Bertelli Jayme A, Goklani Mayur Sureshlal, Gasparelo Karine Rosa, Seltser Anna
Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil.
Department of Plastic Surgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India.
J Hand Surg Am. 2023 Jan;48(1):82.e1-82.e9. doi: 10.1016/j.jhsa.2021.09.017. Epub 2021 Nov 8.
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.
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.
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.
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.
在腋神经孤立性麻痹的病例中，由于损伤或既往手术造成的瘢痕，在三角肌后缘解剖腋神经远侧残端可能会很困难。为克服这一问题，我们建议采用劈开三角肌的方法解剖腋神经前支（ADAN）。我们研究了与经三角肌入路相关的ADAN的解剖结构，并报告了该入路在9例孤立性腋神经损伤患者中的临床应用。
在9个新鲜尸体标本中解剖腋神经及其分支。在临床系列研究中，1例病变局限于ADAN的患者接受了神经移植。在其余8例患者中，通过单切口或双切口上臂后侧入路转移肱三头肌下内侧头和肘肌（TLMA）运动支来修复ADAN。
腋神经后支不绕肱骨走行。它支配三角肌后部和小圆肌。在肱骨后缘，ADAN与小圆肌腱相邻。ADAN在肱骨外侧的走行轨迹距肩峰中点65 mm（标准差±8 mm）。距起点1厘米处，ADAN发出一支粗大分支至三角肌中部，并在肩胛下肌腱远侧的手术颈处向前绕过肱骨。在我们所有的患者中，经三角肌入路都是可行的。在ADAN无任何张力的情况下可到达TLMA。1例接受移植的患者三角肌中部肌力评分为M3，而其余接受神经移位的患者三角肌前部和中部肌力评分为M4。
对于腋神经损伤，优先恢复ADAN的神经再支配。三角肌后部和中部之间的经三角肌入路为ADAN提供了一种直接且可行的入路。
研究类型/证据水平：治疗性研究V级
