COMMON SURGICAL APPROACHES TO THE SHOULDER
The deltopectoral approach is most commonly used for major reconstruction of the shoulder for treatment of complex fractures of the proximal humerus or glenoid. It is the most common approach for joint replacement for all indications. The incision is generally 10 to 15 cm in length and is located over the anterior aspect of the shoulder and is centered over the tip of the coracoid. For major reconstructive procedures, the incision is angled from the lateral third of the clavicle toward the insertion site of the deltoid muscle and follows the cephalic vein. The deep part of the approach separates the natural plane between the deltoid and pectoralis major muscles, usually bringing the cephalic vein with the deltoid muscle as it is retracted laterally. Entry into the glenohumeral joint is through the subscapularis tendon and muscle. This can be done by splitting the tendon and muscle fibers from lateral to medial without detachments of the insertion site. This provides exposure of limited procedures. Most of the indications for this approach have been replaced by arthroscopic procedures. Larger reconstructive procedures such as a joint replacement are generally performed by midtendon incision, as shown on Plate 1-58 with a similar incision in the underlying capsule. Alternatively, the subscapularis tendon can be sharply removed from the lesser tuberosity and then sewn back to the position using sutures in the bone. Recent advances have shown better healing and clinical results when the tendon is removed with a thin piece of its bony insertion and then reattached with suture to achieve bone-to-bone healing, which is generally more consistent than tendon-to-bone healing or tendon-to-tendon healing, particularly in older patients who have age-related tendon degeneration.
Most repair and reconstructive procedures are done by arthroscopic techniques. In general, several small 3- to 4-mm incisions (portals) are made for a repair or reconstructive procedure and can be placed in superior, anterior, and posterior aspects of the shoulder. In most reconstructive procedures, multiple portals are used at the same time. At least one portal at any one time is always used for the arthroscope to view the surgical procedure while at least one other is used to pass instruments or devices to modify the tissue and to repair or insert an implant. In general, procedures that are performed within the glenohumeral joint utilize portals in the posterior and anterior joint line for ligament reconstruction, the portal of Wilmington for SLAP repairs, and superior and lateral portals for rotator cuff repair.