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Is There a Safe Area for the Axillary Nerve in the Deltoid Muscle?A Cadaveric Study
Ozgur Cetik, MD1; Murad Uslu, MD1; Halil Ibrahim Acar, MD2; Ayhan Comert, MD2; Ibrahim Tekdemir, MD2; Hakan Cift, MD1
1 Kirikkale Universitesi Tip Fakultesi Ortopedi ve Travmatoloji Anabilim Dali, 71100 Kirikkale, Turkey. E-mail address for O. Cetik: ozgurcetik@hotmail.com
2 Halil Ibrahim Acar, MD Ayhan Comert, MD Ibrahim Tekdemir, MD Ankara Universitesi Tip Fakultesi Anatomi Anabilim Dali, 06650 Sihiye, Ankara, Turkey. E-mail address for A. Comert: drayhancomert@yahoo.com
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Department of Orthopaedics and Traumatology, Kirikkale University School of Medicine, Kirikkale, Turkey, and Department of Anatomy, Ankara University School of Medicine, Ankara, Turkey

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Nov 01;88(11):2395-2399. doi: 10.2106/JBJS.E.01375
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: Several authors have defined a variety of so-called safe zones for deltoid-splitting incisions. The first aim of the present study was to investigate the distance of the axillary nerve from the acromion and its relation to arm length. The second aim was to identify a safe area for the axillary nerve during surgical dissection of the deltoid muscle.

Methods: Twenty-four shoulders of embalmed adult cadavers were included in the study. The distance from the anterior edge of the acromion to the course of the axillary nerve was measured and was recorded as the anterior distance. The same measurement from the posterior edge of the acromion to the course of the axillary nerve was made and was recorded as the posterior distance for each limb. Correlation analysis was performed between the arm length and the anterior distance and the posterior distance for each limb. The ratios between arm length and the anterior and posterior distances were calculated for each case and were recorded as an anterior index and a posterior index.

Results: The average arm length was 30.40 cm. The average anterior distance was 6.08 cm, and the average posterior distance was 4.87 cm. There was a significant correlation between arm length and both anterior distance (r = 0.79, p < 0.001) and posterior distance (r = 0.61, p = 0.001). The axillary nerve was not found to lie at a constant distance from the acromion at every point along its course. The average anterior index was 0.20, and the average posterior index was 0.16.

Conclusions: The present study describes a safe area above the axillary nerve that is quadrangular in shape, with the length of the lateral edges being dependent on the individual's arm length. Using this safe area should provide a safe exposure for the axillary nerve during shoulder operations.

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    Ozgur Cetik
    Posted on November 24, 2006
    Dr. Cetik & Dr. Uslu respond to Dr. Kontakis
    Kirikkale University, School of Medicine, Orthopaedics & Traumatology, Kirikkale, TURKEY

    We appreciate the comments of Dr Kontakis regarding our recent article(1). While deltoid length can be easily measured in a cadaver, we were not able to find a method for reproducibly measuring the deltoid length in a patient. In our opinion, measuring deltoid length requires additional techniques.

    A reference point for a surgical exposure must be easy to locate by palpation because the surgeon may need to check the reference site again later in the operation. With that need in mind, the upper border of the deltoid muscle, as recommended by Kontakis et al.(2), may not be sufficiently discrete to serve as a reference point intraoperatively.

    Kontakis et al(2). are concerned about relatively larger distances of the nerve. It is possible that the difference between our findings(1) and those of the previous study by Kontakis et al.(2)occurred because the proximal reference points in the two studies were different.

    An important point made by Dr.Kontakis in his letter is that the safe area for muscle splitting is restricted to a zone between the posterior and the middle deltoid. By using the anterior and posterior edges of the acromion as references, the surgeon can more easily perform muscle splitting in the safe area (Fig. 1). If we consider using the upper border of the deltoid muscle as a whole, the distance between the axillary nerve and the deltoid may be very small at the anterior portion. Therefore,the anterior portion of the deltoid should not split.(Fig. 1).

    In summary, we agree that there is a serious risk for axillary nerve injury during deltoid splitting and all complementary information will guide the surgeon to a safer exposure.


    Fig. 1

    Photograph showing the axillary nerve and its projection. The deltoid is detached from clavicle. Note that the distance between axillary nerve and the deltoid may be very low at anterior portion.

    DAP: Deltoid Anterior Portion. AEA: Anterior edge of acromion.

    References:

    1. Cetik O, Uslu M, Acar HI, Comert A, Tekdemir I, Cift H. Is there a safe area for the axillary nerve in the deltoid muscle? A cadaveric study. J Bone Joint Surg Am. 2006;88:2395-2399.

    2. Kontakis GM, Steriopoulos K, Damilakis J, Michalodimitrakis E. The Position of the axillary nerve in the deltoid muscle. A cadaveric study. Acta Orthop Scand. 1999;70:9-11.

    George M. Kontakis, M.D.
    Posted on November 12, 2006
    The axillary nerve in the deltoid muscle
    University of Crete, Greece

    To The Editor:

    I read with interest the article entitled “Is there a safe area for the axillary nerve in the deltoid muscle?”(1) and I would like to express some comments:

    There is general agreement that the distance of the axillary nerve in relation to certain acromial sites is variable. The authors of this study tried to determine a safe area to avoid injuring the axillary nerve during deltoid muscle splitting. According to their findings, the surgeon can determine a so called safe area during surgery by measuring the arm length. In my opinion this is not accurate.

    The axillary nerve is extended more anteriorly from the anterior acromial edge and more posteriorly from the posterior acromial edges before it enters into the muscle belly. The so called safe area concerns only the portion of the nerve parallel to the lateral acromion border. Measurement of arm length during surgery does not allow accurate application of a linear regression equation for the determination of the safe zone for the nerve.

    We published a study(2) on this topic, and found that in about 25% of our deltoid cadaveric specimens (134 specimens from 67 fresh cadavers) the axillary nerve’s vertical distance from the upper border of the deltoid muscle was less than 4 cm in both shoulders, having a minimal distance of 2 cm. Also we found that the nerve is located a mean 2.6cm (range, 1.7-3.7cm.) above the midpoint of the vertical plane (length) of the deltoid. Our finding were in agreement with a previous publication (3). Burkhead et al.(4) studied the axillary nerve in 51 embalmed and 5 fresh cadaveric specimens and found that in nearly one fifth of the cadavers, the nerve was less than 5 cm from the palpable edge of the acromion and at a minimal distance of 3.1 cm.

    With this information in mind, I am concerned about thee relatively larger distances of the nerve, from the anterior and the posterior edges of the acromion, reported by Cetik et al.(1) I do not know if differences in the material (fresh vs embalmed cadavers, population characteristics ect.) explains these differences.

    Regarding the recommended posterior deltoid splitting approach, by Wirth et al.(5), our laboratory studies showed that it was safe only when the splitting was strictly between the posterior and the middle deltoid. We must keep in mind that the axillary nerve after passing the quadrilateral space and giving off its branch to the teres minor, divides into a posterior (runs to the posterior deltoid) and an anterior (runs to the middle and the anterior deltoid) branch.

    In summary, I think that in clinical practice we must be very careful when performing a deltoid splitting procedure. It is certainly possible to cause an iatrogenic nerve damage even with a deltoid splitting of 4 cm from the acromial edge. The axillary nerve is always located at a level inferior to the subacromial bursa and above the vertical to the middle of the deltoid length. The application of the suggested arm length determination of the safe area should be used as complementary information only.

    The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

    References:

    1. Cetik O, Uslu M, Acar HI, Comert A, Tekdemir I, Cift H. Is there a safe area for the axillary nerve in the deltoid muscle? A cadaveric study. J Bone Joint Surg Am. 2006;88:2395-2399.

    2. Kontakis GM, Steriopoulos K, Damilakis J, Michalodimitrakis E. The position of the axillary nerve in the deltoid muscle. A cadaveric study. Acta Orthop Scand. 1999;70(1):9-11.

    3. Kulkarni RR, Nandedkar AN, Mysorekar VR. Position of the axillary nerve in the deltoid muscle. Anat Rec. 1992;232(2):316-7.

    4. Burkhead WZ, Scheinberg RR, Box G. Surgical anatomy of the axillary nerve. J Shoulder Elbow Surg. 1992; 1:31-36

    5. Wirth MA, Butters KP, Rockwood CA Jr. The posterior deltoid- splitting approach to the shoulder. Clin Orthop Relat Res. 1993;(296):92- 8.

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