Complications of the Fingers and Hand After Arthroscopic Rotator Cuff Repair

Postoperative Pathologies of the Hand Following Shoulder Surgery

Purpose

Shoulder arthroscopy and arthroplasty are increasingly common procedures used to address shoulder pathologies. This study sought to evaluate the incidence of hand-related pathologies, including carpal tunnel syndrome (CTS), cubital tunnel syndrome (CuTS), trigger finger (TF), de Quervain tenosynovitis, and Dupuytren disease following shoulder arthroscopy and arthroplasty procedures. We hypothesized that patients undergoing shoulder surgery would have a higher incidence of hand-related pathologies within 1 year of surgery compared to controls.

Methods

This was a retrospective analysis of 12,179 patients who underwent shoulder arthroscopy or arthroplasty surgery that were subsequently diagnosed with CTS, CuTS, TF, de Quervain tenosynovitis, or Dupuytren disease within 1 year after surgery. Relative risk of having associated hand pathologies following shoulder surgery was compared to controls.

Results

In total, 10,285 patients underwent shoulder arthroscopy procedures during this period, of whom 815 (7.9%) had an associated hand pathology within 1 year from their shoulder procedure. Arthroscopic surgery was associated with an increased likelihood of having a hand pathology (RR 1.65, 95% CI 1.54-1.76), CTS (RR 1.57, 95% CI 1.42-1.73), CuTS (RR 2.25, 95% CI 1.94-2.61), TF (RR 1.76, 95% CI 1.53-2.03), and Dupuytren disease (RR 2.02, 95% CI 1.54-2.65), but was not associated with a higher likelihood of having de Quervain tenosynovitis. In total, 1,894 patients underwent shoulder arthroplasty procedures during this period, of whom 188 (9.9%) had an associated hand pathology within 1 year. Shoulder arthroplasty was associated with an increased likelihood of having a hand pathology (RR 2.04, 95% CI 1.78-2.34), CTS (RR 2.10, 95% CI 1.72-2.57), CuTS (RR 3.29, 95% CI 2.48-4.39), and TF (RR 1.99, 95% CI 1.47-2.70), but was not associated with an increased likelihood of having de Quervain tenosynovitis or Dupuytren disease.

Conclusions

Shoulder arthroscopy and arthroplasty procedures were associated with an increased likelihood of having a CTS, CuTS, or a TF diagnosis made within 1 year of surgery. Only shoulder arthroscopy procedures were associated with a higher likelihood of having Dupuytren disease. Neither shoulder arthroscopy nor arthroplasty procedures were associated with an increased likelihood of a diagnosis of de Quervain tenosynovitis. These associations, however, do not necessarily imply causation, and further investigation is warranted to delineate this relationship.

Type of study/level of evidence

Differential Diagnosis/Symptom Prevalence Study Level 3.

Peripheral neuropathies after shoulder arthroscopy: a systematic review

Purpose

Peripheral neuropathies after shoulder arthroscopy are rare, though likely under-reported. Many resolve spontaneously, but some patients are left with permanent neurological deficits. The purpose of this study was to review the literature to better characterize this patient population, diagnostic tests performed, the timing and type of surgical intervention, and report clinical outcomes.

Methods

A systematic literature review was performed. Articles in English were identified from PubMed, EMBASE, and CINAHL in August 2021. Article titles and abstracts were screened for relevance by two authors and discordant abstracts were resolved by the senior author. Data were subsequently extracted from the included articles.

Results

Seventeen articles were identified yielding a total of 91 patients. The average age was 53 ± 12 years, and most patients were male (72%). Rotator cuff repair (62%) was the most common procedure performed. A peripheral neuropathy was identified an average of 80 ± 81 days from the index procedure (range, 0-240 days). Most commonly, peripheral nerve injury presented as a mononeuropathy, with the median nerve (39%) and ulnar nerve (17%) affected predominantly. Seventeen percent of patients underwent a secondary surgery at an average of 232 ± 157 days after the index procedure. At the final follow-up, 55% of neuropathies had resolved, 14% partially improved, and 22% showed no clinical improvement. The most proposed etiologies were postoperative immobilization (29%) and intraoperative positioning (20%), but several possible etiologies have been suggested.

Conclusions

Peripheral neuropathies after arthroscopic shoulder procedures are rare. While most spontaneously resolve, up to 1 in 5 patients may have persistent neuropathic symptoms. A high index of suspicion should be maintained throughout the postoperative period. When neurologic deficits are identified, patients should undergo a thorough diagnostic workup and be referred to a subspecialist in a timely manner.

The Incidence of Carpal Tunnel Syndrome Diagnosis Increases after Arthroscopic Shoulder Surgery

Purpose

Arthroscopic shoulder surgery has been identified as a potential risk factor for carpal tunnel syndrome (CTS). The purposes of this study were as follows: to (1) examine the percentage of patients who underwent arthroscopic shoulder procedures and later developed ipsilateral CTS within 1 year of the procedure, (2) determine the percentage of those patients with CTS who subsequently underwent an injection or release, and (3) examine comorbidities associated with developing CTS after surgery.

Methods

Patients who underwent arthroscopic rotator cuff repair (RCR), labral repair, or biceps tenodesis were retrospectively identified in a national database. Within 1 year, we compared the rates of ipsilateral CTS diagnoses versus the contralateral side. The rates of comorbidities between those who did and did not develop CTS were also compared.

Results

Within 1 year, arthroscopic RCR patients (1.47% vs 1.00%; odds ratio [OR], 1.48; P < .001) and arthroscopic labral repair patients (0.76% vs 0.52%; OR, 1.47; P < .001) had a significantly higher rate of ipsilateral carpal tunnel diagnosis versus contralateral side diagnosis. Arthroscopic RCR patients were also significantly more likely to have ipsilateral carpal tunnel injection (0.16% vs 0.11%; OR, 1.45; P < .001) and release (0.46% vs 0.37%; OR, 1.24; P < .001). Patients who had an ipsilateral carpal tunnel diagnosis following arthroscopic RCR and labral repair were both significantly older (both P < .001), a higher percentage of women (both P<.001), and more likely to have had a preoperative nerve block (both P < .05). Both cohorts had significantly higher mean Elixhauser comorbidity Index (P < .001) and more comorbidities.

Conclusions

This study demonstrated a significantly higher incidence of operative side CTS within 1 year following arthroscopic RCR and labral repairs. Arthroscopic RCR was also demonstrated to result in significantly higher rates of injections and carpal tunnel release. The cohort that developed ipsilateral CTS was older, had higher percentage of women, and had more comorbidities.

Type of study/level of evidence

Prognostic III.

Iatrogenic Ulnar Nerve Neuropathy Following Reverse Total Shoulder Arthroplasty: Electrodiagnostic Findings in 18 Patients

Background A reverse total shoulder arthroplasty (RTSA) is often recommended for rotator cuff pathology and may be associated with a myriad of complications, including prosthetic instability, infection, humeral problems, and glenoid loosening. Neurological injuries following an RTSA are infrequent and are usually related to brachial plexus or proximal nerve injury in the affected arm. Iatrogenic ulnar nerve neuropathy is exceedingly rare. Aims This study describes the clinical and electrodiagnostic (EDX) features of 18 patients with ulnar nerve neuropathy complicating RTSA. Materials and methods All patients underwent EDX studies, and 14 had an ultrasound (US) study. Results All patients complained of numbness, tingling, hyperalgesia, and/or allodynia in the distribution of the ulnar nerve. Eight (44%) patients reported hand weakness, and one (6%) noted wasting of the intrinsic hand muscles. Decreased pinprick sensation in the ulnar nerve distribution was detected in all patients. Seventeen (94%) patients had weakness of the ulnar nerve-innervated intrinsic hand muscles. All patients had focal slowing of the motor conduction of the ulnar nerve across the elbow. Sensory potentials were either absent or of a low amplitude over the digital and/or dorsal cutaneous branch of the ulnar nerve in all patients. Twelve (86%) patients showed an increase in the cross-sectional area (CSA) of the ulnar nerve at the elbow; six (43%) had a hypoechoic ulnar nerve. Ulnar nerve neuropathy was confirmed at the elbow in all 18 patients. Of the 14 (78%) patients who underwent surgical intervention for ulnar nerve neuropathy following an RTSA, only four had complete symptom resolution. Conclusions Surgeons should be cognizant of ulnar nerve neuropathy as a potential complication of an RTSA and take precautions to avoid damage to the ulnar nerve intraoperatively. EDX and US studies should be performed to confirm and assess the site and severity of the injury.

Risk factors related to complications of the fingers and hand after arthroscopic rotator cuff repair - carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome

Hypothesis/Background

Complications involving the fingers and hand after arthroscopic rotator cuff repair (ARCR) include complex regional pain syndrome, carpal tunnel syndrome (CTS), and flexor tenosynovitis (TS). The aims of this study were to diagnose the complications after ARCR and investigate the risk factors that could predispose individuals to these finger and hand complications.

Methods

Fifty patients (50 shoulders) who underwent ARCR participated in this study. The patients’ ages ranged from 36 to 84 years (mean, 63 years). Before ARCR, we determined the disease history of the fingers and hand (CTS or TS) and subjectively assessed their symptoms using a questionnaire that included a scale ranging from 1 (no symptoms or no disability) to 5 (the worst symptoms or severest disability). ARCR was performed in all patients using suture anchors. The mean observation period after surgery was 15.5 months (range, 12-48 months). We diagnosed complications involving the fingers and hand after ARCR and investigated the preoperative, intraoperative, and postoperative risk factors that could predispose patients to these complications using univariable and multivariable analyses.

Results

After ARCR, 20 patients (20 hands) (40%) had complications of the fingers and hand. Among them, the diagnosis was CTS in 2 hands, TS in 15 hands, and both CTS and TS in 3 hands. None of the hands exhibited complex regional pain syndrome. These complications occurred at an average of 1.8 months (range, 0.1-4 months) after ARCR. In the 47 patients who did not have symptoms just before the operation, both univariable and multivariable analyses between the complication group (n = 17) and the no-complications group (n = 30) showed a significant difference in the presence of a past history of CTS or TS (complication frequency: past history: 88%, no past history: 25%) (P < .05) and the preoperative subjective assessment for edema of the fingers and hand (complication frequency: edema ≥ 2 points: 89%, edema < 2 points: 24%) (P < .05). There were no relationships between the other candidate intraoperative and postoperative factors and complications.

Conclusion

In all 20 hands with complications of the fingers and hand after ARCR, the diagnosis was CTS or TS. Complications of the fingers and hand after ARCR easily occurred in patients with a past history of CTS or TS and in patients with edema as per a subjective assessment. We speculate that the ARCR triggered the occurrence of CTS and TS postoperatively in patients who had subclinical CTS or TS before surgery.

Complex Region Pain Syndrome Following Shoulder Surgery

Purpose

To describe the clinical features, treatment, and outcomes in patients with complex region pain syndrome (CRPS) following shoulder surgeries.

Methods

Three patients were diagnosed with CRPS according to the Budapest criteria. Patients were followed up prospectively at regular intervals for a minimum of 2 years. Demographic data, clinical symptoms, physical examination findings, treatment received, and outcomes were collected and reported.

Results

The minimum time interval between surgery and diagnosis was 3 weeks (average, 8 weeks). The index procedures included 2 arthroscopic rotator cuff repairs and 1 open Latarjet. Neurologic pain, muscle spasms, hand and wrist swelling, and joint stiffness were seen in the shoulder, wrist, and hand, but the elbow was spared in all patients. Despite the use of multimodal treatment modalities, the symptoms were refractory to treatment for prolonged periods (range, 6-12 months). Hand and wrist symptoms took an average of 4 months longer than shoulder symptoms to improve. At the latest follow-up (range, 24-26 months), varying degrees of residual hand dysfunction, pain, and inability to make a fist or fully extend the fingers were noted in all 3 patients.

Conclusions

CPRS type 1 following shoulder surgery is a disabling condition with a long-protracted clinical course. CRPS can present as early as few weeks after shoulder surgery, with symptoms of neuropathic pain, spasm, and stiffness affecting the entire upper-extremity joints except the elbow. CRPS symptoms resolve earlier in the shoulder compared with the wrist and hand, with pain improving first, followed by recovery of motion and function. Residual stiffness affecting grip function is last to recover and can present up to 2 years after onset of symptoms. Although prompt recognition and multimodal approach are considered the mainstay of treatment, there is no gold standard treatment modality that can reproducibly alter the natural history of CRPS.

Level of Evidence

IV, therapeutic case series.

Perioperative anaesthetic considerations for rotator cuff repair surgeries: A current concept review

Surgeries for Rotator Cuff (RC) pathologies are required for either trauma or degenerative related aetiologies. Various surgical techniques from open to arthroscopic repair, are being undertaken by orthopaedic surgeons. Peri-operative anaesthetic management of the patients undergoing rotator cuff repair requires understanding the surgical procedure and patient status for optimal anaesthetic planning. Such management mandates a thorough pre-operative evaluation, including clinical history, examination, and relevant investigations. Patients with acute trauma associated Rotator Cuff (RC) tears should be assessed for visceral injuries using appropriate injury evaluation systems before such repairs. On the other hand, patients with degenerative tears tend to be older with associated comorbidities. Hence pre-operative optimisation is necessary according to risk stratification. Anaesthetic techniques for Rotator Cuff (RC) surgery include general anaesthesia or regional anaesthesia. These are individualised according to patient assessment and surgical procedure planned. Knowledge of relevant surgical anatomy is essential for intra-operative, and post-operative neural blockade techniques since optimal peri-operative analgesia improve overall patient recovery. The occurrence of a peri-operative complication should be recognised as timely management improves the patient-related surgical outcomes. We describe the relevance of surgical anatomy, the effect of patient positioning, irrigating fluids, various anaesthetic techniques and an overview of regional and medical interventions to manage pain in patients undergoing for Rotator Cuff (RC) surgery.

Clinical outcome in patients with hand lesions associated with complex regional pain syndrome after arthroscopic rotator cuff repair

Background

Complex regional pain syndrome (CRPS)-related hand lesions are one of the complications following arthroscopic rotator cuff repair (ARCR). This study aimed to investigate the clinical outcomes of patients with CRPS-related hand lesions following ARCR.

Methods

Altogether, 103 patients with ARCR were included in this study (mean age, 63.6±8.2 years; 66 males and 37 females; follow-up period, preoperative to 12 months postoperative). Clinical assessment included the Japanese Orthopaedic Association (JOA) score, University of California, Los Angeles (UCLA) score, Constant score, 36-item short form health survey (SF-36) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score from preoperative to 12 months postoperatively. The patients were either assigned to the CRPS group or non-CRPS group depending on CRPS diagnosis until the final follow-up, and clinical outcomes were then compared between the groups.

Results

Of 103 patients, 20 (19.4%) had CRPS-related hand lesions that developed entirely within 2 months postoperatively. Both groups showed significant improvement in JOA, UCLA, and Constant scores preoperatively to 12 months postoperatively (p<0.001). Comparisons between the two groups were not significantly different, except for SF-36 “general health perception” (p<0.05) at 12 months postoperatively. At final follow-up, three patients had residual CRPS-related hand lesions with limited range of motion and finger edema.

Conclusions

CRPS-related hand lesions developed in 19.4% of patients following ARCR. Shoulder or upper-limb function improved in most cases at 12 months, with satisfactory SF-36 patient-based evaluation results. Patients with residual CRPS-related hand lesions at the last follow-up require long-term follow-up.

Early detection and treatment of complications in the fingers and hand after arthroscopic rotator cuff repair

Background

Complications in the fingers and hand after arthroscopic rotator cuff repair (ARCR) have been reported to include carpal tunnel syndrome (CTS), flexor tenosynovitis (TS), and complex regional pain syndrome. These studies were conducted retrospectively; however, the reported complications have not been examined prospectively. The aim of this study was to evaluate the outcomes of early detection and treatment of the complications after ARCR.

Methods

Forty-six patients (48 shoulders) who underwent ARCR were prospectively examined to investigate complications in the fingers and hand after ARCR. We attempted to immediately detect and proactively treat these complications. We evaluated the outcomes of the early detection and treatment of the complications.

Results

Complications were observed in 17 hands (35%) and occurred an average of 1.5 months after ARCR. The symptoms in 3 hands resolved spontaneously, 2 hands were diagnosed with CTS, and 12 hands were diagnosed with TS. Of the 12 hands with TS, 11 exhibited no triggering of the fingers. Among the 14 hands diagnosed with CTS or TS, 13 hands (CTS: 2 hands, TS: 11 hands) were treated with corticosteroid injections; the mean interval between treatment initiation and symptom resolution was 1.0 months (0.5-3.0 months). None exhibited complex regional pain syndrome.

Conclusions

When symptoms occur in the fingers and hand after ARCR, CTS or TS should be primarily suspected. The diagnosis of TS must be made carefully because most patients with TS have no triggering. For patients with CTS or TS after ARCR, rapid corticosteroid injection administration can lead to improvement in these symptoms.

Clinical effect of thumb finger reconstruction using dorsal foot flap transplant for treating thumb defects

It was found that conventional toe graft alone could not meet the patients' needs for wound repair, so we hypothesized that it would be more effective to treat thumb and finger defect by toe graft with dorsalis foot flap. This prospective study was conducted in 104 thumb defect patients to investigate the clinical effect of thumb reconstruction using toe graft with dorsal foot flap for the treatment of thumb defects. These patients were randomly divided into the dorsal foot group and the control group by randomized double-blind method, with 52 patients in each group. The second toe was used for thumb reconstruction transplant in both the groups. After thumb reconstruction, the abdominal pedicled flap was used to repair the surgical wound in the control group whereas the dorsal foot flap was used to repair the surgical wound in the dorsal foot group. Three months after surgery, the efficacy of surgical treatment, evaluation of two-point discrimination, postoperative complications, function of reconstructed thumb, operation time, and hospitalization time were recorded and compared between the two groups. MHOQ questionnaire was used to evaluate and compare the patients' satisfaction with finger reconstruction in both the groups. The surgical therapeutic effect, the function of the reconstructed thumb, and satisfaction with finger reconstruction were significantly higher in the dorsal foot group compared to the control group (all p < 0.05). The postoperative two-point discrimination, postoperative complication rate, operation time, and hospitalization time of patients in the dorsal foot group were significantly lower compared to the control group (all p < 0.05). Thumb finger reconstruction using the second toe transplant with dorsal foot flap had a beneficial effect on thumb defect patients. It can effectively improve finger function and sensory recovery of patients while reducing complications.