alt="Image"/> Rotator Cuff Tendon
4
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 APPROACH TO THE SUPRASCAPULAR NERVE
USES
This approach is used primarily to release the suprascapular notch in cases of suprascapular nerve entrapment. It also allows exposure of the lateral portion of the trapezius and the supraspinatus muscle belly.
ADVANTAGES
By approaching the nerve from the posterior side, we avoid all the vascular structures anteriorly and the brachial plexus. Also, this approach allows the branch of the nerve to the infraspinatus to be freed simply by taking the posterior deltoid off of the spine of the scapula and coming down onto the region of the nerve.
DISADVANTAGES
For the purposes for which it is intended, this approach does not have disadvantages.
STRUCTURES AT RISK
Posteriorly, there are no significant structures at risk. The trapezius is lifted off of the spine of the scapula subperiosteally to promote the ease of the repair. If the repair of the trapezius is not done carefully, the potential for its avulsion exists.
The suprascapular artery will not uncommonly pass superior to the suprascapular ligament while the nerve goes underneath it. You cannot indiscriminately release the ligaments until you are sure that there is no artery at risk. If there is, be sure to gently retract it out of the way before releasing the ligament.
TECHNIQUE
The incision is made just superior to the scapular spine and typically is 6 or 7 cm in length. You go through the subcutaneous tissue until you encounter the fascia overlying the trapezius muscle. Palpate the spine of the scapula and strip the trapezius muscle along with its periosteum off of the scapula. As you are moving anteriorly through the trapezius, be aware of the orientation of the fibers. When you come to the fibers running medially and laterally, you are looking at the supraspinatus muscle and you want to stay on top of that muscle. Strip as much trapezius as necessary to obtain adequate visualization.
Once the supraspinatus is clearly in view, palpate the base of the
