JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Ozgur Cetik, Murad Uslu, Halil Ibrahim Acar, Ayhan Comert, Ibrahim Tekdemir, and Hakan Cift
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 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Dr. Cetik & Dr. Uslu respond to Dr. Kontakis
Ozgur Cetik, Murad Uslu   (29 November 2006)
[Read Letter to the Editor] The axillary nerve in the deltoid muscle
George M. Kontakis, M.D.   (15 November 2006)

Dr. Cetik & Dr. Uslu respond to Dr. Kontakis 29 November 2006
Previous Letter to the Editor Top
Ozgur Cetik,
Assistant Professor
Kirikkale University, School of Medicine, Orthopaedics & Traumatology, Kirikkale, TURKEY,
Murad Uslu

Send letter to journal:
Re: Dr. Cetik & Dr. Uslu respond to Dr. Kontakis

ozgurcetik{at}hotmail.com Ozgur Cetik, et al.

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.
The axillary nerve in the deltoid muscle 15 November 2006
Next Letter to the Editor Top
George M. Kontakis, M.D.,
Assistant Professor of Orthopaedics
University of Crete, Greece

Send letter to journal:
Re: The axillary nerve in the deltoid muscle

kontak{at}med.uoc.gr George M. Kontakis, M.D.

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.