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

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.