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Cunningham G, Bernardo L, Brandariz R, Holzer N, Da Rocha D, Beaulieu JY. Radial and median nerves distal peripheral tension after reverse shoulder arthroplasty: a cadaveric study. JSES Int 2024; 8:873-879. [PMID: 39035641 PMCID: PMC11258839 DOI: 10.1016/j.jseint.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Background Peripheral nerve injury is a recognized complication after reverse shoulder arthroplasty (RSA) that has mainly been studied at the level of the brachial plexus and its proximal branches. However, the impact of RSA on distal peripheral nerves and the influence of elbow and wrist position is not known. This cadaveric study aimed to analyze the effect of RSA implantation and upper limb position on tension in the distal median and radial nerves. The hypothesis was that RSA increased distal nerve tension, which could be further affected by elbow and wrist position. Methods 12 upper limbs in 9 full fresh-frozen cadavers were dissected. Nerve tension was measured in the median nerve at the level of the proximal arm, elbow, and distal forearm, and in the radial nerve at the level of the elbow, using a customized three-point tensiometer. Measurements were carried out before and after RSA implantation, using a semi-inlay implant (Medacta, Castel San Pietro, Switzerland). Two different configurations were tested, using the smallest and largest available implant sizes. Three upper-limb key positions were considered (plexus at risk, plexus relief, and neutral), from which the effect of elbow and wrist position was further tested. Results RSA implantation significantly increased median and radial nerve tension throughout the upper limb. The distal nerve segments were particularly dependent on elbow and wrist position. The plexus at risk position induced the most tension in all nerve segments, especially with the large implant configuration. On the other hand, the plexus relief position induced the least amount of tension. Flexing the elbow was the most efficient way to decrease nerve tension in all tested nerve segments and key positions. Wrist flexion significantly decreased nerve tension in the median nerve, whereas wrist extension decreased tension in the radial nerve. Conclusion RSA significantly increases tension in the median and radial nerves and makes them more susceptible to wrist and elbow positioning. The mechanism behind distal peripheral neuropathy after RSA may thus result from increased compression of tensioned nerves against anatomical fulcrums rather than nerve elongation alone. Elbow flexion was the most effective way to decrease nerve tension, while elbow extension should be avoided when implanting the humeral component. Further studies are needed to assess the ulnar nerve.
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Affiliation(s)
- Gregory Cunningham
- Shoulder and Elbow Center La Colline, Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | | | - Nicolas Holzer
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Daniel Da Rocha
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean-Yves Beaulieu
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Cochrane E, Vollans S, Bourke G. Brachial plexus deficits in patients undergoing shoulder arthroplasty. Shoulder Elbow 2023; 15:65-70. [PMID: 37692871 PMCID: PMC10492527 DOI: 10.1177/17585732221089299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/28/2022] [Accepted: 03/01/2022] [Indexed: 09/12/2023]
Abstract
Background Nerve deficit following shoulder arthroplasty can cause significant morbidity. We examined the incidence and pattern of nerve injury following shoulder arthroplasty in a University Hospital. Methods Retrospective review of all patients undergoing shoulder arthroplasty over a five-year period (September 2014 to August 2019). Patients were identified using clinical codes and relevant data extracted by review of patient records. We excluded patients with preoperative nerve injuries. Results 220 arthroplasties were performed in 210 patients. The overall nerve deficit rate was 2.3% (5/220). Five nerve deficits occurred following reverse total shoulder arthroplasty (rTSA). In two patients, nerve recovery occurred within 12 months. Two patients had persistent deficits at 12 months. One patient had a deficit at seven months, but incomplete follow up. There was no clear documentation of discussions with clinicians specialising in nerve injury. Conclusion Nerve injury rates in our series for rTSA are low and comparable to systematic review data. We purport that for rTSA, adequate soft tissue releases, careful arm positioning and retraction alongside limiting over-lowering the centre of rotation may prevent nerve injuries. A postoperative nerve deficit should warrant an opinion from a specialist in nerve surgery with clear referral pathways to allow efficient access to services.
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Affiliation(s)
- Elliott Cochrane
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals, Leeds, UK
| | - Sam Vollans
- Department of Trauma & Orthopaedic Surgery, Leeds Teaching Hospitals, Leeds, UK
| | - Gráinne Bourke
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals, Leeds, UK
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
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Hawkes D, Brookes-Fazakerley S, Robinson S, Bhalaik V. Intraoperative and early postoperative complications of reverse shoulder arthroplasty: A current concepts review. J Orthop 2023; 35:120-125. [PMID: 36471697 PMCID: PMC9718996 DOI: 10.1016/j.jor.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/19/2022] [Accepted: 11/19/2022] [Indexed: 11/27/2022] Open
Abstract
Background Reverse shoulder arthroplasty is a common procedure performed for a variety of shoulder pathologies. Aims and objectives This current concept review evaluates the intraoperative and early postoperative complications, with a specific focus given to neurological and vascular injury, fracture, dislocation and venous thromboembolism. Conclusion A detailed knowledge of potential complications will allow surgeons to mitigate risk and maximise outcomes.
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Affiliation(s)
- David Hawkes
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Steven Brookes-Fazakerley
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Simon Robinson
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Vijay Bhalaik
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
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Olson JJ, O’Donnell EA, Dang K, Huynh TM, Lu AZ, Kim C, Haberli J, Warner JJ. Prevalence, management, and outcomes of nerve injury after shoulder arthroplasty: a case-control study and review of the literature. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:458-463. [PMID: 37588461 PMCID: PMC10426532 DOI: 10.1016/j.xrrt.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Neurologic injury is a rare and potentially devastating complication of shoulder arthroplasty. Patients typically present with a mixed plexopathy or mononeuropathy, most commonly affecting the axillary and radial nerves. Given the paucity of studies available on the topic, our goal was to elucidate the prevalence of nerve injury after shoulder arthroplasty and to describe the treatment course and outcomes of neurologic injuries. Methods This is a retrospective case-control study performed at a single, urban, academic institution. Consecutive patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA) by a single surgeon from 2014 to 2020 were reviewed, and patients with a documented nerve injury were identified. A control group of patients without nerve injury were selected in a 2:1 ratio controlling for age and procedure type (TSA vs. RSA; primary vs. revision). Data collected included demographics, comorbidities as per the Charlson Comorbidity Index, radiographic evaluations, surgical and implant details, patient-reported outcome measures, and perioperative complications. Results Of 923 patients, 33 (3.6%) sustained an iatrogenic nerve injury: 10 (2.1%) after TSA, 23 (5.0%) after RSA, and 3 (7.8%) after revision arthroplasty. Axillary mononeuropathy was most common (42%), followed by brachial plexopathies (18%). There was no significant difference in age, sex, race, body mass index, and preoperative diagnoses between groups. Patients with nerve injury had fewer comorbidities (Charlson Comorbidity Index <3, 33 vs. 65%, P<.001). Patients with nerve injury had higher rates of cervical spine pathology (15 vs. 6%; P = .15) and increased postoperative lateralization (8.9 mm [7.2] vs. 5.5 mm [7.3]; P<.06). The majority (91%) were managed with observation alone. Three (9%) underwent an additional procedure: carpal tunnel release (1, 3%), ulnar nerve decompression (1, 3%), and ulnar nerve transposition (1, 3%) for peripheral compressive neuropathies. At the final follow-up, 19 (57%) nerves fully recovered, and 14 (43%) showed mild residual sensorimotor dysfunction. The mean time to first sign of recovery and ultimate recovery were 11 (7.2) and 36 (23.5) weeks, respectively. At the final follow-up, patients with nerve injury performed worse on patient-reported outcomes, including visual analog score pain (2.2 vs. 1.0, P<.001), American Shoulder and Elbow Surgeons score (67.8 vs. 84.8, P<.001), and Single Assessment Numeric Evaluation scores (62 vs. 77, P = .009). Discussion Nerve injury after shoulder arthroplasty is rare, occurring in 3.6% of our patient population. Axillary mononeuropathy and brachial plexopathies are the most common. Most patients can be managed expectantly with observation and will recover at least partial nerve function, although clinical outcomes remain inferior to those without nerve complication.
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Affiliation(s)
| | - Evan A. O’Donnell
- Sports Medicine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Khang Dang
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Tiffany M. Huynh
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Amy Z. Lu
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christine Kim
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jillian Haberli
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jon J.P. Warner
- Boston Shoulder Institute, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Dutton LK, Barlow JD, Loosbrock MF, Spinner RJ, Bishop AT, Shin AY. Persistent and profound peripheral nerve injuries following reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:2128-2133. [PMID: 35500809 DOI: 10.1016/j.jse.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/17/2022] [Accepted: 03/21/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Peripheral nerve injuries associated with reverse total shoulder arthroplasty (rTSA) are rarely reported and are often dismissed as neuropraxias, particularly in the setting of perioperative nerve blocks. The purpose of this study was to evaluate nerve injuries following rTSA to determine if there is a pattern of injury and to evaluate outcomes of patients who sustain an intraoperative nerve injury. METHODS A retrospective review was performed identifying patients who underwent rTSA and had a concomitant major nerve injury who were referred to a multidisciplinary peripheral nerve injury clinic. Demographic data, preoperative nerve block use, physical examination, electrodiagnostic studies, injury pattern, and time from injury to referral was collected. Radiographs, Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score, and outcomes surveys were obtained at final follow-up. RESULTS Twenty-two patients were identified with postoperative nerve injuries. Average time from injury to referral was 9.0 months, with 18.8 months' follow-up. Eight patients had undergone prior shoulder surgery, and 11 patients had prior shoulder trauma. Injury patterns were variable and involved diffuse pan-plexopathies with severity localized to the posterior and medial cords (11), the upper trunk (5), lateral cord (2), and axillary nerve (4). The average postoperative acromiohumeral distance (AHD) was 3.7 cm, with an average change of 2.9 cm. The average postoperative lateral humeral offset (LHO) was 1.1 cm, with an average change of 0.2 cm. Seventeen patients were confirmed to have undergone preoperative nerve blocks, which were initially attributed as the etiology of nerve injury. Eighteen patients were initially treated with observation: 11 experienced residual debilitating neuropathic pain and/or disability, and 7 had substantial improvement. One patient underwent nerve transfers, whereas the others underwent procedures for hand dysfunction improvement. The average QuickDASH score was 53.5 at average of 4 years post rTSA. CONCLUSIONS Although uncommon, permanent peripheral nerve injuries following rTSA do occur with debilitating effects. Preoperative regional blocks were used in most cases, but none of the blocks could be directly attributed to the nerve injuries. Nerve injuries were likely secondary to traction at the time of arthroplasty and/or substantial distalization and lateralization of the implants. Patients with medial cord injuries had the most debilitating loss of hand function. Surgeons should be cognizant of these injuries and make a timely referral to a peripheral nerve specialist.
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Affiliation(s)
- Lauren K Dutton
- Department of Orthopedic Surgery and Hand Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jonathan D Barlow
- Department of Orthopedic Surgery and Hand Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michelle F Loosbrock
- Department of Orthopedic Surgery and Hand Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert J Spinner
- Department of Orthopedic Surgery and Hand Surgery, Mayo Clinic, Rochester, MN, USA
| | - Allen T Bishop
- Department of Orthopedic Surgery and Hand Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery and Hand Surgery, Mayo Clinic, Rochester, MN, USA.
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Serrano Mateo L, Maranillo Alcaide E, Arvinius C, Sañudo Tejero JR, Marco F. Elongation of the brachial plexus after reverse shoulder arthroplasty: an anatomical study. Surg Radiol Anat 2022; 44:861-868. [PMID: 35381847 DOI: 10.1007/s00276-022-02929-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The use of reverse shoulder arthroplasty (RSA) is becoming more extended and its clinical results are good or excellent according to the literature. The main biomechanical characteristic of RSA is that it lowers and medializes the centre of rotation of the shoulder causing an arm lengthening. Although the number of neurological complications is low (5%), there are more neurophysiological changes in the brachial plexus with RSA than with the anatomic shoulder arthroplasty. The main goal of this study was to quantify the lengthening of the terminal branches of the brachial plexus suffered after RSA implantation. MATERIALS AND METHODS 20 Embalmed cadavers were analysed. Four distances using bone references were employed to measure the lengthening of the arm and subacromial space. The brachial plexus and its terminal branches (radial, axillary, ulnar, musculocutaneous and median nerves) and the axillary artery, were identified and marked. Measurements were made to determine the change of position of the neurovascular structures, the arm lengthening and the lengthening of each nerve before and after the implantation of RSA. Two models of RSA were used: SMR®(Lima) and Delta Xtend®(DePuy-Synthes). RESULTS The mean arm elongation was 10.5 mm. The subacromial space suffers an elongation of 20.5-29.8%. All the neurovascular structures suffered elongation: median nerve 23.1%, musculocutaneous nerve 22.1%, ulnar nerve 19%, radial nerve 17%, axillary nerve 12-14.5%, axillary artery 24.8%. There were no differences in the results between the types of prosthesis. CONCLUSIONS Due to its design, the RSA causes an arm lengthening which is reflected by the elongation of the neurovascular structures of the arm.
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Affiliation(s)
- Laura Serrano Mateo
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain.
| | - Eva Maranillo Alcaide
- Anatomy and Embryology Department, Medicine Faculty, Complutense University, Madrid, Spain
| | - Camilla Arvinius
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain
| | | | - Fernando Marco
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain
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Patel MS, Daher M, Fuller DA, Abboud JA. Incidence, Risk Factors, Prevention, and Management of Peripheral Nerve Injuries Following Shoulder Arthroplasty. Orthop Clin North Am 2022; 53:205-213. [PMID: 35365265 DOI: 10.1016/j.ocl.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In this article, the authors review the incidence and causes of iatrogenic peripheral nerve injuries following shoulder arthroplasty and provide preventative measures to decrease nerve injury rate and management options. They describe common direct and indirect causes of injury such as laceration and retractor use versus arm positioning and lengthening, respectively. Preventative measures include an understanding of anatomy and high-risk locations in the shoulder, minimizing extreme ranges of arm motion and utilization of intraoperative nerve monitoring. Lastly, the authors review diagnosis and management of neurologic symptoms including how and when to use electrodiagnostic studies, nerve grafts, transfers, or muscle/tendon transfers.
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Affiliation(s)
- Manan S Patel
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Mohammad Daher
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - David A Fuller
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut Street 5th Floor, Philadelphia, PA 19107, USA.
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Burnett Z, Werner BC. Risk Factors, Management, and Prognosis of Brachial Plexopathy Following Reverse Total Shoulder Arthroplasty. Orthop Clin North Am 2022; 53:215-221. [PMID: 35365266 DOI: 10.1016/j.ocl.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Brachial plexus injuries can have a significant impact on patient outcomes following RTSA by slowing the overall recovery and return of function. Risk factors for brachial plexopathy include traction injury related to arm positioning and exposure during the procedure, direct nerve injury from surgical dissection, and compression injury from retractor placement. Risk of nerve injury can be minimized by limiting the time spent with the arm extended and externally rotated and avoiding excessive traction on the arm during humeral preparation and implant insertion. Prompt identification of postoperative brachial plexopathy is important to optimize the recovery of function.
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Affiliation(s)
- Zachary Burnett
- Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22903, USA
| | - Brian C Werner
- University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22903, USA.
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Nabergoj M, Denard PJ, Collin P, Trebše R, Lädermann A. Radiological changes, infections and neurological complications after reverse shoulder arthroplasty related to different design types and their rates: Part II. EFORT Open Rev 2021; 6:1109-1121. [PMID: 34909229 PMCID: PMC8631237 DOI: 10.1302/2058-5241.6.210040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Early reported complication rates with the Grammont-type reverse shoulder arthroplasty (RSA) were very high, up to 24%.A 'problem' is defined as an intraoperative or postoperative event that is not likely to affect the patient's final outcome, such as intraoperative cement extravasation and radiographic changes. A 'complication' is defined as an intraoperative or postoperative event that is likely to affect the patient's final outcome, including infection, neurologic injury and intrathoracic central glenoid screw placement.Radiographic changes around the glenoid or humeral components of the RSA are very frequently observed and described in the literature.High complication rates related to the Grammont RSA design led to development of non-Grammont designs which led to a dramatic fall in the majority of complications.The percentage of radiological changes after RSA is not negligible and remains unsolved, despite a decrease in its occurrence in the last decade. However, such changes should be now considered as simple problems because they rarely have a negative influence on the patient's final outcome, and their prevalence has dramatically decreased.With further changes in indications and designs for RSA, it is crucial to accurately track the rates and types of complications to justify its new designs and increased indications. Cite this article: EFORT Open Rev 2021;6:1109-1121. DOI: 10.1302/2058-5241.6.210040.
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Affiliation(s)
- Marko Nabergoj
- Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint- Grégoire, France
| | - Rihard Trebše
- Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Automated Nerve Monitoring in Shoulder Arthroplasty: A Prospective Randomized Controlled Study. Anesthesiology 2021; 135:83-94. [PMID: 33930115 DOI: 10.1097/aln.0000000000003797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Evoked potential monitoring is believed to prevent neurologic injury in various surgical settings; however, its clinical effect has not been scrutinized. It was hypothesized that an automated nerve monitor can minimize intraoperative nerve injury and thereby improve clinical outcomes in patients undergoing shoulder arthroplasty. METHODS A prospective, blinded, parallel group, superiority design, single-center, randomized controlled study was conducted. Study participants were equally randomized into either the automated nerve-monitored or the blinded monitored groups. The primary outcome was intraoperative nerve injury burden as assessed by the cumulative duration of nerve alerts. Secondary outcomes were neurologic deficits and functional scores of the operative arm, and the quality of life index (Euro Quality of life-5 domain-5 level score) at postoperative weeks 2, 6, and 12. RESULTS From September 2018 to July 2019, 213 patients were screened, of whom 200 were randomized. There was no statistically significant difference in the duration of nerve alerts between the automated nerve-monitored and control groups (median [25th, 75th interquartile range]: 1 [0, 18] and 5 [0, 26.5]; Hodges-Lehman difference [95% CI]: 0 [0 to 1] min; P = 0.526). There were no statistically significant differences in secondary outcomes between groups. However, in the ancillary analysis, there were reductions in neurologic deficits and improvements in quality of life index occurring in both groups over the course of the study period. CONCLUSIONS Protection from nerve injury is a shared responsibility between surgeons and anesthesiologists. Although a progressive improvement of clinical outcomes were observed over the course of the study in both groups as a consequence of the real-time feedback provided by the automated nerve monitor, this trial did not demonstrate that automated nerve monitoring by itself changes important clinical outcomes compared with no monitoring. EDITOR’S PERSPECTIVE
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Vajapey SP, Contreras ES, Cvetanovich GL, Neviaser AS. Neurologic complications in primary anatomic and reverse total shoulder arthroplasty: A review. J Clin Orthop Trauma 2021; 20:101475. [PMID: 34178600 PMCID: PMC8213914 DOI: 10.1016/j.jcot.2021.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022] Open
Abstract
Neurologic injury during shoulder replacement is one of the less common complications of the procedure, however the clinical implications can be significant. The purpose of this paper is to review the current literature on neurologic complications in various types of shoulder replacement and provide recommendations regarding avoidance, evaluation, and management of these complications.
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Affiliation(s)
- Sravya P. Vajapey
- Corresponding author. Department of Orthopaedics, The Ohio State University Wexner Medical Center, 241 W. 11th Avenue, Suite 6081, Columbus, Ohio, 43201.
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12
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Definition of a Risk Zone for the Axillary Nerve Based on Superficial Landmarks. Plast Reconstr Surg 2021; 147:1361-1367. [PMID: 34019506 DOI: 10.1097/prs.0000000000007950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to investigate the axillary nerve's location along superficial anatomical landmarks, and to define a convenient risk zone. METHODS A total of 123 upper extremities were evaluated. After dissection of the axillary nerve, the vertical distance between the upper border of the anterolateral edge of the acromion and the proximal border of the nerve was measured. Furthermore, the interval between the proximal border and the distal border of the axillary nerve's branches was evaluated. The interval between the distal border of the branches and the most distal part of the lateral humeral epicondyle was measured. The distance between the anterolateral edge of the acromion and the lateral humeral epicondyle was evaluated. Measurements were expressed as proportions with respect to the distance between the acromion and the lateral humeral epicondyle. RESULTS The distance between the acromion and the proximal border of the axillary nerve's branches was at a height of 10 percent of the distance between the acromion and the lateral humeral epicondyle, starting from the acromion (90 percent when starting from the lateral humeral epicondyle). The interval between the proximal and distal margins of the axillary nerve's branches was between 10 percent and 30 to 35 percent of this interval, starting from the acromion (65 to 70 percent when starting from the lateral humeral epicondyle). CONCLUSIONS The authors were able to locate the branches of the axillary nerve at an interval between 10 and 35 percent of the distance between the acromion and the lateral humeral epicondyle, starting from the acromion. This makes the proximal third of this distance an easily applicable risk zone during shoulder surgery.
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13
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Kim HJ, Kwon TY, Jeon YS, Kang SG, Rhee YG, Rhee SM. Neurologic deficit after reverse total shoulder arthroplasty: correlation with distalization. J Shoulder Elbow Surg 2020; 29:1096-1103. [PMID: 32081632 DOI: 10.1016/j.jse.2019.11.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 11/15/2019] [Accepted: 11/23/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neurologic problems after reverse total shoulder arthroplasty (RTSA) have been reported, but there are a lack of studies regarding which nerve(s) are damaged and the outcomes for the patients who had neurologic complications after RTSA. The purpose of this study was to assess the prevalence and outcomes of neurologic deficit after RTSA and to evaluate the correlation between nonanatomic rearrangement of the shoulder joint and neurologic complications after RTSA. We hypothesized that the neurologic deficit was associated with excessive distalization or lateralization of the humerus after RTSA. METHODS RTSA was performed on 182 consecutive shoulders with cuff tear arthropathy. Comparative analysis was performed on 34 shoulders with (group 1) and 148 shoulders without (group 2) neurologic deficit. RESULTS The mean follow-up period in the study was 58.5 months (range: 24-124). The mean age was 71.5 ± 7.7 years in group 1 and 73.1 ± 7.2 years in group 2. Neurologic deficit after RTSA was found in 34 shoulders (19%). The mean postoperative acromiohumeral distance was 34.1 ± 11.0 mm in group 1 and 29.4 ± 7.6 mm in group 2 (P = .015). Significant differences in terms of postoperative distalization of the humerus were seen between group 1 (24.5 ± 9.4 mm) and group 2 (20.5 ± 8.3 mm) (P = .009). The most common forms of neurologic deficit after RTSA were axillary nerve (41.2%) and radial nerve (15%) injuries. Thirty shoulders (88%) had neuropraxia, and 4 shoulders (12%) had axonotmesis. By conservative treatment, all patients with neurologic complications achieved complete recovery without any additional surgery; the mean recovery period was 7.4 months (range: 2-38 months). CONCLUSION Neurologic deficit occurred in 19% of patients who underwent RTSA, and it was significantly correlated with humeral distalization after surgery. Axillary nerve was mostly involved, and all patients with neurologic deficit achieved complete recovery without any additional surgery.
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Affiliation(s)
- Hwan Jin Kim
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Tae Yoon Kwon
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yoon Sang Jeon
- Department of Orthopaedic Surgery, College of Medicine, Inha University, Incheon, Republic of Korea
| | - Se Gu Kang
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yong Girl Rhee
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sung-Min Rhee
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
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Kang JR, Logli AL, Tagliero AJ, Sperling JW. The router bit extraction technique for removing a well-fixed humeral stem in revision shoulder arthroplasty. Bone Joint J 2019; 101-B:1280-1284. [DOI: 10.1302/0301-620x.101b10.bjj-2018-1592.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims A number of methods have been described to remove a well-fixed humeral implant as part of revision shoulder arthroplasty. These include the use of cortical windows and humeral osteotomies. The router bit extraction technique uses a high-speed router bit to disrupt the bone-implant interface. The implant is then struck in a retrograde fashion with a square-tip impactor and mallet. The purpose of this study was to determine the characteristics and frequency of the different techniques needed for the removal of a well-fixed humeral stem in revision shoulder arthroplasty. Patients and Methods Between 2010 and 2018, 288 revision shoulder arthroplasty procedures requiring removal of a well-fixed humeral component were carried out at a tertiary referral centre by a single surgeon. The patient demographics, indications for surgery, and method of extraction were collected. Results Of the 288 revisions, 284 humeral stems (98.6%) were removed using the router bit extraction technique alone. Four humeral stems (1.39%) required an additional cortical window. Humeral osteotomy was not necessary in any procedure. Most of the humeral stems removed (78.8%) were cementless. Of the four humeral stems that required a cortical window, three involved removal of a hemiarthroplasty. Two were cemented and two were cementless. Conclusion The router bit extraction technique removed a well-fixed humeral component in a very high proportion of patients (98.6%). This method allows surgeons to avoid more invasive approaches involving a cortical window or humeral osteotomy, and their associated complications. Cite this article: Bone Joint J 2019;101-B:1280–1284
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Affiliation(s)
- Jason R. Kang
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony L. Logli
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam J. Tagliero
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John W. Sperling
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
The purpose of this study was to report surgical tips and techniques on the use of additional medial buttress plate fixation in proximal humeral fractures with unstable medial column restoration after lateral locking compression plate fixation. Between April 2011 and January 2017, 17 patients with medial cortical deficiency were treated using this technique. The average follow-up period was 30 (range, 12-81) months. Successful fracture healing was achieved in all 17 cases. The mean neck-shaft angle change was 1.33 degree (range, 0-7.4 degree). Anterior glenoid rim erosion occurred in 1 patient. No avascular necrosis of the humeral head or significant loss of reduction, and no implant failure or screw perforation occurred. In the first part of this study, we described in detail the indications and surgical technique applied to these fractures. In the second part, we reviewed the clinical and radiographic outcomes of these patients. Supplemental medial buttress plate fixation after lateral locking compression plate fixation was effective in preventing varus collapse and implant failure for proximal humeral fractures with an unstable medial column.
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Shinagawa S, Shitara H, Yamamoto A, Sasaki T, Ichinose T, Hamano N, Shimoyama D, Endo F, Kuboi T, Tajika T, Kobayashi T, Osawa T, Takagishi K, Chikuda H. Intraoperative neuromonitoring during reverse shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:1617-1625. [PMID: 31064684 DOI: 10.1016/j.jse.2019.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/19/2018] [Accepted: 01/06/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the risk of nerve injury with neuromonitoring during reverse total shoulder arthroplasty. MATERIALS This study included 15 shoulders of 15 patients (11 females and 4 males) who underwent reverse total shoulder arthroplasty. The mean age was 74.8 ± 4.4 years. Nine shoulders had cuff tear arthropathy, 4 had massive rotator cuff tears, 2 had osteoarthritis, and 1 had rheumatoid arthritis. The somatosensory evoked potentials of the median nerve, transcranial motor evoked potentials, and free-electromyograms from 6 upper-extremity muscles were measured intraoperatively. We defined a nerve alert as 50% amplitude attenuation or 10% latency prolongation of the somatosensory evoked potentials and transcranial motor evoked potentials and sustained neurotonic discharge on free-electromyogram. RESULTS Thirty-one alerts were recorded in 11 patients. The axillary nerve was associated with 17 alerts. Eleven alerts occurred during the glenoid procedure and 5 alerts occurred during the humeral procedure. One patient who did not recover from the alert of the axillary nerve had clinically incomplete paralysis of the deltoid muscle. CONCLUSION The present findings suggest that the axillary nerve was the nerve most frequently exposed to the risk of injury, especially during glenoid and humeral implantation.
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Affiliation(s)
- Satoshi Shinagawa
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hitoshi Shitara
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Atsushi Yamamoto
- Department of Orthopedics, Gunma Sports Orthopedics, Maebashi, Gunma, Japan
| | - Tsuyoshi Sasaki
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tsuyoshi Ichinose
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Noritaka Hamano
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Daisuke Shimoyama
- Department of Orthopedics, St-Pierre Hospital, Takasaki, Gunma, Japan
| | - Fumitaka Endo
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takuro Kuboi
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tsuyoshi Tajika
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tsutomu Kobayashi
- Department of Physical Therapy, Takasaki University of Health and Welfare, Takasaki, Gunma, Japan
| | - Toshihisa Osawa
- Department of Orthopedics, Takasaki General Medical Center, Takasaki, Gunma, Japan
| | - Kenji Takagishi
- Department of Orthopedics, St-Pierre Hospital, Takasaki, Gunma, Japan
| | - Hirotaka Chikuda
- Department of Orthopedics, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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17
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A Pilot Study of a Novel Automated Somatosensory Evoked Potential (SSEP) Monitoring Device for Detection and Prevention of Intraoperative Peripheral Nerve Injury in Total Shoulder Arthroplasty Surgery. J Neurosurg Anesthesiol 2019; 31:291-298. [DOI: 10.1097/ana.0000000000000505] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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18
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LiBrizzi CL, Rojas J, Joseph J, Bitzer A, McFarland EG. Incidence of clinically evident isolated axillary nerve injury in 869 primary anatomic and reverse total shoulder arthroplasties without routine identification of the axillary nerve. JSES OPEN ACCESS 2019; 3:48-53. [PMID: 30984892 PMCID: PMC6444175 DOI: 10.1016/j.jses.2018.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background It has been suggested that, during primary shoulder arthroplasty, surgeons should identify the axillary nerve through direct visualization, palpation, or the “tug test” to prevent iatrogenic nerve injury. Our goal was to document the rate of isolated axillary nerve injury (IANI) in patients who had undergone primary anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) without routine identification of the axillary nerve. Methods Data on 869 cases of primary shoulder arthroplasty (338 TSAs and 531 RTSAs) performed by 1 surgeon between 2003 and 2017 were reviewed. Neither the tug test nor identification of the axillary nerve through palpation or visualization was used in any case. The primary outcome was new IANI documented within 3 months after arthroplasty. The frequency of IANI was summarized using point estimates and 95% confidence intervals (CIs). Results Six cases met the criteria for IANI. The overall incidence of IANI was 0.7% (95% CI, 0.3%-1.4%). The incidence of IANI was 0.3% (95% CI, 0%-1.6%) after TSA and 0.9% (95% CI, 0.3%-2.1%) after RTSA. All IANIs were cases of neurapraxia, and all patients had experienced complete neurologic recovery at last follow-up. Conclusion Complete, permanent IANI resulting from direct surgical trauma during primary shoulder arthroplasty can be avoided without using the tug test or routine identification of the nerve. A low incidence of partial temporary IANI can be expected, which may be related to indirect traction injuries.
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Affiliation(s)
- Christa L LiBrizzi
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Jorge Rojas
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Jacob Joseph
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Alexander Bitzer
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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19
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Lowe JT, Lawler SM, Testa EJ, Jawa A. Lateralization of the glenosphere in reverse shoulder arthroplasty decreases arm lengthening and demonstrates comparable risk of nerve injury compared with anatomic arthroplasty: a prospective cohort study. J Shoulder Elbow Surg 2018; 27:1845-1851. [PMID: 30111503 DOI: 10.1016/j.jse.2018.06.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/04/2018] [Accepted: 06/13/2018] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Grammont-style reverse shoulder arthroplasty (RSA) has an increased risk of nerve injury compared with anatomic total shoulder arthroplasty (TSA) due to arm lengthening. We hypothesized that an RSA with a lateralized glenosphere and 135° neck-shaft angle would reduce humeral lengthening and decrease the risk of nerve injury to the level of a TSA. METHODS The study prospectively enrolled 50 consecutive patients undergoing RSA (n = 30) or TSA (n = 20) as determined by a power analysis based on previous research for our institution. Intraoperative neuromonitoring was used to detect nerve alerts during 4 distinct stages of the procedure. Preoperative and postoperative arm lengths were measured on scaled radiographs. Patients were examined immediately postoperatively and at follow-up visits for neurologic complications. RESULTS Mean motor and sensory nerve alerts per case were similar for TSA and RSA (motor: TSA, 1.5 ± 2; RSA, 1.5 ± 2; P = .96; sensory: TSA, 0.6 ± 0.9; RSA, 0.2 ± 0.6; P = .06). The mean change in arm length was 3 ± 7 mm in the TSA cohort vs. 14 ± 7 mm in the RSA cohort (P = .0001). Temporary neurologic changes postoperatively were noted in 1 TSA and 1 RSA patient, amounting to a 4% incidence of nerve injury. CONCLUSIONS An RSA design with a lateralized glenosphere and a lower neck-shaft angle decreases arm lengthening compared with the Grammont design. The reduction in lengthening appears to eliminate the historically increased risk of neurologic injury associated with RSA relative to TSA.
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Affiliation(s)
- Jeremiah T Lowe
- New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Sarah M Lawler
- New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Edward J Testa
- New England Baptist Hospital, Boston, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Andrew Jawa
- New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA.
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20
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Boutsiadis A, Lenoir H, Denard PJ, Panisset JC, Brossard P, Delsol P, Guichard F, Barth J. The lateralization and distalization shoulder angles are important determinants of clinical outcomes in reverse shoulder arthroplasty. J Shoulder Elbow Surg 2018; 27:1226-1234. [PMID: 29602633 DOI: 10.1016/j.jse.2018.02.036] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/24/2018] [Accepted: 02/01/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse shoulder arthroplasty (RSA) designs vary in the lateralization and distalization geometry, which may affect functional outcomes. The purpose was to determine the effect of RSA lateralization and distalization on final functional outcomes by using the "lateralization shoulder angle" (LSA) and the "distalization shoulder angle" (DSA). METHODS Forty-six consecutive patients who underwent RSA for cuff tear arthropathy were retrospectively evaluated. Functional outcome and radiographs were evaluated at a minimum of 2 years postoperatively and compared between implants with or without glenoid lateralization and with or without humeral-sided lateralization. Anteroposterior shoulder radiographs were used to evaluate the LSA and DSA. RESULTS Both angles showed substantial to almost perfect intrarater and inter-rater agreement. Higher LSA values were found in more lateralized RSAs (P = .027), and values between 75° and 95° were correlated with better active external rotation (quadratic regression analysis R2 = 0.553, P < .001). Postoperative active anterior elevation (R2 = 0.2, P = .008), Constant (rs = 0.29, P = .05), and Activities of Daily Living Requiring External Rotation scores (rs = 0.4 P = .007) had a positive correlation with the LSA. The quadratic regression analysis also showed that a DSA between 40° and 65° resulted in better active anterior elevation (R2 = 0.4, P < .001) and abduction (R2 = 0.4, P < .001). The negative correlation between the LSA and DSA (rs = -0.7, P < .001) revealed that, according to the implant used, the more distally the RSA is placed the less lateralization is achieved. CONCLUSIONS The LSA and the DSA are reproducible measurements that may be used to estimate "lateralization and distalization" after RSA. These measurements are correlated with postoperative clinical outcomes.
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Affiliation(s)
- Achilleas Boutsiadis
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | - Hubert Lenoir
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | | | - Jean-Claude Panisset
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | - Paul Brossard
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | - Philippe Delsol
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | - Frédéric Guichard
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France
| | - Johannes Barth
- Department of Orthopaedic Surgery, Centre Osteoarticulaire des Cèdres, Grenoble, France.
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21
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Kam AW, Lam PH, Haen PSWA, Tan M, Shamsudin A, Murrell GAC. Preventing brachial plexus injury during shoulder surgery: a real-time cadaveric study. J Shoulder Elbow Surg 2018; 27:912-922. [PMID: 29370965 DOI: 10.1016/j.jse.2017.11.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/08/2017] [Accepted: 11/14/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Brachial plexopathy is not uncommon after shoulder surgery. Although thought to be due to stretch neuropathy, its etiology is poorly understood. This study aimed to identify arm positions and maneuvers that may risk causing brachial plexopathy during shoulder arthroplasty. METHODS Tensions in the cords of the brachial plexuses of 6 human cadaveric upper limbs were measured using load cells while each limb was placed in different arm positions and while they underwent shoulder hemiarthroplasty and revision reverse arthroplasty. Arthroplasty procedures in 4 specimens were performed with standard limb positioning (unsupported), and 2 specimens were supported from under the elbow (supported). Each cord then underwent biomechanical testing to identify tension corresponding to 10% strain (the stretch neuropathy threshold in animal models). RESULTS Tensions exceeding 15 N, 11 N, and 9 N in the lateral, medial, and posterior cords, respectively, produced 10% strain. Shoulder abduction >70° and combined external rotation >60° with extension >50° increased medial cord tension above the 10% strain threshold. Medial cord tensions (mean ± standard error of the mean) in unsupported specimens increased over baseline during hemiarthroplasty (sounder insertion [4.7 ± 0.6 N, P = .04], prosthesis impaction [6.1 ± 0.8 N, P = .04], and arthroplasty reduction [5.0 ± 0.7 N, P = .04]) and revision reverse arthroplasty (retractor positioning [7.2 ± 0.8 N, P = .02]). Supported specimens experienced lower tensions than unsupported specimens. CONCLUSIONS Shoulder abduction >70°, combined external rotation >60° with extension >50°, and downward forces on the humeral shaft may risk causing brachial plexopathy. Retractor placement, sounder insertion, humeral prosthesis impaction, and arthroplasty reduction increase medial cord tensions during shoulder arthroplasty. Supporting the arm from under the elbow protected the brachial plexus in this cadaveric model.
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Affiliation(s)
- Andrew W Kam
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, St George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - Patrick H Lam
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, St George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - Pieter S W A Haen
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, St George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - Martin Tan
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, St George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - Aminudin Shamsudin
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, St George Hospital Campus, University of New South Wales, Sydney, NSW, Australia
| | - George A C Murrell
- Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery, St George Hospital Campus, University of New South Wales, Sydney, NSW, Australia.
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Abstract
Since the introduction of reverse total shoulder arthroplasty (RTSA) in 1987 (in Europe) and 2004 (in the United States), the number of RTSAs performed annually has increased. Although the main indication for RTSA has been rotator cuff tears, indications have expanded to include several shoulder conditions, many of which involve dysfunction of the rotator cuff. RTSA complications have been reported to affect 19% to 68% of patients and include acromial fracture, haematoma, infection, instability, mechanical baseplate failure, neurological injury, periprosthetic fracture and scapular notching. Current controversies in RTSA include optimal baseplate positioning, humeral neck-shaft angle (135° versus 155°), glenosphere placement (medial, lateral or bony increased offset RTSA) and subscapularis repair. Improvements in prosthesis design, surgeon experience and clinical results will need to occur to optimize this treatment for many shoulder conditions.
Cite this article: EFORT Open Rev 2018;3:58–69 DOI: 10.1302/2058-5241.3.170044
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Affiliation(s)
- Filippo Familiari
- Department of Orthopaedics and Traumatology, Villa del Sole Clinic, Italy
| | - Jorge Rojas
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, USA
| | - Mahmut Nedim Doral
- Department of Orthopaedics and Traumatology, Hacettepe University, Turkey
| | - Gazi Huri
- Department of Orthopaedics and Traumatology, Hacettepe University, Turkey
| | - Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, USA
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Mehta VM, Mandala CL, Shriver RJ, Shah R. Proximal humeral fracture-dislocation with axillary artery involvement treated with reverse shoulder arthroplasty. JSES OPEN ACCESS 2018; 2:100-103. [PMID: 30675575 PMCID: PMC6334852 DOI: 10.1016/j.jses.2017.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Rachit Shah
- Fox Valley Orthopaedic Institute, Geneva, IL, USA
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Ekelund AL. Management of painful reverse shoulder arthroplasty. Shoulder Elbow 2017; 9:212-222. [PMID: 28588662 PMCID: PMC5444609 DOI: 10.1177/1758573217702333] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/02/2017] [Indexed: 12/25/2022]
Abstract
Even though reverse shoulder arthroplasty is a very successful procedure, painful complications occur. During the initial postoperative years, the most common reasons for pain are instability, postoperative fracture of the acromion or spine, and periprosthetic infection. Later, aseptic loosening, with humeral loosening being more frequent that glenoid loosening, can be a source of pain and reduction in function. A careful patient history, clinical examination, plain radiographs, computed tomography and blood tests give an explanation for the pain in most cases. The majority of these complications can be successfully treated, maintaining a functional reverse shoulder arthroplasty. However, if all examinations are normal, it is important to remember that nonshoulder conditions such as tumour of the lung or degenerative changes of the cervical spine can give shoulder pain.
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Affiliation(s)
- Anders L. Ekelund
- Anders L. Ekelund, Department of Orthopaedics, Capio St Görans Hospital, SE-112 81, Stockholm, Sweden.
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