A comparative study in the functional outcomes after conventional Deltopectoral approach vs. anterior deltoid split approach for fixation of proximal humerus fractures

Abstract

Background

Proximal humeral fractures represent 4%-5% of all fractures, with increasing frequencies in the geriatric population due to conditions such as osteoporosis and high-velocity injuries. Treatment options vary based on factors like age, bone quality, fracture complexity, and surgical expertise. Management may involve conservative methods or surgical procedures, such as open reduction and internal fixation using Proximal Humerus Interlocking Osteosynthesis (PHILOS) plates. The choice of approach depends on the fracture fragments and their displacement. This study compares the functional outcomes of 2 surgical approaches: ‘The Conventional Deltopectoral approach and the Anterior Deltoid split approach’, postoperatively at a 1 year follow-up measured using Neer's Criteria.

Methods

This prospective observational study was conducted at a tertiary care hospital from April 2021 to November 2022. It included 40 patients with displaced proximal humerus fractures, equally divided into 2 groups: 1 treated with the conventional Deltopectoral approach, and the other with the Anterior Deltoid split approach. All patients underwent fixation with PHILOS. Functional outcomes were assessed at 4 weeks, 3 months, 6 months, 9 months, and finally at 1 year using Neer's criteria.

Results

Patients had similar functional outcomes at the 1-year follow-up in both groups. The Anterior Deltoid split approach had advantages such as less intraoperative blood loss and better early functional scores due to minimal soft tissue dissection. However, it involved a longer operative time than the Deltopectoral approach. The Deltopectoral approach provided a wider surgical field and was more effective for treating anterior dislocations. The Deltopectoral approach had a higher risk of humeral head necrosis, likely due to extensive soft tissue disruption, whereas the deltoid split approach better preserved blood supply, reducing risk of avascular necrosis. The deltoid split approach was ideal for posterior comminution, posterior fracture dislocations, and utilized an avascular plane, while the Deltopectoral approach was preferred for medial calcar comminution, anterior fracture dislocations, and followed an internervous plane.

Conclusion

Both the Deltopectoral and Anterior Deltoid split approaches are effective in managing proximal humerus fractures, with no significant differences in long-term functional outcomes. The choice of approach should depend on the surgeon's familiarity with the technique, specific fracture characteristics, and the need to minimize soft tissue damage to enhance recovery and reduce the chances of avascular necrosis. This study suggests that either approach can provide satisfactory functional results in open reduction and internal fixation with PHILOS plating for proximal humerus fractures.

Proximal humerus fractures are defined as fractures occurring at or proximal to the surgical neck of the humerus. They are the most common fracture affecting the shoulder girdle in adults, and their incidence is rising.⁹ Proximal humerus fractures constitute 4%-5% of all fractures and 45% of all humerus fractures.⁶ Females are more commonly affected than males in a ratio of 2:1.⁶ The average incidence of proximal humeral fractures in females above the age of 40 years and males above the age of 60 years increases at a rate of 40% every 5 years.⁹ Due to the increase in high velocity trauma, there is an increased incidence of displaced proximal humerus fractures. These fractures occur more commonly in elderly patients, after the cancellous bone of the humeral neck has been weakened by osteoporosis, but these fractures are also seen in patients of all ages and may merge with epiphyseal separations. The most serious fractures and fracture dislocations are often seen in active, middle-aged patients.¹¹ These fractures can be extremely disabling, and their management often demands experienced surgical skills and judgment.²¹ The preferred treatment varies depending on the patient's age, bone quality, the surgical expertise of the team, and the patient's expectations. Although several reports have described the outcome of treatment of proximal humeral fractures, comparison of these fractures is hampered by the inconsistency in fracture classification, treatment, and the evaluation methods.² The object of osteosynthesis is to reduce the displacement (usually rotation) of each fragment and hold it in place with an implant.¹³ Neer recommended open reduction and internal fixation (ORIF) for displaced 2- and 3-part fractures.²⁰

In this study, the Conventional Deltopectoral approach and the Anterior Deltoid Split approaches were chosen for Proximal Humerus Interlocking Osteosynthesis (PHILOS; Johnson & Johnson MedTech, New Brunswick, NJ, USA) plating and fixation of proximal humerus fractures. While dissecting in the region of the proximal humerus, the following structures should be kept in mind to prevent injury to these structures during dissection and fracture reduction: cephalic vein, anterior circumflex humeral artery, ascending branch of anterior circumflex humeral artery, posterior circumflex humeral artery, musculocutaneous nerve, and axillary nerve.¹²

The Deltopectoral approach utilizes an internervous plane between the deltoid muscle, supplied by the axillary nerve, and the pectoralis major muscle, which is supplied by the medial and lateral pectoral nerves.^8,12,27

The Anterior Deltoid Split approach is also known as the Anterolateral approach or the Mackenzie approach to proximal humerus. The skin incision lies in a straight line extending from a point just posterior to the acromioclavicular joint for a distance of 9 cm. This approach utilizes an avascular plane between the clavicular part and the acromial part of the deltoid muscle, ie, the interval between the A3 and M1 fibers of the deltoid as described by Sakoma et al.²⁴ This incision does not extend 5 cm distal to the lateral edge of the acromion, as the axillary nerve lies 1 cm below the distal extent of this incision. This is a relatively avascular plane, as it lies away from the anterior and posterior circumflex humeral arteries.^{8,10,12,24,26} In this approach, excessive strong retraction in the region of the inferior part of the deltoid split can cause damage to the axillary nerve, which lies just below the distal extent of the deltoid split. This can cause denervation of the anterior fibers of the deltoid muscle.¹⁹ This study aims to compare the 2 approaches on the basis of the intraoperative blood loss, surgical time, Neer's score, and postoperative pain-free status on day 1, at 1 month, 3 months, 6 months, and 1 year follow-up.

Material and methods

Study design

This is a prospective observational comparative study involving 40 patients operated in a tertiary care hospital. The sample population is divided into 2 groups consisting of 20 patients each, based on the approach used for fracture fixation–namely, the Conventional Deltopectoral approach and the Anterior Deltoid Split approach.

Source of the data

The subjects of the study were the patients admitted to the hospital with displaced proximal humerus fractures meeting the inclusion criteria. Information on the patients was compiled from history at presentation, case sheets, operation theater notes, and follow-up records. The following are the inclusion and exclusion criteria.

Inclusion criteria

• 1.Age >18 years.
• 2.Patients diagnosed with proximal humerus displaced fractures (2-, 3-, or 4-part displaced fractures) on clinical and radiological evaluation.

Exclusion criteria

• 1.Open fractures.
• 2.Pathological fractures.
• 3.Medically unfit or unwilling to undergo surgery.
• 4.Pre-existing deltoid muscle paralysis or axillary nerve injury.
• 5.Pre-existing neuromuscular deficit.

The patients were operated on in the hospital with ORIF using the PHILOS plate, by the approach chosen by the operating surgeon. Their function on follow-up was assessed and recorded at regular follow-ups. The final assessment of functional outcome was compared at 1 year follow-up using Neer's score. Neer's score uses a scoring system with categories such as pain, functional performance of the shoulder with respect to activities of daily living, range of movement, and anatomy of the united fracture at follow-up, with a maximum score of 100.⁵

Study duration

The study duration was from April 2021 to November 2022.

Sample size calculation

Sample size was calculated on the basis of the following formula:

$$\mathrm{N}=\frac{{2\mathrm{x}\left(\mathrm{Z}\alpha +\mathrm{Z}\beta \right)}^2}{{\Delta }^2}$$

where

$$\Delta =\frac{{\mathrm{P}}_1–{\mathrm{P}}_2}{\surd ˉ\mathrm{P}ˉ\left(1-ˉ\mathrm{P}ˉ\right)}$$

and

$$ˉ\mathrm{P}ˉ=\frac{{\mathrm{P}}_1+{\mathrm{P}}_2}{2}$$

Significance level 5% = 1.96 i.e. Zα.

Power of study 90% = 1.2816 i.e. Zβ.

P1 = expected number of patients in the Deltopectoral group.

P2 = expected number of patients in the Anterior Deltoid split group.

Based on the studies quoted as references for the sample size calculation.

These values when applied on the study of Mehmet Fatih Korkmaz et al; The Turkish Journal of Trauma and Emergency Surgery (TJTES) 2015¹⁷ and Vipin Sharma et al; Journal of Orthopaedics, Trauma and Rehabilitation (JOTR) 2019,²⁵ the sample size is, N = 32.178686.

Considering 10% drop in patients, we took 40 samples for this study.

Sample size

Forty patients were operated on in a single tertiary care hospital by 2 orthopedic surgeons, attached to the hospital, between April 2021 and November 2022. The patients were divided into 2 groups of 20 each, depending on the approach used for fixation of proximal humerus fractures.

Conduct of study

Patients with proximal humerus fractures were admitted to the hospital. After obtaining proper informed consent, all necessary clinical details were recorded in a trauma sheet, comprising the following:

• 1.A detailed history of the patients and the attendants with mode of injury.
• 2.Thorough local and systemic examination. A secondary survey was conducted to assess other bone injuries, neurovascular status, and musculotendinous injuries, for any swelling and deformity of the shoulder, circulatory status with distal pulses in the affected limb, sensation in the shoulder and arm for assessing axillary nerve function, and the condition of the skin.
• 3.They were diagnosed both clinically and radiologically. Radiographic evaluation of the shoulder was done according to Neer's trauma series which consists of the following: A true anteroposterior view of the scapula and an axillary view of the shoulder. In addition, imaging in the form of computed tomography scan was done if required to better delineate fracture anatomy.²⁶
• 4.Fractures were classified according to the Neer's classification,⁴ and patients were shifted to the ward after initial temporary immobilization using a universal shoulder immobilizer on the affected shoulder.
• 5.
  Routine preoperative investigations were conducted on all the patients for achieving complete medical and anesthesia fitness for surgery. The following factors were considered when deciding on the treatment modality:

  • 1.
    Neer's classification 2-, 3-, or 4-part fracture with associated displacement.
  • 2.
    Presence of humeral head dislocation
  • 3.
    Humeral head comminution.
  • 4.
    Valgus impaction.
  • 5.
    Comminution at the medial cortex of the humeral neck-shaft junction.
  • 6.
    Quality of bone.
  • 7.
    Open fracture.
  • 8.
    Age of the patient.
  • 9.
    Associated general and medical conditions of the patient.
  • 10.
    Other associated lesions, eg, brachial plexus palsy and fractures of other bones.
  • 11.
    Functional requirements of the patient.¹⁴

Surgery was performed under antibiotic cover, and analgesics were administered. The approach to the proximal humerus was based on the surgeon's preference and the fracture anatomy. Postoperatively, patients were given intravenous antibiotics and analgesics on postoperative day 0 and 1 which were later converted to oral antibiotics and analgesics for 5 days after discharge. Wound check was done on postoperative day 2 and day 5. Suture removal was done between postoperative days 12 and 14.

Postoperative rehabilitation protocol

Patients were given a universal shoulder immobilizer for 6 weeks postoperatively, after which gradual progression of physiotherapy was done. If the fracture pattern and stability of fixation were found to be satisfactory by the operating surgeon, passive range of motion exercises were started between 2 to 4 weeks after surgery with forward elevation, external rotation, and pendulum exercises. At 6 weeks postsurgery, if clinical and radiological healing were found to be satisfactory, then active-assisted range of motion exercises were started.¹¹,²¹

Follow-up

Patients were asked to follow-up at regular time intervals at 4 weeks, 3 months, 6 months, 9 months, and 1 year after surgery. Results and complications were assessed at the 1-year follow-up, and data were recorded according to the Neer's Criteria for Evaluation of Results.⁵

Neers score for evaluation of results

Neer's score was used in all our patients to assess functional outcomes following proximal humerus fracture fixation using PHILOS plating at 1-year follow-up.⁵

Primary end parameters

• 1)Evaluation of patients' functional outcome at follow-up periods of 1 month, 3 months, 6 months, and 1 year according to Neer's score
• 2)Reduction of fragments obtained intraoperatively.
• 3)Intraoperative blood loss and surgical time associated with these approaches.
• 4)Postoperative pain free status postsurgery and day 1 visual analog scale (VAS) scores.

Results

There was an early return of range of motion in the Anterior Deltoid Split group postoperatively at 3 months follow-up especially with respect to forward flexion and extension. An early return of Deltoid muscle function was also seen in the Anterior Deltoid Split group. The range of motion for abduction, adduction, internal, and external rotation was found to be comparable in both groups. At 1-year follow-up, the range of motion in both groups were found to be similar. Intraoperative blood loss was lower in the Anterior Deltoid Split group, whereas the operative time was shorter in the Deltopectoral group. Table I shows the average blood loss and surgical time measured intraoperatively in both the approaches. The blood loss in the deltopectoral group was higher and the average surgical time in the Anterior Deltoid Split group was higher.

Table I.

Comparison of average blood loss and surgical time between the 2 groups.

Group	Average of blood loss	Average of surgical time
Deltoid split	117	209
Deltopectoral	140	144
Grand total	128	176

The average blood loss was found to be more in the deltopectoral group and the average surgical time was found to be higher in the deltoid split group.

Radiographic assessment was done postoperatively on follow-up x rays and commented on for varus collapse, avascular necrosis of humeral head, screw cut outs, and hardware failure complications. Out of all the patients included in this study, only 1 patient in the Conventional Deltopectoral group underwent Humeral head necrosis and 1 had malreduction. In the Anterior Deltoid Split group, no patients had evidence of humeral head necrosis, loss of reduction, or nonunion on serial radiographs. There was no residual neurological deficit in any of the patients included in our study. The postoperative pain-free period was achieved 1 month earlier in the Anterior Deltoid Split group compared to the Deltopectoral group, with majority of the patients achieving pain-free status 3 months postoperatively. These findings and data have been summarized in Table II and Figure 1, respectively.

Table II.

Comparison of postoperative pain free status postsurgery.

Postoperative period in months	Anterior deltoid split	Deltopectoral	Grand total
1 month	11	6	17
3 months	8	12	20
6 months	0	1	1
Still painful	1	1	2
Grand Total	20	20	40

Anterior Deltoid Split group showed earlier pain free status at 1 mo follow-up compared to the deltopectoral group.

Figure 1.

Comparison of pain free status postsurgery. X axis–postoperative period in months, Y axis–number of patients. In this comparative bar chart, we can see that the pain free status postsurgery is better for the Deltopectoral approach group in the first month and steadily decreases, while for the deltoid split group, it is quite high in the early postoperative period compared to the Deltopectoral group and that can be attributed to the splitting of the deltoid in the former approach.²⁷

Comparison of postoperative day 1 VAS

An assessment and comparison of the 2 groups for postoperative day 1 VAS for pain was carried out using unpaired t-test, with a P value of < .05 considered to be statistically significant.

The P value on analysis was found to be .0150, and hence patients in the Anterior Deltoid Split group were less painful on postoperative day 1 compared to the patients in the Conventional Deltopectoral group.

Confidence interval

The mean of Deltopectoral group minus Anterior Deltoid Split group equals 1.55. Ninety-five percent confidence interval of this difference was from 0.32 to 2.78. The values for the mean and standard deviation of postoperative day 1 VAS are stated in Table III.

Table III.

Comparison of mean and standard deviation of postoperative day 1 VAS (visual analog scale).

Group	Anterior deltoid split	Deltopectoral
Mean	3.15	4.70
Standard deviation	1.60	2.20
Number	20	20

This data show that the postoperative day1 VAS, was consistently lower in the Anterior Deltoid Split group compared to the deltopectoral group.

Comparison of Neer’s score analysis between the 2 groups

A preliminary analysis of functional outcome in both the groups based on Neer's score revealed more failures in the Conventional Deltopectoral group compared to the Anterior Deltoid Split group. Table IV states the values for mean and standard deviation in Neer's score of both the groups on 1-year follow-up and Table V along with Figure 2 states the values of Neer's score in both the groups with the number of patients in each outcome category for Neer's score. An unpaired t-test was carried out to check the statistical significance of the difference in functional outcome between the 2 groups with P value < .05 taken as significant. On analysis with unpaired t-test, it was found that the P value was .1564, and hence was found to be statistically nonsignificant. Therefore, there is no difference in functional outcome between the 2 groups.

Table IV.

Comparison of mean and standard deviation of Neer's score on 1 yr follow-up.

Group	Anterior deltoid split	Deltopectoral
Mean	82.60	73.90
Standard deviation	15.63	21.91
Number	20	20

The Anterior Deltoid Split group had higher Neer's scores compared to the Deltopectoral group at 1 yr follow-up.

Table V.

Comparison of Neer's score on 1 yr follow-up between the 2 groups.

Neer’s score	Anterior deltoid split	Deltopectoral	Grand total
Excellent (>90)	6	6	12
Satisfactory (80-89)	10	5	15
Unsatisfactory (70-79)	1	3	4
Failure (<70)	3	6	9
Grand total	20	20	40

The number of patients having excellent and satisfactory outcomes are higher in the Anterior Deltoid Split group whereas the number of patients with low outcomes are higher in the deltopectoral group.

Figure 2.

Comparison of Neer's score analysis between the 2 groups. X axis– Neer's score categories, Y axis–number of patients. Here, we can see that the number of patients having excellent and satisfactory outcomes are more in the Deltoid split group, and conversely the number of patients having unsatisfactory outcomes and failures are more in the Deltopectoral group.

Confidence interval

The mean of Deltopectoral group minus Anterior Deltoid Split group equals −8.70.

Ninety-five percent confidence interval of this difference: −20.88 to 3.48.

Table V Comparison of Neer's score on 1 year follow-up between the 2 groups. The number of patients having excellent and satisfactory outcomes are higher in the Anterior Deltoid split group, whereas the number of patients with low outcomes are higher in the deltopectoral group.

These were the results of our study when compared with statistics and functional outcome analysis between the 2 groups.

Discussion

Proximal humerus fractures have become increasingly more common in the elderly age group owing to increased life expectancy, osteoporosis, and generalized poor nutrition in the elderly leading to fractures following trivial trauma or fall.³ Males are more commonly involved compared to females as they are exposed to more activities outside the house and are more often seen commanding motor vehicles which lead to high velocity trauma and fracture in the nonosteoporotic younger population.² Once diagnosed with a proximal humerus fracture, it is necessary to understand the fracture anatomy and the mechanism of injury in order to guide reduction and fixation of the fracture fragments.

Patients with 2-, 3-, and 4-part fractures of the proximal humerus were included in this study. About 85% of proximal humerus fractures are amenable to conservative management.²⁵ The rest (15%) require surgical intervention for which various modalities like closed reduction with K wire fixation, ORIF with PHILOS plate fixation, hemiarthroplasty, and shoulder replacement surgeries are available.¹⁶ With the advent of PHILOS plates and their proven efficacy in holding and maintaining reduction in osteoporotic bones, head conserving surgeries with ORIF and PHILOS plating are given preference over replacement surgeries following complex trauma with complex fracture anatomy.^23,25

Apart from the surgical aspect of treatment, the rehabilitation aspect is just as important to achieve a good functional outcome. Despite having a good reduction on table, if the patient does not adhere to a strict rehabilitation protocol, they will land up with painful, stiff shoulder movements, and low functional outcome.^15,18

The most important factor in assessing recovery following ORIF using PHILOS plating is the reduction of the fracture fragments on table, the correction of the displacement and angulation, and how the reduction has been ultimately locked into place with the PHILOS plate.⁷

The first step in aiding reduction of fracture fragments is to understand the mechanism of injury causing displacement of fracture fragments. Once the mechanism of injury is understood, it is imperative to reverse the deforming forces in order to aid reduction. The temporary reduction is held into place with the use of K wires, and then the plate is applied to the bone. The entire screw plate construct is completed as described previously, and the tuberosity reduction as well is locked into place using stay sutures taken through the supraspinatus, infraspinatus, and the subscapularis, and fastened to the plate with surgical knots.⁸

After analysis of our data between the 2 groups, it was found that there was no statistically significant difference in the functional outcome between the Conventional Deltopectoral group and the Anterior Deltoid Split group. This study proves that either approach will give you a good functional outcome regardless of the approach used for fixation of a proximal humerus fracture. The findings are consistent with a study done by Buecking et al, which stated that both the approaches showed similar Constant scores at 1-year follow-up.³

The choice of using either of these approaches rests with the surgeon and his familiarity with the approach. A study done by Luke S. Harmer et al on 10 arms of 5 fresh frozen cadaveric torsos was carried out with 1 arm undergoing the conventional Deltopectoral approach and the other undergoing the Anterior Deltoid Split approach. The aim of this study was to ascertain the surface area and the exposure which each of these approaches could provide and the superiority of 1 over the other. It showed that with the Conventional Deltopectoral approach the surface area of exposure was 22.9 (±6.3) cm², whereas with the Anterior Deltoid Split approach it was found to be 16.3 (±6.4) cm². The Conventional Deltopectoral Approach thus helps in exposure of more surgical area compared to the Anterior Deltoid Split approach; however, the access it provides to different parts of the proximal humerus varies.⁸

The Conventional Deltopectoral approach was useful in achieving easy access to the anterior structures of the proximal humerus and exposed 1.4 times the area exposed by that of the Anterior Deltoid Split approach. However, the Anterior Deltoid Split approach was more useful in exposing the posterior structures in the proximal humerus. The access to the posterior structures can be increased by releasing 20% of the Deltoid insertion when using the Conventional Deltopectoral approach.⁸

A meta-analysis carried out by Xie L. et al, showed that the functional outcome following Deltopectoral or Anterior Deltoid Split approach is the same irrespective of the postoperative period of follow-up. The operative time in the Deltopectoral group was significantly less than the Anterior Deltoid Split group, which was similar to the findings in our study. The intraoperative blood loss was found to be lesser in the Deltoid Split group as compared to the Deltopectoral group in a study done by Zhao et al which is consistent with the findings of our study as well. The postoperative hospital stay in both the groups was found to be similar.^27,28 The meta-analysis further proved that due to less amount of soft tissue dissection and retraction in the Anterior Deltoid Split group, the humeral head necrosis rates were lesser. The humeral head has a tenuous blood supply with the arcuate branch of the anterior circumflex humeral artery providing majority of the blood supply to the humeral head in a retrograde fashion. The Conventional Deltopectoral approach causes a lot of dissection on the under surface of the Deltoid muscle thus leading to a lot of surface blood loss and increased chances of humeral head necrosis. When using the Anterior Deltoid Split approach, it exposes a bare spot on the lateral surface of the proximal humerus between the penetrating branches of the anterior and posterior circumflex humeral artery thus obviating the need for excessive lateral or posterior dissection and preserving the surface blood supply of the humeral head. Lesser soft tissue dissection and limited exposure might be the cause of higher early functional scores in the Anterior Deltoid Split group according to the study.²⁷ The Conventional Deltopectoral approach uses an internervous plane whereas the Anterior Deltoid Split approach uses an avascular plane. The operative time was found to be less in the Anterior Deltoid Split group in the study done by Xie et al, which contrasts with the findings in our study. Here, the expertise and comfort of the operating surgeon with the approach is important. As no dorsal retractors are placed near the humeral shaft, no distracting malalignment results, and thus restoring the anatomic head-shaft axis is easier in the Anterior Deltoid Split group. There has been no difference in rates of osteosynthesis between the 2 groups and no axillary nerve damage in both the groups in this study which is comparable to the results found in our study as well.²⁷

Agarwal N et al found that the reduction of tuberosities in 3- or 4-part fracture was better in the Anterior Deltoid Split group as there was more exposure to the posterior and lateral quadrant in this approach.¹ A study done by R. Ragavanandam et al concluded that the Conventional Deltopectoral approach is better for accessing the lesser tuberosity and for addressing anterior dislocations. It is also useful in fractures where the medial calcar needs to be reconstructed. The Anterior Deltoid Split approach is better in terms of tuberosity reduction as the greater tuberosity is found to be displaced posteriorly and superiorly which is easily accessible with the splitting of the anterior and medial deltoid fibers. It is also useful in posterior dislocations as there is more access with less soft tissue dissection or forceful retraction with the deltoid split approach.²²

Conclusion

This study was done to compare the functional outcome following ORIF with PHILOS plating in patients operated using the Conventional Deltopectoral approach vs. the Anterior Deltoid Split approach. Our study shows that there was no statistically significant difference in the functional outcome in both these groups at 1-year follow-up. However, less soft tissue dissection and retraction along with obliviating the need of erasing the anterior insertion of the Deltoid muscle to increase posterior exposure, makes the Deltoid stronger in the Anterior Deltoid Split group with higher early return of range of motion and higher functional outcome scores on follow-up in the early postoperative period within 1-3 months.

The operative area exposed with the Anterior Deltoid Split group is less compared to the Conventional Deltopectoral approach, but the former is preferred for comminuted displaced fractures of the tuberosities and in associated posterior dislocation. The latter is more useful in cases associated with lesser tuberosity fractures, anterior dislocation, and medial calcar comminution.

The Anterior Deltoid Split approach uses an avascular plane and the Conventional Deltopectoral approach uses an internervous plane. Thus, there is less intraoperative blood loss in the Anterior Deltoid Split approach. There is no threat to the axillary nerve in the Anterior Deltoid Split approach if the nerve is isolated 5 cm below the edge of the acromion and protected adequately. Due to less soft tissue dissection, the Anterior Deltoid Split approach leads to lesser rates of humeral head necrosis by preserving the blood supply to the humeral head. The postoperative VAS scores were found to be significantly lesser in the Anterior Deltoid Split group due to less dissection and retraction forces subjected to the Deltoid muscle.

Thus, the choice of approach does not influence the functional outcome of shoulder following ORIF and PHILOS plating as both approaches result in the same functional outcome on 1-year follow-up. The choice of approach lies entirely with the surgeon based on the decision made after studying the fracture anatomy thoroughly and his expertise with either of the approaches to aid and facilitate adequate exposure without excessive soft tissue dissection.

Disclaimers

Funding: No funding was disclosed by the authors.

Conflicts of interest: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.