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Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach

Year 2020, Volume: 4 Issue: 8, 645 - 648, 01.08.2020
https://doi.org/10.28982/josam.777069

Abstract

Aim: The most common complication of the Lateral deltoid splitting approach (LDSA), which is used in the shoulder area, especially for posterior extension fractures and other soft tissue pathologies, is axillary nerve injury. Determining the frequency of nerve injuries that may occur after LDSA is decisive for the applicability of this approach. Therefore, in our study, we aimed to evaluate the axillary nerve integrity and shoulder functions in patients who underwent LDSA.
Methods: In this prospective cohort study, 55 patients who were operated with LDSA for proximal humerus fractures between February 2015 and July 2018 were evaluated. Among these patients, 35 were selected and included in the study. Six months later Electrophysiological tests (Electroneuromyelography – ENMG) and Constant Shoulder Score (CSS) were used for evaluation of each operated and non-operated shoulder. CSS difference between the operated and non-operated sides was graded as mild (11-20 point), moderate (21-30) and severe (>30).
Results: Mean age of the group was 66 (9) years. Twenty-five patients were female and 10 were male. Mean follow-up time was 4 (1) years. Mean latencies of axillary nerve were 4.6 (1.8) msn, 3.7 (0.54) msn and mean amplitudes of axillary nerve were 6.6 (2.21) mV, 8.4 (2.80) mV in the operated and non-operated shoulders, respectively. There was no statically significant difference between the operated and non-operated sides according to latency and amplitude (latency P=0.25, amplitude P=0.16). Mean CSS of the patients were 28.7. CSS of 12 patients were severe (mean: 39.08), 18 patients, moderate (mean 25.4) and 5 patients, mild (mean 16). There was no statically significant correlation between CSS and axillary nerve latency / amplitude (P= 0.62, r=0.267 / P=0.98, r=-0.339). Fracture type and CSS showed a statically significant correlation (P=0.032, r= 0.829).
Conclusion: This study revealed that LDSA provides wide and versatile fracture control without compromising the deltoid muscle functions and axillary nerve, especially in fractures extending to the posterior part of the proximal humerus.

References

  • 1. Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014;472:1576–85. doi:10.1007/s11999-013-3415-7.
  • 2. Hoppenfeld S. deBoer P. Surgical exposures. Philadelphia: Lippincott, Williams and Wilkins; 2003.
  • 3. Saran N, Bergeron SG, Benoit B, Reindl R, Harvey EJ, Berry GK. Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide. Injury. 2010;41:1037–40. doi:10.1016/j.injury.2010.04.014.
  • 4. Gardner MJ, Voos JE, Wanich T, Helfet DL, Lorich DG. Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma. 2006;20:602–7. doi:10.1097/01.bot.0000246412.10176.14.
  • 5. Gerber C, Werner CML, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg - Series B. 2004;86:848–55. doi:10.1302/0301-620X.86B6.14577.
  • 6. Kayaokay K, Mirzazade C, Küçük L, Coşkunol E. Comparison of open acromioplasty outcomes according to approach type; anterior and lateral. J Surg Med. 2017;1:49–51. doi:10.28982/josam.351717.
  • 7. Perlmutter GS. Axillary nerve injury. In: Clin Orthop Relat Res. Lippincott Williams and Wilkins; 1999. p. 28–36. doi:10.1097/00003086-199911000-00005.
  • 8. Gurushantappa PK, Kuppasad S. Anatomy of axillary nerve and its clinical importance: a cadaveric study. J Clin Diagn Res. 2015 Mar;93:13-7.
  • 9. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160–4.
  • 10. Westphal T, Woischnik S, Adolf D, Feistner H, Piatek S. Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings. J Shoulder Elb Surg. 2017;26:464–71. doi:10.1016/j.jse.2016.07.027.
  • 11. Singh H, Batra A, Patel D. Lateral transdeltoid approach to proximal humerus fractures. Int Surg J. 2015;2:337–40. doi:10.18203/2349-2902.isj20150400.
  • 12. Robinson CM, Murray IR. The extended deltoid-splitting approach to the proximal humerus: Variations and extensions. J Bone Joint Surg. 2011;93 B:387–92. doi:10.1302/0301-620X.93B3.25818.
  • 13. Wu CH, Ma CH, Yeh JJH, Yen CY, Yu SW, Tu YK. Locked plating for proximal humeral fractures: Differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011;71:1364–70. doi:10.1097/TA.0b013e31820d165d.
  • 14. Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res. 2005;123–9. doi:10.1097/01.blo.0000152872.95806.09.
  • 15. Khan LAK, Robinson CM, Will E, Whittaker R. Assessment of axillary nerve function and functional outcome after fixation of complex proximal humeral fractures using the extended deltoid-splitting approach. Injury. 2009;40:181–5. doi:10.1016/j.injury.2008.05.031.
  • 16. Isiklar Z, Kormaz F, Gogus A, Kara A. Comparision of deltopectoral versus lateral deltoid split approach in operative treatment of proximal humeral fractures. J Bone Joint Surg Br. 2010;92:352.
  • 17. Cheung S, Fitzpatrick M, Lee TQ. Effects of shoulder position on axillary nerve positions during the split lateral deltoid approach. J Shoulder Elbow Surg. 2009;18:748–55. doi:10.1016/j.jse.2008.12.001.
  • 18. Laflamme GY, Rouleau DM, Berry GK, Beaumont PH, Reindl R, Harvey EJ. Percutaneous humeral plating of fractures of the proximal humerus: Results of a prospective multicenter clinical trial. J Orthop Trauma. 2008;22:153–8. doi:10.1097/BOT.0b013e3181694f7d.
  • 19. Robinson CM, Stirling PHC, Goudie EB, Macdonald DJ, Strelzow JA. Complications and Long-Term Outcomes of Open Reduction and Plate Fixation of Proximal Humeral Fractures. J Bone Joint Surg. 2019;101:2129–39. doi:10.2106/JBJS.19.00595.
  • 20. Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: The effect of initial fracture pattern on outcome. J Orthop Trauma. 2009;23:113–9. doi:10.1097/BOT.0b013e31819344bf.
  • 21. Jung SW, Shim SB, Kim HM, Lee JH, Lim HS. Factors that influence reduction loss in proximal humerus fracture surgery. J Orthop Trauma. 2015;29:276–82. doi:10.1097/BOT.0000000000000252.
  • 22. Hardeman F, Bollars P, Donnelly M, Bellemans J, Nijs S. Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus. Injury. 2012;43:153–8. doi:10.1016/j.injury.2011.04.003.
  • 23. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13:427–33. doi:10.1016/j.jse.2004.01.034.
  • 24. Fisher ND, Barger JM, Driesman AS, Belayneh R, Konda SR, Egol KA. Fracture severity based on classification does not predict outcome following proximal humerus fracture. Orthopedics. 2017;40:368–74. doi:10.3928/01477447-20170925-04.

Lateral deltoid splitting yaklaşım uygulanan hastalarda aksiller sinir bütünlüğünün ve omuz fonksiyonlarının değerlendirilmesi

Year 2020, Volume: 4 Issue: 8, 645 - 648, 01.08.2020
https://doi.org/10.28982/josam.777069

Abstract

Amaç: Omuz bölgesinin özellikle posterior uzanımlı kırıklarında ve diğer yumuşak doku patolojilerinde uygulanmakta olan Lateral deltoid splitting yaklaşım (LDSY)’ın en bilinen komplikasyonu aksiller sinir yaralanmasıdır. LDSY sonrası oluşabilecek sinir yaralanmalarının sıklığını belirlemek bu yaklaşımın uygulanabilirliği açısından belirleyicidir. Bu nedenle çalışmamızda, LDSY uygulanan vakalarda aksiller sinir bütünlüğünü ve omuz fonksiyonlarını değerlendirmek amaçlanmıştır.
Yöntemler: Prospektif kohort tipteki bu çalışmada Şubat 2015-Temmuz 2018 tarihleri arasında proksimal humerus kırığı nedeniyle LDSA uygulanarak opere edilen 55 hastanın verileri incelendi. Bu hastalar arasından seçilen 35 hasta çalışmaya alındı. Altı ay sonra tüm hastaların opere edilen ve edilmeyen omuzları elektrofizyolojik testler (Elektronöromiyelografi - ENMG) ve Constant Omuz Skoru (CSS) ile karşılaştırmalı olarak değerlendirildi. Opere edilen ve edilmeyen omuzların CSS farkları hafif (11-20), orta (21-30), şiddetli (>30) olarak derecelendirildi.
Bulgular: Hastaların yaş ortalaması 66(9) idi. Hastaların 25’i kadın, 10’u erkek hasta idi. Ortalama takip süresi 4(1) yıl idi. Opere olan ve olmayan omuz bölgelerinde yapılan ENMG incelemelerinde aksiller sinirin ortalama latansı sırasıyla 4,6(1,8) msn, 3,7(0,54) msn ve ortalama amplitude’u sırasıyla 6,6(2,21) mV, 8,4(2,80) mV idi. Latans ve amplitude değerlerine göre ameliyat edilen ve ameliyat edilmeyen taraflar arasında istatistiksel olarak anlamlı bir fark saptanmadı (latans P=0,25, amplitude P=0,16). Hastaların ortalama CSS skoru 28,7 idi. CSS’in 12 hastada şiddetli (ortalama: 39,08), 18 hastada orta (ortalama 25,4) ve 5 hastada hafif (ortalama 16) olduğu saptandı. CSS ve aksiller sinir latans / amplitude değerleri arasında istatistiksel olarak anlamlı bir korelasyon saptanmadı (P= 0,62, r=0,267 / P=0,98, r=-0,339). Kırık tipi ve CSS arasında ise istatistiksel olarak anlamlı korelasyon olduğu görüldü (P=0,032, r=0,829).
Sonuç: Bu çalışma sonucunda, LDSA’nın aksiller sinir’e ve omuz fonksiyonlarına zarar vermeden özellikle proksimal humerusun arka kısmına uzanan kırıklarda geniş ve çok yönlü kırık kontrolü sağladığı saptanmıştır.

References

  • 1. Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014;472:1576–85. doi:10.1007/s11999-013-3415-7.
  • 2. Hoppenfeld S. deBoer P. Surgical exposures. Philadelphia: Lippincott, Williams and Wilkins; 2003.
  • 3. Saran N, Bergeron SG, Benoit B, Reindl R, Harvey EJ, Berry GK. Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide. Injury. 2010;41:1037–40. doi:10.1016/j.injury.2010.04.014.
  • 4. Gardner MJ, Voos JE, Wanich T, Helfet DL, Lorich DG. Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma. 2006;20:602–7. doi:10.1097/01.bot.0000246412.10176.14.
  • 5. Gerber C, Werner CML, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg - Series B. 2004;86:848–55. doi:10.1302/0301-620X.86B6.14577.
  • 6. Kayaokay K, Mirzazade C, Küçük L, Coşkunol E. Comparison of open acromioplasty outcomes according to approach type; anterior and lateral. J Surg Med. 2017;1:49–51. doi:10.28982/josam.351717.
  • 7. Perlmutter GS. Axillary nerve injury. In: Clin Orthop Relat Res. Lippincott Williams and Wilkins; 1999. p. 28–36. doi:10.1097/00003086-199911000-00005.
  • 8. Gurushantappa PK, Kuppasad S. Anatomy of axillary nerve and its clinical importance: a cadaveric study. J Clin Diagn Res. 2015 Mar;93:13-7.
  • 9. Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160–4.
  • 10. Westphal T, Woischnik S, Adolf D, Feistner H, Piatek S. Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings. J Shoulder Elb Surg. 2017;26:464–71. doi:10.1016/j.jse.2016.07.027.
  • 11. Singh H, Batra A, Patel D. Lateral transdeltoid approach to proximal humerus fractures. Int Surg J. 2015;2:337–40. doi:10.18203/2349-2902.isj20150400.
  • 12. Robinson CM, Murray IR. The extended deltoid-splitting approach to the proximal humerus: Variations and extensions. J Bone Joint Surg. 2011;93 B:387–92. doi:10.1302/0301-620X.93B3.25818.
  • 13. Wu CH, Ma CH, Yeh JJH, Yen CY, Yu SW, Tu YK. Locked plating for proximal humeral fractures: Differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011;71:1364–70. doi:10.1097/TA.0b013e31820d165d.
  • 14. Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res. 2005;123–9. doi:10.1097/01.blo.0000152872.95806.09.
  • 15. Khan LAK, Robinson CM, Will E, Whittaker R. Assessment of axillary nerve function and functional outcome after fixation of complex proximal humeral fractures using the extended deltoid-splitting approach. Injury. 2009;40:181–5. doi:10.1016/j.injury.2008.05.031.
  • 16. Isiklar Z, Kormaz F, Gogus A, Kara A. Comparision of deltopectoral versus lateral deltoid split approach in operative treatment of proximal humeral fractures. J Bone Joint Surg Br. 2010;92:352.
  • 17. Cheung S, Fitzpatrick M, Lee TQ. Effects of shoulder position on axillary nerve positions during the split lateral deltoid approach. J Shoulder Elbow Surg. 2009;18:748–55. doi:10.1016/j.jse.2008.12.001.
  • 18. Laflamme GY, Rouleau DM, Berry GK, Beaumont PH, Reindl R, Harvey EJ. Percutaneous humeral plating of fractures of the proximal humerus: Results of a prospective multicenter clinical trial. J Orthop Trauma. 2008;22:153–8. doi:10.1097/BOT.0b013e3181694f7d.
  • 19. Robinson CM, Stirling PHC, Goudie EB, Macdonald DJ, Strelzow JA. Complications and Long-Term Outcomes of Open Reduction and Plate Fixation of Proximal Humeral Fractures. J Bone Joint Surg. 2019;101:2129–39. doi:10.2106/JBJS.19.00595.
  • 20. Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: The effect of initial fracture pattern on outcome. J Orthop Trauma. 2009;23:113–9. doi:10.1097/BOT.0b013e31819344bf.
  • 21. Jung SW, Shim SB, Kim HM, Lee JH, Lim HS. Factors that influence reduction loss in proximal humerus fracture surgery. J Orthop Trauma. 2015;29:276–82. doi:10.1097/BOT.0000000000000252.
  • 22. Hardeman F, Bollars P, Donnelly M, Bellemans J, Nijs S. Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus. Injury. 2012;43:153–8. doi:10.1016/j.injury.2011.04.003.
  • 23. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13:427–33. doi:10.1016/j.jse.2004.01.034.
  • 24. Fisher ND, Barger JM, Driesman AS, Belayneh R, Konda SR, Egol KA. Fracture severity based on classification does not predict outcome following proximal humerus fracture. Orthopedics. 2017;40:368–74. doi:10.3928/01477447-20170925-04.
There are 24 citations in total.

Details

Primary Language English
Subjects Orthopaedics
Journal Section Research article
Authors

Ömer Kays Unal 0000-0002-9445-1552

Miruna Florentina Ateş 0000-0001-5953-4240

Mirza Zafer Dağtaş 0000-0001-6861-6555

Ender Ugutmen 0000-0003-1829-5700

Publication Date August 1, 2020
Published in Issue Year 2020 Volume: 4 Issue: 8

Cite

APA Unal, Ö. K., Ateş, M. F., Dağtaş, M. Z., Ugutmen, E. (2020). Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach. Journal of Surgery and Medicine, 4(8), 645-648. https://doi.org/10.28982/josam.777069
AMA Unal ÖK, Ateş MF, Dağtaş MZ, Ugutmen E. Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach. J Surg Med. August 2020;4(8):645-648. doi:10.28982/josam.777069
Chicago Unal, Ömer Kays, Miruna Florentina Ateş, Mirza Zafer Dağtaş, and Ender Ugutmen. “Evaluation of Axillary Nerve Integrity and Shoulder Functions in Patients Who Underwent Lateral Deltoid Splitting Approach”. Journal of Surgery and Medicine 4, no. 8 (August 2020): 645-48. https://doi.org/10.28982/josam.777069.
EndNote Unal ÖK, Ateş MF, Dağtaş MZ, Ugutmen E (August 1, 2020) Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach. Journal of Surgery and Medicine 4 8 645–648.
IEEE Ö. K. Unal, M. F. Ateş, M. Z. Dağtaş, and E. Ugutmen, “Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach”, J Surg Med, vol. 4, no. 8, pp. 645–648, 2020, doi: 10.28982/josam.777069.
ISNAD Unal, Ömer Kays et al. “Evaluation of Axillary Nerve Integrity and Shoulder Functions in Patients Who Underwent Lateral Deltoid Splitting Approach”. Journal of Surgery and Medicine 4/8 (August 2020), 645-648. https://doi.org/10.28982/josam.777069.
JAMA Unal ÖK, Ateş MF, Dağtaş MZ, Ugutmen E. Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach. J Surg Med. 2020;4:645–648.
MLA Unal, Ömer Kays et al. “Evaluation of Axillary Nerve Integrity and Shoulder Functions in Patients Who Underwent Lateral Deltoid Splitting Approach”. Journal of Surgery and Medicine, vol. 4, no. 8, 2020, pp. 645-8, doi:10.28982/josam.777069.
Vancouver Unal ÖK, Ateş MF, Dağtaş MZ, Ugutmen E. Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach. J Surg Med. 2020;4(8):645-8.