Download Axillary nerve - ISHA Annual Scientific Meeting 2016

Nerve Injury in Shoulder and
Elbow Arthroscopy
David S. Ruch, MD
Chief of Division of Hand Surgery
Professor and Vice Chair Orthopedic Surgery
Duke University Medical Center
Background
 Elbow arthroscopy represents a rapidly
growing number of surgical procedures in
the US
 1986 ANNA survey indicated 0.4% of
arthroscopic procedures in US
 O’Driscoll indicated 11% of arthroscopic
procedures by 2001
 Annual incidence of procedures doubled from
1996 to 2001
With increased use of a procedure
increase in complications
70y status post
elbow
arthroscopy for
loose body
Complications-Remain Isolated Case
Reports over past 15 years
It’s Complicated
• Retrospective review of 473 elbow arthroscopies
• Serious complication: 0.8% all of which were
pyarthrosis
• Minor complication: 11%
• Including 12 transient nerve palsies (2.3%)
• 0% complete nerve injuries
• In our current medical legal environment this remains
the standard
Materials and Methods
 Survey the ASSH membership to ascertain the
frequency of elbow arthroscopy-related nerve
injuries that they had evaluated and/or treated
over the past five years.
 Secondary questions included the identification
of risk factors leading to such complications,
and elucidation of ultimate outcomes after
treatment.
ASSH Member Survey
 The Survey was sent out to all members of
the ASSH
 349 respondents- 39% response rate
 29% of all respondents replied “yes” to
initial question “Have you treated a nerve
injury in the last five years?”
 If so the respondent continued the
questionnaire
Results
 1.8 nerve injuries per respondent
 1 member reported median radial and ulnar
nerve transection in a single patient
 Total of 190 complete nerve injuries reported
over the last five years
Total
Incidence
of Major
Nerve
PearlDiver
Research
University
Injury
Program# of -.03%
Scopes in US
Age
2007
2008
2009
2010
2011
CAGR
< 65
12,526
13,195
13,015
14,035
13,623
2.1%
65 +
282
312
322
245
-3.4%
Total
12,808
13,327
14,356
13,869
2.0%
217
13,413
Source: PearlDiver Private Payer Database, CMS Standard Analytical File, U.S. Census
Bureau
Specific Nerve Injured
MABC, 6%
PIN, 20%
Ulnar, 40%
AIN, 6%
Radial, 18%
Median, 10%
Median Radial and Ulnar Nerves
The injury typically results
in a large zone of injury
Procedures associated with injury
Unknown
12%
Other
7%
Capsular release
16%
Loose body removal
16%
Synovectomy
19%
Debridement OA
29%
0%
5%
10%
15%
20%
25%
30%
35%
procedure
Portals involved in injury
Unknown,
44%
Proximal
medial, 25%
Anterolater
al, 20%
Posterior ,
4%
Posterolate
ral, 3%
Proximal
lateral,
4%
Shoulder Arthroscopy-similar
findings
 Reported injuries to all major peripheral
nerves
 Procedure dependent
 Position of patient can affect
 Exact incidence unknown
background
 Nerve injuries
 “in up to 8.2% of procedures for
anterior instability, and 1% to 2% of
rotator cuff repair procedures.”
 Although these injuries often involve
terminal nerve branches, a large portion
are mixed plexopathies, which have
more variable clinical presentations and
prognoses.
Glenohumeral arthroscopy portals established using
an outside-in technique: neurovascular anatomy at
risk.
Lo IK1, Lind CC, Burkhart SS.
 Except for the cephalic vein, all of the
neurovascular structures were more than 20
mm away from all the portals evaluated.
 When creating either an anterior portal or a
5-o'clock position portal, the mean distance
from the portal to the cephalic vein was 18.8
mm and 9.8 mm, respectively.
 In one anterior portal, a direct injury to the
cephalic vein occurred.
Suprascapular Nerve
 Suprascapular nerve injury may be a
complication of several surgical procedures
 decompression of suprascapular nerve
entrapment
 blind drilling during arthroscopic Bankart and
SLAP repair
 advancement of rotator cuff during the repair
of massive retracted rotator cuff tears
Suprascapular Nerve
 Warner et al found that the neurovascular
pedicle was at risk of injury with lateral cuff
mobilization >3 cm.
Axillary nerve
 Axillary nerve courses adjacent to the inferior
shoulder capsule and through the quadrilateral
space
 it is susceptible to injury from
 inferior capsulolabral reconstruction
 inferior thermal capsulorrhaphy
 inferior capsular release
Determining the Relationship of the Axillary Nerve to the
Shoulder Joint Capsule from an Arthroscopic Perspective
Matthew R. Price, MD, MS; Edward D. Tillett, MD; Robert D. Acland, MD; G.
Stephen Nettleton, PhD
J Bone Joint Surg Am, 2004 Oct; 86 (10): 2135 -2142 .
 Axillary nerve travels at a
fixed distance from the
inferior glenohumeral
ligament throughout its
course
 study showed that the
nerve came closest to the
glenoid rim at the 6o’clock position, with the
average distance
measuring 12.4 mm.
Determining the Relationship of the Axillary Nerve to the
Shoulder Joint Capsule from an Arthroscopic Perspective
Matthew R. Price, MD, MS; Edward D. Tillett, MD; Robert D. Acland, MD; G.
Stephen Nettleton, PhD
J Bone Joint Surg Am, 2004 Oct; 86 (10): 2135 -2142 .
 The axillary nerve traveled
adjacent to the capsule and
was separated from it by
an average distance of 2.5
mm.
Arthroscopic relationship of the axillary nerve to the
shoulder joint capsule: An anatomic study
Akifumi Uno, MD, Gregory I. Bain, MBBS, FRACS, and Janak A. Mehta,
MS(Orth), DNB(Orth),
 The axillary nerve was held to the shoulder capsule
with loose areolar tissue in the zone between 5 and
7 o'clock
 closest to the glenoid in the neutral position, in
extension, and in internal rotation
 Abduction, external rotation, and perpendicular
traction increase the zone of safety during
arthroscopic anterioinferior capsulotomy adjacent
to the glenoid between the 5 and 7 o'clock
positions.
Radial to Axillary Nerve Transfer
 Anterior Branch Axillary Nerve
 2704 axons
 5.4 fascicles
 2.2 mm diameter
 Nerve to Long Head Triceps
 1233 axons (45% of original motor pool)
 Normal muscle force achieved with 30% of original
motor neuron pool
 3.6 fascicles
 1.2 mm diameter
 Nerves easily reach each other without nerve graft
Witoonchart, Leechavengvongs. Nerve Transfer to Deltoid Muscle Using the Nerve to the Long Head of the Triceps: An
Anotomic Feasibility Study. The Journal of Hand Surgery. 28(4) 2003.
Cutaneous Branch
Axillary N
Posterior Branch
to Deltoid
Anterior Branch
to Deltoid
Nerve Transfer
Quadrilateral space 
Axillary nerve
Triangular interval  Radial
nerve
Radial to Axillary Nerve Transfer





Seven Patients (13-35 yrs)
Injury to Surgery Mean = 7 months
Average follow-up = 20 months
All had M4 triceps prior to surgery
Results
 All Patients developed M4 Deltoid
 Mean shoulder abduction = 124 degrees
 No Shoulder subluxation
 No functional triceps deficits
Witoonchart, Leechavengvongs. Nerve Transfer to Deltoid Muscle Using the Nerve to the Long Head of the Triceps: A
Report of Seven Cases. The Journal of Hand Surgery. 28(4) 2003.
Conclusions
• Complete Nerve injuries following
arthroscopy are uncommon but do occur
• Specifically, the incidence of severe injuries
appears higher than previously reported
• This incidence may increase as elbow
arthroscopy is more frequently and widely
practiced
• A better understanding of the nature and
sequelae of these complications is essential
Conclusions
 Reporting of neurologic complications
following shoulder arthroscopic surgery is
still largely anecdotal
 Plethora of anatomic studies
 Few case series
Thank you