2. INTRODUCTION
• Also known as Deltopectoral approach
• Fairly extensile exposure – gives access to the anterior, medial and lateral
aspects of the shoulder
• Can extend distally to include the anterior approach to the humerus.
3. INDICATIONS
• Shoulder arthroplasty
• Proximal humerus fractures
• Reconstruction of recurrent dislocations
• Injury to long head of the biceps – repair
• Septic glenohumeral joint – drainage
• Biopsy and excision of tumours
6. Blood supply around humeral head
The current concept is that the antero-lateral branch of
the anterior circumflex humeral artery is the main
blood supply to the head of humerus
It runs horizontally between the coracobrachialis and
short head of biceps- brachii muscle in front of neck of
humerus
9. POSITION OF THE PATIENT
• Beach chair position – patient lying supine with head end of the table
elevated by 30-45 degrees
• Sandbag under the spine at the medial
end of the scapula
10. Landmarks
• Coracoid process
– Lies 2.5 cm distal to the point of maximum concavity of the distal clavicle
– Directed anterolaterally and covered by Pectoralis major
• Deltopectoral groove
– Look for cephalic vein which runs in this groove
– Easily seen in thin patients, but difficult in obese individuals
11. INCISION
• 10 - to 15 cm linear incision is made along the deltopectoral groove
• Begins just above the tip of
coracoid process
The incision is sized according to
surgical need of the patient
12. Superficial dissection
• Superficial skin vessels can bleed
significantly – cauterize
• Deltopectoral fascia is
encountered first
• Cephalic vein is the landmark to
identify the deltopectoral interval
13. Superficial dissection
• Mobilize the cephalic vein either medially or laterally
• Deltoid fibers are retracted laterally and fibers of pectoralis major are
retracted medially
14. deep dissection
• Conjoint tendon of short head of
biceps and coracobrachialis arise
from the coracoid process –
retracted medially
• Musculocutaneous nerve enters
the biceps 5-8cm distal to the
coracoid process – conjoint tendon
to be retracted with care
15. deep dissection
• Fascia lateral to the conjoint tendon is cut to expose the subscapularis tendon
• External rotation of the shoulder makes the subscapularis tendon taut and
pulls it away from the axillary nerve, which travels through the quadrangular
space
16. deep dissection
• Subscapularis tendon can be mobilized either by incising the tendon
perpendicular to its fibers or by releasing its insertion on the LT
subperiosteally or via osteotomy
18. Enlargement of exposure
• Extend the skin incision proximally along the clavicle and distally along the
deltopectoral groove
• Release deltoid either from its origin from the clavicle or from its insertion on
the humerus
• Partial detachment of pectoralis major tendon from its insertion
• Use of suitable retractors – Bankart skid for manipulation of humeral head
• Internal and external rotation of shoulder to expose the different areas of the
joint
20. Advantages of this approach
• It is an inter-nervous and inter-planar approach(Between deltoid
and pectoralis major)
• It preserves the origin of the muscles
• Less bleeding is observed
• Approaching the glenohumeral joint from the front allows for
easier access to the inferior structures, including the inferior
humeral osteophytes and the inferior capsule
• Positioning of the glenoid component is also easier with this
approach as the inferior portion of the glenoid is more readily
available.
21. Disadvantages
• The delto-pectoral approach to the shoulder requires the
release of the subscapularis tendon with subsequent repair;
however, it is not uncommon for these repairs to fail, leading
to a risk of instability in these patients
• Difficulty reaching the more posterior structures including the
glenoid, capsule, and greater tuberosity.
• Delto-pectoral approach is an independent risk factor for
neurologic complications in total shoulder arthroplasty
22. DANGERS
• Musculocutaneous nerve – Neurapraxia if conjoint tendon is retracted
vigorously
• Cephalic vein – has to be preserved, works as landmark in case of reversion
surgeries. Can be ligated if injures
• Axillary nerve – can be injured while incising the subscapularis tendon
– Can be avoided by external rotation of the shoulder
• Anterior circumflex humeral artery – runs anteriorly around the proximal
humerus proximal to pectoralis major tendon and so may be injures easily
