What are the considerations and potential complications of using the deltopectoral surgical approach for shoulder procedures?

From the Guidelines

The deltopectoral approach is a recommended surgical technique for accessing the shoulder, providing good access to the anterior shoulder, glenohumeral joint, and proximal humerus, and is suitable for procedures like arthroplasty, ORIF of proximal humeral fractures, and Bankart repairs. Key considerations include proper patient positioning in a beach chair or lateral decubitus position, and careful identification of anatomical landmarks including the coracoid process and cephalic vein 1. Potential complications of this approach include injury to the cephalic vein, which should be retracted laterally or medially based on surgeon preference; damage to the axillary nerve, which lies approximately 5-7 cm from the lateral edge of the acromion; and injury to the musculocutaneous nerve when working medially.

Important Considerations

• Patients may experience postoperative stiffness requiring early rehabilitation protocols
• The approach offers limited posterior shoulder access
• Surgeons should maintain meticulous hemostasis throughout the procedure and consider the patient's body habitus, as the approach may be more challenging in obese patients or those with significant musculature
• Postoperative management typically includes appropriate pain control, wound care, and a structured rehabilitation program to optimize functional outcomes According to a study published in the Journal of the American College of Radiology 1, the complication rate for shoulder arthroplasties has been reported to be as high as 39.8%, with revision rates up to 11%. However, another study published in The Journal of the American Academy of Orthopaedic Surgeons 2 recommends total shoulder arthroplasty rather than hemiarthroplasty, which may help reduce the risk of complications.

Potential Complications

• Injury to the cephalic vein
• Damage to the axillary nerve
• Injury to the musculocutaneous nerve
• Postoperative stiffness
• Limited posterior shoulder access
• Challenges in obese patients or those with significant musculature Overall, the deltopectoral approach is a viable option for shoulder procedures, but it requires careful consideration of the potential complications and meticulous technique to optimize outcomes.

From the Research

Considerations of the Deltopectoral Surgical Approach

• The deltopectoral approach is a common surgical procedure for shoulder arthroplasty, but it may require detachment of the subscapularis, which can lead to muscle damage and difficult postoperative rehabilitation 3, 4.
• The approach involves making an incision in the deltopectoral groove and retracting the deltoid muscle and pectoralis major muscle to expose the shoulder joint 4, 5.
• The safe plane for going around the humeral head and positioning retractors is the plane of the subacromial deltoid bursa, and it is essential to stay close to the bone during capsule release 4.

Potential Complications of the Deltopectoral Surgical Approach

• The deltopectoral approach may result in muscle damage, particularly to the deltoid muscle, which can lead to difficult postoperative rehabilitation and deteriorated function 3.
• The approach may also cause injury to the axillary nerve, which can result in numbness, weakness, or paralysis of the deltoid muscle 5.
• Other potential complications include infection, glenoid loosening, acromion fractures, and hematoma 6.

Variations of the Deltopectoral Surgical Approach

• The anterior muscle-sparing (AMS) approach is a variation of the deltopectoral approach that preserves the subscapularis, providing a solution to the problems associated with subscapularis detachment 6.
• The AMS approach has been shown to be a safe and reproducible technique, with potential benefits regarding internal rotation and stability 6.
• Another variation is the combined approach, which consists of a deltopectoral approach in conjunction with a subcutaneously performed lateral deltoid split with a single skin incision 3.

Comparison with Other Surgical Approaches

• The deltopectoral approach has been compared to the Judet approach for glenoid exposure, and it has been found that less than 50% of the glenoid rim can be exposed by either approach 7.
• The superior part of the glenoid fracture is considered inaccessible via the deltopectoral or Judet approach, and a single approach may be difficult to expose and fix some complex glenoid fractures 7.