DELTOPECTORAL APPROACH

USES

This approach can be used for any anterior shoulder surgery, including capsular shift and dislocation procedures, proximal humeral fracture work, shoulder prosthetic replacement, and long head of the biceps tendon repair.

ADVANTAGES

The approach is through an internervous plane between the deltoid and pectoralis major. The incision can be expanded proximally or distally as needed.

DISADVANTAGES

For anterior shoulder surgery, this approach is clearly the best, and it has no significant disadvantages.

STRUCTURES AT RISK

Superiorly, the major structure at risk is the acromial branch of the thoracoacromial artery, which is in the medial aspect of the coracoacromial ligament. Inferiorly, the musculocutaneous nerve comes out and enters the biceps approximately 5 cm distal to the coracoid. This structure is usually not cut, but it can be retracted and damaged with the retraction. The axillary nerve is also at risk. This crosses the inferior aspect of the capsule of the shoulder. A retractor placed below the subscapularis and the capsule puts this nerve in grave danger. The cephalic vein can also be damaged if it is not identified and protected as the deltopectoral groove is being developed.

TECHNIQUE

The incision is in the deltopectoral groove and is usually placed directly over one of the axillary skin folds to provide a more cosmetic incision. If the procedure is a capsular shift procedure, then typically most of the incision will be toward the axilla and hardly noticeable. If a more extensive exposure is needed, the incision can be carried all the way from the clavicle to the deltoid insertion.

When working deep to the subcutaneous tissue, it is important to identify the cephalic vein and the deltopectoral groove. The fascia of these two muscles is conjoined, and so frequently there is a small amount of exploration necessary to find that interval. The clue to finding it is usually an indentation, which is occasionally present, or some fat between the muscles. Another clue is the difference in fiber orientation, with the deltoid being more vertical and the pectoralis major being more horizontal. That difference is usually more apparent distally than proximally.

Once the groove is identified and the cephalic vein is identified, usually it is retracted laterally along with the deltoid. However, it can be retracted medially if it looks like that retraction would require the ligation of fewer tributaries or put less stretch on the vein.