Transdeltoid Approach to Axillary Nerve Repair: Anatomical Study and Case Series.

PURPOSE: In cases of isolated paralysis of the axillary nerve, dissection of the distal stump at the posterior deltoid border can be difficult because of scarring from an injury or previous surgery. To overcome this, we propose dissecting the anterior division of the axillary nerve (ADAN) using a deltoid-splitting approach. We investigated the anatomy of the ADAN as it pertains to the transdeltoid approach and report the clinical application of this approach in 9 patients with isolated axillary nerve injury. METHODS: The axillary nerve and its branches were dissected in 9 fresh cadaver specimens. In the clinical series, 1 patient with a lesion confined to the ADAN underwent nerve grafting. In the remaining 8 patients, the ADAN was repaired by transferring the triceps lower medial head and anconeus (TLMA) motor branch via a single-incision or double-incision posterior arm approach. RESULTS: The posterior division of the axillary nerve does not travel around the humerus. It innervated the posterior deltoid and teres minor muscles. At the posterior margin of the humerus, the ADAN ran adjacent to the teres minor tendon. The ADAN's trajectory on the lateral side of the humerus was 65 mm (SD ± 8 mm) from the midpoint of the acromion. One centimeter from the origin, the ADAN offered a prominent branch to the middle deltoid and wound around the humerus anteriorly at the surgical neck just distal to the infraspinatus tendon. A transdeltoid approach was feasible in all our patients. The TLMA was reached without any tension in the ADAN. Middle deltoid strength in 1 patient who had received a graft scored M3, while anterior and middle deltoid strength in the remaining patients who underwent nerve transfers scored M4. CONCLUSIONS: With axillary nerve lesions, reinnervation of the ADAN is a priority. The transdeltoid approach between the posterior and middle deltoid offers a direct and feasible approach to the ADAN. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Latissimus dorsi tendon transfer to restore shoulder abduction in patients with deltoid paralysis: A novel technique.

Background: Shoulder abduction is an essential movement for placement of the hand in space and thus for upper limb function. The objective of this study was to introduce and test the effectiveness of a new technique of latissimus dorsi tendon transfer to deltoid insertion to restore shoulder abduction. Methods: We prospectively included 10 male patients with a lost deltoid function. Their mean age was 34.6 years (range, 25-46). We describe a new technique to compensate for the loss of the deltoid function using a latissimus dorsi tendon transfer augmented with a semitendinosus tendon graft. The tendon graft is passed over the acromion and attached to the anatomical deltoid insertion. Postoperatively, a shoulder spica in 90° abduction was used for six weeks followed by physiotherapy. Results: Patients were followed up for a mean of 25.4 months (range, 12-48). The mean range of active shoulder abduction rose to 110° (range, 90-140°) with a mean gain of 83° of abduction. Conclusions: This procedure can be a useful technique for restoration of a significant range and strength of active shoulder abduction.

Shoulder function in patients with deltoid paralysis and intact rotator cuff.

INTRODUCTION/HYPOTHESIS: The purpose of this study is to determine the mid/long term shoulder function in patients with complete deltoid paralysis and intact rotator cuff. 27 patients with at least 2-years FU were included. MATERIALS AND METHODS: Outcome measures included pain, range of motion (including the swallowtail test STT), deltoid extension lag test DELT and Bertelli test), subjective fatigability using the injured shoulder and postoperative modified Neer ratings. RESULTS: At an average 68 months FU, mean shoulder abduction was 131°, flexion 153°, external rotation with the arm at the side 58° and 58° with the arm abducted. All patients reported quick fatiguability with repetitive use of the injured arm which did not change over time. Average pain score was 2. Eighteen patients had positive STT and DELT tests and all patients had positive Bertelli test. DISCUSSION: This study demonstrates that patients with deltoid paralysis and intact rotator cuff do maintain most of their shoulder function and this is sustained over time. LEVEL OF EVIDENCE: Level IV; prognostic Study: case series.

Triceps motor branch transfer for isolated axillary nerve injury: Outcomes in 9 patients.

INTRODUCTION: Triceps motor branch transfer has been used for more than ten years to restore deltoid function after axillary nerve injury. However, there have been few reports of the outcome of this procedure in isolated axillary nerve injury. HYPOTHESIS: Triceps motor branch transfer could be an effective method to restore deltoid function for patients with isolated axillary nerve injury. MATERIALS AND METHODS: Nine patients who underwent triceps motor branch transfer for treatment of isolated axillary nerve injury were followed up for at least 22 months. Shoulder abduction was assessed for all patients. The DASH outcome questionnaire was completed by every patient. Electrophysiological study was performed on 7 patients. RESULTS: All patients regained≥90° (mean, 137°) shoulder abduction. Mean DASH score decreased from 35.2 before surgery to 13.1 at the last follow-up. There was no noticeable weakness of elbow extension in any patient. DISCUSSION: Triceps motor branch transfer provided good results and may be a feasible alternative to nerve grafting for the treatment of complete isolated axillary nerve injury. TYPE OF STUDY: IV, retrospective cohort study.