**3. Deltopectoral approach**

regard to glenoid exposure as well as technical challenges for component implantation. The aim of this chapter is to describe these two different approaches to the glenohumeral joint, the

The semirecumbent, or beach-chair position, is the optimum position for open approaches to glenohumeral joint. It allows improved orientation for the surgeon, optimal rotational control of the arm, and allows for gravity traction on both the glenohumeral joint and the subacromial space [8]. It is critical that patient positioning allows for stabilization of the scapula to assure proper glenoid orientation. Additionally, equally important is that the patient is placed in a position on the operating table that allows for extension of the shoulder. Failure to recognize this is one of the most commonly made mistakes that can result in difficulty in exposure for both delivery of the proximal humerus out of the surgical wound and adequate exposure of

To begin, the patient should be transferred to the operating table and placed into the supine position for intubation. After successful induction of general anesthesia, the patient should be appropriately positioned on the table while supine in order to allow for the safest and easiest transition to the beach-chair position. While the patient is being elevated into position, the anesthesiologist should maintain cervical support while monitoring the airway. The head support should then be elevated to fit the patient's occiput and secured in place. Care must be taken to ensure that the patient's cervical spine remains in a neutral position as anesthesia literature has shown evidence of cerebrovascular and airway incidents that are felt to be caused by inappropriate cervical positioning and subsequent kinking of the carotid artery or trachea [9, 10]. The head should then be secured to the head support in a secure fashion and the endotracheal

**Figure 1.** Appropriate positioning and preparation of the shoulder. Please note that the operative shoulder is placed off

the edge of the table to allow for extension of the shoulder during the procedure.

indications for use, and the advantages of each.

**2. Positioning and draping**

64 Advances in Shoulder Surgery

the glenoid (**Figure 1**).

The deltopectoral approach is an anterior approach to the shoulder that utilizes the plane between the deltoid and the pectoralis major muscles. It utilizes an internervous plane between the axillary nerve and the medial and lateral pectoral nerves. It is a robust approach to the shoulder as it has been used for fixation of proximal humerus fractures, reconstruction for shoulder instability, access to the glenohumeral joint in the setting of a septic shoulder, and others [15, 16]. When accessing the glenohumeral joint from the deltopectoral approach, the subscapularis tendon lies directly anterior to the joint capsule. It must be released to access the joint and there are a variety of methods for doing so which will be described in this chapter [17–19].
