HOW TO TELL IF YOU ARE LOST
The main way of getting lost with this approach is being too far anterior or posterior for the pathology you are trying to fix. If the shoulder was arthroscoped prior to the open procedure, a suture can be placed percutaneously into the rotator cuff tear, so you come directly down on the tear. If you are too far superior, you will hit the acromion and that will be obvious.
FIGURE 3–1 The skin incision, which starts 1 cm medial to the edge of the acromion and proceeds distally for approximately 4 cm.
FIGURE 3–2 The subcutaneous tissue split with the deltoid underneath it.
FIGURE 3–3 The deltoid split with the underlying bursa now apparent.
FIGURE 3–4 The bursa split with the rotator cuff visible underneath it.
FIGURE 3–5 The view of the subacromial space when the bursa is resected. The rotator cuff is seen in the bottom of the figure.
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TRANSACROMIAL APPROACH
USES
This approach is used for repair of massive rotator cuff tears that require more exposure than can be obtained with an acromioplasty.
ADVANTAGES
This approach gives an excellent view of the entire supraspinatus muscle and tendon, and of the rest of the rotator cuff as it inserts into the humeral head. It is possible to obtain this wide exposure without stripping the deltoid off of the acromion.
DISADVANTAGES
Because it splits the acromion in two, this approach requires an extra step in the surgery to internally fix the acromion. If the acromion goes on to nonunion, the patient will experience pain with the use of the shoulder.
STRUCTURES AT RISK
The deltoid is split with this approach and if it is split more than 4 cm distally, the axillary nerve is at risk.
If the bone split is too anterior, there is the risk of damage to the clavicle. If it is too posterior, there is the risk of splitting into the spine of the scapula.
TECHNIQUE
The technique is the same as that for the deltoid splitting approach (see Case 3). The incision, however, is carried more medially, usually to the medial aspect of the acromion. This V-shaped space between the posterior aspect of the clavicle and the spine of the scapula is usually easy to palpate. It represents the medial edge of the acromion. The incision is carried down through the subcutaneous tissue. The acromion is palpated. The soft tissues over the acromion are split down to the bone in one layer. A chisel or saw is then used to cut through the acromion. A lamina spreader is used to retract the fragments anteriorly and posteriorly.
Repair of the acromion can be done with small screws if an acromioplasty is not done. If an acromioplasty is done, the anterior acromial piece is usually too thin to hold screws, in which case tension band wires are the most efficient way to solve this problem.
TRICKS
The major trick is to be sure to cut through the acromion in the middle and that this cut does not drift into the lateral clavicle and acromioclavicular joint or posteriorly into the spine of the scapula. This cut is done by feeling the V formed by the posterior border of the clavicle and the anterior border of the spine of the scapula and cutting to the apex of the V.
HOW TO TELL IF YOU ARE LOST
It is practically impossible to get lost with this approach, because the goal of this approach is to split the acromion, which is palpable.
FIGURE 4–1 The deltoid splitting approach, already done. The soft tissues are still overlying the acromion.
FIGURE 4–2 The soft tissues cleaned off of the acromion.
FIGURE 4–3 The acromion split, with the rotator cuff visible.
FIGURE 4–4 The fat around the axillary nerve. At this point we are more than 5 cm distal to the acromial edge.
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SUPERIOR