Rockwood Adults CH34

1122

SECTION TWO • Upper Extremity

A

B

C

D

Figure 34-46.  A: Deltopectoral approach for open capsular shift. Bicipital groove is identified ( arrow ) and subscapularis tenotomy is performed 1 cm medial ( star ) to the tendon insertion to allow for repair at the end of the case. B: The capsule ( blue arrow ) is separated from the subscapularis muscle belly ( yellow arrow ) and tagged with sutures. Shoulder link retractors are used for the exposure. A Fakuda is inserted into the glenohumeral joint to help retract the humeral head posteriorly. A “T” capsulotomy is performed with either a small residual tissue from the humeral insertion or directly off the humeral insertion. C: Suture anchors with no. 2 braided sutures are inserted into the humeral head at the original insertion of the cap- sule to perform the shift. D: The sutures are passed into the capsule with 90-degree passers with the arm in abduction (20 to 30 degrees) and external rotation (20 to 30 degrees). It is essential to keep the arm in this position when tying down the sutures so that the shoulder is not constraint and to prevent stiffness.

The deltopectoral interval is identified and opened with the cephalic vein taken laterally. The pectoralis major tendon can be tenotomized at the upper 1 cm to ease visibility if needed and then repaired at the conclusion of the case. The clavipectoral fascia is incised just lateral to the muscle fibers of the conjoint tendon. The conjoint tendon is then retracted medially, taking care to not place undue strain on the underlying musculocuta- neous nerve. Superior exposure can be improved by identifying and debriding the anterior-lateral aspect of the CA ligament. The bursa covering the subscapularis is then resected for better

visualization. The upper and lower borders of the subscapularis are identified. The anterior humeral circumflex artery and two veins that accompany it (the three sisters) are identified. The subscapularis can then be tenotomized approximately 1 cm medial to its insertion ( star ), leaving an adequate cuff of tissue for later repair (Fig. 34-46A). The biceps tendon (Fig. 34-46A, arrow ) is an excellent landmark to help identify the loca- tion of the subscapularis tendon. The subscapularis (Fig. 34-46B, yellow arrow ) must then be dissected from the underlying cap- sule (Fig. 34-46B, blue arrow ). This is most easily accomplished