**1. Introduction**

Shoulder arthroplasty is becoming an increasingly popular procedure performed for a variety of problems. It has been utilized with great success for advanced degenerative and traumatic conditions of the shoulder [1–5]. Because the shoulder joint is surrounded by vital structures including muscles, nerves, and blood vessels, great care must be taken to ensure safe but adequate exposure to the glenohumeral joint when performing shoulder arthroplasty. To date, the deltopectoral approach [6] and the anterosuperior lateral approach [7] are the two main approaches that have been well described in the literature for access to the glenohumeral joint for shoulder arthroplasty. Each approach offers distinct advantages and disadvantages with

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

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 indications for use, and the advantages of each.

tube should be positioned toward the nonoperative side. A pre-scrub with chlorhexidine, alcohol, and/or hydrogen peroxide may then be performed. Finally, a sterile skin preparation with chlorhexidine may be applied prior to final draping. The final draping should consist of down sheets to cover the head and lower extremities with split drapes or a specialized shoulder drape may be used to isolate the operative shoulder. The distal extremity can be placed in a stockinette and covered with a coban wrap, if preferred. An iodine-impregnated plastic drape or any other sterile adhesive dressing may be used to ensure that the edges of the drape adhere to the skin, ensuring a sterile field through the duration of the case. Prior to skin incision, it is important to administer appropriate antibiotics. Typically, this involves a second-generation cephalosporin such as cefazolin or, if the patient has an allergy to penicillin, clindamycin may be substituted. If preoperative testing indicates that the patient is colonized with methicillin-resistant *Staphylococcus aureus* (MRSA), studies show an increased risk of surgical-site infection [11]. In these situations, it is recommended either to decolonize the patient before the surgery or to give a one-time dose of vancomycin [12]. In addition to antibiotics, pre-incision intravenous administration of tranexamic acid has been shown in multiple studies to decrease intraoperative blood

Surgical Approaches in Shoulder Arthroplasty http://dx.doi.org/10.5772/intechopen.70363 65

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].

The surgeon should begin by palpating the bony landmarks around the shoulder, including the acromion, the clavicle, and the coracoid process. An 8–10-cm incision should be marked out, extending from the lateral margin of the coracoid process and extending down the deltopectoral groove toward the deltoid tuberosity. A scalpel should be used to carry the incision through the skin and the dermal layer. Electrocautery can then be used to address any bleeding in the subcutaneous layer. Dissection can continue through the subcutaneous tissue until the fascia overlying the deltoid and the pectoralis muscles is reached. At this point, careful dissection should be used to identify the interval between these muscles. The cephalic vein may be visualized running in the deltopectoral groove. If it is not evident, often times, a stripe of fat overlying the cephalic vein may be identified and used as a helpful marker for identifying the interval (**Figure 2**). The vein should be freed from the surrounding structures and retracted either medially or laterally, depending on surgeon preference. An anatomic study was performed on 40 cadaveric specimens with latex injection of the cephalic vein.

loss [13, 14]. At this point, skin incision is ready to be made.

**3. Deltopectoral approach**

**3.1. Superficial dissection**
