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

• 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, 2016

• 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 JSES 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

JBJS 2017

Fracture Surgery

• Nerves at risk

‒Injury ‒Fracture fixation

• Axillary nerve – Proximal

humerus

• Radial nerve – Humeral shaft

‒Neural anatomy knowledge critical

• 40 patients – ORIF proximal humerus

fractures

‒ Deltoid splitting approach

• 4 of 40 (10%) with permanent injury

to some degree

‒ 28 months follow-up

JBJS 2017

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

• 416 Latarjets reviewed
• Complications - 5%

‒Hardware problems ‒Infection ‒Neurologic injury (3.1%)

• Most common complication
• Axillary, Musculocutaneous, Suprascapular

nerves most often affected

JBJS 2017

• 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

JSES 2014

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

Thank You