Introduction Overview Not frequently used due to the development of arthroscopy Provides exposure to the coracoacromial ligament and supraspinatus tendon Indications Rotator cuff repair Repair of the long head of the biceps Acromioclavicular joint decompression Anterior shoulder decompression Internervous plane & Applied Anatomy Internervous plane None (deltoid split proximally to the axillary nerve) Applied anatomy The deltoid is difficult to repair back to the acromion; limited detachment is recommended. Preparation Anesthesia general brachial plexus block (interscalene) Position beach chair Tourniquet none Approach Incision An incision is made along the anterolateral edge of the shoulder, generally starting at the coracoid. 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 Dangers Axillary nerve This nerve runs transversely across the surface of the deltoid muscle approximately 7 cm distal to the acromion Acromial branch of the thoracoacromial artery Runs directly under the deltoid muscle