This review walks through the three open surgical exposures of the glenohumeral joint: deltopectoral, deltoid-splitting, and posterior. It centers on the anatomy that constrains each approach, especially the axillary nerve, and the trade-offs that guide approach selection. It also covers subscapularis management options and the trend toward less invasive, subscapularis-sparing techniques.
The axillary nerve governs every open shoulder approach. Memorize the number: 5 to 7 cm below the acromion, but under 5 cm in one in five patients. That single fact drives the stay suture in the deltoid-splitting approach and the caution during retractor placement in the deltopectoral approach.
Approach selection is pathology-driven. Deltopectoral is the extensile workhorse for anterior work but cannot reach the back of the joint. Deltoid-splitting gives in-line glenoid access for reverse arthroplasty and may lower instability, but it cannot be extended distally.
For the posterior glenoid, scapula, or spinoglenoid notch, use the posterior approach through the infraspinatus-teres minor interval, and spare the posterior deltoid. Understand subscapularis biology: osteotomy heals bone-to-bone, a peel relies on tendon-to-bone healing, and failed subscapularis repair after arthroplasty predicts instability and poor outcomes.
This review walks through the three open surgical exposures of the glenohumeral joint: deltopectoral, deltoid-splitting, and posterior. It centers on the anatomy that constrains each approach, especially the axillary nerve, and the trade-offs that guide approach selection. It also covers subscapularis management options and the trend toward less invasive, subscapularis-sparing techniques.
The axillary nerve governs every open shoulder approach. Memorize the number: 5 to 7 cm below the acromion, but under 5 cm in one in five patients. That single fact drives the stay suture in the deltoid-splitting approach and the caution during retractor placement in the deltopectoral approach.
Approach selection is pathology-driven. Deltopectoral is the extensile workhorse for anterior work but cannot reach the back of the joint. Deltoid-splitting gives in-line glenoid access for reverse arthroplasty and may lower instability, but it cannot be extended distally.
For the posterior glenoid, scapula, or spinoglenoid notch, use the posterior approach through the infraspinatus-teres minor interval, and spare the posterior deltoid. Understand subscapularis biology: osteotomy heals bone-to-bone, a peel relies on tendon-to-bone healing, and failed subscapularis repair after arthroplasty predicts instability and poor outcomes.