cortex in anticipation of self-drilling, self-tapping screw fixation

4

Insert the graft

  • retrieve the coracoid from its position under the pectoralis major
  • place the graft in prepared anterior inferior prepared defect using the guide pin placement tool
L

Guide Pin Placement and Screw Insertion

1

Place guidepins

  • after the graft is in the appropriate position place two parallel guide pins

2

Remove the guide pin placement tool

3

Place malleolar screws

  • using a cannulated drilling system, drill over one guidewire
  • place a 4.5-mm partially threaded malleolar screw into the inferior hole (tendinous end).
  • the length of this screw is typically 35 mm but can be verified by adding together the depth of the coracoid and the depth of the glenoid hole
  • place the screw into the already drilled inferior hole
  • tighten into position
  • ensure that the coracoid lies parallel to the anterior border of the glenoid with no overhang
  • make a second drill hole through the superior hole already drilled in the coracoid
  • measure the hole and place a malleolar screw
N

Capsular, Subscapularis Split and Deltopectoral Closure

1

Close the capsule

  • copiously irrigate the wound
  • suture the capsule to the stump of the coracoacromial ligament using number 1 dexon suture with the arm in external rotation

2

Close the subscapularis split

  • close the subscapularis split using non-absorbable suture
  • test the repair by internally and externally rotating the arm
  • optional placement of platelet rich plasma at the graft site

3

Close the deltopectoral interval

  • remove the self retractors
  • close the deltopectoral interval using 0-vicryl

4

Superficial closure

  • close the subcutaneous tissue with 3-0 vicryl
  • close with a singular subcuticular 4-0 monocry suture
  • apply steristrips
  • place prowick sponges that have been primed with liquid betadine over the incisions
Postoperative Patient Care
 

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