Rockwood Adults CH34

1100

SECTION TWO • Upper Extremity

A

B

C

D

Figure 34-36.  A: Standard approach to the shoulder is done with a mid-axillary crease incision centered over the coracoid. B: Deltopectoral approach is performed and the coracoid ( circle ) along with the conjoint tendon ( arrow ) is identified. The pectoralis minor is released from the medial aspect of the coracoid and the medial along with the lateral edge of the conjoint tendon is freed up. C: A 90-degree sagittal saw blade is used to harvest the coracoid at the base from the medial to lateral direction. At least 1.5 cm of the coracoid must be harvested for the procedure. D: The undersurface of the coracoid is flattened with a saw, and two holes are predrilled into the coracoid. The authors use 2.7-mm drill bits for the 5-mm partially threaded osteopenia screws (Smith and Nephew, Memphis, TN).

identified in the bicipital groove. The lesser tuberosity is medial to the groove and the greater tuberosity is lateral to the groove. External rotation of the arm will help better expose the sub- scapularis tendon. The authors prefer a horizontal split of the subscapularis at the mid aspect of the muscle belly and tendon. A Cobb elevator is used to peel off the muscle from the anterior capsule. A curved cobra retractor is placed inferiorly into the split to retract the subscapularis and a regular retractor is placed superiorly to further expose the anterior capsule. Posterior-directed force on the humerus will help subluxate the humeral head and better identify the joint line. A vertical capsulotomy is made at the glenohumeral joint with a no. 10 blade. A humeral head retractor is inserted into the glenohumeral joint through

the capsulotomy to retract the humeral head posteriorly. Ante- rior glenoid neck retractor is used to expose the labral tear and glenoid bone loss. A curved cobra retractor is placed inferiorly to the glenoid rim to protect the axillary nerve. A Steinman pin is used superiorly to retract the subscapularis muscle. The pectoralis minor muscle is released from the medial coracoid and the conjoint tendon is freed from the fascia. The CA ligament is resected from the acromion to preserve the entire length of the ligament. A 90-degree oscillating saw is used to cut the coracoid at the base from a medial-to-lateral direction (Fig. 34-36C, blue arrow ). At least 1.5 to 2 cm of the coracoid must be harvested for the procedure. The soft tissues are dissected off the coracoid and the conjoint tendon is also