Neu eurologic/ c/Vascu cular: My A Arm is Swollen a en and Num - PowerPoint PPT Presentation

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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