New open and arthroscopic-assisted approaches of the Axillary Nerve
Andrés A. Maldonado, MD, PhD1,2; Bassen T Elhassan, MD2; Allen Bishop, MD3; Alex Shin, MD4; Robert J Spinner, MD5; (1)BG Unfallklinik, Frankfurt, Germany, (2)Mayo Clinic, Rochester, MN, (3)Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, (4)Orthopedic Surgery, Mayo Clinic, Rochester, MN, (5)Department of Neurological Surgery, Mayo Clinic, Rochester, MN
Introduction: Previous studies have described a segment of the axillary nerve (AN) that cannot be surgically explored through standard open surgical approaches (blind zone). The aim of this study is to evaluate the feasibility of combining the standard posterior approach to the AN with the use of the arthroscope to visualize all segments of the AN; and determine the AN length that can be seen through standard and extended anterior, axillary and posterior approaches.
Material and methods: Ten fresh frozen shoulders in five adult human torsos were included in the study. A standard posterior approach was performed on four shoulders and dry arthroscopy was performed through the surgical opening in an attempt to visualize all segments of the AN. A surgical clip was applied to the most proximal and anterior segments of the AN that could be visualized with the arthroscope. A standard open deltopectoral approach was then performed to determine the exact location of the surgical clip and its relation to the origin of the AN. Then, we attempted to explore the AN through 3 different surgical approaches (each approach was performed in 2 shoulders): a standard and extended anterior, axillary and posterior approaches. Surgical clips were used to mark the AN length that was visualized through each approach.
Results: Using the arthroscopic-assisted approach, all segments of the AN (including the blind zone) were visualized from the quadrilateral space to their origin from the posterior cord in all four specimens. The surgical clip was found at an average 1 cm (range from 0.5 to 1.5 cm) from the origin of the AN from the posterior cord. Compared to the standard approaches, the extended anterior, axillary and posterior approaches improved the visualization of the AN by 3.6 cm, 1.5 cm and 2.8 cm respectively.
Conclusions: This cadaveric study shows that it is feasible to visualize all segments of the AN (including the blind zone) using this novel arthroscopic-assisted approach that combines the use of the standard posterior approach to the AN with dry arthroscopic exploration. Clinical studies are necessary to evaluate the utility of this novel approach. None of these extended approaches independently was sufficient to expose the entire course of the AN.
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