JSES reviews, reports, and techniques · 2026
The course of the anterior branch of the axillary nerve and its implications on arthroscopic shoulder surgery.
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Lai Cara H, Hoffer Alexander J, Anderson Megan L, Hiredesai Annika N, Tokish John M
Аннотация
BACKGROUND: The anterior branch of the axillary nerve supplies most of the anterior and middle deltoid. Prior studies have described its consistent course inferior to the superior border of the pectoralis major tendon (PMT) in open deltopectoral approaches. Arthroscopic procedures such as suprapectoral biceps tenodesis often use an extra-articular cannula placed near this region, with the superior PMT commonly serving as a landmark. This study aimed to define the anatomic course of the anterior axillary nerve branches to the deltoid and their proximity to the PMT and a standard suprapectoral biceps tenodesis portal. We hypothesized that these branches would lie near the superior border of the PMT, placing them at risk during portal creation.
METHODS: Thirty fresh-frozen cadaveric shoulders underwent creation of an arthroscopic suprapectoral biceps tenodesis portal followed by a standard open deltopectoral approach. The anterior branch of the axillary nerve was identified on the deep surface of the deltoid and traced to its most distal insertion. The number of terminal nerve limbs was recorded. Five distances were measured: from the superior PMT to both the anterior nerve branch and its most inferior limb, from the arthroscopic portal to both structures, and from the anterior deltoid border to the most distal nerve branch. In a subset of specimens, the distance between the anterolateral acromion and the anterior nerve branch was also measured.
RESULTS: In more than two-thirds of specimens, the anterior branch of the axillary nerve coursed superior to the superior PMT border. The mean distance between the superior PMT and the most inferior limb of the axillary nerve was 4.0 ± 7.2 mm, with the 2 structures ≤3 mm apart in over half of specimens. The mean distance between the superior PMT and the main anterior branch was 20.3 ± 7.4 mm. The suprapectoral portal was 11.6 ± 10.6 mm from the anterior branch on average. In 13 specimens, the portal needle directly pierced or came within 5 mm of the anterior branch or its inferior limb.
DISCUSSION: The anterior axillary nerve or its distal arborizations are at risk during suprapectoral biceps tenodesis portal placement. A safer technique may involve centering the portal over the PMT and angling instrumentation cranially, as this position minimizes risk to the nerve's anterior branches.
METHODS: Thirty fresh-frozen cadaveric shoulders underwent creation of an arthroscopic suprapectoral biceps tenodesis portal followed by a standard open deltopectoral approach. The anterior branch of the axillary nerve was identified on the deep surface of the deltoid and traced to its most distal insertion. The number of terminal nerve limbs was recorded. Five distances were measured: from the superior PMT to both the anterior nerve branch and its most inferior limb, from the arthroscopic portal to both structures, and from the anterior deltoid border to the most distal nerve branch. In a subset of specimens, the distance between the anterolateral acromion and the anterior nerve branch was also measured.
RESULTS: In more than two-thirds of specimens, the anterior branch of the axillary nerve coursed superior to the superior PMT border. The mean distance between the superior PMT and the most inferior limb of the axillary nerve was 4.0 ± 7.2 mm, with the 2 structures ≤3 mm apart in over half of specimens. The mean distance between the superior PMT and the main anterior branch was 20.3 ± 7.4 mm. The suprapectoral portal was 11.6 ± 10.6 mm from the anterior branch on average. In 13 specimens, the portal needle directly pierced or came within 5 mm of the anterior branch or its inferior limb.
DISCUSSION: The anterior axillary nerve or its distal arborizations are at risk during suprapectoral biceps tenodesis portal placement. A safer technique may involve centering the portal over the PMT and angling instrumentation cranially, as this position minimizes risk to the nerve's anterior branches.