Department of Trauma, Hand and Upper Extremity Service, Hospital del Trabajador, Chile; School of Medicine, Universidad Andrés Bello, Santiago, Chile.
University of Rochester Medical Center, Rochester, NY.
J Hand Surg Am. 2020 Jul;45(7):659.e1-659.e7. doi: 10.1016/j.jhsa.2019.11.013. Epub 2020 Jan 13.
The aim of this study was to evaluate the feasibility of exploring the axillary nerve (AN) at the 6 o'clock position (blind spot) using the deltopectoral approach, with the interval lateral to the conjoint tendon (CJT) or combined with the axillary approach.
Four ANs were dissected combining the deltopectoral approach-medial to the CJ (A), the deltopectoral approach-lateral to the CJT (B) and the axillary approach (C) in 3 sequences: A-B-C, B-A-C, and C-B-A. After the first approach was completed, the proximal and distal margins were marked. Additional exposure with the second and third approaches and the 6 o'clock position were also marked. Then, the AN was excised and the amount of exposed nerve with the 3 approaches was measured.
The deltopectoral approach-medial to the conjoint tendon did not allow exposure of the AN at the 6 o'clock position. Six o'clock position exposure was accomplished using the lateral interval of the deltopectoral and the axillary approaches. A deltopectoral approach lateral to the CJT allowed exploration of the AN at the blind spot, but not the terminal branches. The axillary approach was able to expose the AN at the 6 o'clock position, the terminal branches, but not the nerve-muscle junction. Combining the 3 approaches exposed 81% to 94% of the total length of the AN.
The deltopectoral approach allowed visualization of the AN at the 6 o'clock position when explored lateral to the CJT. The axillary approach allowed visualization of the terminal branches of the AN and the 6 o'clock position of the glenoid.
The deltopectoral approach lateral to the conjoint tendon allows the surgeon to assess continuity of the AN at the 6-o'clock position and to perform a neurolysis. If nerve repair, nerve grafting, or nerve transfer is attempted, a combination of the 3 approaches could be used.
本研究旨在评估经三角肌胸大肌入路在 6 点钟位置（盲点）探查腋神经（AN）的可行性，该位置在联合肌腱（CJT）的外侧或联合腋路。
在三角肌胸大肌入路的基础上，结合 3 种不同的顺序对 4 根 AN 进行解剖：先经三角肌胸大肌入路至 CJT 内侧（A），再至 CJT 外侧（B），最后行腋路（C）。完成第一个入路后，标记近端和远端边界。同时，用第二个和第三个入路进一步暴露，并标记 6 点钟位置。然后切除 AN，并测量 3 种入路暴露的神经长度。
三角肌胸大肌入路至 CJT 内侧不能暴露 6 点钟位置的 AN。经三角肌胸大肌外侧间隙和腋路可以暴露 6 点钟位置的 AN。三角肌胸大肌入路至 CJT 外侧可以暴露 AN 的盲点区域，但不能暴露其终末支。腋路可以暴露 AN 的 6 点钟位置、终末支，但不能暴露神经肌接头。三种入路结合可以暴露 AN 的 81%到 94%总长度。
经三角肌胸大肌入路外侧至 CJT 可以暴露 AN 的 6 点钟位置。腋路可以暴露 AN 的终末支和肩胛盂的 6 点钟位置。
三角肌胸大肌入路至 CJT 外侧可以评估 AN 在 6 点钟位置的连续性，并进行神经松解术。如果需要进行神经修复、神经移植或神经转移，则可以使用三种入路的组合。
