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Partial Radial Nerve Transfers for Patients with Isolated Traumatic Axillary Nerve Injuries
Antony Hazel, MD; James Clune, MD; Helen Vasey, NP; Neil F. Jones, MD; Ranjan Gupta, MD
University of Calfironia, Irvine, Orange, CA

Hypothesis: Isolated axillary nerve injuries can occur subsequent to trauma or as a direct complication from shoulder procedures. While partial radial to axillary nerve transfers have previously been described, there has been a lack of information related to patient selection, surgical methodology, and outcomes. We hypothesize that partial radial to axillary nerve transfers is an under-utilized, promising treatment option for patients with this devastating injury.

Methods: We performed a retrospective analysis of all partial radial nerve transfers for isolated axillary nerve injuries (n=7) performed by a single surgeon over the past four years. All patients had nerve conduction studies verifying a complete axillary nerve lesion with no reinnervation as detailed by fibrillation potentials without evidence of nascent potentials. The surgery consisted of (1) using a direct posterior approach to the arm, (2) isolating one fascicle of the radial nerve responsible for only elbow flexion as confirmed by intra-operative monitoring, and (3) coapting this branch to the proximal portion of the axillary nerve in the quadrilateral space. All patients were protected in a shoulder sling for three weeks until the nerve repair healed.

Results: There was no donor nerve deficit for any patient. Four of the seven patients had undergone previous shoulder surgery and had received a preoperative nerve block. One patient had the nerve transfer performed within four months of injury and regained functional motion with forward elevation to 160 degrees and M4 strength. The other patients had surgery after the initial 7 months after the injury and did not have any meaningful improvement in function after the nerve transfer. The other three patients had an axillary nerve injury related to a traumatic injury and had nerve transfer performed within the initial 6 month time period. One patient has subsequent restoration of his deltoid muscle; however, his range of motion was limited due to an underlying proximal humerus nonunion. The other two patients have forward elevation to 160 degrees with M4 strength.

Conclusion: For patients with axillary nerve injuries, a partial radial to axillary nerve transfer is a safe procedure without donor deficit that can provide functional recovery with early intervention. While the expanded use of regional anesthesia may cloud the initial post operative exam for patients undergoing shoulder surgery, the surgeon should be suspicious of patients who do not demonstrate recovery and refer patients early for intervention rather than prolonged observation in order to maximize the chances of recovery.

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