ISAKOS Congress 2021

2021 ISAKOS Biennial Congress Paper


Anterior Deltoid Muscle Reflection in a Deltopectoral Approach is Safe and Does not Influence the Outcome of Reversed Shoulder Arthroplasty.

Bart-Jan Jd Veen, MD, Enschede NETHERLANDS
Esther J Smits, PhD, St Lucia, Queensland AUSTRALIA
Andrew Ker, MBChB, BSc (Hons), FRCSed (T+O), Brisbane, QLD UNITED KINGDOM
Brandon Ziegenfuss, BSc(Hons) MPH, Brisbane, Queensland AUSTRALIA
Ashish Gupta, MBBS, MSc, FRACS, Brisbane, QLD AUSTRALIA
Kenneth Cutbush, MBBS, FRACS, FAOrthA, Spring Hill, QLD AUSTRALIA

Brisbane Private Hospital, Brisbane, Queensland, AUSTRALIA

FDA Status Not Applicable


No difference in shoulder function after 24 months for patients receiving an RSA with or without reflection of the anterior deltoid muscle.



The deltopectoral approach is well accepted for shoulder arthroplasty procedures. The extended deltopectoral approach with detachment of the anterior deltoid from the clavicle allows increased joint exposure and can protect the anterior deltoid from traction injury. The efficacy of this extended approach has been demonstrated in anatomical total shoulder replacement surgery. However, this has not been shown in reverse shoulder arthroplasty (RSA).

The primary aim of this study was to evaluate safety of the extended deltopectoral approach in RSA. The secondary aim was to evaluate the performance of the deltoid reflection approach in terms of functional and radiological outcomes up to 24 months post-surgery.


A prospective non-randomised comparative study was performed between January 2012 and October 2020 including 77 patients in the deltoid reflection group and 73 patients in the comparative group. Based on the intra-operative evaluation on avoiding injury on the deltoid muscle, the deltoid muscle was either reflected from the distal clavicle or preserved. The occurrence of any complication observed was recorded at each postop visit. Additionally, patients were followed up for at least 24 months for evaluation of their shoulder function and ultrasound evaluation in the deltoid reflection group. Functional outcome measures included the Oxford Shoulder Score (OSS), Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder Elbow Society Score (ASES), pain intensity (VAS 0-100), range of motion (forward flexion (FF), abduction (AD), internal rotation (IR) and external rotation (ER)).


There were no significant differences in the rate of complications between the two groups (15.8% in the deltoid reflection group and 13.8% in the comparative group, p=0.327). Ultrasound evaluation of the anterior deltoid muscle was available in 57 (76%) patients and no proximal detachment was observed. Small focal dehiscence was observed in five (7%) patients and one patient showed a seroma. In addition, there were no significant differences in functional outcome measures both pre-operatively and at 24 months post-operation between the groups. Mean VAS pain score at 24 months was similar (11.0 (SD 18.5) deltoid reflection vs 8.2 (SD 16.1) comparative, p=0.333). There were no significant differences in any of the other functional outcome measures (OSS (p=0.123), DASH (p=0.560), AESES (p=0.716), and ROM (p=0.527 ER, p=0.756 IR)) between the groups at both timepoints. Adjustment for possible confounders in a regression model indicated that only prior surgery significantly influenced the model for VAS pain (p 0.026, 95%CI 0.760 – 11.93). Deltoid reflection (p=0.102), age (p=0.806), sex (p=0.916), glenoid graft (p=0.106), prosthesis manufacturer (p=0.340) and pre-op VAS score (p=0.308) were not of influence.



of this study show an extended deltopectoral approach for RSA, with selected reflection of the anterior deltoid muscle improving exposure and preventing anterior deltoid muscle injury followed by re-attachment, is safe. Patients with the anterior deltoid muscle reflected in RSA surgery had similar functional scores pre-op and at 24 months compared to a control group. Multiple regression analyses indicated that only prior surgery affected VAS pain score at 24 months. Furthermore, ultrasound evaluation showed intact reattachments.

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