Deltopectoral Approach to Shoulder

What it exposes. The deltopectoral approach is the gold-standard anterior exposure of the shoulder, giving direct access to the anterior glenohumeral joint, the proximal humerus, the subscapularis and rotator interval, and the glenoid. It is the first approach most orthopaedic surgeons learn and the last they use in practice — the internervous workhorse for the majority of shoulder arthroplasties, around 80 percent of surgically-managed proximal humerus fractures, and virtually all open anterior stabilisation procedures. Why it dominates shoulder surgery. Three reasons: 1. A true internervous plane (at muscle level) — deltoid (axillary nerve, C5-C6) versus pectoralis major (medial and lateral pectoral nerves, C5-T1), so no major muscle is denervated. 2. Extensile without consequence — it can be extended from the clavicle to the mid-humerus without crossing a new nerve territory. 3. Subscapularis preservation — direct visualisation allows an anatomic subscapularis repair, which is critical for postoperative stability and function. Indications. The approach serves four broad groups of pathology: - Shoulder arthroplasty (most common) — anatomic total shoulder arthroplasty (glenohumeral arthritis with an intact rotator cuff); reverse total shoulder arthroplasty (cuff-tear arthropathy, massive irreparable cuff tears, proximal humerus fracture sequelae); hemiarthroplasty (4-part and head-split fractures, avascular necrosis in younger patients, glenoid bone loss); and revision arthroplasty (loosening, instability, staged infection).

• Proximal humerus fractures — 3-part (displaced greater tuberosity plus surgical neck with the deltoid origin intact), 4-part (AVN risk 20 to 75 percent), head-split, and fracture-dislocation.
• Anterior shoulder instability — Latarjet coracoid transfer (recurrent instability with significant glenoid bone loss greater than 20 percent), open Bankart repair (failed arthroscopic stabilisation, revision), and capsulorrhaphy.
• Other pathology — isolated subscapularis repair, biceps tenodesis, proximal humeral tumour resection, and debridement of glenohumeral sepsis or hardware infection (staged). Contraindications. Absolute: active infection (unless debridement is the goal) and an inadequate soft-tissue envelope. Relative: pre-existing axillary-nerve palsy or brachial plexus injury (document the deficit preoperatively — retraction may worsen it), previous surgery (scarred planes, higher infection risk), and posterior pathology (the wrong approach — use a posterior exposure).

Anaesthesia — interscalene block. An interscalene block (C5-C6-C7 roots) provides superior early postoperative pain control and is standard of care for shoulder arthroplasty in most centres. It causes 100 percent ipsilateral hemidiaphragm paralysis (phrenic nerve, C3-C4-C5), so it is relatively contraindicated in severe COPD (FEV1 less than 40 percent) or contralateral phrenic palsy — use liposomal bupivacaine field infiltration instead. Pre-operative assessment. Document axillary-nerve function (deltoid power and lateral-arm sensation) and rotator-cuff status (belly-press, bear-hug, lift-off; external-rotation lag) preoperatively. Mandatory imaging is a true AP, scapular-Y lateral and axillary lateral (Velpeau axillary if the patient cannot abduct); CT with 3D reconstruction for fracture pattern, glenoid bone loss and Hill-Sachs impaction; MRI for cuff integrity, labral pathology and Goutallier fatty infiltration.

Work down through the deltopectoral interval, protecting the cephalic vein, then divide the clavipectoral fascia lateral to the conjoint tendon to reach the subscapularis, which is taken down to enter the joint. The axillary nerve is the dominant danger throughout — keep all inferior dissection out of its zone.

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Structures at risk, by layer.

The internervous plane — and the fascial trap. The true internervous plane is between deltoid (axillary nerve, posterior cord) and pectoralis major (medial and lateral pectoral nerves). The subtlety: dividing the clavipectoral fascia lateral to the conjoint tendon sacrifices branches of the lateral pectoral nerve to pectoralis minor — so it is not an internervous plane at the fascial level, only at the muscle level. This matters only as a viva point, because denervating pectoralis minor has no functional consequence. Subscapularis management — the examinable debate.

Postoperative management. Protect the subscapularis repair in a sling for 6 weeks with pendulums and distal-joint ROM only (Phase 1). Progress to passive and active-assisted ROM at 6 to 12 weeks (Phase 2), active ROM and light strengthening at 12 to 24 weeks (Phase 3), and unrestricted function by 6 to 12 months (Phase 4). Return to work: sedentary 6 to 8 weeks, light duty about 3 months, heavy or overhead labour 6 to 12 months. Avoid driving until out of the sling and safely in control (commonly 6 to 12 weeks for dominant-side surgery). Outcomes depend strongly on supervised, protocol-driven rehabilitation and patient compliance.

• Anatomic total shoulder arthroplasty and reverse shoulder arthroplasty — the principal operations; reverse TSA now outnumbers anatomic TSA in most major registries (AOANJRR, NJR England/Wales, AJRR, Nordic).
• Shoulder hemiarthroplasty for proximal humerus fractures (4-part, head-split) and avascular necrosis.
• Revision shoulder arthroplasty — loosening, instability, staged infection.
• ORIF of proximal humerus fractures — 3-part and 4-part patterns in younger patients with good bone (PHILOS locking plate plus heavy suture and anchors).
• Latarjet coracoid transfer and open Bankart repair for recurrent anterior instability with glenoid bone loss greater than 20 percent or failed arthroscopic stabilisation.
• Biceps tenodesis for long-head-biceps pathology and SLAP tears in patients over 40.
• Pectoralis major tendon repair and isolated subscapularis repair.
• Proximal humeral tumour resection and glenohumeral debridement for sepsis (staged).