Unusual anatomic variant of the axillary nerve challenging the deltopectoral approach to the shoulder: a case report

BACKGROUND: The deltopectoral approach is a well-described surgical approach to the proximal humerus and glenohumeral joint. One of the structures at risk during this approach is the axillary nerve. Typically, the axillary nerve arises off the posterior cord of the brachial plexus and courses lateral to the proximal humerus and inferior to the glenohumeral joint, exiting the axilla through the quadrangular space. We describe a case of an aberrant axillary nerve, coursing anteriorly across the glenohumeral joint within the deltopectoral groove encountered during a reverse total shoulder arthroplasty. CASE PRESENTATION: A 73-year-old female presented complaining of atraumatic progressive right shoulder pain of several months duration. Clinical and radiographic findings were consistent with advanced rotator cuff arthropathy. After failing appropriate non-operative treatment, the patient elected to undergo reverse total shoulder arthroplasty. During the deltopectoral approach to the glenohumeral joint, the axillary nerve was found to be coursing deep to the cephalic vein within the deltopectoral interval. The nerve was isolated and protected, and the glenohumeral joint was accessed via a small window in the anterior deltoid muscle. The remainder of the procedure was performed without complication. The patient was found to be healing well and with normal axillary nerve function at 4-month follow-up. CONCLUSIONS: Neurologic lesions are well-documented complications of reverse total shoulder arthroplasty. The integrity of the axillary nerve is of particular importance to reverse total shoulder arthroplasty as it innervates the deltoid and post-operative function of the extremity is dependent upon a functioning deltoid muscle. Extreme care must be taken to avoid insult to the axillary nerve and any aberrant paths it may course around the glenohumeral joint.