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Purpose Pathology of the biceps tendon can contribute to significant shoulder pain and dysfunction for which biceps tenodesis may be indicated. A variety of techniques tenodesing the biceps tendon have been described. Recently, tenodesis using a uni- or bicortical button has been advocated. This cadaveric study investigates the proximity of the axillary nerve to the position of bicortical drill passages during biceps tenodesis. Methods Twelve cadaveric shoulder specimens were used. The axillary nerve was marked during a preparatory dissection using wire. Drills were passed through the humerus at the proximal and distal ends of the bicipital groove, and at the superior insertion point of pectoralis major (PM). These were left in situ. The distances between these drills and the axillary nerves were measured using computed tomography imaging. Results The drill bits placed at the superior insertion of PM were in closest proximity to the axillary nerve (3D distance mean 10.7 mm, 95 % confidence interval 7.2–14.2 mm). A drill placed at the distal end of the bicipital groove was a mean distance of 18.2 mm from the nerve. Conclusions This study highlights the need for caution when drilling the posterior humeral cortex during biceps tenodesis, particularly during drilling at the superior insertion of PM as this is the location that poses the highest risk to the axillary nerve. To our knowledge, this is the first cadaveric study to radiologically assess the proximity of the axillary nerve to the positions of biceps tenodesis. Surgeons should therefore be cautious when performing bicortical drilling for biceps tenodesis, and a supero-lateral drill trajectory would pose a smaller risk to the axillary nerve.

Background The suprascapular and axillary nerves can be subject to entrapment due to both their anatomical courses and their anatomical relationships with surrounding anatomical structures around shoulder. These entrapments were previously considered as a diagnosis of exclusion. However, today these pathologies can be diagnosed as primary. The most common complaints of patients are pain and sometimes weakness. The clinician’s suspicion is very important in making diagnosis. The patient’s history, duration of symptoms, and information such as the movements in which the complaints increase should be questioned carefully and in detail. In physical examination, symmetrical evaluation of both shoulders can provide important information. In addition, cervical and brachial plexus pathologies should be kept in mind. According to the suprascapular and axillary nerve innervations, muscle atrophy should be evaluated during inspection. Range of motion and neurological examination around shoulder should be performed. Since these entrapments can be seen together with rotator cuff tears and labrum pathologies etc., these additional pathologies should also be targeted during evaluation. The evaluation should be expanded with imaging methods such as plain radiographs, ultrasonography, computed tomography, magnetic resonance imaging, electrodiagnostic studies and local anaesthetic injections to the entrapment area. There is no definitive method to diagnose these pathologies. As a result of all these evaluations, a diagnosis can be made. There is no consensus on treatment. In isolated entrapment cases where there are no additional surgical pathologies such as space-occupying lesions, non-operative treatment is primarily recommended. It is generally recommended to try non-operative treatment for at least six months. Surgical treatment is recommended in cases where non-operative treatment fails or in cases where there are additional pathologies requiring surgery or in cases where there is extrinsic compression such as sapce-occupying lesions. In the decision and choice of surgical treatment, it is very important to determine the aetiology precisely. Surgical treatment can be performed open and arthroscopically. Various additional arthroscopic portals and techniques have been described. However, there is no clear consensus on the superiority of these treatments over each other. Although physical therapy is recommended after surgical treatment, there is no consensus on this issue in the literature. Aim This review aims to summarize the diagnosis and management of suprascapular and axillary nerve entrapments in athletes, focusing on clinical presentation, diagnostic methods, treatment options, and current controversies.

Background and AimsRegional anesthesia has become an increasingly popular approach in arteriovenous fistula(AVF) creation surgery, due to the higher primary patency rates. The sympathectomy-like effect of brachial plexus block may cause perioperative vasodilation and increased brachial artery blood flow. This study aimed to estimate the minimum effective anesthetic concentration of lidocaine required for ultrasound-guided axillary nerve block in 90% (MEAC90) of patients with chronic kidney disease undergoing AVF creation surgery.MethodsThis study was based on a biased coin design up-and-down sequential method. Patients undergoing primary AVF creation surgery were enrolled. Ultrasound-guided perineural axillary block was performed with 20 ml 0.9% lidocaine. The following concentration was determined by the result of the previous patient. If the patient underwent the operation under pure nerve block, the next patient was randomized to receive the same lidocaine concentration or a concentration of 0.1% less. However, if the rescue medications were required, the lidocaine concentration was increased by 0.1% in the next patient.Abstract EP136 Table 1Patient demographicAbstract EP136 Table 2Surgical and Anesthetic variablesAbstract EP136 Figure 1Patients’ responses as lidocaine concentrations changeResultsThirty participants were enrolled, with 25 positive responses and 5 negative responses that needed additional medications during the operation. The mean MEAC90 was estimated to be 1.13% [95% confidence interval, 1.098-1.173].ConclusionsIn the current preliminary study, ultrasound-guided injection of 20ml of 1.13% lidocaine through perineural axillary block could provide a successful block for AVF creation surgery in 83.3% patients.Ethics Committee Approval from FEMH

The shoulder region is a common area for pain. The shoulder has the largest range of motion and the most complex mechanical anatomy. The shoulder girdle and related tendons allow for numerous painful disorders to occur. Also, given the overall use of the shoulder, arthritic deformities are all too common. Finally, pain from more complex states such as poststroke shoulder pain and status post total shoulder arthroplasty pain have always been a difficult diagnosis to treat with effectiveness. The innervation to the shoulder predominantly comes from the suprascapular and axillary nerves. Both nerves relatively follow an expected anatomic course and whereby they can be targeted with ultrasound or fluoroscopy. Recently, there has been an increase in evidence that suggests peripheral nerve stimulation can make a difference in these patients with shoulder pain. To provide a basic overview of peripheral nerve stimulator placement targeting the axillary and suprascapular nerves. Furthermore, to demonstrate the suggested implantation and current evidence of peripheral nerve stimulation for the treatment of shoulder pain. Anatomic clinical review. A comprehensive review was performed regarding the available literature through targeting articles reporting on the use of peripheral nerve stimulation to treat pain of the shoulder region. We compiled and discuss the current evidence available in treating shoulder pain utilizing peripheral stimulation. The strongest evidence currently is for peripheral nerve stimulation targeting either the axillary or suprascapular nerve, as well as placement targeting the motor points of the deltoid. The most common treated pathology is poststroke shoulder pain. Peripheral nerve stimulation has been trialed and is promising for several shoulder pain pathologies; however, there remains a need for large-scale, randomized, placebo-controlled clinical trials to further evaluate the efficacy of most treatments. Much of the current data relies on case reports without randomization or placebo controls. Overall there is fair to moderate evidence for peripheral nerve stimulation to treat shoulder pain in hemiplegic poststroke patients. There is limited evidence when treating other shoulder pain etiologies. Utilizing ultrasound or fluoroscopic guidance, the procedure has proven to be safe allowing proper placement of the electrodes near the target nerves. Considering the high prevalence of shoulder pain from degenerative conditions and overuse, future studies are undoubtedly warranted to evaluate whether peripheral nerve stimulation can modify our treatment algorithm for management of these conditions.

Background: The brachial plexus is the primary nerve source for the upper limb. Variations in its anatomy can alter the nerve supply to the upper extremity. Such deviations are clinically important, as they can change the symptomatology of various pathologic conditions, leading to misdiagnosis, inadequate treatment, and surgical failures as a consequence.Materials and Methods: The upper limbs of 16 human cadavers (32 extremities) were dissected at the Department of Anatomy, Histology and Embryology, Medical University–Plovdiv, Bulgaria. Eight cadavers were male and eight female, with age ranging 40–95 years (mean age: 72.63 years).Results: Three variations (18.8%) were identified unilaterally, exclusively in male cadavers; however, no statistically significant sex-based distribution was observed. The first variation involved a communicating branch between the musculocutaneous nerve and median nerve. The second was a high bifurcation of the radial nerve in the axillary fossa into two divisions. The third one was a communicating branch between the axillary nerve and the radial nerve, forming a loop beneath the subscapular artery.Conclusion: Our study identified greater variability in the branches of the posterior cord compared to the existing literature. These variations must be taken under clinical consideration to prevent diagnostic, therapeutic, and surgical errors.

The brachial plexus shows frequent anatomical variations that can complicate diagnosis, surgical planning, and anesthetic procedures. Detailed knowledge of these variations is essential to prevent iatrogenic injury and improve clinical outcomes. Eighteen donors (36 upper limbs) were dissected at Mercer School of Medicine, Columbus, Georgia, United States. The sample included 10 males and 8 females, aged 36-89 years (mean age: 67.67 years). Dissections followed , 17th edition, with all variations in the infraclavicular brachial plexus and its branches in the axillary region and upper arm documented, photographed, and measured. Variations were found in 16 brachial plexuses (44.4%) from nine donors. In total, 32 variations were identified, involving the medial and posterior cords, median, musculocutaneous, ulnar, radial, axillary, lower subscapular, and thoracodorsal nerves. Bilateral variations were more common (77.8%) than unilateral ones (22.2%), often with two to three variants on one side. Several rare or previously undescribed findings were noted, including a median nerve with an accessory lateral root located between the main and aberrant axillary arteries, a rare communication between the medial cord and lateral root of the median nerve, a rare communication between the ulnar and median nerves in the upper arm, bifurcation of the musculocutaneous nerve, trifurcation of the radial nerve, trifurcation of the axillary nerve, posterior division of the axillary nerve passing through the triangular space, posterior division of the axillary nerve supplying both teres minor and teres major, bifurcated axillary nerve accompanied by an accessory subscapularis muscle, accessory thoracodorsal nerve arising from the axillary nerve, and quadfurcation of the posterior cord. Contrary to previous literature, axillary nerve variations were the most common. Bilateral deviations were frequent, often associated with arterial variations. Multiple rare and undescribed patterns identified in this study expand current knowledge of infraclavicular brachial plexus anatomy.

Purpose Suprascapular nerve block (SSNB) is the most commonly used block for the relief of postoperative pain from arthroscopic rotator cuff repair and can be used in combination with axillary nerve block (ANB). Dexmedetomidine (DEX) is a type of alpha agonist that can elongate the duration of regional block. The aim of this study was to compare the effects of the use of dexmedetomidine combined with SSNB and ANB with those of the use of SSNB and ANB alone on postoperative pain, satisfaction, and pain-related cytokines within the first 48 h after arthroscopic rotator cuff repair. Methods Forty patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this single-center, double-blinded randomized controlled trial study. Twenty patients were randomly allocated to group 1 and received ultrasound-guided SSNB and ANB using a mixture of 0.5 ml (50 μg) of DEX and 9.5 ml of 0.75% ropivacaine preemptively. The other 20 patients were allocated to group 2 and underwent ultrasound-guided SSNB and ANB alone using a mixture of 0.5 ml of normal saline and 9.5 ml of ropivacaine. The visual analog scale (VAS) for pain and patient satisfaction (SAT) scores were postoperatively checked within 48 h. The plasma interleukin (IL)-6, IL-8, IL-1β, cortisol, and serotonin levels were also postoperatively measured within 48 h. Results Group 1 showed a significantly lower mean VAS (visual analog scale of pain) score 1, 3, 6, 12, 18 and 24 h after operation, and a significantly higher mean SAT (patient satisfaction) score 1, 3, 6, 12, 18, 24 and 36 h after the operation than group 2. Group 1 showed a significantly lower mean plasma IL-8 level 1 and 48 h after the operation, and a significantly lower mean IL-1β level 48 h after the operation than group 2. Group 1 showed a significantly lower mean plasma serotonin level 12 h after the operation than group 2. The mean timing of rebound pain in group 1 was significantly later than that in group 2 (36 h > 23 h, p  = 0.007). Six patients each in groups 1 and 2 showed rebound pain. The others did not show rebound pain. Conclusions Ultrasound-guided SSNA and ANB with DEX during arthroscopic rotator cuff repair resulted in a significantly lower mean VAS score and a significantly higher mean SAT score within 48 h after the operation than SSNB and ANB alone. Additionally, SSNB and ANB with DEX tended to result in a later mean timing of rebound pain accompanied by significant changes in IL-8, IL-1β, and serotonin levels within 48 h after the operation. The present study could provide the basis for selecting objective parameters of postoperative pain in deciding the optimal use of medication for relieving pain. Level of Evidence Level I. Trial Registration 2015–20, ClinicalTrials.gov Identifier: NCT04398589. IRB number 2015–20, Hallym University Chuncheon Sacred Heart Hospital.

Purpose The comprehensive arthroscopic management (CAM) procedure is a useful joint-preserving option for young or active patients with glenohumeral osteoarthritis (GHOA). Our objective was to evaluate the results and prognostic factors of the CAM procedure without direct axillary nerve release or subacromial decompression. Methods A retrospective observational study among patients with GHOA who underwent the CAM procedure was conducted. Neither axillary nerve neurolysis nor subacromial decompression was performed. Both primary and secondary GHOA were considered; the latter was defined as a history of shoulder pathology (mainly instability or proximal humerus fracture). The American Shoulder and Elbow Surgeons scale, Simple Shoulder Test, Visual Analogue Scale, activity level, Single Assessment Numeric Evaluation, EuroQol 5 Dimensions 3 Levels, Western Ontario Rotator Cuff Index, and active range of motion (aROM) were analysed. Results Twenty-five patients who underwent the CAM procedure met the inclusion criteria. After a mean follow-up of 42.4 ± 22.9 months, we found improvement ( p  < 0.001) in all postoperative values of the different scales. The procedure increased aROM overall. Patients with arthropathy due to instability showed worse results. The rate of CAM failures, defined as conversion to shoulder arthroplasty, was 12%. Conclusions This study showed that the CAM procedure without direct axillary nerve neurolysis or subacromial decompression might be a valid alternative in active patients with advanced GHOA to improve shoulder function (aROM and scores), decrease pain, and delay arthroplasty. This technique showed good subjective functional scores, high patient satisfaction, and a low rate of complications. Level of evidence IV.

Background Postoperative pain management is the part of shoulder surgery to improve patient satisfaction, start rehabilitation process rapidly and decrease for hospital stay. Various treatment modalities have been used for pain management, but they have some limitations, side effects and risks. Throughout intraoperative and postoperative period, nerve blocks have been used more popularly than others because of efficacy. For the regional nerve block, local anesthetic should be infiltrated close to the nerve for maximum effect. Consequently, aim of this study was to evaluate analgesic efficacy when catheters are placed with assistance of arthroscope to block suprascapular and axillary nerves in patients undergoing arthroscopic repair of rotator cuff under general anesthesia. Materials and Methods 24 patients (5 males, 19 females; mean age: 54.3 years) who underwent arthroscopic repair of rotator cuff between June 2014 and September 2014 and were catheterized to block suprascapular and axillary nerves during shoulder arthroscopy were included in the study. Clinical outcomes were assessed using visual analog scale (VAS) scores preoperatively and at 0 h, 6 h, 12 h, 18 h, 24 h, and postoperative day 2. Results Preoperative and postoperative 0 h, 6 h, 12 h, 18 h, 24 h, and day 2 mean VAS scores were 6.38 ± 0.77, 0.44 ± 0.42, 0.58 ± 0.42, 0.63 ± 0.40, 0.60 ± 0.44, 0.52 ± 0.42, and 1.55 ± 0.46, respectively. No statistical difference was found among 0 h, 6 h, 12 h, 18 h, and 24 h time points; however, comparison of postoperative day 2 and postoperative 0 h, 6 h, 12 h, 18h and 24 h VAS scores showed statistically significant difference ( P < 0.05). All patients were discharged at the end of 24 h with no complication. The mean time (in minutes) required for blocking suprascapular nerve and axillar nerve were 14.38 ± 3.21 and 3.75 ± 0.85, respectively. Conclusion These results demonstrated that blocking two nerves with arthroscopic approach was an excellent pain management method in postoperative period. Accordingly, patients could recover rapidly and patients’ satisfaction could be improved.

•To define Axillary Circumflex Nerve Block•The sensory block extension of the Axillary Circumflex Nerve Block•Axillary Circumflex Nerve Block for arthroscopy of the shoulder