import { ComparisonTable, ContentSection, EvidenceCard, ExamCheatSheet, ExamPearl, ExamWarning, InfoCard, InfoCardGrid, MedicalImage, MnemonicCard, OnePagerSummary, SafetyAlert, Tab, Tabs, Timeline, TimelineItem, VivaScenario, VivaScenarioSection } from '@/components/mdx' {/* SECTION 1: ONE-PAGER SUMMARY */} {/* SECTION 2: EXAM WARNING */} **Deltoid receives axillary nerve**. **Pectoralis major receives medial and lateral pectoral nerves**. The interval between them is truly internervous - no motor nerves are divided. This is why it is so safe and can be re-entered repeatedly. The **cephalic vein runs in the deltopectoral groove** and is your key landmark. Take it laterally with deltoid (preferred) or medially with pectoralis. Preserving it reduces venous congestion and maintains collateral drainage. The **axillary nerve descends 5cm below the coracoid tip** within the deltoid. Avoid inferior retraction of the deltoid beyond 5cm from coracoid. Use stay sutures on deltoid rather than forceful retraction. The **musculocutaneous nerve enters coracobrachialis 3-8cm distal to coracoid tip** (average 5cm). During deep dissection medial to conjoint tendon, protect this nerve. Avoid aggressive medial retraction of conjoint tendon. {/* SECTION 2.5: QUICK DECISION GUIDE */} {/* SECTION 3: MNEMONICS */} {/* SECTION 4: OVERVIEW */} **The anterior deltopectoral approach** is the workhorse approach to the shoulder. First described by von Langenbeck in 1857, it remains the most versatile and widely used approach for shoulder surgery. Its popularity stems from the fact that it is a true internervous plane, provides excellent exposure of anterior and superior shoulder structures, and can be extended proximally and distally for extensive procedures. **Why this approach is preferred:** - **Internervous plane** - no motor nerves divided, muscles retracted not cut - **Extensile** - can be extended superiorly to clavicle or inferiorly to mid-humerus - **Familiar anatomy** - consistent landmarks make it safe and reproducible - **Reusable** - can be re-entered multiple times without additional risk - **Low morbidity** - minimal functional deficits when performed correctly The deltopectoral approach is a **true internervous plane**. The deltoid is innervated by the axillary nerve (C5, C6), while pectoralis major is innervated by the medial and lateral pectoral nerves (C5-T1). No motor nerves cross the plane of dissection, making it inherently safe. **Primary indications:** 1. **Shoulder arthroplasty** - anatomic total shoulder, hemiarthroplasty, reverse total shoulder 2. **Proximal humerus fracture ORIF** - anatomic neck, surgical neck, tuberosity fractures 3. **Anterior shoulder instability** - open Bankart repair, bone block procedures (Latarjet, Eden-Hybinette) 4. **Rotator cuff pathology** - massive tears, irreparable tears requiring superior capsular reconstruction or graft 5. **Tumor and infection** - biopsy, resection, debridement 6. **Failed arthroplasty** - revision surgery, hardware removal 7. **Fracture nonunion/malunion** - proximal humerus, surgical neck {/* SECTION 5: ANATOMY */} **Surface landmarks:** - Clavicle (palpable along entire length) - Coracoid process (2-3cm inferior to distal third of clavicle, beneath anterior deltoid) - Acromion process (lateral and posterior shoulder prominence) - Deltopectoral groove (depression between deltoid and pectoralis major) **The deltopectoral interval:** The interval between the deltoid and pectoralis major is one of the few true internervous planes in the body. The deltoid is supplied by the axillary nerve (posterior cord, C5-6), while pectoralis major has dual innervation from medial pectoral (medial cord, C8-T1) and lateral pectoral (lateral cord, C5-7) nerves. No motor nerves cross this plane. **Key anatomical structures:** **Vascular anatomy:** The cephalic vein is the most visible vessel in this approach. It arises from the dorsal venous arch of the hand, ascends along the radial forearm and anterolateral arm, then enters the deltopectoral groove and pierces the clavipectoral fascia to drain into the axillary vein. Preservation of the cephalic vein reduces postoperative venous congestion and maintains collateral drainage. **Nerve anatomy:** - **Axillary nerve** (C5, C6) - emerges from posterior cord, travels with posterior circumflex humeral artery through quadrangular space, winds around surgical neck of humerus deep to deltoid. Its anterior branch is at risk approximately 5-7cm inferior to the acromion or 5cm below the coracoid tip. - **Musculocutaneous nerve** (C5, C6, C7) - branch of lateral cord, pierces coracobrachialis muscle 3-8cm (highly variable) distal to coracoid tip, then travels between biceps and brachialis. Can be injured with aggressive medial retraction of conjoint tendon. - **Lateral pectoral nerve** - from lateral cord, enters deep surface of pectoralis major. Protected as muscle is retracted, not divided. {/* SECTION 5.5: INTERNERVOUS PLANE */} The deltopectoral approach utilizes the interval between the **Deltoid** (Axillary Nerve, C5-6) and the **Pectoralis Major** (Medial and Lateral Pectoral Nerves, C5-T1). Because these muscles are supplied by different nerves, the interval can be developed safely without denervating any muscle fibers. This makes it one of the safest and most extensile approaches in the body. {/* SECTION 6: PATIENT POSITIONING */} ### Beach Chair Position (Preferred for Arthroplasty) **Advantages:** - Easy conversion to open if arthroscopy fails - Familiar anatomy orientation - Easy to assess arm position, tension, and stability intraoperatively - Lower risk of brachial plexus injury compared to lateral - Better access for anesthesia The beach chair position is preferred by most surgeons for shoulder arthroplasty and open procedures. **Setup:** Patient supine on standard OR table with beach chair attachment. Back of table elevated 30-45 degrees. Hips and knees flexed for comfort and to prevent sliding. Head secured in padded head holder or ring. Head neutral or slightly tilted to contralateral side. Avoid excessive rotation to prevent cerebral hypoperfusion. Arm free draped and mobile. Place pneumatic arm holder or use assistant/Mayo stand for support during surgery. Arm must be freely mobile for assessment. Pad contralateral shoulder, elbows, sacrum, heels. Check no pressure on peroneal nerve at fibular head if legs positioned laterally. Maintain mean arterial pressure greater than 70mmHg in beach chair position to prevent cerebral hypoperfusion. Risk of watershed infarcts if hypotensive. Communicate with anesthesia if hypotension occurs. ### Lateral Decubitus Position (Alternative) **Indications:** - Arthroscopy with conversion to open - Combined anterior and posterior procedures - Surgeon preference for arthroplasty **Setup:** Patient in true lateral decubitus on beanbag or positioning device. Operative side up. Axillary roll under dependent axilla (protects brachial plexus). Beanbag molded and evacuated. Alternatively use pads and tape. Pelvis and thorax secured with tape or posts to prevent rolling. All bony prominences padded. Arm in 10-15 pounds of balanced suspension or traction, 30-45 degrees abduction, 15-20 degrees forward flexion. Allows arm to hang freely during approach. **Advantages:** - Better arthroscopic view if combined procedure - Gravity assists with glenoid exposure - Lower cerebral perfusion concerns **Disadvantages:** - Less familiar orientation for open surgery - More difficult to assess stability intraoperatively - Risk of brachial plexus stretch with traction Lateral decubitus is most useful for combined arthroscopic and open procedures. {/* SECTION 7: SURGICAL TECHNIQUE */} ### Approach Variations and Extensions **Standard Deltopectoral Approach Variants** ### Subscapularis Management Classification **Classification by Subscapularis Handling** - **Type 1 - Peel**: Tendon released from lesser tuberosity, standard for primary TSA - **Type 2 - LTO**: Lesser tuberosity osteotomy, best healing rates - **Type 3 - Split**: Horizontal split in line with fibers, preserves integrity - **Type 4 - Tenotomy**: Tendon cut, highest failure rate (avoid if possible) **Extensile Options** - Superior extension: Acromion and AC joint access - Inferior extension: Humeral shaft exposure - Medial extension: Brachial plexus, axillary vessels (rarely needed) **Lesser tuberosity osteotomy (LTO)** has 95% healing rate vs 70% for subscapularis peel. Preferred in revision surgery or when subscapularis quality is questionable. Create 5-10mm thick bone wafer, repair with heavy sutures through bone tunnels. ### Preoperative Clinical Assessment **Patient Factors Affecting Approach** - Body habitus: Obesity increases difficulty of exposure - Previous surgery: Scarring, altered anatomy, subscapularis status - Skin condition: Previous incisions, skin quality, radiation - Coagulation status: Anticoagulation management **Physical Examination Relevant to Approach** - Palpate coracoid process for incision planning - Assess deltoid muscle bulk and function - Document preoperative nerve function (axillary, musculocutaneous) - Evaluate subscapularis integrity (belly press, lift-off test) **Range of Motion Assessment** - Document passive and active ROM in all planes - Assess external rotation (subscapularis flexibility) - Note any contractures affecting positioning ### Advanced Clinical Considerations **Nerve Function Documentation** - **Axillary nerve**: Deltoid contraction, lateral shoulder sensation - **Musculocutaneous nerve**: Biceps contraction, lateral forearm sensation - **Document baseline** - essential for comparison postoperatively **Subscapularis Assessment** - **Belly press test**: Internal rotation strength against abdomen - **Lift-off test**: Ability to lift hand off lower back - **Bear-hug test**: Internal rotation strength in flexion - Failed tests suggest subscapularis compromise - affects repair strategy **Skin and Soft Tissue** - Previous incisions: Plan to incorporate or avoid - Thin skin/steroid use: Increased wound complication risk - Irradiated tissue: May require flap coverage **Document baseline nerve function** preoperatively. Postoperative axillary nerve palsy is the most common neurological complication. If you haven't documented preoperative function, you cannot determine if the deficit is new. ### Preoperative Imaging **Plain Radiographs** - True AP (Grashey): Joint space, humeral head position - Axillary lateral: Glenoid version, subluxation - Scapular Y: Acromion morphology **CT Scan** - Glenoid morphology and version assessment - Bone stock for component planning - 3D reconstruction for templating - Fracture pattern delineation **MRI** - Rotator cuff integrity (especially subscapularis) - Fatty infiltration of cuff muscles - Labral pathology for instability ### Advanced Imaging Considerations **CT Planning for Approach** - Assess glenoid vault depth for screw trajectories - Identify anatomical variants - Plan version correction strategy - Virtual templating for implant sizing **MRI for Subscapularis Planning** - Assess subscapularis integrity preoperatively - Fatty infiltration (Goutallier grade) - If subscapularis damaged, may alter approach strategy **Laboratory Investigations** - Routine preoperative bloods (FBC, UEC, coagulation) - If revision: ESR, CRP for infection screen - Aspiration if infection suspected **CT with 3D reconstruction** is mandatory for arthroplasty planning. Assess glenoid version, bone stock, and plan implant positioning. This reduces intraoperative surprises and improves component placement accuracy. ### Approach Selection Considerations **When to Use Deltopectoral Approach** ### Decision-Making for Approach Modification **Subscapularis Management Decision** - Primary TSA with good tissue: Subscapularis peel - Revision or poor tissue: Lesser tuberosity osteotomy - Instability surgery only: Subscapularis split - Damaged subscapularis: Consider pectoralis major transfer at closure **Extensile Modifications** - Superior extension for AC joint or clavicle pathology - Inferior extension for humeral shaft access - Consider alternative approach if posterior pathology primary concern **Conversion Strategies** - If inadequate exposure: Extend incision inferiorly - If posterior access needed: Add posterior approach (rarely needed) - If subscapularis irreparable: Plan salvage procedure The **deltopectoral approach is extensile** in all directions. It can be extended superiorly to the clavicle, inferiorly along the humerus, or combined with other approaches. This versatility makes it the workhorse approach for shoulder surgery. ### Incision **Marking:** - Identify and mark coracoid process (palpate 2-3cm inferior and medial to anterior acromion) - Mark deltopectoral groove (palpable depression when arm slightly abducted) - Incision starts 1-2cm inferior and lateral to coracoid, extends inferiorly in line with deltopectoral groove **Incision length:** - Arthroplasty/extensive reconstruction: 12-15cm - Fracture ORIF: 10-12cm - Limited procedures (instability): 6-8cm The incision should be placed in Langer's lines (parallel to relaxed skin tension lines) when possible, but the priority is following the deltopectoral groove. This typically creates an oblique incision from superolateral to inferomedial. ### Superficial Dissection Incise skin and subcutaneous tissue sharply in line with incision down to superficial fascia. Use cutting diathermy or scalpel. Achieve hemostasis with bipolar cautery. The deltopectoral groove is immediately apparent as a depression with the cephalic vein running within it. The deltoid is lateral (muscular, bulky), pectoralis major is medial (more tendinous superiorly). Identify cephalic vein within deltopectoral fat stripe. Decision: take vein laterally with deltoid (preferred) or medially with pectoralis. Ligate perforating branches but preserve main trunk if possible. Using blunt dissection, develop the interval between deltoid and pectoralis major. This should be avascular and easy to develop. Use finger or gauze to sweep the tissues apart. Taking the cephalic vein **laterally with the deltoid** is preferred. This preserves venous drainage from the arm and reduces postoperative swelling. If the vein is injured, ligate both ends to prevent bleeding and thrombosis. ### Deep Dissection to Subscapularis At the superior extent of the wound, identify and ligate the deltoid branch of the thoracoacromial artery (runs transversely across the groove). This allows superior retraction of deltoid off the clavicle. The clavipectoral fascia will be visible as a white membrane beneath the deltopectoral interval. It extends from the clavicle to the axillary fascia and invests the coracoid muscles. Palpate and visualize the coracoid process superiorly. The conjoint tendon (short head of biceps and coracobrachialis) originates from the coracoid tip and descends as the medial border of the operative field. Incise the clavipectoral fascia lateral to the conjoint tendon, in line with the skin incision. This exposes the subscapularis muscle belly. Avoid aggressive medial dissection to protect musculocutaneous nerve. The subscapularis muscle is now visible, running from the subscapular fossa medially to insert on the lesser tuberosity laterally. The long head of biceps tendon is in the bicipital groove just lateral to the subscapularis insertion. **Critical structures at this level:** - **Musculocutaneous nerve** - enters coracobrachialis 3-8cm from coracoid, stays medial to conjoint - **Axillary nerve** - runs inferior to subscapularis at its inferior border, approximately 5cm below coracoid - **Long head biceps** - in bicipital groove, defines lateral border of subscapularis insertion The **axillary nerve descends approximately 5cm below the coracoid process** within the deltoid. Do not place inferior retractors on deltoid beyond 5cm from the coracoid tip. Use stay sutures on deltoid rather than forceful inferior retraction. ### Managing the Subscapularis The subscapularis is the key to accessing the glenohumeral joint and glenoid. Management varies by procedure: **Indications:** Shoulder arthroplasty, glenoid access Identify the subscapularis tendon insertion on the lesser tuberosity. The bicipital groove and long head of biceps tendon define the lateral border. Release the capsule from the glenoid neck anteriorly. Place stay sutures in subscapularis tendon and capsule for later repair (use different colored sutures for easy identification). Using sharp dissection or electrocautery, peel the subscapularis tendon and capsule as one layer from the lesser tuberosity, leaving a cuff of tissue on bone for repair. Elevate 1-2cm of tendon from the bone. Bluntly develop the plane deep to subscapularis using finger or elevator. The subscapularis lifts off the anterior scapular neck. Internally rotate the arm to relax the subscapularis and improve mobilization. Place stay sutures (heavy nonabsorbable, e.g., Ethibond 2) in medial and lateral aspects of subscapularis tendon. Retract subscapularis medially. The glenohumeral joint is now accessible. **Key points:** - Preserve a cuff of tissue on lesser tuberosity for repair - Tag with stay sutures before releasing - Internally rotate arm to relax subscapularis and improve exposure Subscapularis peel is the most common technique for shoulder arthroplasty. **Indications:** Revision arthroplasty, concern for subscapularis integrity Mark osteotomy site on lesser tuberosity preserving 5-10mm of bone for subscapularis attachment. Keep osteotomy medial to bicipital groove. Use oscillating saw or curved osteotome to perform osteotomy. Create a 1cm thick wafer of bone with subscapularis attached. The osteotomy should be perpendicular to the tendon. Tag the subscapularis-bone unit with heavy sutures. Gently mobilize medially. The subscapularis stays attached to the bone fragment, theoretically improving healing potential. **Advantages:** - Bone-to-bone healing stronger than tendon-to-bone - Useful in revision when subscapularis quality is poor - Preserves subscapularis length and integrity **Disadvantages:** - Risk of fracture propagation - Technically more demanding - Hardware required for fixation at closure (screws, heavy suture through drill holes) Lesser tuberosity osteotomy provides bone-to-bone healing which may be advantageous in revision surgery. **Indications:** Anterior instability surgery, limited exposure Identify the junction of the upper two-thirds and lower one-third of the subscapularis. This corresponds to the middle glenohumeral ligament. Split the subscapularis in line with its fibers at this junction. Use stay sutures to mark the superior and inferior edges of the split. The split typically runs from 1cm medial to lesser tuberosity to the glenoid neck. The axillary nerve runs at the inferior border of subscapularis. Avoid extending the split inferiorly beyond the lower third to protect this nerve. Place retractor carefully at inferior extent. Open the capsule through the split. This provides direct access to the anterior glenoid for Bankart repair or bone block procedures. **Advantages:** - Preserves subscapularis integrity - Faster approach for limited procedures - Easy to close (side-to-side repair of split) **Disadvantages:** - Limited exposure compared to peel - Not suitable for glenoid instrumentation in arthroplasty Subscapularis split is ideal for anterior instability procedures requiring limited exposure. Failure to repair the subscapularis leads to **anterior instability**, **loss of internal rotation**, and **poor functional outcomes**. Always repair the subscapularis anatomically to its insertion site. Use multiple heavy sutures (minimum 3-4 sutures) through bone or tendon. ### Accessing the Glenohumeral Joint After subscapularis management, the capsule is visible. Incise the capsule in line with skin incision (typically T-shaped or L-shaped for arthroplasty). Place stay sutures in capsule for later repair if desired. Externally rotate and extend the arm to deliver the humeral head anteriorly into the wound. For arthroplasty, the head can be dislocated after capsulotomy. For fracture, keep head reduced and mobilize fragments gently. Place humeral head retractor (Fukuda or Darrach retractor) to hold humeral head posterior. Place anterior glenoid retractor (Hohmann or blunt Bankart) over the anterior glenoid rim. The glenoid is now fully visualized. ### Closure After completing the procedure (arthroplasty, fracture fixation, etc.), reduce the shoulder. Assess stability through range of motion. Ensure no impingement or instability. **Critical step:** Repair subscapularis to anatomic position. If peeled: use transosseous sutures or suture anchors through lesser tuberosity. If osteotomy: fix bone fragment with screws or heavy sutures through drill holes. If split: close split side-to-side with interrupted absorbable sutures. Repair with arm at side in neutral rotation. Repair capsule if tagged (optional for arthroplasty if subscapularis repair is robust). Use absorbable sutures (0 or 1 Vicryl). Close clavipectoral fascia with absorbable suture (2-0 or 3-0 Vicryl). This recreates the anatomic layer and reduces dead space. Close deltopectoral interval by allowing muscles to fall back to anatomic position (do not suture muscles together). Close subcutaneous tissue with absorbable suture (2-0 Vicryl). Close skin with subcuticular monocryl or staples. Apply sterile dressing. Place arm in sling or shoulder immobilizer based on procedure (arthroplasty: sling; fracture ORIF: sling +/- pillow for abduction; instability repair: sling in external rotation). Repair the subscapularis with the **arm at the side in neutral rotation**. If repaired with arm externally rotated, the subscapularis will be overtightened and limit external rotation postoperatively. Tension should be snug but not overly tight. {/* SECTION 8: COMPLICATIONS */} The axillary nerve exits the quadrangular space posteriorly, wraps around the surgical neck of the humerus, and gives off its anterior branch approximately **5cm below the tip of the coracoid**. Placing inferior retractors on the deltoid beyond this distance puts direct traction on the nerve. **Prevention strategies:** - **Nerve protection:** Use anatomic landmarks (5cm rule for axillary nerve, avoid medial retraction for musculocutaneous). Place stay sutures on deltoid and retract with sutures rather than metal retractors. - **Subscapularis integrity:** Tag before release, mobilize gently, repair anatomically with multiple sutures. - **Infection prevention:** Standard perioperative antibiotics (cefazolin 2g or vancomycin 15mg/kg), minimize OR time, meticulous hemostasis, layered closure. {/* SECTION 9: EVIDENCE BASE */} ### Postoperative Protocols After Deltopectoral Approach **Immediate Postoperative Care** - Sling immobilization with arm at side - Ice and elevation for swelling - Pain management: Multimodal approach (regional block, paracetamol, NSAIDs) - Wound check at 2 weeks **Rehabilitation Phases** ### Procedure-Specific Postoperative Protocols **After Shoulder Arthroplasty (TSA/RSA)** - Sling 2-4 weeks (TSA) or 4-6 weeks (RSA) - Protect subscapularis: No active internal rotation 6 weeks - Test subscapularis healing with belly press at 12 weeks **After Fracture ORIF** - Sling 4-6 weeks depending on fixation stability - Early passive motion if stable fixation - Serial radiographs to confirm healing **After Instability Surgery** - Sling in external rotation 4-6 weeks (Bankart repair) - Avoid combined extension and external rotation 12 weeks - Return to contact sports 6 months minimum **Red Flags for Early Review** - New neurological symptoms (axillary nerve palsy) - Wound drainage beyond 48-72 hours - Sudden loss of motion (subscapularis failure) **Subscapularis protection** is the key postoperative consideration after deltopectoral approach. No active internal rotation for 6 weeks, test with belly press at 12 weeks. A positive belly press beyond 12 weeks suggests subscapularis failure - order MRI. ### Outcomes of Deltopectoral Approach **Approach-Related Outcomes** ### Procedure-Specific Outcomes via Deltopectoral **Shoulder Arthroplasty Outcomes** - Patient satisfaction: 85-95% - Pain relief: 90% significant improvement - ROM improvement: Average 30-40° increase in forward flexion - 10-year survival: 90% (TSA), 85% (RSA) **Fracture ORIF Outcomes** - Union rate: 85-90% for proximal humerus fractures - Avascular necrosis: 5-15% depending on fracture pattern - Functional outcomes depend on tuberosity healing **Instability Surgery Outcomes** - Recurrence rate: 5-10% for open Bankart - Return to sport: 70-85% - Patient satisfaction: 85-90% **Factors Affecting Outcomes** - Subscapularis integrity: Most important predictor of function - Nerve injury: Axillary nerve palsy impacts deltoid function - Patient factors: Age, activity level, compliance The **deltopectoral approach** is the gold standard anterior approach to the shoulder with a well-established safety profile. The key to good outcomes is subscapularis management and protection of the axillary nerve (5cm rule from coracoid). {/* SECTION 10: VIVA SCENARIOS */} {/* SECTION 11: MCQ PRACTICE POINTS */} **Q: The deltopectoral approach is a true internervous plane between which two muscles and their respective nerve supplies?** A: **Deltoid (axillary nerve, C5-6)** and **pectoralis major (medial and lateral pectoral nerves, C5-T1)**. No motor nerves are divided in this approach, making it safe and repeatable. **Q: What is the key superficial landmark for the deltopectoral approach and what is the preferred management?** A: The **cephalic vein** running in the deltopectoral groove. Preferred management is to take it **laterally with the deltoid** to preserve venous drainage from the upper limb and reduce postoperative swelling. **Q: How far below the coracoid tip does the anterior branch of the axillary nerve descend, and what is the clinical implication?** A: The axillary nerve descends approximately **5cm below the coracoid tip** within the deltoid muscle. Inferior retraction of the deltoid beyond this distance risks axillary nerve traction injury. Use stay sutures rather than rigid retractors. **Q: Where does the musculocutaneous nerve pierce the coracobrachialis muscle and why is this clinically important?** A: The musculocutaneous nerve pierces coracobrachialis **3-8cm distal to the coracoid tip** (average 5cm, but highly variable). Aggressive medial retraction of the conjoint tendon during deep dissection can injure this nerve, causing loss of biceps and brachialis function and sensory loss over lateral forearm. **Q: What are the three main techniques for managing the subscapularis in the deltopectoral approach and when is each used?** A: **1. Subscapularis peel** - peeling tendon off lesser tuberosity (arthroplasty, extensive exposure). **2. Lesser tuberosity osteotomy** - bone-tendon unit preserved (revision arthroplasty, poor tendon quality). **3. Subscapularis split** - horizontal split at junction upper 2/3 and lower 1/3 (instability procedures, limited exposure). Peel and osteotomy are for arthroplasty; split is for instability. **Q: Why is subscapularis repair critical after deltopectoral approach and what happens if it fails?** A: Subscapularis is the primary **anterior stabilizer** and **internal rotator** of the shoulder. Failure to repair leads to **anterior instability**, **loss of active internal rotation**, and **poor functional outcomes**. The subscapularis must be repaired anatomically to the lesser tuberosity with multiple heavy sutures. {/* SECTION 12: AUSTRALIAN CONTEXT */} **Epidemiology:** The deltopectoral approach is the standard approach for shoulder arthroplasty in Australia. According to the **Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)**, shoulder arthroplasty rates have increased significantly over the past decade, with over 5,000 primary shoulder replacements performed annually. **Practice patterns:** - Beach chair positioning is most common in Australian practice - Subscapularis peel is preferred by most surgeons for arthroplasty - Lesser tuberosity osteotomy gaining popularity for revision cases - Standard perioperative antibiotic prophylaxis: cefazolin 2g (vancomycin if penicillin allergic) **Medicolegal considerations:** - Obtain informed consent discussing nerve injury risk (axillary, musculocutaneous) - Document subscapularis repair technique and quality - Discuss risk of subscapularis failure and its consequences - Early postoperative assessment of nerve function with documentation **Training:** The deltopectoral approach is a core skill for orthopaedic trainees in Australia. Competence is expected for Orthopaedic examination and is a requirement for independent practice in shoulder surgery. {/* SECTION 13: EXAM CHEAT SHEET */}

Anterior Deltopectoral Approach to the Shoulder

Anterior Deltopectoral Approach to the Shoulder