title: Nerve stress during reverse total shoulder arthroplasty: a cadaveric study.
abstract: BACKGROUND
  Neurologic lesions are relatively common after total shoulder arthroplasty. These injuries are mostly due to traction. We aimed to identify the arm manipulations and steps during reverse total shoulder arthroplasty (RTSA) that affect nerve stress.
  
  
  METHODS
  Stress was measured in 10 shoulders of 5 cadavers by use of a tensiometer on each nerve from the brachial plexus, with shoulders in different arm positions and during different surgical steps of RTSA.
  
  
  RESULTS
  When we studied shoulder position without prostheses, relative to the neutral position, internal rotation increased stress on the radial and axillary nerves and external rotation increased stress on the musculocutaneous, median, and ulnar nerves. Extension was correlated with increase in stress on all nerves. Abduction was correlated with increase in stress for the radial nerve. We identified 2 high-risk steps during RTSA: humeral exposition, particularly when the shoulder was in a position of more extension, and glenoid exposition. The thickness of polyethylene humeral cups used was associated with increased nerve stress in all but the ulnar nerve.
  
  
  CONCLUSIONS
  During humeral preparation, the surgeon must be careful to limit shoulder extension. Care must be taken during exposure of the glenoid. Extreme rotation and oversized implants should be avoided to minimize stretch-induced neuropathies.
authors.affiliation: Centre Ostéo-Articulaire des Cèdres, Echirolles, France. Electronic address: hubert.lenoir@laposte.net.
authors.forename: Hubert
authors.initials: H
authors.lastname: Lenoir
authors.affiliation: Hip, Knee and Foot Surgery Unit, Centre Hospitalier Régional Universitaire Montpellier University Hospital, Montpellier, France.
authors.forename: Louis
authors.initials: L
authors.lastname: Dagneaux
authors.affiliation: Hip, Knee and Foot Surgery Unit, Centre Hospitalier Régional Universitaire Montpellier University Hospital, Montpellier, France; Laboratory of Anatomy, Montpellier 1 University, Montpellier, France.
authors.forename: François
authors.initials: F
authors.lastname: Canovas
authors.affiliation: Clinique de l'Yvette, Longjumeau, France.
authors.forename: Thomas
authors.initials: T
authors.lastname: Waitzenegger
authors.affiliation: Toulouse-Purpan University Hospital Center, Toulouse, France.
authors.forename: Thuy Trang
authors.initials: TT
authors.lastname: Pham
authors.affiliation: Hand and Upper Extremity Surgery Unit, Centre Hospitalier Régional Universitaire Montpellier University Hospital, Montpellier, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Chammas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000072228:Arthroplasty, Replacement, Shoulder / Q000009:adverse effects; D001696:Biomechanical Phenomena; D001917:Brachial Plexus / Q000601:surgery; D002102:Cadaver; D005260:Female; D006801:Humans; D008297:Male; D008954:Models, Biological; D010523:Peripheral Nervous System Diseases / Q000503:physiopathology*; D011183:Postoperative Complications / Q000503:physiopathology; D016059:Range of Motion, Articular; D012785:Shoulder Joint / Q000294:innervation* / Q000601:surgery*
keywords: Nerve stress; brachial plexus injury; cadaveric study; neurologic complications; reverse total shoulder arthroplasty; shoulder position