Neu eurologic/ c/Vascu cular: “My A Arm is Swollen a en and Num d Numb… What Hap appened i in T There?” ?” Larry D. Field, MD Mississippi Sports Medicine and Orthopaedic Center Jackson, MS
Disclosures The following relationships exist: 1. Royalties and stock options None • 2. Consulting income Smith & Nephew • 3. Research and educational support Arthrex • Mitek • Smith & Nephew • 4. Other support None •
Shoulder Surgery • Increasingly commonly performed ‒ Arthroscopy ‒ Open reconstruction ‒ Arthroplasty ‒ Fracture surgery Proximal humerus Clavicle • Complications more common
Shoulder Surgery Complications • Broad topic • Complications classified ‒ Surgical failure Indications Recurrence Non-union Infection Vascular Neurologic ‒ Anesthesia
Vascular Complications • Direct injury to major arteries and veins rare • Fractures ‒ Reduction Shoulder fracture-dislocations ‒ Fracture fixation • Post-operative ‒ Upper extremity DVT (UEDVT)
Upper Extremity DVT • Most DVTs occurs in lower extremities ‒ Well known complication • Joffe et al (Circulation, 2004) ‒ 592 patients with DVTs ‒ Upper extremity DVTs 11% of all patients
UEDVT Causes • Central venous lines • Malignancy • Pregnancy • Oral contraceptives • UEDVT occurs after shoulder surgery ‒ Open and arthroscopic Burkhart (Arthroscopy, 1990) • Arthroscopic surgery
Upper Extremity DVT • Incidence (Dattani, JBJS 2013) ‒ Arthroplasty (0.52%) ‒ Fractures (0.64%) • Shoulder arthroscopy incidence ‒ Several retrospective reviews < .01% - .38%
Upper Extremity DVT • Presentation (Kucher, NEJM, 2011) ‒ Edema (~80%) ‒ Pain (30-50%) ‒ Erythema (~15%) ‒ Paresthesias, weakness less common
Upper Extremity DVT • Differential diagnosis ‒ Phlebitis ‒ Cellulitis ‒ Fluid extravasation (Arthroscopic surgery) ‒ Hemorrhage ‒ Muscle tear ‒ Allergy ‒ UEDVT
Upper Extremity DVT Diagnosis • Symptoms may be mild ‒ Easily dismissed Positioning Arm sling “Normal” ‒ True incidence underestimated • Low threshold for duplex ultrasound
Upper Extremity DVT • Ultrasound after TSA for all pts. ‒ Willis (JSES, 2009) DVT – 13% Pulmonary embolus – 3% • Bernardi (Vascular Medicine, 2001) ‒ 36% of DVTs Pulmonary embolism ‒ Chemical prophylaxis? No guidelines exist • Jameson (JSES, 2011) ‒ Enoxaparin for all patients after TSA PE incidence
UEDVT SUMMARY • Occurs after open and arthroscopic surgery ‒ Probably more prevalent than reported ‒ High index of suspicion Duplex ultrasound
Neurologic Injury • Nerve dysfunction uncommon after shoulder surgery ‒ Likely under-reported ‒ Not always recognized Patient considered “normal” Neurologic exam limited post-operatively Transient symptoms resolve
Neurologic Injury • Nerve injury multifactorial ‒ Direct damage to nerve ‒ Cement extrusion ‒ Interscalene blocks ‒ Hematoma ‒ Excessive traction Arm positioning Retraction
Neurologic Injury • Specific nerves at risk vary with procedure and techniques ‒ TSA/RSA ‒ Open surgery Fractures Open reconstruction (Latarjet) ‒ Shoulder arthroscopy
JSES, 2016 • 36 patients ‒ 24 TSA, 12 RSA • Intraoperative neuromonitoring • Nerve alerts common in both groups ‒ 5 times more common in RSA • 2 clinically detectable nerve injuries
JSES 2017 • 211 TSA/RSA/Hemiarthroplasties ‒ 5 year F/U ‒ 44 (21%) sustained nerve complication RSA highest nerve injury rate Mainly transient neurapraxias Probably excessive traction or injury during glenoid exposure ‒ Brachial plexus lateral cord most commonly injured
JBJS 2017 • 19,262 TSAs and RSAs (2006-2015) ‒ 40 months F/U ‒ 122 Studies • Overall complication rate 11% • Neural Injury 1.2% of all shoulders ‒ 5.4% of all complications 70% occurred in RSA • Recommendations: ‒ Intermittent extremity relaxation intra-operatively ‒ Retractor removal for non-essential steps
Fracture Surgery • Nerves at risk ‒ Injury ‒ Fracture fixation Axillary nerve – Proximal humerus Radial nerve – Humeral shaft ‒ Neural anatomy knowledge critical
JBJS 2017 • 40 patients – ORIF proximal humerus fractures ‒ Deltoid splitting approach • 4 of 40 (10%) with permanent injury to some degree ‒ 28 months follow-up
JSES 2017 • 8 cadavers • Radial nerve course relative to humerus investigated ‒ 25-55 mm from latissimus insertion at spiral groove • Highlights risk of iatrogenic injury ‒ Identification/protection key ‒ Avoid circumferential fixation
Latarjet Reconstruction • Much more commonly performed • Complications relatively high ‒ Nerve injuries reported • Techniques/Strategies to minimize risk
JBJS 2017 • 416 Latarjets reviewed • Complications - 5% ‒ Hardware problems ‒ Infection ‒ Neurologic injury (3.1%) Most common complication Axillary, Musculocutaneous, Suprascapular nerves most often affected
JSES 2014 • 34 patients neurologic status monitored intra-operatively • 26 of 34 ( 77% ) had nerve alerts − 50% ↓ amplitude − 10% ↓ latency − Axillary nerves − Musculocutaneous nerves • 21% had axillary nerve deficit post-op − All resolved at 1-6 months • Concluded that nerves at significant risk with Latarjet
Shoulder Arthroscopy • Nerves at risk • Injuries reported for all major nerves • Thorough understanding of anatomy ‒ “Arthroscopic nerve anatomy” ‒ Axillary Nerve – inferior capsule and anterior to subscapularis ‒ Suprascapular nerve – superior glenoid ‒ Musculocutaneous nerve – anterior shoulder
Shoulder Arthroscopy Neurologic Injury • Patient positioning ‒ Proper padding and protection ‒ Protocols should be followed by all OR staff • Lateral decubitus vs beach chair ‒ High majority occur in lateral decubitus Upper extremity traction • “Balanced suspension” dictated instead of “Traction” in medical record 10% transient paresthesias reported after lateral decubitus positioning (Klein, 1987)
Neurologic Injury • Anesthesia ‒ Interscalene block Commonly performed Low complication rate • Most neurologic symptoms transient • Brachial plexus neuropraxia • Occasionally severe or permanent
Summary • Swelling and numbness very common • Serious/permanent neuro-vascular complications uncommon • Maintain suspicion for upper extremity DVT • Understand anatomy and respect neural structures ‒ Patient positioning ‒ Intra-operative technique • Thoroughly assess post-op to improve recognition ‒ UEDVT ‒ Neurologic injury
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