Shoulder arthroscopy and nerve injury: pitfalls and prevention

Neurological Complications Following Arthroscopic and Related Sports Surgery: Prevention, Work-up, and Treatment

Arthroscopy of the shoulder, elbow, hip, and knee has become increasingly utilized due to continued advancements in technique, training, and instrumentation. In addition, arthroscopy is generally safe and effective in the utilization of joint preservation surgical techniques. The arthroscopist must utilize a thorough understanding of the surgical anatomy, detailed care with patient positioning, and safe instrumentation portals to prevent associated neurological injury. In the event of postoperative neurological complications, the physician must carefully document the patient history and physical examination while considering the utilization of additional imaging, testing, or surgical nerve exploration with a specialized team depending upon the severity of neurological injury. In this review, we discuss the prevention, evaluation, and treatment of neurological complications related for arthroscopic procedures of the shoulder, elbow, hip, and knee.

How close is the axillary nerve to the inferior glenoid? A magnetic resonance study of normal and arthritic shoulders

INTRODUCTION

Axillary nerve injury is a major complication of shoulder surgery during glenoid exposure. The aim of this study was to measure the mean distance between the inferior glenoid and the axillary nerve in healthy shoulders and then to compare this distance between osteoarthritic and rotator cuff deficient glenohumeral joints.

METHODS

The magnetic resonance images of 50 patients with normal glenohumeral joints were reviewed. The infra-glenoid tubercle was determined as a fixed point and the distance to the axillary nerve was measured. Two separate assessors measured on the same sagittal sections. With a study power of 80%, the sample needed in each comparison group was 28 patients. Measurements were then performed on scans in patients with osteoarthritis and cuff tear arthropathy. The mean distance was compared between groups.

RESULTS

The mean distance between the infra-glenoid tubercle and axillary nerve was 12mm (standard deviation, SD, 5.6mm) in normal shoulders, 10.6mm (SD 5.4mm) in shoulders with osteoarthritis and 9.7mm (SD 3.7mm) in those with cuff tear arthropathy. For this sample size of 50 patients with a confidence interval of 95%, the mean range is 12mm (95% CI 10.4-13.6). A comparison between normal shoulder and osteoarthritis showed a p-value of 0.3, and between normal and cuff tear arthropathy a p-value of 0.06. This was not statistically significant.

CONCLUSIONS

The axillary nerve lies on average 12mm from the infra-glenoid tubercle. The presence of inferior osteophytes in glenohumeral osteoarthritis and the proximal migration of humeral head in cuff tear arthropathy does not seem to alter the course of the nerve significantly in relation to the inferior glenoid tubercle.

Peripheral Nerve Injury Following Interscalene Blocks: A Systematic Review to Guide Orthopedic Surgeons

The purpose of this review was to determine the incidence and duration of peripheral neurologic symptoms following interscalene blocks for shoulder surgery. Three databases were reviewed for subjective and objective injuries by guidance modality and delivery method. The incidence of neurologic injuries following single site injection interscalene blocks, 3.16%, was significantly less than the 5.24% incidence for continuous catheter infusion interscalene blocks. Less than 0.51% of peripheral neurologic symptoms persisted beyond 1 year for both groups. There is a notable risk of injury following interscalene blocks by all modes of guidance and anesthetic technique, but only a small percentage of injuries persist. [Orthopedics. 2018; 41(5):e598-e606.].

Ocular surface injury after shoulder surgery in the beach-chair position

PURPOSE

During shoulder surgery in the beach-chair position, head fixation can sometimes cause rare complications. The authors share their experience in treating ocular injury due to improper head fixation during surgery in the beach-chair position.

METHODS

The study investigated consecutively 6075 patients who underwent shoulder surgery in the beach-chair position between March 2007 and March 2016, those patients who saw an ophthalmologist with a complaint of post-operative ocular discomfort. In the beach-chair position, surgery is performed with the patient's upper body raised by 70°.

RESULTS

A total of seven patients saw an ophthalmologist due to post-operative ocular discomfort, and a total of five patients (0.082%) had corneal abrasion. Three of these patients underwent arthroscopic surgery, and the other two underwent open surgery. The mean surgery duration for the five patients was 45.0 ± 14.68 minutes. Of these patients, four were male and one was female, and their average age was 46 ± 22.24 years (range: 18-69 years). All patients complained of unbearable ophthalmodynia immediately after surgery that was not resolved using analgesics. The ophthalmodynia resolved immediately after wearing corneal protective lenses.

CONCLUSION

Unlike typical surgery, when shoulder surgery is performed in the beach-chair position, there is a risk of ocular surface injury due to improper head fixation; one manifestation of this problem is corneal injury. If a severe ophthalmodynia that cannot be controlled using analgesics occurs immediately after surgery in the beach-chair position, a corneal injury should be suspected, and the patient should wear a corneal protective lens.

LEVEL OF EVIDENCE

Level IV.

Complications of the Fingers and Hand After Arthroscopic Rotator Cuff Repair

Background

Complications of the fingers and hand that occur after Arthroscopic Rotator Cuff Repair (ARCR) have not been examined in detail.

Objective

The aim of our study was to evaluate the diagnosis and treatment of complications of the fingers and hand that occur after ARCR and to examine treatment outcomes.

Methods

The case records of 40 patients (41 shoulders) who underwent ARCR using suture anchors were retrospectively reviewed to investigate complications of the fingers and hand after ARCR.

Results

Twelve patients (29%) experienced numbness, pain, edema, and movement limitations of the fingers and hand. These symptoms occurred on average 1.1 months (range, 0.1-2.5 months) after ARCR. The diagnoses were cubital tunnel syndrome in 2 hands, carpal tunnel syndrome in 3 hands, and flexor tenosynovitis (TS) in 10 hands. None of the 10 hands with TS exhibited triggering of the fingers. The mean interval between treatment initiation and symptom resolution was 2.2 months for the 5 hands treated by corticosteroid injection or surgery and 5.9 months for the 7 hands treated by alternating warm and cold baths alone. None of the hands exhibited Complex Regional Pain Syndrome (CRPS).

Conclusion

Complications of the fingers and hand after ARCR were observed in 29%. TS was the most frequent complication. When symptoms in the fingers and hand occur after ARCR, rather than immediately suspecting CRPS, TS should be primarily suspected, including when TS symptoms such as triggering are not present, and these patients should be treated proactively using corticosteroid injections or surgery.

Modified Semilateral Decubitus Position for Shoulder Arthroscopy and Its Application for Open Surgery of the Shoulder (One Setting for All Shoulder Procedures)

Two standard patient positions for shoulder arthroscopy are the beach-chair and lateral decubitus positions. Both positions have advantages and disadvantages in many aspects. Surgeons choose the position based on their preferences, mainly the orientation of the anatomy. If an operation needs to be converted to an open procedure, a patient who is placed in the lateral decubitus position might need to undergo repositioning and re-draping, which result in extending the operative time and increasing the risk of infection. For this circumstance, the modified semilateral decubitus position offers the same advantages as the lateral decubitus position and can be adjusted to achieve a more upright position similar to the beach-chair position.

In vivo biomechanical measurement and haptic simulation of portal placement procedure in shoulder arthroscopic surgery

A survey of 67 experienced orthopedic surgeons indicated that precise portal placement was the most important skill in arthroscopic surgery. However, none of the currently available virtual reality simulators include simulation / training in portal placement, including haptic feedback of the necessary puncture force. This study aimed to: (1) measure the in vivo force and stiffness during a portal placement procedure in an actual operating room and (2) implement active haptic simulation of a portal placement procedure using the measured in vivo data. We measured the force required for port placement and the stiffness of the joint capsule during portal placement procedures performed by an experienced arthroscopic surgeon. Based on the acquired mechanical property values, we developed a cable-driven active haptic simulator designed to train the portal placement skill and evaluated the validity of the simulated haptics. Ten patients diagnosed with rotator cuff tears were enrolled in this experiment. The maximum peak force and joint capsule stiffness during posterior portal placement procedures were 66.46 (±10.76N) and 2560.82(±252.92) N/m, respectively. We then designed an active haptic simulator using the acquired data. Our cable-driven mechanism structure had a friction force of 3.763 ± 0.341 N, less than 6% of the mean puncture force. Simulator performance was evaluated by comparing the target stiffness and force with the stiffness and force reproduced by the device. R-squared values were 0.998 for puncture force replication and 0.902 for stiffness replication, indicating that the in vivo data can be used to implement a realistic haptic simulator.

Safety and efficacy of hyperosmolar irrigation solution in shoulder arthroscopy

BACKGROUND

A hyperosmolar irrigation solution has been reported to be safe and have potential benefits for use during shoulder arthroscopy in an animal model study. In this study, the clinical effects of a hyperosmolar solution were compared with a standard isotonic solution when used for shoulder arthroscopy.

METHODS

A prospective, double-blind, randomized controlled trial was performed to compare isotonic (273 mOsm/L) and hyperosmolar (593 mOsm/L) irrigation solutions used for arthroscopic rotator cuff repair. Primary outcomes focused on the amount of periarticular fluid retention based on net weight gain, change in shoulder girth, and pain. All patients were tracked through standard postsurgical follow-up to ensure no additional complications arose. Patients were contacted at 1 year to assess American Shoulder and Elbow Surgeon score, visual analog scale pain score, and the Single Assessment Numeric Evaluation shoulder scores RESULTS: Fifty patients (n = 25/group) were enrolled and completed the study. No statistically significant differences were noted between cohorts in demographics or surgical variables. The hyperosmolar group experienced significantly less mean weight gain (1.6 ± 0.82 kg vs. 2.25 ± 0.77 kg; P = .005), significantly less change in shoulder girth (P < .05), and a significantly lower immediate postoperative visual analog scale pain score (P = .036). At 1 year postoperatively, the differences between groups for American Shoulder and Elbow Surgeons, visual analog scale pain, and Single Assessment Numeric Evaluation were not significant (P > .2).

CONCLUSION

A hyperosmolar irrigation solution provides a safe and effective way to decrease periarticular fluid retention associated with arthroscopic rotator cuff surgery without any adverse long-term effects. Use of a hyperosmolar irrigation solution for shoulder arthroscopy has potential clinical benefits to surgeons and patients.

Clinical Safety of the 5 O'clock Portal in Shoulder Arthroscopy: A Prospective Study

Background

The present study aimed to determine the rate of clinically significant neurovascular complications associated with the routine use of the 5 o'clock portal during arthroscopic Bankart repair.

Methods

Forty-eight consecutive patients underwent arthroscopic Bankart repair with the use of the 5 o'clock portal. These patients were followed at 2 weeks and 6 weeks postoperatively for subjective signs of neurovascular injury (i.e. numbness and tingling) as well as objective signs (i.e. intraoperative bleeding, radial pulse, capillary refill, sensation, motor strength, haematoma and oedema).

Results

Two out of 48 patients (4.2%) experienced transient neurological symptoms in an ulnar nerve distribution, which resolved by 6 weeks. There was no occurrence of clinically significant injury to the axillary nerve, axillary artery, musculocutaneous nerve, lateral cord of the brachial plexus or cephalic vein.

Conclusions

No clinically detectable neurovascular injuries were associated with the use of the 5 o'clock shoulder portal during Bankart repair.

The Supine Position for Shoulder Arthroscopy

Shoulder arthroscopy is traditionally performed with the patient in either the beach chair position or the lateral decubitus position. Each position has its advantages and disadvantages. The main topics for consideration include ease of surgery, view into the surgical field, risks to the patient, and economics of the setup. In the lateral decubitus position, it is inconvenient to work through the anterior portal and it is difficult to convert to an open procedure. In the beach chair position, it is difficult to manage the airway and cerebral oxygenation and the patient's head and the beach chair frame obstruct the insertion of a scope into the superior and posterior portals. This technical note presents the supine position for shoulder arthroscopic surgery. The supine position does not have the disadvantages of the traditional positions. In addition, it is comparatively easy to set up and comfortable for the patient.

Hyperosmolar irrigation compared with a standard solution in a canine shoulder arthroscopy model

BACKGROUND

A hyperosmolar irrigation solution may decrease fluid extravasation during arthroscopic procedures. Demonstrating the safety of a hyperosmolar irrigation solution with respect to chondrocyte viability and cartilage water content was deemed necessary before designing a clinical efficacy study.

METHODS

We designed a translational animal model study in which hyperosmolar arthroscopy irrigation fluid (1.8%, 600 mOsm/L) was compared with normal saline (0.9%, 300 mOsm/L). Purpose-bred research dogs (n = 5) underwent bilateral shoulder arthroscopy. Irrigation fluid was delivered to each shoulder joint (n = 10) at 40 mm Hg for 120 minutes using standard ingress and egress portals. The percentage change in shoulder girth was documented at the completion of 120 minutes. Articular cartilage sections from the glenoid and humeral head were harvested from both shoulders. Chondrocyte viability and tissue water content were evaluated. Differences between groups and compared with time 0 controls were determined, with significance set at P <.05.

RESULTS

The mean percentage change in shoulder girth was higher in the isotonic control group (13.3%) than in the hyperosmolar group (10.4%). Chondrocyte viability and tissue water content for glenoid and humeral head cartilage were well maintained in both treatment groups, and differences were not statistically significant.

CONCLUSIONS

The data from this study suggest that doubling the osmolarity of the standard irrigation solution used for arthroscopy was not associated with any detrimental effects on chondrocyte viability or tissue water content after 2 hours of arthroscopic irrigation. On the basis of potential benefits in conjunction with the safety demonstrated in these data, clinical evaluation of a hyperosmolar solution for irrigation during shoulder arthroscopy appears warranted.

Management of complications after rotator cuff surgery

Rotator cuff repair (RCR) is a common procedure performed by orthopedic surgeons via arthroscopic, open, or mini-open techniques. While this surgery is considered to be of low morbidity, several potential complications can arise either intraoperatively or during the postoperative time period. Some of these complications are related to the surgical approach (arthroscopic or open), while others are patient dependent. Many of these complications can be managed through nonoperative means; however, early recognition and timely treatment is essential in limiting the long-term sequela and improving patient outcome. There are several different ways to classify complications after RCR repair: timing, severity, preventability, whether or not the pathology is intra- or extra-articular, and the type of treatment necessary. It is essential that the surgeon is cognizant of the etiology contributing to the failed RCR surgery in order to provide timely and proper management.

Complications of shoulder arthroscopy

Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. These complications can be minimized with thoughtful consideration of the surgical indications, careful patient selection and positioning, and a thorough knowledge of the shoulder anatomy. Deep infection following arthroscopic shoulder surgery is rare; however, the shoulder is particularly susceptible to Propionibacterium acnes infection, which is mildly virulent and has a benign presentation. The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.

Pseudoaneurysm after arthroscopic subacromial decompression and distal clavicle excision

Arthroscopic shoulder surgery is considered a safe and effective method of treating a variety of shoulder pathologies and is associated with a low complication rate. The type and rate of complications can vary, depending on the procedure, positioning, surgical time, and anesthesia. Fortunately, neurovascular injuries occur infrequently. Numerous studies have described the proximity of neurovascular structures to portals placed in shoulder arthroscopy, in both the beach chair and the lateral decubitus positions. Accurate portal placement is important to avoid damage to adjacent neurovascular structures. Inaccurate placement of portals can lead to inadvertent damage to these structures and create more difficulty with visualization and angle of instrumentation, possibly compromising the success of the procedure. This article describes a 50-year-old man who underwent arthroscopic subacromial decompression and distal clavicle excision for persistent subacromial impingement and acromioclavicular arthritis. During postoperative follow-up, the patient had a small, bulging area located near the anterior portal site. Examination showed a well-healed anterior portal site with a small (approximately 2×2 cm), nontender, immobile mass located within the deep soft tissues just below the anterior portal incision. Ultrasound evaluation showed a pseudoaneurysm of a branch off the axillary artery. The patient underwent successful embolization of the pseudoaneurysm, with complete resolution of symptoms.

Complications of arthroscopic shoulder surgery

Shoulder arthroscopic procedures have become common in today's orthopedic practice. The safety of shoulder arthroscopy though well established, is not without complications both minor and significant. The true incidence of complications is difficult to identify in the current literature. However, as with all procedures, complications associated with shoulder arthroscopy do occur. General complications (ie, infection), those specific to shoulder arthroscopy (ie, positioning) and those associated with specific procedures (ie, failure) all have been recognized. The purpose of this article is to review the current literature regarding complications in shoulder arthroscopy, provide insight into the risk factors and types of complications and to provide guidelines on the prevention and management of complications if and when they occur.

Iatrogenic nerve injuries during shoulder surgery

INTRODUCTION

The current literature indicates that neurologic injuries during shoulder surgery occur infrequently and result in little if any morbidity. The purpose of this study was to review one institution's experience treating patients with iatrogenic nerve injuries after shoulder surgery.

METHODS

A retrospective review of the records of patients evaluated in a brachial plexus specialty clinic from 2000 to 2010 identified twenty-six patients with iatrogenic nerve injury secondary to shoulder surgery. The records were reviewed to determine the operative procedure, time to presentation, findings on physical examination, treatment, and outcome.

RESULTS

The average age was forty-three years (range, seventeen to seventy-two years), and the average delay prior to referral was 5.4 months (range, one to fifteen months). Seven nerve injuries resulted from open procedures done to treat instability; nine, from arthroscopic surgery; four, from total shoulder arthroplasty; and six, from a combined open and arthroscopic operation. The injury occurred at the level of the brachial plexus in thirteen patients and at a terminal nerve branch in thirteen. Fifteen patients (58%) did not recover nerve function after observation and required surgical management. A structural nerve injury (laceration or suture entrapment) occurred in nine patients (35%), including eight of the thirteen who presented with a terminal nerve branch injury and one of the thirteen who presented with an injury at the level of the brachial plexus.

CONCLUSIONS

Nerve injuries occurring during shoulder surgery can produce severe morbidity and may require surgical management. Injuries at the level of a peripheral nerve are more likely to be surgically treatable than injuries of the brachial plexus. A high index of suspicion and early referral and evaluation should be considered when evaluating patients with iatrogenic neurologic deficits after shoulder surgery.

Full thickness tears: retaining the cuff

Repair of rotator cuff tears is technically challenging. Full thickness rotator cuff tears have no potential for spontaneous healing, no reliable tendons substitutes are available, and their management is only partially understood. Many factors seem to contribute to the final outcome, and considerable variations in the decision-making process exist. For these reasons, decisions are often taken on the basis of surgeon's clinical experience. Accurate and prompt diagnosis is fundamental to guide correct management, and the tear pattern should be carefully evaluated to planning the most appropriate repair.

Vertical versus horizontal suture configuration for the repair of isolated type II SLAP lesion through a single anterior portal: a randomized controlled trial

PURPOSE

To compare the clinical and functional outcomes of the repair of an isolated type II SLAP lesion by 2 different configuration techniques (vertical v horizontal suture) through a single anterior portal.

METHODS

We designed a prospective, double-blinded, randomized clinical trial. A junior orthopaedic surgeon, who made the initial diagnosis, used a 10-point visual analog scale for pain and subjective instability and the American Shoulder and Elbow Surgeons (ASES) scoring system and evaluated the range of motion. After a diagnostic arthroscopy that ascertained the presence of an isolated type II SLAP lesion, patients were randomized to receive either vertical suture configuration (group 1) or horizontal suture configuration (group 2), both through a single anterior portal. Thirty-two patients were included in the study. The mean follow-up time was 37 months.

RESULTS

The mean postoperative ASES score was 91.9 in group 1 versus 95.8 in group 2 (P > .05). The differences observed from preoperative ASES score for both groups to postoperative ASES score were statistically significant. The differences observed in preoperative range of motion from the contralateral healthy shoulder and the affected shoulder in both groups were all clinically and statistically significant. Comparing the overall range of motion of the affected limb postoperatively with the range of motion of the contralateral healthy shoulder and between both groups, we found no statistically significant differences in forward flexion (P = .067), external rotation (P = .101), or internal rotation (P = .343).

CONCLUSIONS

The results of this study suggest that the repair of an isolated type II SLAP lesion through a single anterior portal is clinically and functionally beneficial to patients regardless of the suture configuration performed (vertical or horizontal suture) because no differences were observed between these configurations after repair of an isolated type II SLAP lesion.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy

The lateral decubitus and beach-chair positions each offer unique benefits to the shoulder surgeon with respect to visualization, efficiency, and ease during arthroscopic shoulder procedures. The purpose of this article was to comprehensively review the reports and studies documenting independent and dependent complications related to patient positioning and anesthesia during arthroscopic shoulder surgery. The lateral decubitus position has been associated with the potential for peripheral neurapraxia, brachial plexopathy, direct nerve injury, and airway compromise. The beach-chair position has been associated with cervical neurapraxia, pneumothorax, and the potential for end-organ hypoperfusion injuries (when deliberate hypotension is used). Potentially concerning are hypotensive bradycardic events, which may be relatively common in association with the use of epinephrine-containing interscalene anesthetics in beach chair-positioned patients. Irrigant complications (fluid spread, ventricular tachycardia) are avoidable risks not unique to either specific position. Although minor transient anesthetic- and position-related complications (neurapraxia, hypotension) may occur in as many 10% to 30% of patients, major complications such as end-organ damage or permanent impairments are exceedingly rare. Regardless of position, complications are almost uniformly avoidable if surgeon and anesthetist exercise care and prudent attention to position and anesthetic choices. The purpose of this article is to review the potential for position- and anesthesia-related complications and acquaint the shoulder surgeon with the proposed pathophysiologic mechanisms that can lead to them.

Anatomical considerations of subcoracoid neurovascular structures in anterior shoulder reconstruction

Anterior shoulder surgery, using open or arthroscopic technique, places subcoracoid neurovasculature at risk. This study examines the relationships of the brachial plexus and axillary artery to four bony landmarks and provides clinical correlations for anterior shoulder surgery. The musculocutaneous nerve (MN), posterior cord (PC), lateral cord (LC), and axillary artery (AA) were identified in 27 shoulders. Minimum distances (mm) were measured between neurovasculature and the coracoid tip, anterior midglenoid, inferior surface of the midclavicle, and anteromedial aspect of the acromioclavicular joint. Average distances from the coracoid to the MN, PC, LC, and AA were 69.7 ± 31.6, 50.5 ± 9.2, 41.8 ± 9.4, and 60.0 ± 8.0 mm, respectively; from the glenoid equator to the MN, PC, LC, and AA were 61.5 ± 38.5, 37.0 ± 6.1, 35.2 ± 8.7, and 45.2 ± 7.1 mm, respectively; from the midclavicle to the MN, PC, LC, and AA were 114.1 ± 33.9, 62.0 ± 13.6, 56.0 ± 19.7, and 69.9 ± 7.8 mm, respectively; and from the AC joint to the MN, PC, LC, and AA were 112.7 ± 36.5, 87.9 ± 10.6, 84.0 ± 12.0, and 100.9 ± 1.0 mm, respectively. The lateral cord was the closest structure to each bony landmark. The musculocutaneous nerve was the furthest structure from each bony landmark. Open procedures using a deltopectoral approach with the shoulder in the anatomical position, such as the Neer capsular shift and Warner capsular reconstruction, can use these results to prevent direct or retraction injuries. Results indicate a potential safe zone of 30 mm in diameter around the anteromedial coracoid tip for anteroinferior portal placement.

Beach chair position with instrumental distraction for arthroscopic and open shoulder surgeries

Arthroscopy is widely used in the diagnosis and treatment of shoulder disorders. It can be performed in the lateral or sitting position (beach chair). Both have advantages and disadvantages. We present a simple, inexpensive, versatile, portable, continuous distraction device for arthroscopic, combined, and open shoulder surgeries in the sitting position that offers the advantages of the 2 classic positions without their disadvantages. The device was used in 101 consecutive procedures: 61 rotator cuff repairs (29 arthroscopic, 18 mini-open, 14 open), 4 two-part humeral fractures, 1 septic arthritis, 3 calcifying tendinitis, 9 capsular releases, 8 Bankart repairs (6 arthroscopic, 2 open), 13 acromioplasty and biceps tenotomy, and 2 superior labrum anteroposterior repairs. Our experience with this device is extremely positive. We have had no complications and have used it for shoulder arthroscopy, open, and combined surgeries. We have also not had difficulty visualizing or approaching the glenohumeral and subacromial spaces in the treatment of shoulder disorders. It is a safe, practical, easy, and fast set up. Its versatility makes it particularly helpful for the less experienced arthroscopic surgeon.

Complication et prévention de l'arthroscopie du membre supérieur

Arthroscopy for upper limb joints disorders has been used increasingly over the past two decades, and is often considered by population as minor surgery. It would be a mistake to mask potential complications, even if they are less important than equivalent conventional technique. Complications depend on the joint, and despite the relative lack of experience for wrist and small joints, elbow arthroscopy seems to be the arthroscopic technique with most important complication rate. However, most of these complications remain minor and curable. Teaching of anatomy and arthroscopic techniques, respect of elementary prudence rules, should allow to control the risk and the learnig curve. Clear and honest information about potential complications provided to patient is certainly the best way to reduce consequences of these complications.

Innervation patterns of the inferior glenohumeral ligament: Anatomical and biomechanical relevance

Although the Inferior Glenohumeral Ligament (IGHL) has a well known mechanical and proprioceptive relevance in shoulder stability, the interrelation of the ligament's anatomical disposition/innervation has not actually been described previously. The purpose of the study was to determine the IGHL innervation patterns and relate them to dislocation. Forty-five embalmed and 16 fresh-frozen human cadaveric shoulders were studied. Masson's Trichrome staining detailed the intraligamentous nerve fiber arrangements. The effect on the articular nerves of an anteroinferior dislocation of the shoulder joint and the position of 60 degrees abduction and 45 degrees external rotation was studied dynamically. The axillary nerve provided IGHL innervation in 95.08% of the cases. We saw two distinct innervation patterns originating from the axillary nerve. In Type 1, one or two collaterals diverged later from the main trunk to enter the ligament. Type 2 showed innervation to the ligament provided by the posterior branch for three to four neural branches. In both cases, these branches enter the ligament near the glenoid rim and at the 7 o'clock position (right shoulder). The radial nerve (Type 3 innervation pattern) provided IGHL innervation in 3.28% of the cases. Microscopic analysis revealed wavy intraligamentous neural branches. The articular branches relaxed and separated from the capsule at the apprehension position and stayed intact after dislocation. These results showed a special predisposition to avoid possible denervation and suggested that the neural arch probably remains unaffected after most dislocations. Knowledge of the neural anatomy of the shoulder will clearly help in avoiding its injury in surgical procedures.

Immediate postoperative fluid retention and weight gain after shoulder arthroscopy

PURPOSE

The primary purpose of this study was to determine the amount of weight gain immediately after shoulder arthroscopy. In addition, patient and surgical factors correlated with weight gain were analyzed. We hypothesized that there would be a significant increase in weight immediately after shoulder arthroscopy and that the amount of weight gain would correlate with a number of surgical factors.

TYPE OF STUDY

Observational case series.

METHODS

Fifty-three patients were enrolled in the study. There were 34 male and 19 female patients, with a mean age of 47.1 +/- 13.8 years. All patients were weighed before and after surgery using the same weight scale by the same observer. Weight gain was calculated and adjusted to account for the weight of the dressing and sling. Weight gain then was correlated to various clinical and surgical variables. Pearson correlation coefficients, Student t tests, and stepwise regression were used to determine significant correlations between clinical and surgical variables and weight gain.

RESULTS

The mean amount of net weight gain was 8.7 +/- 3.9 lb (range, 0.8-18.8 lb), representing 4.6% +/- 2.1% of preoperative weight. The mean amount of weight gain attributable to arthroscopy fluid only was 4.2 +/- 3.8 lb (range, 0-14.5 lb), representing a gain of 2.2% +/- 2.0% of preoperative weight. The mean amount of intravenous fluid infused was 1,885 +/- 547 mL, and the mean amount of normal saline arthroscopy fluid used was 30 +/- 24 L. Surgical time, the amount of arthroscopy fluid, the size of the rotator cuff tear, the number of tendons involved, the presence of a subscapularis tear, the number of procedures performed, the concomitant performance of a subacromial decompression, the number of BioCorkscrew (Arthrex, Inc., Naples, FL) anchors used, and the total number of anchors used all correlated with increasing weight gain (all P < .05). A procedure of stepwise regression selection did not identify any quantitative parameters attributable to weight gain other than the earlier-described parameters. There were no significant intraoperative or postoperative complications attributable to the amount of weight gain.

CONCLUSIONS

Weight gain immediately after shoulder arthroscopy is a common finding. Although no complications were seen in this group of patients, both patients and surgeons should be aware of this concern after shoulder arthroscopy and the potential complications related to it.

Glenohumeral arthroscopy portals established using an outside-in technique: neurovascular anatomy at risk

PURPOSE

The purpose of this study was to examine the neurovascular structures at risk during placement of glenohumeral arthroscopy portals using an outside-in technique.

TYPE OF STUDY

Anatomic cadaveric study.

METHODS

Five fresh-frozen cadaveric specimens were used in this study. Each shoulder was mounted on a custom-designed apparatus allowing shoulder arthroscopy in a lateral decubitus position. The following portals were established using an outside-in technique and marked using an 18-gauge spinal needle: posterior, posterolateral, anterior, 5-o'clock, anterosuperolateral, and Port of Wilmington. Each specimen was carefully dissected after the procedure, and the distance from each portal site to the adjacent relevant neurovascular structures (axillary nerve, musculocutaneous nerve, lateral cord of the brachial plexus, cephalic vein, and axillary artery) was measured using a precision caliper.

RESULTS

Except for the cephalic vein, all of the neurovascular structures were more than 20 mm away from all the portals evaluated. When creating either an anterior portal or a 5-o'clock position portal, the mean distance from the portal to the cephalic vein was 18.8 mm and 9.8 mm, respectively. In one anterior portal, a direct injury to the cephalic vein occurred.

CONCLUSIONS

Our study suggests that shoulder arthroscopy portals placed in an outside-in fashion are unlikely to produce neurologic injury. However, the cephalic vein is at risk during placement of an anterior or 5-o'clock position portal, although probably with minimal subsequent patient morbidity. Placing portals in an outside-in fashion guarantees the correct angle of approach, with minimal risk to adjacent neurologic structures.

CLINICAL RELEVANCE

This study shows the safety of standard and accessory glenohumeral arthroscopy portals.

Minimally invasive transrotator cuff approach for arthroscopic stabilization of the posterosuperior glenoid labrum

We describe a novel technique for repair of the superior glenoid labrum posterior to the biceps anchor. This approach optimizes access for fixation of the superior and posterosuperior labrum, but involves significantly less trauma to the rotator cuff and subacromial space compared with previously described transrotator cuff methods. We suspect that the relative lack of trauma to the rotator cuff and subacromial space accounts for the superior clinical scores and lower incidence of postoperative impingement symptoms with this technique compared with previously reported transrotator cuff methods.

Is there any effect of suprascapular notch type in iatrogenic suprascapular nerve lesions? An anatomical study

This anatomical study, which is aimed at assessing the effect of suprascapular notch type in iatrogenic suprascapular nerve lesions in surgical interventions, was conducted in two stages. A hundred dry scapulas and 20 scapulas of 11 cadavera were classified according to Rengachary. The point of measurement was determined medially as the deepest point of suprascapular notch and laterally as supraglenoid tubercle in dry scapulas and anchor of biceps in cadavera. It was found that in the measurements made in dry scapulas, notch Type-IV scapulas, despite not being statistically significant, had the lowest average (2.35 cm), with minimum and maximum values of 2.1 cm and 2.78 cm respectively, when compared to other scapula types. It was found in the cadavera study that the measurements of one Type-IV scapula and one Type-V scapula were lower than the other types. Determination of the notch type in the rotator-cuff tears--especially in massive and retracted tears where supraspinatus has to be released from the fossa--may be helpful in avoiding iatrogenic nerve lesion.

Clinical evaluation of the shoulder

Shoulder pain is an exceptionally common problem in physiatric practice. Evaluation and management of patients with shoulder dysfunction can challenge even the most experienced practitioner. The complexity and inherent instability of the shoulder lead to functional overload of various bony and soft tissues within the joint complex and adjacent structures.Additionally, shoulder pain may be the initial manifestation of a potentially serious condition. Consequently, a detailed and systematic approach to the evaluation of a patient with shoulder pain is crucial in establishing a complete and accurate diagnosis. A skillfully performed history and physical examination allows identification of specific tissue pain generators and biomechanical dysfunction throughout the kinetic chain. Only after these elements have been defined clearly can an appropriate rehabilitation program be de-signed. A thorough clinical assessment also can aid in the detection of serious diseases that masquerade as shoulder pain. An effective clinical evaluation enhances the quality and cost-effectiveness of care and facilitates a successful outcome in most cases.

Contralateral brachial plexus neuropathy after arthroscopic shoulder surgery

This case report presents a neurologic complication that occurred after shoulder arthroscopic surgery on the contralateral arm. This brachial plexus palsy has been documented as a reversible C7-T1 lesion, which was the consequence of the patient's unknown cervical rib and the applied lateral position during the operation. In this case, the recovery was almost complete within 3 months postoperatively; however, one should take care to prevent these complications with an appropriate positioning of patients with an anatomic variant.

The trans-rotator cuff approach to SLAP lesions: technical aspects for repair and a clinical follow-up of 31 patients at a minimum of 2 years

PURPOSE

To discuss a new technique for the surgical treatment of type II SLAP lesions as well as the evaluation of the technique's effectiveness with a minimum 2-year follow-up.

TYPE OF STUDY

Retrospective clinical follow-up study.

METHODS

We present a clinical follow-up of 31 patients who were treated arthroscopically for type II SLAP lesions using a trans-rotator cuff portal at an average follow-up time of 3.7 years. Patients were screened for concomitant procedures including rotator cuff repairs, shoulder stabilizations, thermal capsullographies, and previous surgeries. These patients were subsequently excluded from the study. Patients were given a standard physical examination of the upper extremity at our institution and they completed both the L'Isalata and American Shoulder and Elbow Surgeons questionnaires.

RESULTS

All 31 patients identified were available for follow-up at an average time of 3.7 years postoperatively (range, 2.0 to 7.4 years). The average L'Insalata score was 87.0 points (range, 46.1-100 points); the average ASES score was 87.2 points (range, 46.7-100 points). The average pain score was 1.5 (range, 0-5) and only 4 of the 31 patients complained of moderate pain with activity. Sixteen of the 31 patients returned to their preinjury level of sports; 11 of the 31 patients returned to limited activity and 2 patients were inactive at the time of follow-up. Overall satisfaction with the procedure averaged 3.79 points (range, 0-5 points): 22 patients rated overall satisfaction as good or excellent, 6 patients reported a fair outcome, and only 3 patients were unsatisfied with the results of the surgery. One patient who was unsatisfied with the procedure had reinjured his superior labrum and required a second operation. None of the 31 patients had symptoms suggestive of rotator cuff pathology. Of the 30 patients found to have a positive Active Compression test preoperatively, 26 of these patients now had a negative sign.

CONCLUSIONS

The trans-rotator cuff approach allows for a more optimal placement of a biodegradable fixation device and/or suture anchors into the superior labrum. Furthermore, we believe that this approach does not compromise the function of the rotator cuff. The trans-rotator cuff technique is an effective and safe modality to address superior labral pathology.

Arthroscopic release of the rotator interval and coracohumeral ligament: An anatomic study in cadavers

PURPOSE

The purpose of this cadaveric study was to examine the anatomy of the normal glenohumeral joint relevant to an arthroscopic rotator interval release and define both the endpoints of a complete release of the coracohumeral ligament and the relationship to surrounding tendons and nerves.

TYPE OF STUDY

An anatomic cadaveric study.

METHODS

Fifteen fresh-frozen cadaveric specimens were studied with 5 specimens in group I and 10 specimens in group II. Group I specimens were used to examine the relevant anatomy, including the structures at risk, the dimensions of the rotator interval, and potential endpoints for release of the coracohumeral ligament. Measurements included (1) the supraspinatus to the subscapularis distance, (2) the distance from the rotator interval to the deep surface of the coracoid process, and (3) the distance from the rotator interval to the coracoacromial ligament at the level of the glenoid. Group II specimens underwent arthroscopic release of the rotator interval using the appearance of the coracoacromial ligament as the superficial endpoint. Dissection was then performed to examine for complete release of the coracohumeral ligament and to assess the structures at risk of injury.

RESULTS

The distance from the anterior edge of supraspinatus to the superior edge of subscapularis at the glenoid rim was 21.6 mm, which increased to 27.8 mm with joint distention. The minimum distance from the rotator interval to the deep surface of the coracoid process was 11.4 mm. Before distention, the coracoacromial ligament was an average of 6.2 mm from the rotator interval capsule. Arthroscopic release from the supraspinatus to the subscapularis resulted in complete resection of the coracohumeral ligament in all 15 specimens. There were no specimens with evidence of injury to the biceps tendon, supraspinatus, subscapularis, or the conjoint tendon.

CONCLUSIONS

This study confirms that intra-articularly directed arthroscopic release of the rotator interval can safely lead to complete release of the coracohumeral ligament if dissection is taken superficially to the level of the coracoacromial ligament.

Complications associated with arthroscopic shoulder surgery

We review the literature on complication of arthroscopic shoulder surgery and their management. Computer data based searches were used to identify articles regarding complications of shoulder arthroscopy, as well as hand searches of Arthroscopy and Journal of Shoulder and Elbow Surgery over the last decade. Arthroscopic shoulder surgery has become a popular therapeutic and diagnostic procedure during the past two decades. As with all interventions complications can occur which require recognition and management by the orthopedic surgeon. While the literature is helpful with identifying types of complications, establishing the rate of these complications remains elusive. These complications can be divided into general complications, complications generic to all shoulder procedures, and complications specific to the type of procedure performed. General complications such as infection and anesthesia problems continue to show low incidences. Shoulder arthroscopy presents increased risk of complications over knee arthroscopy in regard to vascular and neurologic injury, fluid extravasation, stiffness, iatrogenic tendon injury, and equipment failure. New techniques of increased complexity for subacromial surgery, rotator cuff repair, and arthroscopic instability present new problems related to implant failure, nerve injury, iatrogenic fracture, and capsular necrosis. While the rate of complications especially with newer procedures remain elusive, most studies suggest that the rate is low, 5.8-9.5% in all recent review studies published. Underreporting complications makes assessment of incidence rates of complication difficult. Proper patient selection, attention to operative detail, and careful post-operative monitoring can minimize the morbidity associated with these complications.

The anatomic relationship of the brachial plexus and axillary artery to the glenoid. Implications for anterior shoulder surgery

Iatrogenic brachial plexus injury is an uncommon but potentially severe complication of shoulder reconstruction for instability that involves dissection near the subscapularis muscle and potentially near the brachial plexus. We examined the relationship of the brachial plexus to the glenoid and the subscapularis muscle and evaluated the proximity of retractors used in anterior shoulder surgical procedures to the brachial plexus. Eight fresh-frozen cadaveric shoulders were exposed by a deltopectoral approach. The subscapularis muscle was split in the middle and dissected to reveal the capsule beneath it. The capsule was split at midline, and a Steinmann pin was placed in the equator of the glenoid rim under direct visualization. The distance from the glenoid rim to the brachial plexus was measured with calipers with the arm in 0 degrees, 60 degrees, and 90 degrees of abduction. The brachial plexus and axillary artery were within 2 cm of the glenoid rim, with the brachial plexus as close as 5 mm in some cases. There was no statistically significant change in the distance from the glenoid rim to the musculocutaneous nerve, axillary artery, medial cord, or posterior cord with the arm in various degrees of abduction. Retractors placed superficial to the subscapularis muscle or used along the scapular neck make contact with the brachial plexus in all positions tested.

The accessory posterior portal for shoulder arthroscopy: Description of technique and cadaveric study

As the indications for shoulder arthroscopy continue to expand, so too does the need for complete access to the glenohumeral joint. Specific regions of the joint, including the axillary recess, are often times difficult to access using traditionally described posterior and anterior portals. In this article, we describe a technique for the placement of an accessory posterior portal into the inferior hemisphere of the glenohumeral joint, effectively in the 8 o'clock or 4 o'clock position. To demonstrate the safety and effectiveness of this portal, 6 cadaveric specimens were dissected after the placement of a standard and accessory posterior portal. The proximity of the posterior portals to the axillary and suprascapular nerves was analyzed. Measurements were made in simulated beach-chair and lateral decubitus positions. The authors show that the accessory posterior portal is safe to use and may prove useful to the surgeon who wishes to gain access to the inferior recesses of the glenohumeral joint.

Arthroscopic shoulder instability surgery. Complications

Complications associated with arthroscopic shoulder stabilization are relatively common. Excluding recurrence, complications are rarely disabling. Current statistics undoubtedly underestimate the true incidence of complications. Many complications, including neurovascular injuries and articular damage, are preventable and can be minimized through familiarity with anatomy, proper surgical technique and instrumentation, and clinical experience. Nevertheless, despite these efforts, a few complications, including recurrent instability, persist. Despite careful patient selection and attention to labral pathology and capsular laxity, arthroscopic repairs continue to have success rates lower than those achieved through open means. While cautiously proceeding toward a more complete understanding of the instability continuum, surgeons must maintain a high index of suspicion for new techniques that purport to "solve" the problem of arthroscopic shoulder stabilization, lest the history of enthusiastic but ultimately unsubstantiated claims is repeated. Outcomes must withstand the rigors of scientific scrutiny and the test of time. Without this cautious vigilance, the appeal of today's solutions becomes the fodder of tomorrow's articles about the complications of arthroscopic shoulder stabilization.

The adduction distraction maneuver

The adduction distraction maneuver is presented as an adjunct to the surgeon's technical skills to assist with the initial introduction of the shoulder arthroscope. Both novice and experienced arthroscopists can experience difficulty establishing access to the glenohumeral joint. Often this results in articular cartilage or soft tissue damage. The adduction distraction maneuver when used in the "beach chair" seated position for shoulder arthroscopy can facilitate posterior portal placement and minimize iatrogenic trauma.