Incidence of clinically evident isolated axillary nerve injury in 869 primary anatomic and reverse total shoulder arthroplasties without routine identification of the axillary nerve

Abstract

Background It has been suggested that, during primary shoulder arthroplasty, surgeons should identify the axillary nerve through direct visualization, palpation, or the “tug test” to prevent iatrogenic nerve injury. Our goal was to document the rate of isolated axillary nerve injury (IANI) in patients who had undergone primary anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) without routine identification of the axillary nerve. Methods Data on 869 cases of primary shoulder arthroplasty (338 TSAs and 531 RTSAs) performed by 1 surgeon between 2003 and 2017 were reviewed. Neither the tug test nor identification of the axillary nerve through palpation or visualization was used in any case. The primary outcome was new IANI documented within 3 months after arthroplasty. The frequency of IANI was summarized using point estimates and 95% confidence intervals (CIs). Results Six cases met the criteria for IANI. The overall incidence of IANI was 0.7% (95% CI, 0.3%-1.4%). The incidence of IANI was 0.3% (95% CI, 0%-1.6%) after TSA and 0.9% (95% CI, 0.3%-2.1%) after RTSA. All IANIs were cases of neurapraxia, and all patients had experienced complete neurologic recovery at last follow-up. Conclusion Complete, permanent IANI resulting from direct surgical trauma during primary shoulder arthroplasty can be avoided without using the tug test or routine identification of the nerve. A low incidence of partial temporary IANI can be expected, which may be related to indirect traction injuries.

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“…The occurrence of nerve complications following rTSA, relates to direct nerve damage, indirect traction, compression secondary to retractors use and post-operative hematoma formation [14]. Isolated axillary nerve stupor [15]. as well as persisting residual dysesthesia in the territory innervated by the median nerve, produced by an injury of the upper sensitive trunk have been described [16].…”

Neurologic complications in primary anatomic and reverse total shoulder arthroplasty: A review

“…9,11,12 LiBrizzi et al showed that the incidence of axillary nerve injury was 0.3% for TSA and 0.9% after rTSA in their study of 869 primary shoulder arthroplasty cases. 20 Similarly, Ball reported a nerve complication rate of 20% for TSA and 22.9% for rTSA, with median nerve and musculocutaneous nerve being most commonly involved. 13 This increased risk of nerve injury is thought to be due to the lengthening of the arm that generally occurs during rTSA that is not present with TSA.…”

“…In a retrospective study of 869 TSA and rTSA cases by LiBrizzi et al, one hundred percent of the patients with axillary nerve palsydregardless of whether they had partial or complete sensorimotor deficitsdexperienced complete neurologic recovery by nine months postoperatively. 20 Similarly, Lopiz et al found that most of the axillary nerve lesions due to acute injury during shoulder replacement were transient and had no functional impact at final follow-up, with complete recovery seen on EMG at 6 months postoperatively. 26 6.…”

“…While motor deficits are the most devastating consequence of axillary nerve lesions, sensory changes such as numbness along the lateral arm are the most common presenting symptoms. 20…”

When should reverse total shoulder arthroplasty be considered in glenohumeral joint arthritis?

“…(3) Nerve injury is very rare in shoulder arthroplasty. However, in shoulders with stiffness, the risk of nerve injury could increase as excessive soft tissue traction or soft tissue release often is required [51][52][53]. (4) It often is difficult to repair the rotator cuff after implantation.…”