Anterolateral Approach to the Shoulder

Anterolateral Approach to the Shoulder offers excellent exposure to the acromioclavicular joint and the coracoacromial ligament and supraspinatus tendon, and it’s used for:

1. Rotator cuff repair.
2. Repair of the long head of the biceps.
3. Acromioclavicular joint decompression.
4. Anterior shoulder decompression.

The use of arthroscopic subacromial decompression has reduced the use of this approach in the treatment of impingement syndrome and for some cases of rotator cuff repair.

Anterolateral approach to the shoulder, however, remains clinically relevant in large numbers of cases involving extensive degenerative disease of the rotator cuff.

Position of the Patient

The patient is Placed in the supine position on the operating table in a beach chair position, with a sandbag under the spine and medial border of the scapula to push the affected side forward.

Landmarks and Incision

Landmarks:

• Coracoid Process.
• Acromion.

Incision:

Make a transverse incision that begins at the anterolateral corner of the acromion and ends just lateral to the coracoid process.

Internervous plane

There is no internervous plane for the anterolateral approach to the shoulder (deltoid split proximally to the axillary nerve).

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.

Approach Extension

The Anterolateral Approach to the Shoulder can’t be extended proximally or distally.

Dangers

Structures at risk during shoulder anterolateral approach include:

1. Axillary nerve: This nerve runs transversely across the surface of the deltoid muscle approximately 7cm distal to the acromion.
2. Acromial branch of the thoracoacromial artery: it runs directly under the deltoid muscle

References & More

1. Surgical Exposures in Orthopaedics – 4th Edition
2. Mouraria GG, Zoppi A, Kikuta FK, Moratelli L, Cruz MA, Etchebehere M. ANTEROLATERAL APPROACHES FOR PROXIMAL HUMERAL OSTEOSYNTHESIS: A SYSTEMATIC REVIEW. Acta Ortop Bras. 2019 May-Jun;27(3):178-182. doi: 10.1590/1413-785220192703215572. PMID: 31452617; PMCID: PMC6699402.
3. Hettrich CM, Paul O, Neviaser AS, Borsting EA, Lorich DG. The anterolateral approach to the proximal humerus for nonunions and delayed unions. Int J Shoulder Surg. 2011 Jan;5(1):21-5. doi: 10.4103/0973-6042.80466. PMID: 21660194; PMCID: PMC3109769.
4. Kongcharoensombat W, Wattananon P. Risk of Axillary Nerve Injury in Standard Anterolateral Approach of Shoulder: Cadaveric Study. Malays Orthop J. 2018 Nov;12(3):1-5. doi: 10.5704/MOJ.1811.001. PMID: 30555639; PMCID: PMC6287134.