Complications in Arthroscopic Shoulder Surgery [1st ed. 2020] 978-3-030-24573-3, 978-3-030-24574-0

Table of contents :
Front Matter ....Pages i-vi
General Problems and Complications (Malte Holschen, Jens Agneskirchner)....Pages 1-10
Complications in General Glenohumeral and Subacromial Space Procedures (Mathias Wellmann)....Pages 11-24
Complications in Arthroscopic Release of the Stiff Shoulder (Johannes Plath)....Pages 25-31
Complications in AC Joint Stabilization (Richard L. Auran, Evan S. Lederman, Reuben Gobezie)....Pages 33-38
Complications of Soft Tissue Repair Techniques for Shoulder Instability (Rupert Meller, Nael Hawi)....Pages 39-50
Complications of Bony Procedures for Shoulder Instability (Ion-Andrei Popescu, David Haeni)....Pages 51-64
Complications of Subscapularis Repair (Jörg Nowotny, Philip Kasten)....Pages 65-71
Complications in Posterosuperior and Three Tendon Rotator Cuff Repair (Stefan Pauly, Markus Scheibel)....Pages 73-82
Complications of Superior Capsular Reconstruction (Stefan Greiner, Leonard Achenbach)....Pages 83-90
Complications in Tendon Transfers (Daniel Henderson, Simon Boyle)....Pages 91-102
Complications in Biceps Tendon Management: Long Head of Biceps Tenotomy and Tenodesis (Johannes Plath)....Pages 103-111
Complications in Arthroscopic Fracture Management (Philipp Moroder, Maximilian Haas, Markus Scheibel)....Pages 113-127
Vascular Complications in Shoulder Arthroscopy (Laurent Lafosse, Thibault Lafosse)....Pages 129-137
Neurological Complications in Shoulder Arthroscopy (Thibault Lafosse, Laurent Lafosse)....Pages 139-148

Citation preview

Complications in Arthroscopic Shoulder Surgery Laurent Lafosse Jens Agneskirchner Thibault Lafosse Editors

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Complications in Arthroscopic Shoulder Surgery

Laurent Lafosse  •  Jens Agneskirchner Thibault Lafosse Editors

Complications in Arthroscopic Shoulder Surgery

Editors Laurent Lafosse Department of Orthopedics Clinique Générale Annecy France

Jens Agneskirchner Gelenkchirurgie Orthopädie Hannover Hannover Germany

Thibault Lafosse Department of Orthopedics Clinique Générale Annecy France

ISBN 978-3-030-24573-3    ISBN 978-3-030-24574-0 (eBook) https://doi.org/10.1007/978-3-030-24574-0 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

1 General Problems and Complications�������������������������������������������   1 Malte Holschen and Jens Agneskirchner 2 Complications in General Glenohumeral and Subacromial Space Procedures ����������������������������������������������������������������������������  11 Mathias Wellmann 3 Complications in Arthroscopic Release of the Stiff Shoulder������  25 Johannes Plath 4 Complications in AC Joint Stabilization����������������������������������������  33 Richard L. Auran, Evan S. Lederman, and Reuben Gobezie 5 Complications of Soft Tissue Repair Techniques for Shoulder Instability������������������������������������������������������������������������������������������  39 Rupert Meller and Nael Hawi 6 Complications of Bony Procedures for Shoulder Instability ������  51 Ion-Andrei Popescu and David Haeni 7 Complications of Subscapularis Repair����������������������������������������  65 Jörg Nowotny and Philip Kasten 8 Complications in Posterosuperior and Three Tendon Rotator Cuff Repair������������������������������������������������������������������������  73 Stefan Pauly and Markus Scheibel 9 Complications of Superior Capsular Reconstruction������������������  83 Stefan Greiner and Leonard Achenbach 10 Complications in Tendon Transfers������������������������������������������������  91 Daniel Henderson and Simon Boyle 11 Complications in Biceps Tendon Management: Long Head of Biceps Tenotomy and Tenodesis �������������������������������������� 103 Johannes Plath 12 Complications in Arthroscopic Fracture Management���������������� 113 Philipp Moroder, Maximilian Haas, and Markus Scheibel

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vi

13 Vascular Complications in Shoulder Arthroscopy������������������������ 129 Laurent Lafosse and Thibault Lafosse 14 Neurological Complications in Shoulder Arthroscopy ���������������� 139 Thibault Lafosse and Laurent Lafosse

Contents

1

General Problems and Complications Malte Holschen and Jens Agneskirchner

1.1

Preoperative Complications (Indication)

Patient selection and assessment of potential problems and complications are of major importance for successful arthroscopic shoulder surgery. Next to the correct indication for the surgical procedure the patient’s general condition and comorbidities need to be regarded to avoid and per- and postoperative complications. Comorbidities are known to affect the overall postoperative complication rate [1] and the infection rate [2]. These risk factors are summarized in Table 1.1. Patient history aids the identification of risk factors of general problems and complications. The most relevant risk factors for per operative complications are cardiovascular diseases like high arterial blood pressure and coronary heart disease, obstructive pulmonary diseases, bleeding disorder and cerebral hypoperfusion. These risk factors need to be investigated prior to surgery by the anesthesiologist as well as the shoulder surgeon. Because shoulder arthroscopy is a planned surgical procedure in most of the cases, patients with one ore more of these major risk factors need M. Holschen (*) Raphaelsklinik, Münster, Germany J. Agneskirchner Klinik für Gelenkchirurgie und Orthopädie (GOH), Hannover, Germany e-mail: [email protected]

Table 1.1  Risk factors for overall postoperative complications according to the findings of Shields et al. [1] and risk factors for postoperative infection according to the findings of Cancienne et al. [2] Risk factors for overall postoperative complications – Age between 30 and 60 years – Diabetes – Chronic obstructive pulmonary disease – Coronary heart disease – Arterial hypertension – History of cerebrovascular accident – Disseminated cancer – ASA class III or higher – Inpatient shoulder arthroscopy – Duration of surgery >90 min – Further surgical procedures in addition to shoulder arthroscopy

Risk factors for postoperative infection – Revision surgery – Male sex – Age 15  mm and multiple calcifications as well as a duration of symptoms >11  months. These factors may therefore serve as indication criteria for arthroscopic treatment of RCCT. Even though the arthroscopic treatment of RCCT is known to be a basic and straightforward procedure there are a few pitfalls und possible complications during the clinical pathway.

2.3.1 P  re Operative Complications (Indication) The aim of indicating arthroscopic treatment of RCCT is to detect all calcific deposits on the one hand and on the other hand to exclude patients with RCCT, which will certainly respond to non-­ operative treatment. Therefore the clinical and radiological examination should consider even unusual locations of calcific deposits and patients with multiple calcifications. In their medical history patients with an acute RCTT typically report a sudden onset of the symptoms, with severe pain causing a drastic limitation of active motion, right up to a pain related pseudoparalysis. Pain during rest und during the night is also typical. In up to 20% of the patients there have been similar episodes on the contralateral side before.During physical examination a restriction of active abduction with near to normal external rotation is typical. Further there should by positive Impingement-tests (Hawkins and Neer). Nevertheless calcific deposits in the infraspinatus und subscapularis tendon may be missed just expecting the idealtypic clini-

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cal constellation. Therefore clinical test for the infraspinatus and subscapularis tendon should be included in the standard examination sequence. For initial radiologic diagnosis X-ray or ultrasound may be used. However, regarding the indication for operative vs. non-operative treatment plain radiographs may be beneficial to define the relevant characteristics of the deposit. Oftentimes the patients present in the outpatient clinic acutely suffering from pain or with an escalation of the pain level in chronic courses. There is evidence that especially the absorptive phase during RCCT is associated with acute pain caused by increased intratendinous pressure and potential extravasation of the calcium crystals in the subacromial bursa. Therefore a current radiographic examination (not pre-date 1 week) should be available before surgery to avoid spontaneous absorption of the calcific deposit at the time of surgery. If current radiographs are missing, an X-ray investigation using an image intensifier can be performed before surgery. If this is done the arm position to exactly place the calcific deposit under the acromion in the AP view can be defined. Reproducing this arm position simplifies the detection of the calcific deposit during surgery. Key Points –– Evidenced based criteria for arthroscopic treatment of RCCT are: Calcific deposits with a sharp border and dense structure (Gärtner Type I), a calcification extent >15  mm and multiple calcifications as well as a duration of symptoms >11 months. Other types of RCCT ma respond to conservative treatment. –– Don’t miss unusual calcific deposits in the subscapularis and infraspinatus tendon and multiple calcifications (Figs.  2.10 and 2.11). To detect them, AP X-rays in internal rotation and external rotation or ultrasound investigation should be performed (Fig. 2.12). –– Be sure to obtain current X-rays at the time of surgery to exclude spontaneous resorption of the calcific deposit at this time and keep the surgical morbidity low, if only a bursectomy is necessary.

M. Wellmann

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a

b

Fig. 2.10  Preoperative X-rays of a patient with RCCT involving the supraspinatus and subscapularis tendon (a, b). The calcium deposit in the supraspinatus tendon is mutilobular including two deposits (b). X-rays 2 months after arthroscopic calcium removal (c, d): Only the smaller portion of the deposit in the supraspinatus tendon

a

b

c

d

has been removed. The main deposit in the supraspinatus tendon was not detected intraoperatively, while the deposit in the subscapularis tendon has not been diagnosed preoperatively. The patient presented with persistent complaints and had to be revised

c

d

Fig. 2.11  Preoperative X-rays of a patient with RCCT involving the subscapularis and infraspinatus tendon (a, b). The subacromial space in the AP view is therefore clear of any calcium deposit. The deposit in the infraspi-

natus is covered by the spine of the scapula in the Y-view (b). Postoperative X-rays showing complete removal of both deposits (c, d)

2.3.2 Per Operative Complications

the standard diagnostic evaluation of the glenohumeral joint is completed, a “low” lateral working and viewing portal should be established. The low lateral portal enables a complete subacromial and subdeltoidal bursectomy and facilitates a broad overview during the detection process. If the deposit is intuitively apparent the extirpation can be done immediately. If not, a systematic search by sector (anterosuperior, superior, posterior cuff) using a spinal needle should be performed. If necessary, the arm position can be sequentially changed (abduction with internal and external rotation) during this process.

There are a few technical tips to facilitate arthroscopic treatment of RCCT. One basic issue is to identify all deposits before starting surgery and to be sure, that there has been no spontaneous absorption at the time of surgery. If an MRI scan is available, the localization of the deposits can be done using soft tissue of bony landmarks (biceps tendon, anterior border of the supraspinatus tendon). Otherwise it is essential to be very systematic during systematic during the arthroscopic detection process. Therefore, after

2  Complications in General Glenohumeral and Subacromial Space Procedures

a

b

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c

Fig. 2.12  Preoperative X-rays of a patient with RCCT of the infraspinatus tendon. (a) In the AP view in neutral rotation the subacromial space is clear of calcium deposits. (b) In the Y-view the deposit is located in projection on

the inferior part of the infraspinatus tendon. (c) The AP view in internal rotation clearly shows the dimension an location of the calcium deposit

Again, bony and soft tissue landmarks may be useful to match with the deposit location given by the MRI or X-ray. For detection of deposits in the infraspinatus tendon a marked internal rotation may be necessary, because the deposits are often located in the inferior part of the infraspinatus tendon. For evisceration of deposits located in the subscapularis tendon a resection of the rotator interval capsule should be performed in the first step viewing from the posterior standard portal. Afterwards, an anterolateral portal is used to clean up the subcoracoidal space and to clearly expose the subscapularis tendon. Then the arthroscope is placed in the anterolateral portal and the detection of the deposit is performed from the anterior standard portal. Depending of the mediolateral location of the deposit the position of the viewing and working portal may be switched or alternatively the arm position may be adapted. In general the extension of each deposit regardless of its location should be marked using spinal needles. This step should be done to ensure a central position of the incision, which is needed to best possible evacuate the calcific deposit. For a successful arthroscopic evisceration an aggressive debridement or even resection the affected rotator cuff tendon is not necessary and should be avoided. If the tendon seems to be substantially weakened after evisceration, a side-to-side repair using

absorbable sutures may be performed to close the bursal tendon layer. Further, after evisceration the subacromial space should be thoroughly cleaned from calcific substance to avoid persistent bursitis or secondary adhesive capsulitis. An additional acromioplasty seems not to be beneficial based on a randomized controlled trial [32].

2.3.3 Immediate Postoperative Complications In most of the cases the postoperative treatment of RCCT is quite straightforward. However, as an immediate complication persistent pain may occur. This complication can be avoided applying a suprascapular nerve block at the end of surgery, especially in patients who had high pain levels preoperatively. In our experience persistent pain is oftentimes associated with an incomplete removal of the calcific deposit [33] (Fig.  2.10). In case of a doubt, the surgeon should therefore prevent incomplete evisceration using an image intensifier at the end of surgery.

2.3.4 Middle Term Complications In a study by Jacobs et al. the incidence of adhesive capsulitis after arthroscopic treatment of

M. Wellmann

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calcific deposits [35]. However, such cases do not reflect to typical case of RCCT.  On the other hand a rotator cuff tear may occur after arthroscopic removal of the calcium deposit depending on the extent of tendon resection. There is some evidence that persisting pain after arthroscopic calcium removal is associated with a higher rate of partial supraspinatus tendon tears [36]. Therefore a symptomatic rotator cuff tear should be ruled out in the case of persistent complaints. 2.3.5 Long Term Complications An uncommon complication of RCCT is A coexisting rotator cuff tear can appear pre-­ given by greater tuberosity osteolysis [37, 38] operatively, intraoperatively or postoperatively (Fig.  2.13). Due to this complication the cliniin the course of treatment. In earlier times cal course of RCCT may be prolonged leading it was proposed, that there is no coexistence to a longer duration of symptoms and greater of both entities. Nevertheless, some authors functional impairment. Such lesions are not observed a relevant percentage of rotator cuff related to shape or size of the deposits but do tears to be associated with smaller dystrophic negatively affect the prognosis and seem to be RCCT has been quantified as high as 18% and was supposed to be caused by residual calcium debris [34]. In such cases conservative treatment with application of corticosteroids (oral or injection) and mild manual therapy is recommended. If there are signs of adhesive capsulitis during arthroscopy such treatment should be initiated immediately after surgery.

a

Fig. 2.13  Preoperative CT (a) and MRI (b) scan of a patient with greater tuberosity osteolysis associated with RCCT of the supraspinatus tendon. The CT scan shows

b

the subcortical bone lesion while the MRI shows the bone marrow edema, which has been attributed for persistent pain even after accurate removal of the calcium deposit

2  Complications in General Glenohumeral and Subacromial Space Procedures

particularly resistant to conservative treatment. But, even after accurate arthroscopic removal of the deposit such patients gain lower postoperative clinical scores.

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24 a cadaveric model. Arthroscopy. 2007;23(12):1278–84. https://doi.org/10.1016/j.arthro.2007.07.004. 20. Apivatgaroon A, Sanguanjit P.  Arthroscopic distal clavicle and medial border of acromion resection for symptomatic acromioclavicular joint osteoarthritis. Arthrosc Tech. 2017;6(1):e25–9. https://doi. org/10.1016/j.eats.2016.08.033. 21. Gaillard J, Calò M, Nourissat G. Bipolar acromioclavicular joint resection. Arthrosc Tech. 2017;6(6):e2229– 33. https://doi.org/10.1016/j.eats.2017.08.027. 22. Pandhi NG, Esquivel AO, Hanna JD, Lemos DW, Staron JS, Lemos SE.  The biomechanical stability of distal clavicle excision versus symmetric acromioclavicular joint resection. Am J Sports Med. 2013;41(2):291–5. https://doi.org/10.1177/0363546512469873. 23. Baxter JA, Phadnis J, Robinson PM, Funk L.  Functional outcome of open acromioclavicular joint stabilization for instability following distal clavicle resection. J Orthop. 2018;15(3):761–4. https://doi. org/10.1016/j.jor.2018.05.013. 24. Strauss EJ, Barker JU, McGill K, Verma NN.  The evaluation and management of failed distal clavicle excision. Sports Med Arthrosc Rev. 2010;18(3):213– 9. https://doi.org/10.1097/JSA.0b013e3181e892da. 25. Begly J, Tyagi V, Strauss E. Diffuse idiopathic skeletal hyperostosis (DISH) as a cause of failure following distal clavicle excision a case report and review of the literature. Bull Hosp Jt Dis (2013). 2017;75(4):279–81. 26. Tytherleigh-Strong G, Gill J, Sforza G, Copeland S, Levy O.  Reossification and fusion across the acromioclavicular joint after arthroscopic acromioplasty and distal clavicle resection. Arthroscopy. 2001;17(9):E36. 27. Zumstein MA, Schiessl P, Ambuehl B, Bolliger L, Weihs J, Maurer MH, et  al. New quantitative radiographic parameters for vertical and horizontal instability in acromioclavicular joint dislocations. Knee Surg Sports Traumatol Arthrosc. 2018;26(1):125–35. https://doi.org/10.1007/s00167-017-4579-6. 28. Tragord BS, Bui-Mansfield LT, Croy T, Shaffer SW.  Suprascapular neuropathy after distal clavicle resection and coracoclavicular ligament reconstruction: a resident’s case problem. J Orthop Sports Phys Ther. 2015;45(4):299–305. https://doi.org/10.2519/ jospt.2015.5416. 29. Ghodadra N, Lee GH, Kung P, Busfield BT, Kharazzi FD.  Distal clavicle fracture as a complication of

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3

Complications in Arthroscopic Release of the Stiff Shoulder Johannes Plath

3.1

Introduction

Frozen shoulder is a common musculoskeletal disorder. Primary frozen shoulder affects 2–5% of the general population and is slightly more frequent in females [1, 2]. The pathophysiology of this condition is fibrosis of the glenohumeral joint capsule of unknown aetiology [3]. Frozen shoulder has, however, been found to be closely connected to certain comorbidities such as diabetes, thyroid disease, Dupuytren’s disease, nephrolithiasis and cancer [3]. Three distinct phases have been described: During the first phase (freezing phase), a persistent global shoulder pain is the leading symptom with a gradually increasing stiffness. This phase lasts around 10–36  weeks. NSAIDs and oral or intra-articular corticosteroids are commonly used for pain control. During the frozen phase, which lasts around 4–12 months, pain gradually decreases but stiffness is substantial. At this stage physiotherapy below pain level is usually recommended. The final phase, the so called thawing phase, is distinguished by a gradual restoration of range of motion. Pain is resolved. This last phase is usually the longest and may last longer than 2 years.

J. Plath (*) Department of Trauma, Orthopaedic, Hand and Plastic Surgery, University Hospital of Augsburg, Augsburg, Germany

Although this idiopathic form is believed to be benign and usually self-limiting, conservative treatment may be long-lasting and a certain group of patients does not respond well to conservative therapy, with persistent pain and severe stiffness [4]. These patients may benefit from an operative intervention. A frozen shoulder must be distinguished from secondary shoulder stiffness, where the cause for stiffness is known. These may be subacromial (e.g. calcific tendinitis or rotator cuff tears), post-­traumatic (e.g. proximal humerus fracture in 2–9%) or post-surgical pathologies (i.e. rotator cuff repair in up to 33%, open and arthroscopic shoulder instability repair, arthroplasty and others) as well as osteoarthritis, infections or neurological disorders [3, 5–9]. Besides capsular contracture, extracapsular adhesions or ossifications are typically present in secondary shoulder stiffness [10]. In contrast to primary shoulder stiffness secondary stiffness does not follow a characteristic, self-limiting progression. If conservative treatments fails, surgical treatment is usually indicated [11]. In post-surgical cases, the release is frequently accompanied by open or arthroscopic hardware removal. In this chapter, we will discuss potential complications of stiff shoulder release as well as tips and tricks how to avoid them.

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_3

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3.2

Pre-Operative Complications (Indications)

Thorough pre-operative planning is imperative for successful surgical treatment in orthopaedic surgery in general. This is particularly true when performing release of the stiff shoulder. Planning starts with a thorough patient examination and imaging, to clearly identify the cause of the stiffness, and continues through proper patient selection, realistic counselling of the patient as well as determining the right timing of surgery. Pre-operative patient examination includes thorough range of motion assessment, both active and passive with stabilization of the scapula. Loss of external rotation and pain is usually the initial and characteristic symptom of a frozen shoulder. A global “frozen” shoulder is typically seen in the frozen phase and has previously been defined as forward flexion of less than 100°, external rotation of less than 10° and internal rotation to less than L5 level [3]. Secondary stiff shoulders more often show a specific limitation in certain directions depending on the precise cause. Potential causes of secondary shoulder stiffness such as rotator cuff pathology, peripheral nerve injury, muscle atrophy, crepitus, as well as signs of infection need to be evaluated by the treating physician. Plain radiographs should always be performed to rule out the following: Calcific tendinitis, fracture, deformity, tumor, osteoarthritis as well as glenohumeral dislocation. A chronic locked posterior shoulder dislocation may be misdiagnosed as shoulder stiffness given that the most consistent finding in a locked posterior dislocation is mechanical block to external rotation while elevation and internal rotation can be surprisingly well preserved [12, 13]. In postoperative cases potential hardware conflicts need to be ruled out, too. We do not generally recommend further imaging studies, especially in idiopathic shoulder stiffness, however, if there is reasonable concern regarding the underlying cause of a secondary shoulder stiffness, MRI and/or CT may be necessary.

The optimal timing for performing an arthroscopic capsular release is not well investigated in the literature. Usually, arthroscopic stiff shoulder release is suggested in the frozen phase in patients with refractory symptoms despite conservative treatment of more than 6  months. If surgery is performed too early, it may lead to overtreatment of patients with a mild and potentially self-limiting course. Furthermore, a surgical intervention may theoretically carry the risk of an additional capsular inflammatory response, which may even prolong time to recovery. For manipulation under anaesthesia, however, some authors have found superior outcomes in patients that were treated early, between 6 and 9  months after onset of symptoms, when compared to late intervention [14, 15]. To our knowledge, Sabat and Kumar [16] published the only study on timing of arthroscopic shoulder release. The authors evaluated the outcomes of an early release during the freezing phase, between 3 and 6  months after onset of symptoms, and found reliable outcomes regarding range of motion, pain relief and return to work. In the particular case of shoulder stiffness concomitant with a rotator cuff tear, one stage shoulder release with arthroscopic rotator cuff repair is considered the standard of care. The current literature shows comparable results of non-­massive rotator cuff tear repair in patients with and without a concomitant moderate shoulder stiffness [17]. A two-step surgical approach, with capsular release first and rotator cuff repair at a later stage, as well as a pre-repair physical therapy to regain a full range of motion will delay rotator cuff repair for month and bears the risk tear propagation, retraction as well as muscular atrophy and fatty degeneration. Many studies have shown the effectiveness of arthroscopic frozen shoulder release [3, 4, 10, 11, 18–23], however, arthroscopic release usually produces worse outcomes in postoperative shoulder stiffness when compared to idiopathic or post-traumatic shoulder stiffness [11, 24]. Furthermore, clinical studies suggest that patients with diabetes have a slower postoperative f­unctional recovery when compared to patients without diabetes following a frozen

3  Complications in Arthroscopic Release of the Stiff Shoulder

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release the tip of the radiofrequency probe should always be facing towards the joint, away from the neurovascular structures, while dissecting close to the glenoid, leaving the labrum intact. The surgeon must be aware of the anatomic location of the suprascapular and the axillary nerve to avoid nerve injury. The suprascapular nerves lies at the spinoglenoid notch approximately 19 mm medial to the glenoid [30]. The axillary nerve can be found on average 12.4 mm inferolateral to the 6 o’clock glenoid position [31]. The inferior capsular release is usually performed last to afford an improved overall view during this delicate step. Deltoid contraction when using 3.3 Per-Operative Complications the radiofrequency probe for inferior release serves as a warning that the surgeon is in close Arthroscopic release of the stiff shoulder is a proximity to the axillary nerve [4]. If the assistechnically demanding procedure. Even the ini- tant applies a slight abduction at neutral rotatial entry of the trocar into the joint via the pos- tion during inferior capsular release, it improves terior standard portal can be challenging due to visualization and increases the distance between an abnormally thickened posterior joint capsule. inferior glenoid and nerve, thereby protecting A spinal needle can be used to palpate the joint the axillary nerve [32]. Although potentially at line to facilitate this step, however when multiple risk, axillary nerve lesions in the published litattempts are required to enter the joint, iatrogenic erature are rare [33]. cartilage damage to the humeral head or glenoid When using the radiofrequency probe for is often inevitable and in rare cases intra-articular extensive periods, it is imperative to maintain entry can even be impossible. Lafosse et al. [4] a good flow of fluid for cooling. Jerosch and published an alternative arthroscopic technique, Aldawoudy [34] published the rare but severe starting from an extra-articular entry portal to complication of a thermal induced global glenoavoid this pitfall. Starting with a midlateral extra-­ humeral joint chondrolysis following release of a articular portal the arthroscope is first introduced stiff shoulder. into the subacromial space. Working through an During capsular release the capsule is usually antero-lateral portal the coracoacromial ligament incised in a 360° fashion (Fig. 3.1a, b). The role is identified and followed down to its origin at the of posterior capsule release, however, has previcoracoid process. Here the coracohumeral liga- ously been a matter of some debate. While some ment is located and resected laterally to the cora- authors recommend posterior capsular release to coid process. This serves both to gain access to improve internal rotation, several authors have the glenohumeral joint and to remove the primary not found any significant functional advantages restriction of external rotation as the first step of of an additional posterior capsular release in clinthe stiff shoulder release. From there on capsular ical outcome studies [19, 35–38]. release is continued in the usual manner. The most commonly reported complication Intra-articularly the surgeon’s orientation is in stiff shoulder release in the literature, howoften hampered by distorted intra-articular anat- ever, is recurrence, with a described incidence as omy and commonly by a reduced joint volume. high as 11% [23, 24, 39]. The inferior and posteThis increases the risk of iatrogenic neurovascu- rior capsule is often dramatically thickened and lar, cartilage and soft-tissue injuries and shaver fibrotic, therefore, in cases of global shoulder and radiofrequency probe should always be used stiffness we routinely perform a circumferenunder direct vision. While performing capsular tial 360° release. The main restraint to shoulder shoulder release [25–27]. The same is true for male patients with frozen shoulder, who are usually at greater risk of having a prolonged recovery and a more severe functional disability [28, 29]. The surgeon needs to counsel patients accordingly. Unrealistic patient expectations may lead to dissatisfaction despite a potentially successful operation from the surgeon’s point of view. Educating patients to improve shared decision making, setting their expectations appropriately and closely following them up is key for patients’ satisfaction.

J. Plath

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a

b

Fig. 3.1  Arthroscopic capsular release (left shoulder, visualisation from the antero-lateral portal). The capsule is released in a 360° fashion, incision of the anterior (a) and posterior (b) capsule with the radiofrequency probe

Fig. 3.2  Release of a severely scarred rotator interval in post-operative shoulder stiffness following a proximal humerus fracture osteosynthesis (right shoulder, visualisation from the posterior portal). The interval is widely opened. Labrum (L), Conjoined tendon (CT), Subscapularis tendon (SSC)

mobility is usually the severely thickened rotator interval. In order to avoid recurrence of external rotational restrictions we usually not only release but also resect the rotator interval from the upper border of subscapularis to the anterior border of supraspinatus with a shaver to avoid further scarring (Fig.  3.2). Medially the lateral coracoid is skeletonized, laterally the interval is resected up to the medial pulley sling, which is spared so as not to jeopardise biceps stability. If the biceps tendon appears scarred to the articular layers of the supraspinatus or the rotator inter-

val, however, long head of biceps tenotomy is often indispensable, and if in doubt should be performed anyway. Biceps tenodesis, by contrast, may carry the risk of further intraarticular scarring, and is in our experience unnecessary in any case, as the scarred biceps tendon tends to self-tenodese in the bicipital groove. A postoperative “popeye” deformity following simple tenotomy in stiff shoulder release is rare [4]. Following interval resection, thorough haemostasis using electrocautery should be performed to avoid post-operative haemarthrosis and recurrence of intra-articular scarring. Finally, in our practice, an intra-articular injection of corticosteroids is routinely performed at the end of the procedure to minimize the risk of further inflammation and recurrent adhesions. Particularly in cases of secondary shoulder stiffness, following trauma or surgery, the subacromial space is often affected by severe scarring [10]. Thus, the subacromial space should also be addressed, in order not to compromise the patient’s outcome. This is usually performed after the capsular release to avoid early soft tissue swelling which would hamper intra-articular dissection. In post-surgical cases of stiffness, i.e. open reduction and internal fixation of proximal humerus or glenoid fractures, subacromial release is often accompanied by hardware removal via an mini-open or arthroscopic-­assisted approach.

3  Complications in Arthroscopic Release of the Stiff Shoulder

At the end of the procedure the shoulder should be assessed for range of motion to ensure, and document, an adequate surgical release. A brusque manipulation of the glenohumeral joint must not be performed as it bears the risk of iatrogenic fractures, glenohumeral dislocation, osteochondral lesions and soft tissue trauma [40].

3.4

Immediate Postoperative Complications

Besides typical complications in the immediate post-operative setting such as infection, haematoma and wound dehiscence, specific complications of an arthroscopic stiff shoulder release include insufficient post-operative rehabilitation, insufficient pain therapy, as well as post-­operative shoulder instability. Post-operative infections following an arthroscopic capsular release have been rarely described in the literature. While most studies report no post-operative infections, Jerosch et al. [23] reported of a single case of infection in their large population of 173 shoulders, which corresponds to an overall infection rate of 0.57% [4, 11, 19, 41]. To our knowledge, only a single case of post-­ release shoulder instability has been published. Gobezie et  al. [42] reported a case of shoulder instability 6  weeks after arthroscopic revision stiff shoulder release. The patient was treated successfully with conservative measures. Insufficient post-operative mobilisation of the shoulder, often due to insufficient pain control, is by far the most common issue during the immediate post-operative period. In order to maintain the achieved range of motion immediate and intensive physiotherapy is mandatory, starting immediately following surgery, at least twice per day during in-patient hospital stay, and on a daily basis after discharge for at least 2  weeks. Afterwards therapy is individualised and patients are encouraged to use hydro-therapy whenever possible. All patients receive an interscalene brachial plexus catheter prior to surgery, which is left

29

in situ for the duration of the in-patient stay in hospital. NSAIDs are recommended for at least 2  weeks post-operatively, both for pain relief and the prevention of secondary heterotrophic ossification. No sling immobilisation is permitted and patients are encouraged to use their shoulder again for activities of daily living as soon as they are able.

3.5

Mid-Term Complications

The benefit of capsular release of the shoulder may be appreciated immediately following surgery. Especially if interscalene brachial plexus catheter is left in situ during in-hospital stay, patients are often impressed with the early post-­ operative results. In order to avoid early dissatisfaction, however, patients should be informed that following removal of the regional block catheter, a certain range of motion is often lost and has to be regained in the following weeks and months of physiotherapy. Final range of motion, and pain reduction, is usually achieved between 3 and 6 months post-operatively, but may take up to a year in some cases [4, 10, 11, 18, 19, 35, 41, 43]. Recurrence of stiffness following shoulder release has been reported to be as high as 11% in early outcome studies [39]. More recent studies reporting the outcomes of large and representative patient populations, however, describe recurrence rates of between 3% and 6% [23, 24].

3.6

Long Term Complications

Other than recurrence, arthroscopic release of the stiff shoulder does not carry any specific long-­ term complications. As described previously, risk of recurrence is affected by many modifiable and non-modifiable factors. Long-term outcome studies have seen that the achieved range of motion and pain reduction can be maintained, and even further improved upon, on follow-up up to 7 years post-operatively [19, 20].

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References 1. White D, Choi H, Peloquin C, et al. Secular trend of adhesive capsulitis. Arthritis Care Res (Hoboken). 2011;63:1571–5. https://doi.org/10.1002/acr.20590. 2. Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA.  Current review of adhesive capsulitis. J Shoulder Elbow Surg. 2011;20:502–14. https://doi. org/10.1016/j.jse.2010.08.023. 3. Itoi E, Arce G, Bain GI, et al. Shoulder stiffness: current concepts and concerns. Arthroscopy. 2016;32:1402– 14. https://doi.org/10.1016/j.arthro.2016.03.024. 4. Lafosse L, Boyle S, Kordasiewicz B, et  al. Arthroscopic arthrolysis for recalcitrant frozen shoulder: a lateral approach. Arthroscopy. 2012;28:916–23. https://doi.org/10.1016/j.arthro.2011.12.014. 5. Tauro JC.  Stiffness and rotator cuff tears: incidence, arthroscopic findings, and treatment results. Arthroscopy. 2006;22:581–6. https://doi. org/10.1016/j.arthro.2006.03.004. 6. Audige L, Blum R, Müller AM, et al. Complications following arthroscopic rotator cuff tear repair: a systematic review of terms and definitions with focus on shoulder stiffness. Orthop J Sports Med. 2015;3:2325967115587861. https://doi. org/10.1177/2325967115587861. 7. Huberty DP, Schoolfield JD, Brady PC, et  al. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy. 2009;25:880–90. https://doi.org/10.1016/j. arthro.2009.01.018. 8. Ueda Y, Sugaya H, Takahashi N, et  al. Rotator cuff lesions in patients with stiff shoulders: a prospective analysis of 379 shoulders. J Bone Joint Surg. 2015;97:1233–7. https://doi.org/10.2106/ JBJS.N.00910. 9. Fu T, Xia C, Li Z, Wu H. Surgical versus conservative treatment for displaced proximal humeral fractures in elderly patients: a meta-analysis. Int J Clin Exp Med. 2014;7:4607–15. 10. Levy O, Webb M, Even T, et  al. Arthroscopic capsular release for posttraumatic shoulder stiffness. J Shoulder Elbow Surg. 2008;17:410–4. https://doi. org/10.1016/j.jse.2007.11.014. 11. Holloway GB, Schenk T, Williams GR, et  al. Arthroscopic capsular release for the treatment of refractory postoperative or post-fracture shoulder stiffness. J Bone Joint Surg Am. 2001;83-A:1682–7. 12. Rouleau DM, Hebert-Davies J, Robinson CM. Acute traumatic posterior shoulder dislocation. J Am Acad Orthop Surg. 2014;22:145–52. https://doi. org/10.5435/JAAOS-22-03-145. 13. Van Tongel A, Karelse A, Berghs B, et  al. Posterior shoulder instability: current concepts review. Knee Surg Sports Traumatol Arthrosc. 2010;19:1547–53. https://doi.org/10.1007/s00167-010-1293-z. 14. Flannery O, Mullett H, Colville J. Adhesive shoulder capsulitis: does the timing of manipulation influence outcome? Acta Orthop Belg. 2007;73:21–5.

J. Plath 15. Vastamäki H, Varjonen L, Vastamäki M. Optimal time for manipulation of frozen shoulder may be between 6 and 9 months. Scand J Surg. 2015;104:260–6. https:// doi.org/10.1177/1457496914566637. 16. Sabat D, Kumar V. Early arthroscopic release in stiff shoulder. Int J Shoulder Surg. 2008;2:36–40. https:// doi.org/10.4103/0973-6042.40455. 17. Sabzevari S, Kachooei AR, Giugale J, Lin A.  One-­ stage surgical treatment for concomitant rotator cuff tears with shoulder stiffness has comparable results with isolated rotator cuff tears: a systematic review. J Shoulder Elbow Surg. 2017;26:e252–8. https://doi. org/10.1016/j.jse.2017.03.005. 18. Tsai M-J, Ho W-P, Chen C-H, et  al. Arthroscopic extended rotator interval release for treating refractory adhesive capsulitis. J Orthop Surg. 2017;25:230949901769271. https://doi. org/10.1177/2309499017692717. 19. Ide J, Takagi K.  Early and long-term results of arthroscopic treatment for shoulder stiffness. J Shoulder Elbow Surg. 2004;13:174–9. https://doi. org/10.1016/j.jse.2003.11.001. 20. Le Lievre HMJ, Murrell GAC. Long-term outcomes after arthroscopic capsular release for idiopathic adhesive capsulitis. J Bone Joint Surg. 2012;94:1208– 16. https://doi.org/10.2106/JBJS.J.00952. 21. Baums MH, Spahn G, Nozaki M, et  al. Functional outcome and general health status in patients after arthroscopic release in adhesive capsulitis. Knee Surg Sports Traumatol Arthrosc. 2007;15:638–44. https:// doi.org/10.1007/s00167-006-0203-x. 22. Smith CD, Hamer P, Bunker TD. Arthroscopic capsular release for idiopathic frozen shoulder with intra-­ articular injection and a controlled manipulation. Ann R Coll Surg Engl. 2014;96:55–60. https://doi.org/10. 1308/003588414X13824511650452. 23. Jerosch J, Nasef NM, Peters O, Mansour AMR. Mid-­ term results following arthroscopic capsular release in patients with primary and secondary adhesive shoulder capsulitis. Knee Surg Sports Traumatol Arthrosc. 2013;21:1195–202. https://doi.org/10.1007/ s00167-012-2124-1. 24. Elhassan B, Ozbaydar M, Massimini D, et  al. Arthroscopic capsular release for refractory shoulder stiffness: a critical analysis of effectiveness in specific etiologies. J Shoulder Elbow Surg. 2010;19:580–7. https://doi.org/10.1016/j.jse.2009.08.004. 25. Cho C-H, Kim D-H, Lee Y-K.  Serial comparison of clinical outcomes after arthroscopic capsular release for refractory frozen shoulder with and without diabetes. Arthroscopy. 2016;32:1515–20. https://doi. org/10.1016/j.arthro.2016.01.040. 26. Cinar M, Akpinar S, Derincek A, et  al. Comparison of arthroscopic capsular release in diabetic and idiopathic frozen shoulder patients. Arch Orthop Trauma Surg. 2010;130:401–6. https://doi.org/10.1007/ s00402-009-0900-2. 27. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M.  The resistant frozen shoulder. Manipulation ver-

3  Complications in Arthroscopic Release of the Stiff Shoulder sus arthroscopic release. Clin Orthop Relat Res. 1995:238–48. 28. Sheridan MA, Hannafin JA.  Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am. 2006;37:531–9. https://doi.org/10.1016/j. ocl.2006.09.009. 29. Boyle-Walker KL, Gabard DL, Bietsch E, et al. A profile of patients with adhesive capsulitis. J Hand Ther. 1997;10:222–8. 30. Bigliani LU, Dalsey RM, McCann PD, April EW. An anatomical study of the suprascapular nerve. YJARS. 1990;6:301–5. 31. Price MR, Tillett ED, Acland RD, Nettleton GS. Determining the relationship of the axillary nerve to the shoulder joint capsule from an arthroscopic perspective. J Bone Joint Surg Am. 2004;86-A:2135–42. 32. Yoo JC, Kim JH, Ahn JH, Lee SH. Arthroscopic perspective of the axillary nerve in relation to the glenoid and arm position: a cadaveric study. Arthroscopy. 2007;23:1271–7. https://doi.org/10.1016/j. arthro.2007.07.011. 33. Harryman DT, Matsen FA, Sidles JA.  Arthroscopic management of refractory shoulder stiffness. YJARS. 1997;13:133–47. 34. Jerosch J, Aldawoudy AM. Chondrolysis of the glenohumeral joint following arthroscopic capsular release for adhesive capsulitis: a case report. Knee Surg Sports Traumatol Arthrosc. 2007;15:292–4. https:// doi.org/10.1007/s00167-006-0112-z. 35. Kim Y-S, Lee H-J, Park I-J.  Clinical outcomes do not support arthroscopic posterior capsular release in addition to anterior release for shoulder stiffness. Am J Sports Med. 2014;42:1143–9. https://doi. org/10.1177/0363546514523720.

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36. Snow M, Boutros I, Funk L.  Posterior arthroscopic capsular release in frozen shoulder. Arthroscopy. 2009;25:19–23. https://doi.org/10.1016/j. arthro.2008.08.006. 37. Chen J, Chen S, Li Y, et al. Is the extended release of the inferior glenohumeral ligament necessary for frozen shoulder? Arthroscopy. 2010;26:529–35. https:// doi.org/10.1016/j.arthro.2010.02.020. 38. Nicholson GP.  Arthroscopic capsular release for stiff shoulders: effect of etiology on outcomes. Arthroscopy. 2003;19:40–9. https://doi.org/10.1053/ jars.2003.50010. 39. Watson L, Dalziel R, Story I.  Frozen shoulder: a 12-month clinical outcome trial. J Shoulder Elbow Surg. 2000;9:16–22. 40. Loew M, Heichel TO, Lehner B.  Intraarticular lesions in primary frozen shoulder after manipulation under general anesthesia. J Shoulder Elbow Surg. 2005;14:16–21. https://doi.org/10.1016/j. jse.2004.04.004. 41. Mukherjee RN, Pandey RM, Nag HL, Mittal R.  Frozen shoulder: a prospective randomized clinical trial. WJO. 2017;8:394–7. https://doi.org/10.5312/ wjo.v8.i5.394. 42. Gobezie R, Pacheco IH, Petit CJ, Millett PJ.  Dislocation and instability after arthroscopic capsular release for refractory frozen shoulder. Am J Orthop. 2007;36:672–4. 43. Trsek D, Cicak N, Zunac M, Klobucar H. Functional results and patient satisfaction after arthroscopic capsular release of idiopathic and post-traumatic stiff shoulder. Int Orthop (SICOT). 2014;38:1205–11. https://doi.org/10.1007/s00264-014-2283-4.

4

Complications in AC Joint Stabilization Richard L. Auran, Evan S. Lederman, and Reuben Gobezie

4.1

Introduction

Arthroscopic surgery offers an effective and minimally invasive surgical treatment for disorders of the acromioclavicular joint (ACJ), most frequently ACJ separation, distal clavicle osteolysis, and ACJ arthritis. Utilization of arthroscopic surgery is not without its complications, and for these procedures there is a unique set of complications that must be recognized and properly addressed by the orthopaedic surgeon. This chapter aims to introduce the common complications of surgical repair of ACJ injuries and techniques for management.

R. L. Auran Department of Orthopaedic Surgery, University of Arizona College of Medicine—Phoenix, Phoenix, AZ, USA E. S. Lederman Department of Orthopaedic Surgery, University of Arizona College of Medicine—Phoenix, Phoenix, AZ, USA The Orthopedic Clinic Association, Phoenix, AZ, USA R. Gobezie (*) The Cleveland Shoulder Institute, Beachwood, OH, USA

4.2

Pre-Operative Complications (Indications)

ACJ injuries are relatively common, comprising 9% of injuries to the shoulder girdle. Male athletes in their twenties make up the most common demographic for patients with ACJ involvement when the shoulder is afflicted [1]. ACJ separation and dislocation is the most common acute problem in this setting that requires evaluation and treatment. It is widely accepted that Rockwood types I & II AC separations are best managed non-surgically, while types IV–VI require surgical intervention for acceptable outcomes. The management of type III injuries remains controversial. When surgical intervention is indicated, there are many options available to the orthopaedic surgeon. Many surgical procedures to stabilize ACJ injuries are reported in the literature [2], both open and arthroscopic, however no consensus “gold standard” is agreed upon. Similar outcomes and complication rates are reported when comparing open and arthroscopic procedures [3]. The apparent benefits of arthroscopic surgery include smaller skin incisions, less required soft tissue dissection, improved visualization of deep structures, and concurrent treatment of associated pathology [4]. For the most part, complications of ACJ reconstructive surgery is specific to the techniques utilized and are similar whether the procedure is performed arthroscopic or open.

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_4

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In general, surgery for ACJ stabilization involves fixation between the clavicle and the coracoid process, repair or reconstruction of the ACJ ligaments, and repair of the deltotrapezial fascia. Many described techniques utilize fixation devices including sutures, screws, buttons, or plates and are frequently augmented with tendon grafts. Autograft or allograft tendon, most commonly gracilis, semitendinosus, or palmaris longus [5–7], may be used in anatomic or nonanatomic fashion to maintain stability at the ACJ or coracoclavicular interval. Complications from arthroscopic repair and reconstruction of the ACJ arise in 13–27% of cases, and these rates are roughly consistent across the various methods of surgical fixation. The most commonly reported complications include CC calcification (32%), shoulder pain (27%), loss of reduction (27%), fracture (5%), and superficial infection (4%) [8–11]. Many of these complications may occur at various timepoints post-operatively and are not strictly seen in specific post-operative windows. As such, it is the responsibility of the surgeon to recognize complications, avoid them when possible, and to understand the next steps in treatment. The source of failure must be identified so that it may be addressed during the revision procedure. The overall goal remains to provide a pain-free shoulder with good strength and range of motion, and there are several described revision surgeries in the literature that help achieve this goal.

4.3

Peri-Operative Complications

One of the most challenging complications to address associated with ACJ repair is fracture of the coracoid or clavicle. Fracture may occur intra-operatively, requiring the surgeon to radically alter their treatment plan while in the operating room. Approximately 5.3% of procedures which require drilling tunnels in the coracoid base or distal clavicle will result in iatrogenic fracture [10]. Care must be taken when drilling tunnels through the coracoid and clavicle, and

risk of fracture can be minimized by maximizing distance between bony tunnels and placing tunnels as far from bone edges as possible [12]. Spacing clavicle tunnels over 20  mm apart and maintaining a distance of over 10  mm between tunnels and the distal clavicle will minimize the risks of clavicle fracture [13]. Smaller coracoid tunnels may also reduce the risk of fracture [14]. Fracture of the coracoid is more common than fracture of the clavicle. Fracture of the clavicle can be managed by clavicle plating. Coracoid fracture requires primary fixation or clavicle plating with a hook plate. A hook plate requires staged removal after suitable healing, and the surgeon must remain cognizant of the fact that fracture of the acromion has been reported [15] (Fig 4.1). These fractures more commonly occur post-operatively, however the management of these injuries remains similar. ACJ stabilization via a CC ligament reconstruction is more challenging in this injury pattern, however there are still some options for fixation of the clavicle to the scapula. The coracoid bypass procedure has been described to address coracoid fracture or coracoid insufficiency in revision CC ligament reconstruction. In this procedure, a bone tunnel is drilled through the scapular body inferior to the coracoid base. A tendon graft is passed through this tunnel, and the free end of the tendon is then passed around or through tunnels in the clavicle [16]. Reduction of the coracoid fracture fragment and fixation with a screw may also be considered, generally in combination with a hook plate. This has been described using provisional Kirschner wire (K-wire) fixation through the coracoid into the scapular body and neck using intra-operative fluoroscopy. A cannulated screw may then be passed over the guidewire for definitive fixation [17]. Following this approach, if the coracoid fixation is deemed stable with the screw in place, a loop of tendon graft or tape may be considered for passage around the coracoid to provide fixation and stabilization to the clavicle. The reported rate of coracoid fracture union is excellent [18], and in the event that the strength of fixation is in doubt this injury may be approached in two stages. The coracoid fracture may be fixed with

4  Complications in AC Joint Stabilization

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Fig. 4.1  Grade III AC separation fixed with a hook plate. 3 months post op the device displaced, the lateral portion cut through the acromion and hardware is loose

secondary return for use of the coracoid in ACJ stabilization following confirmed union on imaging.

in all cases of deep infection. General complications of arthroscopy and instrumentations and are covered in other chapters.

4.4

4.5

Immediate Post-Operative Complications

Superficial infection following arthroscopic ACJ intervention is described as one of the more common complications occurring in the short-term following surgery. It has been reported to occur in 3.8% of patients, based on a pooled analysis of multiple studies, and may be successfully treated with a short course of oral antibiotics [10]. There are limited reports of superficial infections not resolving with medical management alone, requiring operative removal of hardware and irrigation and debridement of the intra-articular space [19]. Deep infection of the joint is a risk of surgery, however it has not been frequently reported in the literature. Removal of foreign material and debridement of the joint is indicated

Middle-Term Complications

Loss of fixation following ACJ repair is seen in 26.8% of cases [10]. Complications resulting in poor AC joint reduction on radiographic imaging are more commonly seen following procedures using allograft or autograft tendon alone for chronic ACJ injuries [12]. The average time to loss of reduction on pooled analysis of several studies is 7 weeks, and this loss is more commonly due to suture rupture than to failure of the fixative hardware [10, 20]. While radiographic findings of loss of reduction do not always coincide with clinically poor outcomes, it has been shown that this complication is related to lower scores in the pain and activities subsets of the Constant score assessed post-operatively [11]. Loss of fixation due to rupture of graft or

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Fig. 4.3  Failed AC joint reconstruction with allograft and sutures due to tunnel malposition. Note development of heterotopic bone along the allograft

Fig. 4.2  Grade III AC separation fixed with a suture button device. The coracoid button sutures cut through the coracoid

suture allows revision surgery to be performed with a similar technique. When loss of fixation is secondary to button migration through bone, revision options require assessment of the quality of remaining bone (Fig. 4.2). Bone failure or fixation pullout can generally be traced to tunnel malposition and can be avoided by proper adherence to surgical technique. One challenge of arthroscopic ACJ stabilization is that the joint is reduced with a drill guide and the clavicle and coracoid tunnels are drilled together. Proper hole placement with this common technique can be challenging [21]. Use of smaller drill holes or drilling the coracoid and clavicle independently can reduce malposition. Pain following operative fixation of the AC joint is one of the most commonly reported complications in the literature. There are varying etiologies and underlying factors leading to pain in these patients. Most commonly, local irritation secondary to prominent implants or sutures is bothersome to patients and reported to occur in 25–39% of cases [11, 19, 22]. Pain may also be secondary to inadequate restoration of anatomy during repair. Over, under, or loss of reduction of the ACJ is common. With improper placement of suture or graft, either during non-anatomic reconstruction or with poor placement of bone tunnels,

vertical stability may be restored while anterior-­ posterior instability remains [23] (Fig. 4.3). Calcification of the CC ligament remnants is another frequently observed complication following surgical repair of AC joint injuries. It occurs in 31.6% of cases [10], presenting within 6  months of the procedure and remaining stable following this time point. For calcification incidentally noted on radiographic exams, no intervention is required. Although infrequent, calcification causing pain or limiting motion may require excision. Care must be taken not to disrupt the repair of the index procedure during excision of the calcified ligaments.

4.6

Long-Term Complications

Literature reporting on the long-term complications following arthroscopic repair and reconstruction of the ACJ is very limited. The most common complications seen several years removed from surgery are loss of reduction and hardware failure. Distal clavicle osteolysis or ACJ arthritis can be seen as a long-term consequences of these injuries and surgical procedures. These conditions arise from repetitive micromotion at the AC joint and generate pain for the patient. Treatment includes activity modifications, NSAIDs, injections, and distal clavicle excision. Perhaps the most challenging and poorly understood complication is horizontal instability. Most described techniques for ACJ repair involve only CC stabilization. These procedures may not reliably restore horizontal stability. At minimum, to prevent horizontal instability the distal clavicle should be preserved and not routinely removed [24]. Additionally, the ACJ ligaments should be

4  Complications in AC Joint Stabilization

repaired. In the failed or chronically unstable ACJ with horizontal instability, the surgeon should consider direct repair, device stabilization, or graft augmentation of the ACJ ligaments [25].

4.7

Conclusion

As we gain better understanding of complications, the surgeon can better avoid these potential issues with proper mastering of the technical aspects of surgical reconstruction. Pre-operative assessment and planning is a crucial stage in the treatment of complications arising from arthroscopic repair and reconstruction of the ACJ. Identification of the mode of failure is essential as it allows for a strategic approach to address both the original injury and the complicating factors surrounding the unsuccessful index procedure. The restoration of a stable, functional, pain-free shoulder remains the overall goal of surgical intervention at the ACJ. Developing a good working knowledge and skill set of the techniques described in this chapter will aid the surgeon managing these difficult injuries.

References 1. Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med. 1998;26(1):137–44. 2. Geaney LE, Miller MD, Ticker JB, Romeo AA, Guerra JJ, et  al. Management of the failed AC joint reconstruction: causation and treatment. Sports Med Arthrosc Rev. 2010;18(3):167–72. https://doi. org/10.1097/JSA.0b013e3181eaf6f7. 3. Helfen T, Siebenbürger G, Ockert B, Haasters F. Therapy of acute acromioclavicular joint instability: meta-analysis of arthroscopic/minimally invasive versus open procedures. Unfallchirurg. 2015;118(5):415– 26. https://doi.org/10.1007/s00113-015-0005-z. 4. Tischer T, Salzmann GM, El-Azab H, Vogt S, Imhoff AB. Incidence of associated injuries with acute acromioclavicular joint dislocations types III through V.  Am J Sports Med. 2009;37(1):136–9. https://doi. org/10.1177/0363546508322891. 5. Pühringer N, Agneskirchner J. Arthroscopic technique for stabilization of chronic acromioclavicular joint instability with coracoclavicular and acromioclavicular ligament reconstruction using a gracilis tendon graft. Arthrosc Tech. 2017;6(1):e175–81. https://doi. org/10.1016/j.eats.2016.09.036.

37 6. Tauber M, Gordon K, Koller H, Fox M, Resch H.  Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a prospective comparative study. Am J Sports Med. 2009;37(1):181–90. https://doi.org/10.1177/0363546508323255. 7. Kocaoglu B, Ulku TK, Gereli A, Karahan M, Türkmen M.  Palmaris longus tendon graft versus modified Weaver-Dunn procedure via dynamic button system for acromioclavicular joint reconstruction in chronic cases. J Shoulder Elbow Surg. 2017;26(9):1546–52. https://doi.org/10.1016/j.jse.2017.01.024. 8. van Bergen CJA, van Bemmel AF, Alta TDW, van Noort A. New insights in the treatment of acromioclavicular separation. World J Orthop. 2017;8(12):861– 73. https://doi.org/10.5312/wjo.v8.i12.861. 9. Warth RJ, Martetschläger F, Gaskill TR, Millet PJ.  Acromioclavicular joint separations. Curr Rev Musculoskelet Med. 2013;6(1):71–8. https://doi. org/10.1007/s12178-012-9144-9. 10. Woodmass JM, Esposito JG, Ono Y, Nelson AA, Boorman RS, et  al. Complications following arthroscopic fixation of acromioclavicular separations: a systematic review of the literature. Open Access J Sports Med. 2015;6:97–107. https://doi. org/10.2147/OAJSM.S73211. 11. Clavert P, Meyer A, Boyer P, Gastaud O, Barth J, et  al. Complication rates and types of failure after arthroscopic acute acromioclavicular dislocation fixation: prospective multicenter study of 116 cases. Orthop Traumatol Surg Res. 2015;101(8 Suppl):S313–6. https://doi.org/10.1016/j. otsr.2015.09.012. 12. Milewski MD, Tompkins M, Giugale JM, Carson EW, Miller MD, Diduch DR.  Complications related to anatomic reconstruction of the coracoclavicular ligaments. Am J Sports Med. 2012;40(7):1628–34. https://doi.org/10.1177/0363546512445273. 13. Carofino BC, Mazzocca AD.  The anatomic coracoclavicular ligament reconstruction: surgical technique and indications. J Shoulder Elbow Surg. 2010;19(2 Suppl):37–46. https://doi.org/10.1016/j.jse.2010.01.004. 14. Martetschläger F, Saier T, Weigert A, Herbst E, Winkler M, et  al. Effect of coracoid drilling for acromioclavicular joint reconstruction techniques on coracoid fracture risk: a biomechanical study. Arthroscopy. 2016;32(6):982–7. https://doi. org/10.1016/j.arthro.2015.11.049. 15. Kienast B, Thietje R, Queitsch C, Gille J, Schulz AP, Meiners J. Mid-term results after operative treatment of rockwood grade III-V acromioclavicular joint dislocations with an AC-hook-plate. Eur J Med Res. 2011;16(2):52–6. 16. Virk MS, Lederman E, Stevens C, Romeo AA.  Coracoid bypass procedure: surgical technique for coracoclavicular reconstruction with coracoid ­insufficiency. J Shoulder Elbow Surg. 2017;26(4):679– 86. https://doi.org/10.1016/j.jse.2016.09.031. 17. Kawasaki Y, Hirano T, Miyatake K, Fujii K, Takeda Y. Safety screw fixation technique in a case of coracoid

38 base fracture with acromioclavicular dislocation and coracoid base cross-sectional size data from a computed axial tomography study. Arch Orthop Trauma Surg. 2014;134(7):913–8. https://doi.org/10.1007/ s00402-014-1995-7. 18. Ogawa K, Matsumura N, Ikegami H. Coracoid fractures: therapeutic strategy and surgical outcomes. J Trauma Acute Care Surg. 2012;72(2):E20–6. 19. Salzmann GM, Walz L, Buchmann S, Glabgly P, Venjakob A, Imhoff AB.  Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations. Am J Sports Med. 2010;38(6):1179–87. https://doi. org/10.1177/0363546509355645. 20. Cook JB, Shaha JS, Rowles DJ, Bottoni CR, Shaha SH, Tokish JM. Early failures with single clavicular transosseous coracoclavicular ligament reconstruction. J Shoulder Elbow Surg. 2012;21(12):1746–52. https://doi.org/10.1016/j.jse.2012.01.018. 21. Coale RM, Hollister SJ, Dines JS, Allen AA, Bedi A.  Anatomic considerations of transclavicular-­ transcoracoid drilling for coracoclavicular ligament reconstruction. J Shoulder Elbow Surg.

R. L. Auran et al. 2013;22(1):137–44. https://doi.org/10.1016/j. jse.2011.12.008. 22. Scheibel M, Dröschel S, Gerhardt C, Kraus N.  Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations. Am J Sports Med. 2011;39(7):1507–16. https://doi. org/10.1177/0363546511399379. 23. Mazzocca AD, Santangelo SA, Johnson ST, Rios CG, Dumonski ML, Arciero RA. A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med. 2006;34(2):236–46. 24. Beitzel K, Sablan N, Chowaniec DM, Obopilwe E, Cote MP, et al. Sequential resection of the distal clavicle and its effects on horizontal acromioclavicular joint translation. Am J Sports Med. 2012;40(3):681– 5. https://doi.org/10.1177/0363546511428880. 25. Dyrna FGE, Imhoff FB, Voss A, Braun S, Obopilwe E, et  al. The integrity of the acromioclavicular capsule ensures physiological centering of the acromioclavicular joint under rotational loading. Am J Sports Med. 2018;46(6):1432–40. https://doi. org/10.1177/0363546518758287.

5

Complications of Soft Tissue Repair Techniques for Shoulder Instability Rupert Meller and Nael Hawi

5.1

Introduction

Anterior shoulder dislocation is a common injury in patients between 16 and 60  years. Recurrent instability and deficits in shoulder function are results in up to 60% after nonoperative treatment [1]. The optimal surgical procedure is still on debate and depends on several parameters. Nonetheless, the results of open or arthroscopic procedures for shoulder stabilization are comparable, due to developments in special arthroscopic techniques [2]. A diagnostic challenge is to identify and to determinate significant bone loss of the glenoid and of the humerus. In cases with significant bony defects, the recurrence rate after arthroscopic soft tissue repair is known to be as high as 67% [2, 3]. All complications in soft tissue repair techniques may occur in the anterior (anterior Bankart-repair) and posterior (posterior Bankart-­ repair) shoulder as well as in capsular plication techniques.

R. Meller (*) · N. Hawi Trauma Department, Hannover Medical School (MHH), Hannover, Germany e-mail: [email protected]; [email protected]

5.2

Preoperative Complications (Indication)

A concise history taking, clinical examination and interpretation of imaging studies of the patient is mandatory to prevent a complication at this early stage of patient treatment. It is mandatory to set up the correct diagnosis. For example, if there is no structural problem at all and the patient demonstrates a so called “functional instability”, any type of surgery is contraindicated. Strictly speaking, the first possible complication in the treatment of shoulder instability is to set up a wrong diagnosis and, after that, to indicate surgery for the wrong patients, a patient who needs nonoperative treatment. Many types of instability exist and it is mandatory to clarify if there is a structural damage at all. The Stanmore System is very helpful to classify all patients with shoulder instability. The next step would be to quantify (and classify) the specific structural damage. Many classification systems exist for either soft tissue or bony lesions. Depending on the exact diagnosis (definition of the structure affected, quantification of the amount of the lesion) it is possible to define the appropriate type of treatment for each individual patient. The most important individual factor associated with recurrence is the age of the patient. In order to prevent any type of preoperative complication (indication), the most important

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_5

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concepts of instability and parameters to be considered are summarized in the following chapter.

strated a partial labral detachment and group three demonstrated a complete labral disruption [9].

5.2.1 T  ype of Instability: Stanmore Classification

5.2.3 Age

Instability presents a very complex and heterogeneous diagnostic entity. This is also confirmed by different classification systems. The Stanmore classification distinguishes three different types of instability, depending on the cause of instability [4]: • Polar Type I: Suffered a trauma with resultant instability and structural damage to the glenohumeral joint, causing shoulder instability. • Polar Type II: Patients with constitutional deficit (capsular insufficiency or reduced concavity of the glenoid surface), leading to shoulder instability without necessarily a relevant trauma [5, 6]. • Polar Type III: Shoulder instability is not due to structural defects but rather associated to an aberrant pattern of rotator cuff and periscapular muscles [4]. There is good consensus that patients presenting a type III instability are not going to benefit from surgery. If this type of instability is not diagnosed and patients are operated on this may lead to catastrophic results [4, 7]. Recent studies demonstrate, that a non-surgical treatment by electric stimulation of hypoactive rotator cuff and periscapular muscles could be a more appropriate and successful approach [8].

5.2.2 T  ype of Soft Tissue Lesion: Baker Classification As it comes to soft tissue repair techniques for shoulder instability, a very valuable concept is presented from Baker et  al. What exactly is the structural damage following first time traumatic dislocation? In shoulders with early arthroscopy three groups of patients can be identified: group one had only capsular tears, group two demon-

Evaluating the risk for recurrence rate after primary anterior shoulder dislocation, Kralinger et al. could show, that the only factor associated to recurrence was age between 21 and 30 years. The authors concluded that patients in this age group, who participate in high-risk sports activities, should undergo primary shoulder stabilization [10]. On the other hand, Hovelius et  al. published in their prospective study with a follow-­up of 25 years, that half of the primary anterior shoulder dislocations that had been treated nonoperatively in patients with an age of twelve to twenty-five years had not recurred or had become stable over time [11].

5.2.4 Bone Loss Glenoid Bone loss is identified as one factor contributing for recurrent instability after arthroscopic stabilization. Itoi et  al. could show that an osseous defect with a width that is at least 21% of the glenoid length may cause further instability after arthroscopic stabilization [12]. More recently Shin et  al. considered the critical value even lower, at 17% [13]. In case of physically demanding collision-athletes, Nakagawa et al. reported in their study, that rugby players may not tolerate any bony defect [14].

5.2.5 Bone Loss Humerus Humeral-sided bone loss is also a factor, contributing for recurrent instability after repair. Hill-­ Sachs lesions with more than 20% of the circumference of the humerus are likely to engage at the anterior glenoid rim during external rotation movement [3]. In these cases the remplissage procedure could be an option to avoid engagement [15].

5  Complications of Soft Tissue Repair Techniques for Shoulder Instability

41

G G HS

HS 83%

T

T

Off track

On track

Fig. 5.1  Example of the on/off track scenario

5.2.6 Glenoid Track Concept Yamamoto et  al established the concept of glenoid track, i.e., the contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension. The glenoid track is defined as a distance 84% the width of the glenoid, which becomes smaller in the case of a glenoid bone loss. If the Hill-Sachs lesion extends medially over the margin of the glenoid track, there is a risk of an engagement. This scenario is defined as “off-track” lesion. If the Hill-Sachs lesion did not extend over the margin of the glenoid, it is defined as “on track” [16, 17]. Measurements are based on CT scans, but could also performed arthroscopically. Info Box Fig. 5.1: How can I determine the glenoid track of my patient? Adapted to [17] • Step 1: Measure the diameter (D) of the inferior glenoid, use therefore three-dimensional CT scan with on face view. • Step 2: Measure the width of the anterior glenoid bone loss (d) • Step 3: Calculate the glenoid track (GT): GT = 0.83 × D – d. • Step 4: Measure the Hill-Sachs Interval (HSI), use therefore three-dimensional CT scan: Width of the Hill-Sachs (HS) lesion plus width of the bony bridge (BB) between rotator cuff

attachments and lateral aspect of the Hill-­ Sachs lesion: HSI = HS + BB. • Step 5: On track respectively non-engaging: HSI   GT Fig. 5.1.

5.2.7 I nstability Severity Index Score (ISIS) Balg and Boileau established the Instability Severity Index Score (ISIS) assessing the preoperative likelihood of recurrent instability after arthroscopic repair. The authors reported, that a value of 7 or higher have a 70% recurrence risk. Wherein a score value of 6 or less have only a risk of 10% [18]. Furthermore, Phadnis et al. recommended in their study published in 2015 a value of four or higher (Table 5.1) [19].

5.3

Per-Operative Complications (Surgery)

Once a soft tissue repair for shoulder instability is indicated, several factors have to be considered to safely perform the arthroscopic procedure: What is the optimum positioning of the patient? What implants and instruments should be used? How should the soft tissue repair be done in terms of number and placement of anchors? What is the perfect stitch configuration? Numerous problems

R. Meller and N. Hawi

42 Table 5.1 ISIS pre-operative questionnaire, clinical examination, and radiographs [18] Prognostic factors 20 years old or younger Competitive sports Contact or forced overhead sports Shoulder hyperlaxity (anterior or inferior) Hill-Sachs lesion on AP radiograph visible in external rotation Glenoid loss of contour on AP radiograph Total (points)

Points 2 2 1 1 2 2 10

can occur, most of them will be easy to address but some may even risk the long term outcome of the patient. One sort of per operative complication may be that the preoperative diagnosis was wrong and the surgeon is faced with an unexpected situation: either the arthroscopic finding is “too good” for soft tissue repair (Buford complex), or the arthroscopic finding demonstrates a worse condition as expected. This might be if there is no capsulolabral soft tissue to be fixed to the glenoid. Informed consent to be able to convert to bony procedure may be a good advice to be prepared for this case. The following chapter presents proven concepts in the literature that strive to keep the complication rate low.

5.3.1 Positioning of Patient The arthroscopic stabilization procedure could be performed either in lateral decubitus or in beach chair position. In both excellent results could be obtained and the decision is based more on surgeon experience and familiarity [20].

5.3.2 Surgical Technique (Cases 1, 3, 4) Through diagnostic arthroscopy the labrum, capsular tissue, rotator cuff, the biceps pulley, the humeral head (Hill-Sachs lesion) and the cartilage should be evaluated. As diagnostic tool a load-shift or a drive-through sign can be per-

formed. For description, the glenoid is described as a clock face. The most inferior aspect of the glenoid represents the 6 o’clock position [21]. After setting the portals, the lesion should be adequately mobilized using an elevator. Also, the glenoid should be debrided and decorticated sufficiently to ensure tissue healing after repair. For the capsulolabral lesion a soft tissue grasper should be used. Visualization of muscle fibers of  the subscapularis indicates a sufficient ­mobilization [21]. A biomechanical study, comparing the simple stitch, suture anchor with horizontal mattress stitch, double-louded suture anchor with simple stitch, and knotless suture anchors could show, that all four constructs displayed less than 2-mm displacement when 25  N cyclic loading was applied. But the knotless construct showed significantly less force to ultimate failure [22]. Ranawat et al. could furthermore show that both knotted and knotless anchors fail most often at the suture-tissue interface [23]. Through the antero-superior portal an arthroscopic grasper can be inserted, which allows reducing the labral tissue and further suture retrieval. For reduction of the Bankart lesion, the anchors were placed from inferior to superior, starting as inferior as possible at the 5:30 or 6:30 position [24]. In cases visualization is restricted, the scope could be inserted in the antero-lateral portal or alternatively a 70° arthroscope could be used. Using a suture passer through the anterior portal, the suture is passed through the avulsed capsulolabral tissue, taking into consideration to capture at least 1 cm of capsular tissue in addition to the labrum [21]. Concerning number of anchors Shibata et al. could show that using less than four anchors were significantly more likely to fail [25]. Boileau et al described that patients with three or less suture anchors, were at a higher risk to fail [26].

5.3.3 Anchor Composition and Design (Cases 2 and 5) Implant design and material has improved over years. Metal anchors are associated to loosening

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and migration, could lead to chondral damage and limit further investigation by MRI [27]. Using bioabsorbable anchors, especially made of poly-L-lactic acid (PLLA), complications like inflammatory reaction, osteolysis, and c­ hondrolysis are a known phenomenon. McCarty et al reported in their study, evaluating their results after arthroscopic revision with index surgery using PLLA anchors, in over 50% anchor debris and in 70% a chondral damage [28]. Kim et al. described a 46.4% rate of cyst formation after using bioabsorbable anchors in rotator cuff tears [29]. After development of biocomposite anchors the rate of osteolysis and synovitis has been lowered [30]. Next to the excellent clinical outcome, Milewski et al. described in their study the prevalence of 6.4% cyst formation and the prevalence of 55% tunnel widening [31]. Nonabsorbable biostable anchors are resistant to degradation and osteolysis. However inappropriate positioning or fracture of the material could lead to chondral damage [32]. More recently, all-soft suture anchors were developed for stabilization surgery. Advantages are decreased removal of bone and decreased glenoid volume occupied. Nonetheless, a recent study published by Tompane et  al. demonstrated a significantly tunnel increase in volume 6 and 12 months after shoulder labral surgery. The authors could show low rates of cyst formation [33].

or repairing capsular lesions [36]. If a nerve injury is suspected, performing of an electromyography (EMG) is recommended. After a period, which is controversially debated in literature between 3 and 6  months, a surgical procedure should be taken into consideration [37].

5.4

5.5

Immediate Postoperative Complications

5.4.1 Nerve Injury Nerve injury in arthroscopic shoulder stabilization is not seldom. Nonetheless, Owens et  al. described the rate of nerve injury in Bankart repair procedure with 0.3% [34]. Most frequently injured is the axillary nerve, due its course anterior to the subscapularis muscle and on the inferior border of the tendon before passing posteriorly into the quadrilateral space [35]. The closest position between the nerve and the glenoid rim is at the 6 o’clock position on the inferior glenoid rim and could be injured by placing anchors, sutures,

5.4.2 Infection Infection rate in arthroscopic Bankart repair is according to Owens at 0.22% [34]. Superficial infections of related to the arthroscopic portal infection or deep intraarticular glenohumeral infection is possible. Therefore, prevention of infection in general, but especially in patients suffering from diabetes or atopic dermatitis, is mandatory [37]. If an infection is suspected, aspiration of the joint is performed and analyzed to confirm the suspected infection. This procedure is followed by oral or intravenous antibiotics. Penicillin-­ based or cephalosporin antibiotics as the first choice are recommended. They have to be adapted to the microbiological results as soon as available [38]. If infection cannot be controlled, an arthroscopic approach with synovectomy and drainage is recommended. Matsuki et al. do not recommend removal of the anchors unless peri-­ anchor infection is apparent [37].

Middle Term Complications

5.5.1 Postoperative Stiffness Loss of range of movement is a well known complication after shoulder stabilization surgery. In addition to loss of range of movement, it can cause pain and limit activities of daily living. First treatment in these cases is usually physiotherapy. In cases with severe pain, intraarticular injection of a corticosteroid should be taken into consideration. Most patients respond to the conservative pathway. An arthroscopic intervention should be considered after unsuccessful conservative treatment over 6  months, performing an arthroscopic capsular release.

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In cases with an isolated loss of external rotation, Ando et  al. described an arthroscopic ­procedure with removal of scar tissue of the rotator interval and release of the subscapularis tendon from the anterior glenoid neck, called restoration of anterior transverse sliding (RATS) [39].

5.5.2 Persisting Pain A recent review of the American Academy looked at shoulder arthroscopy specific complications. The overall complication rate in patients undergoing labrum repair was nearly 6%. One of the most common complications was persisting pain [40].

5.5.3 Chondrolysis Chondrolysis is defined by rapid destruction of articular cartilage. Several reasons for initiation or progression are possible. One possible reason is the use of thermal devices, which have been associated with development of chondrolysis [41]. Several recent studies analyzed causation of glenohumeral chondrolysis by postoperative infusion of local anesthetic. They concluded, that the use of postoperative infusion of intraarticular local anesthetic was strongly associated with chondrolysis [42]. According to Sugaya, postoperative injection of local anesthetic through an intra-articular pain pump should be avoided to prevent chondrolysis of the glenohumeral joint. (Matsuki, Sugaya, 2015) Therefore, the use of single postoperative intraarticular injection or the use of intra-articular pain pumps is fallen out of favour.

5.6

erate or severe osteoarthritis [44]. Franceschi et al. analyzed the pre- and postoperative radiography of 60 patients with an average follow-up of 8 years. They concluded, that the incidence of degenerative joint disease was associated with an older age at the time of the first dislocation and at surgery, increased length of time from the first episode to surgery, increased number of preoperative dislocations, increased length of time from the initial dislocation until surgery, increased number of anchors used at surgery, and more degenerated labrum at surgery [45]. Case 1: Intraarticular Failure of a Suture Passer Fracture of a suture passer in the 6 o’clock position while trying to penetrate the inferior capsulolabral portion. Left shoulder. Manipulation through the anteroinferior portal (Figs. 5.2, 5.3, and 5.4).

Fig. 5.2  Distal fragment of the suture passer located in the anteroinferior shoulder

Long Term Complications

5.6.1 Osteoarthritis (Case 6) Previously published studies following Bankart repair reported postoperative rates of osteoarthritis to be as high as 26% [43]. Hovelius et al. published in their study following primary dislocation with a follow-up of 10 years in 11% mild and in 9% mod-

Fig. 5.3  Retrieving the tip of the suture passer through the anteroinferior portal

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45

Fig. 5.4  Site of instrument failure at the junction between body and tip of the device

Fig. 5.6  MRI (proton density, fat-suppressed) showing the anteroinferior cartilage lesion

Fig. 5.5 Arthro CT scan 6  months following initial surgery

Case 2: Osteolysis and Chondral Lesion Due to Anchor Placement Loose chondral flap in the anteroinferior glenoid. Right shoulder. This patient presented with persisting pain in her right shoulder following dislocation and anatomic reconstruction. The CT scan demonstrated a tunnel widening of the glenoid. The MRI showed dye in between the cartilage and the subchondral bone, indicative for an instable chondral surface (Figs. 5.5, 5.6, 5.7, 5.8, and 5.9). Case 3: Knot Tying Problems In this patient a regular anatomic refixation of the anteroinferior structures was planned. Right shoulder. The most inferior fixation was already accomplished. During knot tying of the second suture, a locked construct developed. Shortening

Fig. 5.7  Arthroscopic visualisation of the discontinuity between the cartilage and the subchondral bone at the glenoid

Fig. 5.8  Spinal needle in between the cartilage and the subchondral bone at the glenoid

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Fig. 5.9  Sutures of the anchor lifted from underneath the flap

Fig. 5.12  Without using canulas the control of the suture strands is limited Fig. 5.10 “Blind” knot tying without visualisation resulted in construct that could probably result in a glenohumeral suture impingement

Fig. 5.11  The problem was solved by cutting the suture strands in between the two knots

of the construct solved the problem (Figs.  5.10 and 5.11). Case 4: Unintentional Splicing of the Suture During Suture Manipulation In this patient an anatomic refixation of the anteroinferior labrum was planned. Left

s­houlder. When retrieving the second suture strand through the anteroinferior portal it was noted that it had spiced through the other strand (Figs. 5.12 and 5.13). Case 5: Anchor Material Dislocation (All Suture Anchor) In this patient an anatomic refixation of the anterior labrum was performed. Left shoulder. The patient presented with persisting pain in his left shoulder. During re-arthroscopy the anchor was not attached to the glenoid any more and was removed from the axillary pouch through an inferior posterior portal (Figs.  5.14, 5.15, 5.16, and 5.17). Case 6: Instability Arthropathy In this patient an anatomic refixation of the anterior labrum was done many years ago. Right shoulder. The patient developed an instability arthropathy. During CAM (comprehensive arthroscopic management) procedure the sutures in the 3 o’clock position were still in place.

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Fig. 5.15  Due to persisting pain, revision surgery was done 12  months later. Loose anchor material was found within the joint and removed

Fig. 5.13  It can be tried to separate the two strands outside the joint using a forceps. However this problem may result in the need for a new suture anchor

Fig. 5.16  The suture material was removed from the axillary pouch through a low posterolateral portal, arthroscope in the standard posterior portal

Fig. 5.14  Initial surgery with refixation oft he labrum in the 7 and 10 o’clock position using all suture anchors

However, it is unclear whether arthropathy is a sequelae of the instability or a result of the stabilisation (Figs. 5.18, 5.19, and 5.20).

Fig. 5.17  Suture remnants outside the joint

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Fig. 5.18  Glenohumeral osteoarthritis 15 years following arthroscopic Bankart repair

Fig. 5.19  Arthroscopic view when performing a CAM (comprehensive arthroscopic managmeent) procedure. The sutures are still in place

References 1. Robinson CM, Howes J, Murdoch H, Will E, Graham C.  Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006;88(11):2326–36. 2. Petrera M, Patella V, Patella S, Theodoropoulos J. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1742–7. 3. Burkhart SS, De Beer JF.  Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: sig-

Fig. 5.20  Advanced osteoarthritis oft he glenohumeral joint 15 years following Bankart repair nificance of the inverted-pear glenoid and the humeral engaging Hill-­Sachs lesion. Arthroscopy. 2000;16(7):677–94. 4. Jaggi A, Lambert S. Rehabilitation for shoulder instability. Br J Sports Med. 2010;44(5):333–40. 5. von Eisenhart-Rothe R, Mayr HO, Hinterwimmer S, Graichen H.  Simultaneous 3D assessment of glenohumeral shape, humeral head centering, and scapular positioning in atraumatic shoulder instability: a magnetic resonance-based in  vivo analysis. Am J Sports Med. 2010;38(2):375–82. 6. Moroder P, Ernstbrunner L, Pomwenger W, Oberhauser F, Hitzl W, Tauber M, Resch H, Moroder R. Anterior shoulder instability is associated with an underlying deficiency of the bony glenoid concavity. Arthroscopy. 2015;31(7):1223–31.

5  Complications of Soft Tissue Repair Techniques for Shoulder Instability 7. Takwale VJ, Calvert P, Rattue H.  Involuntary positional instability of the shoulder in adolescents and young adults. Is there any benefit from treatment? J Bone Joint Surg Br. 2000;82(5):719–23. 8. Moroder P, Minkus M, Bohm E, Danzinger V, Gerhardt C, Scheibel M. Use of shoulder pacemaker for treatment of functional shoulder instability: proof of concept. Obere Extrem. 2017;12(2):103–8. 9. Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med. 1990;18(1):25–8. 10. Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G.  Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002;30(1):116–20. 11. Hovelius L, Olofsson A, Sandstrom B, Augustini BG, Krantz L, Fredin H, Tillander B, Skoglund U, Salomonsson B, Nowak J, et  al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up. J Bone Joint Surg Am. 2008;90(5):945–52. 12. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000;82(1):35–46. 13. Shin SJ, Kim RG, Jeon YS, Kwon TH. Critical value of anterior glenoid bone loss that leads to recurrent glenohumeral instability after arthroscopic bankart repair. Am J Sports Med. 2017;45(9):1975–81. 14. Nakagawa S, Mae T, Sato S, Okimura S, Kuroda M.  Risk factors for the postoperative recurrence of instability after arthroscopic bankart repair in athletes. Orthop J Sports Med. 2017;5(9):2325967117726494. 15. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC.  Hill-sachs “remplissage”: an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy. 2008;24(6):723–6. 16. Yamamoto N, Itoi E, Abe H, Minagawa H, Seki N, Shimada Y, Okada K.  Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elbow Surg. 2007;16(5):649–56. 17. Di Giacomo G, Itoi E, Burkhart SS.  Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/ off-track” lesion. Arthroscopy. 2014;30(1):90–8. 18. Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89(11):1470–7. 19. Phadnis J, Arnold C, Elmorsy A, Flannery M. Utility of the instability severity index score in predicting failure after arthroscopic anterior stabilization of the shoulder. Am J Sports Med. 2015;43(8):1983–8. 20. Frank RM, Saccomanno MF, McDonald LS, Moric M, Romeo AA, Provencher MT.  Outcomes of arthroscopic anterior shoulder instability in the beach chair versus lateral decubitus position: a systematic

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review and meta-regression analysis. Arthroscopy. 2014;30(10):1349–65. 21. DeFroda S, Bokshan S, Stern E, Sullivan K, Owens BD.  Arthroscopic Bankart repair for the management of anterior shoulder instability: indications and outcomes. Curr Rev Musculoskelet Med. 2017;10(4):442–51. 22. Nho SJ, Frank RM, Van Thiel GS, Wang FC, Wang VM, Provencher MT, Verma NN.  A biomechanical analysis of anterior Bankart repair using suture anchors. Am J Sports Med. 2010;38(7):1405–12. 23. Ranawat AS, Golish SR, Miller MD, Caldwell PE 3rd, Singanamala N, Treme G, Costic R, Hart JM, Sekiya JK.  Modes of failure of knotted and knotless suture anchors in an arthroscopic bankart repair model with the capsulolabral tissues intact. Am J Orthop (Belle Mead NJ). 2011;40(3):134–8. 24. Owens BDGE.  Uncomplicated anterior instability: the “simple” arthroscopic Bankart reconstruction. In: Abrams JS, Bell RH, Tokish JM, editors. Advanced reconstruction: shoulder 2. Chicago, IL: AAOS; 2018. 25. Shibata H, Gotoh M, Mitsui Y, Kai Y, Nakamura H, Kanazawa T, Okawa T, Higuchi F, Shirahama M, Shiba N.  Risk factors for shoulder re-dislocation after arthroscopic Bankart repair. J Orthop Surg Res. 2014;9:53. 26. Boileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L.  Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88(8):1755–63. 27. Diduch DR, Scanelli J, Tompkins M, Milewski MD, Carson E, Ma SY. Tissue anchor use in arthroscopic glenohumeral surgery. J Am Acad Orthop Surg. 2012;20(7):459–71. 28. McCarty LP 3rd, Buss DD, Datta MW, Freehill MQ, Giveans MR. Complications observed following labral or rotator cuff repair with use of poly-L-lactic acid implants. J Bone Joint Surg Am. 2013;95(6):507–11. 29. Kim SH, Oh JH, Lee OS, Lee HR, Hargens AR.  Postoperative imaging of bioabsorbable anchors in rotator cuff repair. Am J Sports Med. 2014;42(3):552–7. 30. Barber FA, Dockery WD, Hrnack SA.  Long-term degradation of a poly-lactide co-glycolide/beta-­ tricalcium phosphate biocomposite interference screw. Arthroscopy. 2011;27(5):637–43. 31. Milewski MD, Diduch DR, Hart JM, Tompkins M, Ma SY, Gaskin CM. Bone replacement of fast-absorbing biocomposite anchors in arthroscopic shoulder labral repairs. Am J Sports Med. 2012;40(6):1392–401. 32. Suchenski M, McCarthy MB, Chowaniec D, Hansen D, McKinnon W, Apostolakos J, Arciero R, Mazzocca AD.  Material properties and composition of soft-­ tissue fixation. Arthroscopy. 2010;26(6):821–31. 33. Tompane T, Carney J, Wu WW, Nguyen-Ta K, Dewing C, Provencher M, McDonald L, Gibson M, LeClere L.  Glenoid bone reaction to all-soft suture anchors used for shoulder labral repairs. J Bone Joint Surg Am. 2018;100(14):1223–9.

50 34. Owens BD, Harrast JJ, Hurwitz SR, Thompson TL, Wolf JM. Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination. Am J Sports Med. 2011;39(9):1865–9. 35. Hawi N, Reinhold A, Suero EM, Liodakis E, Przyklenk S, Brandes J, Schmiedl A, Krettek C, Meller R.  The anatomic basis for the arthroscopic Latarjet procedure: a cadaveric study. Am J Sports Med. 2016;44(2):497–503. 36. Price MR, Tillett ED, Acland RD, Nettleton GS.  Determining the relationship of the axillary nerve to the shoulder joint capsule from an arthroscopic perspective. J Bone Joint Surg Am. 2004;86-A(10):2135–42. 37. Matsuki K, Sugaya H.  Complications after arthroscopic labral repair for shoulder instability. Curr Rev Musculoskelet Med. 2015;8(1):53–8. 38. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR.  Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250–78. quiz 279–280. 39. Ando A, Sugaya H, Takahashi N, Kawai N, Hagiwara Y, Itoi E. Arthroscopic management of selective loss of external rotation after surgical stabilization of traumatic anterior glenohumeral instability: arthroscopic restoration of anterior transverse sliding procedure. Arthroscopy. 2012;28(6):749–53.

R. Meller and N. Hawi 40. Shin JJ, Popchak AJ, Musahl V, Irrgang JJ, Lin A.  Complications after arthroscopic shoulder surgery: a review of the American Board of Orthopaedic Surgery Database. J Am Acad Orthop Surg Glob Res Rev. 2018;2(12):e093. 41. Levine WN, Clark AM Jr, D’Alessandro DF, Yamaguchi K.  Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability. A report of two cases. J Bone Joint Surg Am. 2005;87(3):616–21. 42. Matsen FA 3rd, Papadonikolakis A.  Published evidence demonstrating the causation of glenohumeral chondrolysis by postoperative infusion of local anesthetic via a pain pump. J Bone Joint Surg Am. 2013;95(12):1126–34. 43. Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, Bach BR Jr, Romeo AA, Verma NN. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013;29(5):920–33. 44. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677–84. 45. Franceschi F, Papalia R, Del Buono A, Vasta S, Maffulli N, Denaro V.  Glenohumeral osteoarthritis after arthroscopic Bankart repair for anterior instability. Am J Sports Med. 2011;39(8):1653–9.

6

Complications of Bony Procedures for Shoulder Instability Ion-Andrei Popescu and David Haeni

With a contemporary increase in the number of surgical options for treating shoulder instability, in any of its forms, the surgeons’ tasks are becoming more complex than ever. Knowing that more than 50% of patients with gleno-humeral instability will undergo surgical treatment and that little consensus exists on the ideal or optimal operative technique, the surgeon has to individualize the treatment for each patient. Shoulder instability involves from 1 to 5 common lesions (capsular, capsulo-labral, glenoid bone loss, humeral bone loss, rotator cuff degloving). It can be acute or chronic, repetitive or occur as unique episode; chronic subluxation with a painful shoulder is also an issue. Treatment indication may be different for contact athletes, other than for weekend warriors or noncontact athletes. The American Shoulder and Elbow Society (ASES) and the German Society for Arthroscopy and Joint Surgery (AGA) are currently working on formal clinical practice guidelines for shoulder instability. However, to date, due to the lack of official consensus, the shoulder surgeon has to establish the ideal treatment based upon a combination of surgical experience and peer-reviewed literature.

I.-A. Popescu (*) Romanian Shoulder Institute, Zetta Hospital, Bucharest, Romania D. Haeni Leonardo Praxis, Hirslanden Klinik Birshof, Basel, Switzerland

The purpose of this chapter is to highlight the complications that may occur during and following arthroscopic bone block procedures for shoulder instability.

6.1

Arthroscopic Latarjet Procedure

The arthroscopic Latarjet is one of the most demanding and complex arthroscopic procedures, recently becoming a popular technique for treating recurrent anterior shoulder instability. Sustained by a correct indication, it can restitute shoulder stability in a mini invasive fashion, bringing superior advantages over the open-­ technique [1, 2] while having similar complication rates [3–5]. However, this technique comes also with specific risks and complications because it implies working endoscopically in the intra and extra-­ articular space, close to the brachial plexus, axillary and subclavicular vessels. Therefore, a trained team with sub-specialized shoulder-­ anesthesiologists [1], a long learning curve and specific arthroscopic skills are required [2]. As any other validated and wide accepted surgical technique, it should be safe, reliable and most important, reproducible in any shoulder surgeon’s hands. In order to achieve that, surgeons are gaining a better understanding of indications, associated risks, complications and their management.

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_6

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6.1.1 Understanding the Contraindications Domos et al. [6] wonderfully described the contraindications for performing the Latarjet procedure, based onto Gilles Walch’s lifetime surgical experience: –– recurrent anterior instability associated with massive irreparable rotator cuff tear and in the older population –– first traumatic dislocation in the older population with or without large glenoid rim fracture, –– voluntary anterior dislocators or subluxators, –– patients with uncontrolled epilepsy, –– transient post-traumatic inferior subluxation –– or the static anterior humeral head subluxation with coracoid impingement. However, once the correct indication is formulated [5, 7–11], the patient and the surgical team have to deal with the prophylaxis of various risks and complications, which may sometimes be slightly different in the arthroscopic technique than in the open one [3, 4, 12].

6.1.2 Perioperative Risks and Postoperative Complications General perioperative risks during arthroscopy (bleeding, hematoma, subcutaneous swelling, pneumothorax, venous or arterial embolism) are discussed in Chap. 1. There are no published studies stating that the infection risk would linearly increase with the number of arthroscopic portals (depending on the used technique, between 4 and 7 standard portals have been described for the Latarjet procedure). Hurley described in his metaanalysis a 1.2% rate of wound infection following arthroscopic Latarjet, smaller than the 1.9% for the open technique [3, 13]. Nevertheless, general recommendations regarding infection prophylaxis in shoulder arthroscopy should be considered [14]. Due to the difficult learning curve, literature reports about complications of arthroscopic

I.-A. Popescu and D. Haeni

Latarjet are very inhomogenous. Early publications report higher complications rates than the more recent studies, as the experience with this technique increases. Single surgeon series demonstrate that the most complications occurred in the first performed cases [8, 15]. More recent studies, either multicentric or large case series, report overall lower complications rates, similar to the open Latarjet technique [3–5, 12, 16]. Although the arthroscopic technique is nowadays perfectly codified, it has a troublesome learning curve. The collaboration with the anesthetist and nurses and the surgery time are crucial to maintain ideal operative conditions. Coracoid preparation and osteotomy, nerve visualization, meticulous hemostasis, subscapularis split, coracoid placement and fixation are difficult steps. Medial instrumentation portals are crossing the brachial plexus whereas the scapula is mobile on the thorax, making the graft positioning a difficult task. The screws must be as parallel as possible to the glenoid surface, the graft should be flush to the glenoid bone, ideal at 5 o’clock. A too medial position can lead to recurrent instability and graft resorption, a proud graft will rapidly create osteoarthritis [2]. In fact, good arthroscopic visualisation and perfect knowledge of the endoscopic anatomy is the key to avoid the most common complications: tendons, nerve or vascular injuries, coracoid fracture, graft and screws (or endobuttons) malplacement, as well as the early onset osteoarthritis.

6.1.3 Neurological Complications Intraoperative neurological complications are rare situations during intra-articular arthroscopy, however, the risk of nerve injury increases as soon as the techniques evolves towards the extra-­ articular space: endoscopic coracoid and conjoint tendon dissection, tenotomy of pectoralis minor and subscapularis split are complex steps which require mandatory nerves visualization [7, 17, 18]. The most common injured nerves are the axillary and the musculocutaneous nerve [19] with consequences explained in Chap. 14 by Thibault Lafosse. Lafosse et  al reported a

6  Complications of Bony Procedures for Shoulder Instability

0.2% rate of nervous injuries in a multicentric 1555 patients study conducted by the French Arthroscopic Society [16]. In comparison with the open technique, it seems that the arthroscopic dissection and visualization of the nerves reduced the chances of nerves injuries. However, systematic reviews by Griesser or Hurley, previously cited, report higher incidences of nerve injury (1.4% and 1%), but not significantly different than in the open technique. Apart from damaging the musculocutaneous or axillary nerves, another possible injury is the damage of the suprascapular nerve (SSN). This situation occurs when the screws are reaching the suprascapular notch dew to their oblique malposition and oversizing [20, 21] or when they are maldirected toward the scapular spine (protruding and impinging the SSN branch for the infraspinatus muscle) [22]. Griesser, Hurley, Athwal as well as Lafosse demonstrated that neurological complications rates are lower in high volume arthroscopic centers or after surpassing the learning curve for the arthroscopic Latarjet [3, 12, 13, 16].

6.1.4 Vascular Complications Similar to the nerves injuries, vascular complications occur during the extra-articular endoscopic steps (see also Chap. 13 by Laurent Lafosse). Subclavian vessels, axillary vessels and terminal branches of the thoraco-acromial artery are common anatomic landmarks seen during the arthroscopic Latarjet procedure. The general recommendation remains the same: see them well and memorize their position in order to be able to avoid any future injury, pseudoaneurysms or lacerations.

6.1.5 C  oracoid Fracture, Graft Avulsion There are different ways to perform a coracoid osteotomy: with a curve osteotome, as described by Michel Latarjet in 1954, with an oscillating saw, by first creating stress risers and prepar-

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ing the coracoid undersurface and then using an osteotome, through different arthroscopic portals and by using various visualization methods [2]. A poor visualization would influence the coracotomy level or can be responsible for a coracoid or even scapula body fracture. The coracoid fixation onto the glenoid rim is traditional made with long compression screws, newer techniques involve endo-buttons with tensioned sutures. In order to decrease coracoid graft fracture risk during osteosynthesis, special washers (called top-hats) or endo-buttons suture tensioneres were developed. Nevertheless, over-tensioning or forcing the screws into the graft, as well as uneven preparation of the osteosynthesis surfaces [15] would finally produce its fracture. Intraoperative graft fractures were reported in few studies, with rates from 1.3% [19] up to 2.8% [23, 24] and even at 7% [15]. We usually advice our patients not to force elbow flexion for the first 6 postoperative weeks. In Fig.  6.1a we showcase a coracoid graft avulsion at 7 days after an arthroscopic Latarjet procedure. The patient felt a ‘pop inside his shoulder’ after pulling up his pants, followed by discrete pain and secondary swelling. The patient was finally programed for a revision arthroscopy with graft reinsertion, respectively for a Bristow procedure. If the graft avulsion would have been older than 6 weeks, we would have performed an arthroscopic Eden Hybinette procedure in order to avoid axial pulling of the conjoint tendon, respectively not to injure the musculocutaneous nerve which may be entrapped in a scar. In Fig.  6.1b we exemplify a hardware failure case in a contact athlete, occurred during performing biceps curls.

6.1.6 Fibrous Non-Union Regardless of the fixation method, a solid osteosynthesis is required for reaching a successful result. This implies a good decortication of the coracoid undersurface and of the glenoid rim to flat surfaces. A coracoid non-union is usually incidentally discovered during routine follow-­ ups, whereas only few patients require reop-

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a

b

Fig. 6.1 (a) Case of a coracoid graft avulsion at 7 days postoperative. (b) Case of hardware failure in a contact athlete who started exercising biceps curls at 4 weeks postoperative

eration [2, 8, 22, 25, 26]. Literature reports are inconstant, demonstrating non-union rates from 1.4% up to 9.4% [12], depending on the surgical routine activity of each arthroscopy center.

6.1.7 Graft Remodeling and Resorption DiGiacomo [27] reported in 2011 a mean of 59.5% osteolysis of the coracoid graft. Newer studies demonstrate a resorption rate of up to 82.7% [4, 28]. It has been proved that the osteolysis process occurs more often at the level of the superior screw (53.3%) than inferiorly (3.3%) [29] and that the graft remodeling process is slower and more discrete in cases with big glenoid bone loss [22, 27, 30, 31], other than in cases with little glenoid defects. There are two current hypothesis explaining this phenomenon, namely the humeral head is creating pressure only on the inferior part of the graft [32] and that the vas-

cularization of the graft is made through the conjoint tendon around the coracoid tip [4, 12, 28, 33, 34]. In most cases with graft osteolysis, there is no clinical significance on recurrence of instability or functional outcome, therefore no revision surgery is needed, fact explained by the persisting sling effect of the conjoint tendon. Generally speaking, graft complications regarding nonunion, graft migration, and graft fracture may occur in 3.2% of cases [3].

6.1.8 G  raft Malpositioning, Screw Impingement Even in experienced hands, a correct positioning of the graft on the glenoid rim remains one of the biggest challenges in the Latarjet procedure. A too high position, above the glenoids’ equator will simultaneously increase the risk of malpositioning the superior screw, thus endangering the SSN. A too low position may predispose to a fibrous non-union because the inferior screw will

6  Complications of Bony Procedures for Shoulder Instability

pass underneath the glenoid neck, creating no biomechanical stability. A too medial graft positioning will be responsible for recurrent instability or chronic subluxation and a too lateral one for early onset osteoarthritis (Fig.  6.2a) [3, 8, 22, 29, 31, 35]. Proeminent screws may also abrade the subscapularis until its destruction or even impinge into the humeral head producing catastrophic outcomes (Fig. 6.2b, c). We consider that screws and graft malposition should be seen more as surgical error than a complication.

a

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6.1.9 S  tiffness, Loss of External Rotation The reportings for loss of external rotation varies from a study to another: Cunningham et al. [35] as well as Hurley [3, 13] demonstrate similar results for open and arthroscopic technique whereas Griesser [12] states a greater loss of mean external rotation in the arthroscopic group (16° vs 12° in open Latarjet group). Lafosse introduced the arthroscopic technique in order to decrease the

b

c

Fig. 6.2  Exemplification of osteoarthritic complications after Latarjet in young patients. (a) 29  years old patient with early onset omarhrosis at 11 months after the index

procedure. (b, c) Destruction of humeral head caused by screw malplacement

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anatomical damage during the open dissection and he reports no significant persistence of external rotation loss at 5 years of follow up [7, 8]. It is believed that the technique used for splitting the subscapularis muscle and for dissecting the conjoint tendon may influence the postoperative range of motion [29].

6.1.10 Persistent Apprehension, Postoperative Pain or Discomfort In an open vs arthroscopic latarjet systematic review [3], Hurley reported that up to 35.7% of patients treated with arthroscopic Latarjet may develop a persistent apprehension, with no instability whatsoever. Furthermore, Marion demonstrated that the arthroscopic Latarjet procedure was significantly less painful than the mini-open procedure [24].

6.1.11 Recurrence The Latarjet procedure is generally associated with low instability recurrence rates, whether it is performed open or arthroscopically [3, 4, 17]. Cerciello reported 2.6% recurrence rate and 6.3% reoperation rate in his latest literature review study [4], whereas Hurley a 2.4% recurrent instability with 1.6% recurrent dislocations [3]. At 5 years follow up, Dumont and Lafosse present a 2% recurrence rate [8]. The revision rate due to recurrent instability is considered to be 2.9% [3].

6.1.12 Osteoarthritis The cells covering the bony surface of the graft have the potential to differentiate themselves into fibrocartilage, thus creating a cartilaginous continuity with the glenoid surface [31, 32, 34], given the graft was correctly positioned. A proud graft position will definitely impinge the humeral head and finally create an irreversible destruction of the humeral cartilage [22, 26, 31, 34]. Sometimes, the remodeling process makes the superior screw becoming proeminent and a following repetitive

contact between humeral head and screws will conduct to early cartilage destruction. As stated before, a subscapularis insufficiency due to screw protrusion may also occur. Gleno-humeral arthritis can be a short-term complication in cases with screws or graft malplacement, as depicted in Fig.  6.2a. However, we see omarthrosis as a potential long-term consequence of the Latarjet procedure. It remains challenging to distinguish consequences of posttraumatic arthropathy from complications or longterm outcomes of surgical related arthropathy. A comprehensive literature review dedicated to this chapter found very little information about early onset arthropathy after arthroscopic Latarjet. Zhu described one case of early onset osteoarthritis out of 52 patients at minimum 2 years follow up [28]. We believe that osteoarthritis, as well as other complications, is underreported, but from a biomechanical point of view, we can extrapolate to results about the open surgery, where the development of arthritis appears in 20% at 20  years [22, 36] or as reported by Hovelius, in 14% (severe arthropathy) or 35% (mild arthropathy) of cases [37, 38].

6.2

 evision Arthroscopy After R Failed Latarjet Procedure

Subsequent revision surgery after a failed arthroscopic Latarjet procedure is a challenging problem that equals dealing with potential complications of an already happened complication. Working in an altered anatomical space may pose new problems and put the patient at even higher risk than during the index procedure. Hardware failure, hematoma, bone block fractures, persistent instability and re-dislocations are common revision causes, among other complications listed above. Revisions after arthroscopic Latarjet due to recurrent instability were reported by Hurley in his latest meta-analysis: 2.9% of 126 patients [3]. Total revisions were reported at 5.4% out of 412 arthroscopic Latarjet procedures [3, 35]. In a 10  years follow-up study, Meraner and Leuzinger reported a 30% revision rate after the arthroscopic Latarjet [5]. The main causes were stiffness (62% of revision cases), recurrent insta-

6  Complications of Bony Procedures for Shoulder Instability

bility (20% of all revisions) and hardware related reasons (screws or guiding k-wires breakage). Serial surgical revision options for recurrent instability were described, starting with arthroscopic screws removal, arthroscopic capsulorrhaphy, secondary Hill-Sachs remplissage up to arthroscopic Eden-Hybinette or J-Span with or without concomitant arthroscopic brachial plexus neurolysis. Other techniques describe the potential of using lateral clavicle or tibia allograft [39, 40] instead of an iliac crest autograft. Capsulorrhaphy after failed Latarjet demonstrated 16.7% recurrent instability [41]. On the other hand, Gianakos et  al. described better clinical outcomes following the arthroscopic Eden-­ Hybinette procedure after failed Latarjet and reported no dislocation recurrence but a high incidence of apprehension and subluxation [31]. Poor outcomes after revision surgery include glenohumeral arthritis, two or more previous instability procedures and age over 30. The most challenging revision cases are the post-Latarjet gleno-humeral arthritis in young patients, with or without persistent instability [31]. A comprehensive arthroscopic management (CAM) procedure may result in temporary symptomatic relief [22, 42]. A definitive solution can be the gleno-­ humeral arthroplasty, however, this is a challenging indication in younger subjects and in persistent instability cases. While technically complex, the arthroscopic Latarjet procedure is a viable and safe technique that permits the surgeon to have a complete visual control over the anatomic structure of interests, thus avoiding unnecessary surgical errors and complications. The main road to a successful arthroscopic Latarjet comprises what we call the 6Gs: –– –– –– –– –– ––

good indication, good planning, good cooperation with your anesthesiologist, good tools and guides, good visualization, good surgical technique.

However, in our hands, each arthroscopic Latarjet or its revision remains a challenging procedure. It is always possible, at any stage of the

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surgery, to convert arthroscopy to an open procedure. Ideally one should be able to perform the both open and arthroscopic techniques, or at least to keep using the technique he masters well. A good open Latarjet is much better than a badly performed arthroscopic Latarjet. Nevertheless, mastering the complications and avoiding risks, carefully passing through the learning curve while having the support of a high-volume arthroscopy center, will offer the best possible care for our patients.

6.3

 he arthroscopic Eden-­ T Hybinette Procedure

Various bone grafting techniques and approaches were historically designed as mechanical dislocation barriers for shoulder instability cases. One of the oldest used principle is to augment the glenoid surface with a free bone block that can be harvested from the iliac crest. During the last 100 years, multiple fixation methods were developed [43]. As a consequence of advancements in arthroscopy and osteosynthesis, the autologous iliac crest bone grafting of the glenoid can be nowadays performed arthroscopically [44]. Although most of the shoulder surgeons today prefer to keep the Eden-Hybinette procedure for revision cases, after a failed Latarjet for example [5, 31], one can choose this technique as a first treatment option. Knowing that the open ­procedure renders similar low complications and recurrences rates as the open Latarjet procedure [45], it is interesting to discuss the early and mid-­ term follow up case series publications on the arthroscopic bone block technique as an alternative to the arthroscopic Latarjet. Scheibel et  al. described in 2008 an all arthroscopic reconstruction of chronic antero-­ inferior glenoid defect using an autologous iliac crest bone block [46]. In his initial study on 15 patients he reported only one recurrent instability case which required a secondary capsular plication [44]. At 20 months mean follow up period, the same research group described in a secondary study no recurrence and good to excellent clinical results, having one neurological complication regarding the hypoesthésia around the anterior

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thigh. Because of the small group study and short term follow up, a clear conclusion on graft resorption or general graft complications couldn’t be drawn. However, postoperative CT scans demonstrated, accordingly to Wolff’s law, that the extraarticular part of the graft resorbs completely [47]. Similar results were reported by Taverna et al. in a study on 26 patients at 29.6  months of mean follow up. There were no recurrent dislocations, the satisfaction rate was 88%, an average loss of 4.4° of external rotation and a demonstrated high healing rate of the graft [48]. However, in a meta-analysis on instability procedures, arthroscopic and open, Longo et  al discovered an overall complication rate (including osteoarthritis) of 17.6% (12 of 68) and a 9.8% of instability recurrence for the Eden-Hybinette procedure [45]. In a mid-term outcome study (at 42 months), Bockmann et al. demonstrated on a group of 32 patients low pain levels and ‘acceptable complications levels’: 9% (3 patients) of re-dislocation after secondary traumatisms, 7% (1 patient) of postoperative graft fracture, 7% (1 patient) persistent instability sensation [49]. Though current evidence is somewhat limited, the arthroscopic Eden-Hybinette procedure as the first choice in treating anterior shoulder instability re-creates the anatomy of the anteroinferior glenoid and leads to good functional results.

6.4

The Implant-Free, Autologous, Iliac Crest Bone Graft Procedure (J-Bone Graft)

The J-bone graft is a feasible alternative bony procedure for the treatment of anterior shoulder instability caused by glenoid bone loss [50, 51]. Several authors presented good clinical outcomes for short, medium and long term follow up with overall little complications and high rates of return to sports [51–53]. The advantage of an implant-free anatomic glenoid augmentation technique is the avoidance of hardware complications, such as screws protrusion or impingement [51, 54]. The reverse of the medal represents,

however, a technical demanding procedure with a steep learning curve, donor site morbidity at the iliac crest and specific intraoperative risks and complications [51].

6.4.1 Intraoperative Complications The osteotomy at the glenoid neck may theoretically produce a complete fracture. Special chisels and a very exact surgical technique were developed [51]. However, no cases of iatrogenic glenoid fracture were found in the literature. Furthermore, during the press fit impaction, the graft’s keel or even the graft itself can break [51]. If the remnant bone block is big enough, one can fixate it with titanium screws or anchors, thus performing a classic Eden Hybinette procedure. Moroder et  al. recommends an additional fixation if the outer cortex of the iliac crest is too weak [52, 55]. Auffahrt [50] reported that 6% of his patients needed an additional fixation due to unsatisfactory stability.

6.4.2 Immediate and Short-Term Postoperative Complications Postoperative hematoma, wound/subcutaneous infection and sensitive nerve injuries are commonly reported at the donor site (iliac crest), more often than at the shoulder level. Between 11% and 14% of patients developed a hypoesthesia due to lateral cutaneous femoral nerve injury [43, 45] and around 6% developed a hematoma. Isolated cases of wound infection were also reported. Anderl reported no early onset osteoarthritis, no recurrent subluxations, dislocations or persisting instability after the arthroscopic technique. Furthermore, within the first 12 months, a regular graft remodeling occurs [53, 55].

6.4.3 Long Term Postoperative Complications In their long term follow up studies, Moroder and Auffarht reported that up to 23% of the patients

6  Complications of Bony Procedures for Shoulder Instability

had a persistent positive apprehension and an overall insignificant loss of range of motion. 80.4% of the patients returned to the same sport level whereas 19.6% changed their favourite sport. As after any bony procedure, arthrosis represents a major concern. At 7.5 years follow-up, 35% of patients who had no arthritic signs before surgery developed arthrosis [50]. Deml et  al. demonstrated at 10 years follow up that the bone graft was anatomically incorporated and remodelled in all of the cases [56]. With an overall 94% satisfaction rate and no patient having a recurrent dislocation, the procedure seems to provide excellent long-term results. Nevertheless, due to the initially non-rigid press-­fit fixation, the patient has to deal with a prolonged postoperative rehabilitation and a retarded return to activity. Given the difficulty of the surgical technique and the overall few publications on outcomes and complications, this technique should be performed only by experimented shoulder surgeons.

6.5

 he Posterior Bone Block T Procedure

Posterior shoulder instability only accounts for 5% of shoulder instabilities. Acute posterior dislocation is a rare condition and may result from high-energy trauma, seizures or electric shock [57]. In case of chronic posterior instability, conservative treatment can obtain good functional results, and is considered the gold standard in voluntary instability related to hyper-laxity. Because of the low incidence of chronic instability, the optimal surgical treatment is still debated and several approach, from capsular plication to open or arthroscopic bone block augmentation, have been described. Already in 1952, McLaughlin described a bone block procedure in combination with capsular augmentation for posterior gleno-humeral instability [58]. In the last years, several techniques with promising results have been described. A bony procedure is required in case of relevant humeral and/or glenoid bone loss. Glenoid osteotomy [59] can be performed in case of glenoid retroversion more than 15°, as already described in the 60’s, but in the last

59

years, bone block augmentation techniques have been often preferred. Gerber et  al. showed that after glenoid osteotomy the humeral head could even migrate anteriorly and that this procedure is related to high intraoperative complication rate such as glenoid fracture or postoperative loss of correction [60]. Surgical treatment can be necessary if non-operative treatment fails. Surgical indication for posterior bone block augmentation, with iliac crest or a pedicle acromial flap, are the following: recurrent post-traumatic posterior dislocations with associated bone defects (reverse Hill Sachs and/or posterior glenoid bone loss), hyperlaxity, glenoid dysplasia and involuntary instability [61].

6.5.1 C  omplications After Posterior Bone Block Procedure The posterior bone block procedure is a good treatment option for posterior dislocation, significantly improving shoulder stability after the procedure. The risk of recurrent dislocation is low. Despite that, postoperative complications and surgical revision after bone augmentation are high and the learning curve for this technique is steep. Both open and arthroscopic techniques show a higher revision rate, if compared to other standardized procedures for anterior instability as Bankart repair and Latarjet procedure. Schwartz et  al. reported complication requiring revision surgery in 36.8% of patients after arthroscopic bone block procedure [61]. Intraoperative complications can be related to hardware breakage, vascular or neurological damage. Immediate postoperative complications such as haematoma or swelling are rare and usually do not require a surgical revision. Delayed postoperative complications such as infection and brachial plexus palsy are not frequently reported. Several studies report a low recurrence rate after this procedure [61, 62]. Sirveaux et  al. did not observe any recurrent dislocation or subluxation at longterm follow up after 13.5  years, but postoperatively 6 out of 18 patients described apprehension [63]. Servien et  al. reported similar results with one out of

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21 patients with postoperative recurrent dislocation and two patients with subjective shoulder instability and positive apprehension [64]. Clavert et al. recently reported the clinical outcome after posterior bone block procedure in a multicenter retrospective study of 66 patients, showing a significant postoperative improvement of the Constant score, with good postoperative Walch-Duplay (81.5) score and Rowe score (86.5) [65]. The major concerns at the long-term follow up are related to gleno-humeral osteoarthritis and graft osteolysis. The correct graft position is still debated during international shoulder meetings and in the recent literature. Since the bone block should fill the bony defect at the glenoid, the decision of the correct superior-inferior graft positioning is often done during surgery. Preoperative CT assessment, in order to anticipate the better graft position, is mandatory and should be performed in a standard fashion. Similarly to the Latarjet procedure, where the coracoid graft is usually placed flush to the subchondral glenoid bone, the posterior bone block should not be placed proud (Fig. 6.3). Too lateral grafts and incorrect hardware posia

tion can accelerate/produce postoperative glenohumeral osteoarthritis. An ongoing study at the Alps Surgery Institute in Annecy (France), under the supervision of Laurent Lafosse, show partial graft osteolysis 6 months after surgery (Fig. 6.4),

Fig. 6.3  Left shoulder: arthroscopic visualization from the antero-lateral portal. The posterior bone block is flush and fits the glenoid bone defect

b

b

Fig. 6.4 (a) The 6  weeks postoperative volume reconstruction of the upper half of the posterior bone graft shows no resorption. (b) 6  months after surgery in the same patient, a partial upper osteolysis of the graft is seen,

causing screw head prominence. (c) 3D reconstruction of the shoulder at 6 months after posterior bone block augmentation showing partial graft osteolysis

6  Complications of Bony Procedures for Shoulder Instability

similar to the results already published for postoperative graft osteolysis after open or arthroscopic Latarjet procedure[32]. Cerciello et al. recently published a systematic review for posterior shoulder instability. Although the lack of qualitative studies is criticised, they could suggest that bone augmentation is a reliable option with a low recurrence rate after surgery. The main concern is related to the aforementioned postoperative osteolysis and glenohumeral osteoarthritis in up to one third of the patients [62].

6.6

 ouble Bone Block D for Multidirectional Instability

Combined anterior and posterior glenoid defects responsible for multidirectional instability are generally rare findings. One can perform a complex anatomical reconstruction of the glenoid in younger patients, but in most of the cases, due to the important cartilage loss and pre-arthritic lesions, only the total shoulder arthroplasty or even arthrodesis can be the solution. The double bone block should be seen as salvage procedure and not as a standard solution out of the pocket. Laurent Lafosse is the first surgeon to perform a full arthroscopic anterior and posterior bony stabilisation (Latarjet procedure and the posterior bone block procedure) in one surgical time. The single available study presents the outcomes of seven patients at a mean clinical follow up of 26  months and radiological follow up range of 5–72  months [66]. The clinical outcomes were fair up to good with no intra-operative complications and complete graft osteointegration proven in postoperative CT scans; four patients returned post-operatively to sport. However, three revision surgeries were performed (one Eden-Hybinette for a patient with Ehlers-Danlos Syndrome and two hardware removal). Due to the limited experience on this specific surgical indication, outcome expectancy and technical difficulty, it must be stated that this highly complex procedure belongs to skilled shoulder surgeons working in high volume arthroscopy centers.

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I.-A. Popescu and D. Haeni 26. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am. 1998;80:841–52. https://doi.org/10.1002/ bjs.18002610104. 27. Di Giacomo G, Costantini A, de Gasperis N, et  al. Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: a computed tomography scan study of twenty-six patients. J Shoulder Elbow Surg. 2011;20:989–95. https://doi. org/10.1016/j.jse.2010.11.016. 28. Zhu YM, Jiang C, Song G, et al. Arthroscopic Latarjet procedure with anterior capsular reconstruction: clinical outcome and radiologic evaluation with a minimum 2-year follow-up. Arthroscopy. 2017;33:2128–35. https://doi.org/10.1016/j.arthro.2017.06.014. 29. Kordasiewicz B, Małachowski K, Kicinski M, et  al. Comparative study of open and arthroscopic coracoid transfer for shoulder anterior instability (Latarjet)—clinical results at short term follow-up. Int Orthop. 2017;41:1023–33. https://doi.org/10.1007/ s00264-016-3372-3. 30. Di Giacomo G, de Gasperis N, Costantini A, et  al. Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss. J Shoulder Elbow Surg. 2014;23:514–8. https://doi. org/10.1016/j.jse.2013.10.005. 31. Giannakos A, Vezeridis PS, Schwartz DG, et al. All-­ arthroscopic revision Eden-Hybinette procedure for failed instability surgery: technique and preliminary results. Arthroscopy. 2017;33:39–48. https://doi. org/10.1016/j.arthro.2016.05.021. 32. Haeni DL, Opsomer G, Sood A, et  al. Three-­ dimensional volume measurement of coracoid graft osteolysis after arthroscopic Latarjet procedure. J Shoulder Elbow Surg. 2017;26:484–9. https://doi. org/10.1016/j.jse.2016.08.007. 33. Lafosse T, Amsallem L, Delgrande D, et  al. Arthroscopic screw removal after arthroscopic latarjet procedure. Arthrosc Tech. 2017;6:e559–66. https:// doi.org/10.1016/j.eats.2016.12.002. 34. Ghodadra N, Gupta A, Romeo AA, et al. Normalization of glenohumeral articular contact pressures after Latarjet or iliac crest bone-grafting. J Bone Joint Surg Am. 2010;92:1478–89. https://doi.org/10.2106/ JBJS.I.00220. 35. Cunningham G, Benchouk S, Kherad O, Lädermann A. Comparison of arthroscopic and open Latarjet with a learning curve analysis. Knee Surg Sports Traumatol Arthrosc. 2016;24:540–5. https://doi.org/10.1007/ s00167-015-3910-3. 36. Mizuno N, Denard PJ, Raiss P, et al. Long-term results of the Latarjet procedure for anterior instability of the shoulder. J Shoulder Elbow Surg. 2014;23:1691–9. https://doi.org/10.1016/j.jse.2014.02.015. 37. Hovelius L, Sandström B, Sundgren K, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively

6  Complications of Bony Procedures for Shoulder Instability followed for fifteen years: study I: clinical results. J Shoulder Elbow Surg. 2004;13:509–16. https://doi. org/10.1016/j.jse.2004.02.013. 38. Samilson RL, Prieto V.  Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983;65:456–60. https://doi.org/10.2106/00004623-198365040-00005. 39. Provencher MT, Ghodadra N, LeClere L, et  al. Anatomic osteochondral glenoid reconstruction for recurrent glenohumeral instability with glenoid deficiency using a distal tibia allograft. Arthroscopy. 2009;25:446–52. https://doi.org/10.1016/j. arthro.2008.10.017. 40. Tokish JM, Fitzpatrick K, Cook JB, Mallon WJ.  Arthroscopic distal clavicular autograft for treating shoulder instability with glenoid bone loss. Arthrosc Tech. 2014;3:e475–81. https://doi. org/10.1016/j.eats.2014.05.006. 41. Castagna A, Garofalo R, Melito G, et al. The role of arthroscopy in the revision of failed Latarjet procedures. Musculoskelet Surg. 2010;94:S47–55. https:// doi.org/10.1007/s12306-010-0060-0. 42. Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensive Arthroscopic Management (CAM) procedure: clinical results of a joint-preserving arthroscopic treatment for young, active patients with advanced shoulder osteoarthritis. Arthroscopy. 2013;29:440–8. https://doi.org/10.1016/j. arthro.2012.10.028. 43. Levy DM, Cole BJ, Bach BR.  History of surgi cal intervention of anterior shoulder instability. J Shoulder Elbow Surg. 2016;25:e139–50. 44. Scheibel M, Kraus N.  Arthroskopische Pfannenrandrekonstruktion mit autologer Spanplastik. Orthopade. 2011;40:52–60. https://doi.org/10.1007/ s00132-010-1679-0. 45. Longo UG i, Loppini M, Rizzello G, et  al. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy. 2014;30:1184–211. https://doi.org/10.1016/j. arthro.2014.04.005. 46. Scheibel M, Kraus N, Diederichs G, Haas NP.  Arthroscopic reconstruction of chronic anteroinferior glenoid defect using an autologous tricortical iliac crest bone grafting technique. Arch Orthop Trauma Surg. 2008;128:1295–300. https://doi. org/10.1007/s00402-007-0509-2. 47. Kraus N, Amphansap T, Gerhardt C, Scheibel M.  Arthroscopic anatomic glenoid reconstruction using an autologous iliac crest bone grafting technique. J Shoulder Elbow Surg. 2014;23:1700–8. https://doi.org/10.1016/j.jse.2014.03.004. 48. Taverna E, Golanò P, Pascale V, Battistella F.  An arthroscopic bone graft procedure for treating anterior-­inferior glenohumeral instability. Knee Surg Sports Traumatol Arthrosc. 2008;16:872–5. https:// doi.org/10.1007/s00167-008-0541-y. 49. Bockmann B, Venjakob AJ, Reichwein F, et  al. Mid-term clinical results of an arthroscopic glenoid rim reconstruction technique for recurrent

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anterior shoulder instability. Arch Orthop Trauma Surg. 2018;138:1557–62. https://doi.org/10.1007/ s00402-018-2964-3. 50. Auffarth A, Schauer J, Matis N, et  al. The J-bone graft for anatomical glenoid reconstruction in recurrent posttraumatic anterior shoulder dislocation. Am J Sports Med. 2008;36:638–47. https://doi. org/10.1177/0363546507309672. 51. Auffarth A, Kralinger F, Resch H. Anatomical glenoid reconstruction via a J-bone graft for recurrent posttraumatic anterior shoulder dislocation. Oper Orthop Traumatol. 2011;23:453–61. https://doi.org/10.1007/ s00064-011-0055-5. 52. Moroder P, Plachel F, Becker J, et  al. Clinical and radiological long-term results after implant-­ free, autologous, iliac crest bone graft procedure for the treatment of anterior shoulder instability. Am J Sports Med. 2018;46:2975–80. https://doi.org/10.1177/0363546518795165. 53. Anderl W, Pauzenberger L, Laky B, et  al. Arthroscopic implant-free bone grafting for shoulder instability with glenoid bone loss: clinical and radiological outcome at a minimum 2-year follow­up. Am J Sports Med. 2016;44:1137–45. https://doi. org/10.1177/0363546515625283. 54. Pauzenberger L, Dyrna F, Obopilwe E, et  al. Biomechanical evaluation of glenoid reconstruction with an implant-free j-bone graft for anterior ­glenoid bone loss. Am J Sports Med. 2017;45:2849–57. https://doi.org/10.1177/0363546517716927. 55. Moroder P, Hirzinger C, Lederer S, et al. Restoration of anterior glenoid bone defects in posttraumatic recurrent anterior shoulder instability using the J-bone graft shows anatomic graft remodeling. Am J Sports Med. 2012;40:1544–50. https://doi. org/10.1177/0363546512446681. 56. Deml C, Kaiser P, van Leeuwen WF, et  al. The J-shaped bone graft for anatomic glenoid reconstruction: a 10-year clinical follow-up and computed tomography-osteoabsorptiometry study. Am J Sports Med. 2016;44:2778–83. https://doi. org/10.1177/0363546516665816. 57. Zumstein MA, Jost B, Gerber C.  Instability of the shoulder in athletes. Schweizerische Zeitschrift fur Sport und Sport. 2005;53:27–35. 58. McLaughlin HL.  Posterior dislocation of the shoulder. J Bone Joint Surg Am. 1952;24 A:584–90. 59. Scott DJ.  Treatment of recurrent posterior dislocations of the shoulder by glenoplasty. Report of three cases. J Bone Joint Surg Am. 1967;49:471–6. https:// doi.org/10.2106/00004623-196749030-00005. 60. Gerber C, Ganz R, Vinh TS.  Glenoplasty for recurrent posterior shoulder instability. An anatomic reappraisal. Clin Orthop Relat Res. 1987:70–9. 61. Schwartz DG, Goebel S, Piper K, et al. Arthroscopic posterior bone block augmentation in posterior shoulder instability. J Shoulder Elbow Surg. 2013;22:1092– 101. https://doi.org/10.1016/j.jse.2012.09.011. 62. Cerciello S, Visonà E, Morris BJ, Corona K.  Bone block procedures in posterior shoulder insta-

64 bility. Knee Surg Sports Traumatol Arthrosc. 2016;24:604–11. 63. Sirveaux F, Leroux J, Roche O, et al. Traitement de l’instabilité postérieure de l’épaule par butée iliaque ou acromiale: À propos d’une série de 18 cas. Rev Chir Orthop Reparatrice Appar Mot. 2004;90:411–9. https://doi.org/10.1016/S0035-1040(04)70167-1. 64. Servien E, Walch G, Cortes ZE, et al. Posterior bone block procedure for posterior shoulder instability. Knee Surg Sports Traumatol Arthrosc. 2007;15:1130– 6. https://doi.org/10.1007/s00167-007-0316-x.

I.-A. Popescu and D. Haeni 65. Clavert P, Furioli E, Andieu K, et al. Clinical outcomes of posterior bone block procedures for posterior shoulder instability: multicenter retrospective study of 66 cases. Orthop Traumatol Surg Res. 2017;103:S193–7. https://doi.org/10.1016/j.otsr.2017.08.006. 66. Haeni D, Sanchez M, Johannes P, et al. Arthroscopic double bone block augmentation is a salvage procedure for anterior and posterior shoulder instability secondary to glenoid bone loss. Knee Surg Sports Traumatol Arthrosc. 2018;26:2447–53. https://doi. org/10.1007/s00167-018-4975-6.

7

Complications of Subscapularis Repair Jörg Nowotny and Philip Kasten

The anterior part of the rotator cuff is formed by the subscapularis muscle (SSC) and acts on the one hand as the most important internal rotator and on the other hand as a static and dynamic stabilizer of the glenohumeral joint. Therefore, a rupture causes muscular imbalance and finally decentering of the shoulder joint (Fig.  7.1). Furthermore, the subscapularis is the largest and strongest muscle of the rotator cuff. For many years, the reconstruction of the subscapular muscle was considered as a domain of open surgery. With the improvement of arthroscopic techniques and instruments, ruptures can now preferentially be refixated arthroscopically. The advantages of arthroscopic treatment are improved visualization and the possibility of treating accompanying injuries. Nevertheless, arthroscopic refixation is still considered demanding. The chapter gives an overview of the possible complications during a reconstruction of the SSC tendon.

The images were created by the authors themselves, so there is no copyright conflict. J. Nowotny (*) UniversityCentrum of Orthopedics and Traumatology, University Hospital Carl Gustav Carus, Dresden, Germany e-mail: [email protected] P. Kasten Orthopädisch Chirurgisches Centrum (OCC) Tübingen, Tübingen, Germany e-mail: [email protected]

torn SSC

Fig. 7.1  Axial MRI image of a torn subscapularis muscle with consecutive decentration of the shoulder

7.1

Overlooked Tendon Defects

The visualization of minor tendon defects of the SSC tendon can be demanding. Cranial medial partial lesions can easily be overlooked (Fig. 7.2). Furthermore, in the case of advanced ruptures (≥2 stage Patte classification), visualization and mobilization of the tendon can be difficult due to the spatial narrowness in the ventral compartment. A completely torn SSC tendon is usually retracted medially and often intergrown with the capsuloligamentary

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_7

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a

SSC

H

b

Fig. 7.3  Illustration of the torn subscapularis tendon with the comma sign. (G glenoid, SSC subscapularis, the comma—sign is drawn)

SSC

Fig. 7.2  Hidden lesion before (a) and after (b) debridement of the insertion (SSC subscapularis, H humerus head)

structures (superior or medial glenohumeral ligament [SGHL/MGHL] and coracohumeral ligament [CHL]). Furthermore, accompanying torn structures of the pulley system and the supraspinatus can be adherent to a scar plate. This is interpreted as a so-called “commasign” and serves on the one hand as a guiding structure of the lateral edge of the tear and on the other hand it must not be misinterpreted as an intact tendon (Fig. 7.3). Intra- and extra-articular imaging is recommended for accurate visualization and better understanding of the tear morphology. Primarily, the posterior portal (approx. 1  cm caudal and

medial of the posterolateral acromion corner) is used to evaluate the tendon and the first anteroinferior working portal (cranial to the upper margin of the SSC in the rotator interval). The second anterolateral working portal (above the bicipital sulcus/anterolateral acromion corner) is then established. In addition to its utilization as a work and suture management portal, the SSC tendon can be completely visualized, prepared and mobilized via this portal from extra-articular with preparation of the ventral compartment including the coracoid process and the conjoined tendon.

7.2

Damage to Neurovascular Structures and Plexus Brachialis

Especially while excessive preparation of the extraarticular ventral compartment using a radiofrequency ablation device may cause thermal or mechanical damage to the two muscular branches to the subscapular muscle, the brachial plexus and, due to its direct proximity to the lower edge of the SSC, to the axillary nerve or musculocutaneous nerve. The literature also describes the damage of the plexus caused by nerve traction due to possible adhesions or secondary through

7  Complications of Subscapularis Repair

fluid extravasation [1, 2]. In the literature, the incidence of nerve injury after arthroscopic therapy of the shoulder is described between 0.2% and 3% [3]. In addition, during a perioperative local anesthesia procedure with e.g. the application of an interscalene nerve block, damage to the neurovascular structures may occur. The rate is given in the literature with 0.35% of major and 11.32% of minor complication rate [4]. In addition, careful positioning of the patient (usually in beach chair position) is essential. On the one hand, excessive flexion or extension of the head can lead to cerebral ischemia, on the other hand neurological damage to the brachial plexus or musculocutaneous nerve can occur with poor positioning of the arm or due to excessive axial traction.

7.3

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Fig. 7.4  Re-ruptur of a subscapularis tendon with placed anchor and torn sutures. (G glenoid, SSC subscapularis, H humerus head)

Re-Rupture

In the literature the healing rate after SSC is indicated between 89% and 95% [5–7]. The causes for a failure of the rotator cuff reconstruction are manifold and include a failure of the anchors, too much tension of the attached tendon or biological failure while degenerative conditions of the tendon. The most important precondition for adequate reconstruction is the sufficient visualization and release of the torn subscapularis tendon, to ensure tension-free refixation. After the establishment of the anteroinferior and anterolateral portal, the subsequent synovectomy of the rotator interval for better visualization is done. The mobilization of complex tendon tears (adhesions to medium glenohumeral ligament, MGHL) with extensive 270° tenolysis is performed as previously described from intra- and extraarticular including the visualization of the coracoidal arch. Care is taken to respect the two muscular nerve branches into the SSC muscle. To ensure sufficient preparation, the reduction of the tendon is verified with an arthroscopic tissue forceps and subsequently a traction suture for the reconstruction management is shuttled through the tendon (Figs. 7.4, 7.5, and 7.6). The lateral tension on the traction suture, which is guided through the superolateral portal, allows

Fig. 7.5  Mobilized subscapularis tendon with removed old sutures, placed traction suture and new anchor sutures. (G glenoid, SSC subscapularis, H humerus head, TS traction suture, AS anchor sutures)

better mobilization of the tendon and better addressing of adhesions. As known from rotator cuff reconstruction, a high tension of the reduced tendon goes along with increased failure rate [8]. Although in general, the double row technique in the refixation of the rotator cuff (mostly supraspinatus tendon) has an advantage in biomechanical studies in regard to the pull-out strength, there is no significant advantage in regard of clinical

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Fig. 7.6  Restored subscapularis tendon (G glenoid, SSC subscapularis, H humerus head)

scores [9]. A biomechanical study was also able to achieve a more stable refixation within the double row technique during isolated SSC tendon examination [9]. However, there are equivalent clinical outcomes for single and double row techniques for isolated SSC tendon ruptures [10, 11]. The footprint of the tubercle minus should be prepared from torn tendon tissue and the bone should be very carefully shaped with the acromionizer depending on the bone quality (in the case of excessive weakening of the cortical bone the stability of the anchors may be adversely affected) so that an adequate osteointegration can be ensured. In addition to the used anchor technique, the correct placement of the portals is important. The entrance level and the possible working radius should be checked with a needle in outside-in technique. Inaccurate positioning of the portals makes it more difficult to handle the reconstruction on the one hand, and the exact anchor fixation on the other. An anchor inserted too shallow can pull out of the bone and lead to the failure of the reconstruction. The stability of the anchor must therefore always be checked by an axial pull on the sutures before reattachment of the tendon. There are several methods to shuttle the sutures of the anchors through the tendon. On one hand this can be done by a lasso-type suture shuttling (e.g. cannulated needle), with an arthroscopic shuttling device (Clever Hock

[DePuy Synthes] or BirdBeak [Arthrex]) or with a suture passer needle. The perforation hole of arthroscopic penetrator device is obviously larger than a needle, although no comparative biomechanical studies are available. Another aspect that can make the operative procedure more difficult and may cause inadequate reconstruction is that by opening the rotator interval the soft tissue swelling increases with the operation time and can limit the overview especially in the ventral aspect of the shoulder. If there is no adequate chance of reconstruction of the tendon during preoperative planning, or the quality of the tendon is insufficient or the reduction of the tendon cannot be achieved during the operation, the rupture auf the SSC can be treated with pectoralis major muscle—or latissimus dorsi muscle transfer. After the surgical reconstruction, the patient is immobilized in a 30° abduction pillow for 4–6 weeks (depending on rupture size and tendon retraction) with no external rotation past neutral position or arm elevation above shoulder height. From week 4 to 12 passive stretching and subsequently active-assisted exercises are allowed. An aggressive passive mobilization without movement limit seems to go along with an increased risk of re-rupture compared to limited passive mobilization [12]. The aim of the reconstruction is to achieve the free mobility of the shoulder and sufficient function of the SSC (belly press test, Fig. 7.7).

7.4

Postoperative Pain and Shoulder Stiffness/ Range of Motion Limitation

If symptoms and function is not improved adequately approx. 3–6  months after surgical treatment, a new imaging (mostly magnetic resonance imaging) should be performed to objectify potential causes. Besides a re-rupture, a persisting instability or medialization/subluxation of the biceps tendon (s.c. Pulley lesion) is possible due to the close relationship of the SSC to the biceps tendon. Especially partial ruptures of the SSC tendon are often associated with lesions

7  Complications of Subscapularis Repair

a

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b

Fig. 7.7  Restorage of range of motion (a) and sufficient function of the SSC in the belly press test (b) after reconstruction of right SSC rerupture

a

b

Fig. 7.8  Tenodesis of the biceps tendon in lasso loop technique, before (a) and after (b) discontinuing from the glenoid

of the pulley [13]. Therefore, the stability and pathology of the biceps tendon should always be evaluated in the context of the reconstruction of the SSC tendon. In case of a Habermeyer stage II–IV lesion, a tenodesis or tenotomy of the long head of the biceps tendon (LHBT) should be performed in addition (Fig. 7.8).

The incidence of shoulder stiffness after reconstruction of the rotator cuff varies considerably in the literature between 0% and 25% [7, 14–17]. If a metabolic disease such as diabetes mellitus is present at the time of surgery, the incidence is particularly high. The cause for stiffness is an inflammation reaction and resulting

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fibrosis which leads to a contracture of the shoulder joint capsule. The low rate of stiffness after arthroscopic surgery is generally attributed to the low rate of soft tissue trauma with low inflammatory stimulus. In contrast, after open shoulder operations frequently scarring tissue around the subscapularis muscle is present. Patients describe mainly a restriction of elevation and external rotation of the arm and a disturbed night sleep [18]. The typical clinical manifestation is the passive and active limitation of range of movement, whereby there is a lack of an exact definition of the disease. Due to the often self-limiting character of shoulder stiffness, conservative therapy must initially be attempted [18]. It is important to inform the patient about the clinical symptoms and the expected process. The basis of the initial ­ conservative therapy is an antiphlogistic therapy with NSAIDs to reduce inflammation and relieve pain. Physiotherapy is an important component of conservative therapy, even though it can induct inflammation as a trigger. Therefore, even at an advanced stage, care must be taken to ensure that physiotherapy takes place below the individual pain level in order not to stimulate a progressive inflammatory reaction. In addition, the local, intra-articular therapy of a long-acting glucocorticoid in combination with a local anesthetic is known to be an important therapeutic approach. The injection should not be performed more than three times every 6–8 weeks to avoid damage to cartilage and tendon tissue. If there has been no improvement in mobility during conservative therapy, the option of operative arthrolysis should be evaluated. Manipulation under anesthesia (MUA) alone often leads to concomitant injuries and should be avoided due to the lack of controllability. Arthroscopic arthrolysis is therefore considered the procedure of choice today. In addition, movement restrictions after reconstruction of the rotator cuffs often occur in the context of peri- and postoperative, sometimes subclinical, infections. These will be further described in the next chapter.

7.5

Peri- and Postoperative Infection

A particularly severe complication, which is sometimes difficult to manage, is the postoperative infection. The incidence of peri- and postoperative infections after rotator cuff reconstruction is indicated by 0.44% and 2.45%, whereby the rate after arthroscopic procedures is significantly lower [19]. The diagnosis of an infection is often made within the first 3  weeks after the operation [20]. If a therapy resistant shoulder stiffness is present, a low grade infection must also be excluded, even if the blood test for inflammation is not very elevated. The most common potential pathogens are Staphylococcus aureus, Propionibacterium acnes and coagulase-negative Staphylococcus infections. In order to avoid peri- and postoperative infections, perioperative antibiotic treatment is recommended, whereby group I cephalosporins (β-lactam antibiotic; e.g. cefazoline) are often used [21]. If a postoperative infection is suspected, a physical examination in regard of infectious signs and a laboratory blood test (leukocyte counts and C-reactive protein level) must be done. The essential diagnostic is the puncture of the shoulder with determination of the number of cells and detection of the pathogen or even an arthroscopic biopsy with 3–5 samples. In case of an infection repetitive debridements (sometimes with resection of the bradytrophic rotator cuff) are therapeutically necessary until no remain pathogen is found. Furthermore, a consistent antibiotic therapy (initial intravenously, later orally) is necessary.

7.6

Deep Vein Thrombosis and Arterial Embolism

Venous thromboembolism (VTE) is a rare complication after rotator reconstruction. The incidence is indicated between 0.02% and 5.7% [22, 23]. Although there is a clear recommendation for prophylaxis during surgery of the lower extremity, this is not consistent in the case of the

7  Complications of Subscapularis Repair

upper extremity and should be handled individually [23]. In terms of arterial embolism after rotator cuff reconstruction, there exist only few case reports [24].

References 1. Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic shoulder surgery. Arthroscopy. 2002;18:88–95. 2. Rodeo SA, Forster RA, Weiland AJ.  Neurological complications due to arthroscopy. J Bone Joint Surg Am. 1993;75:917–26. 3. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy. 1988;4:215–21. 4. Moore DD, Maerz T, Anderson K.  Shoulder surgeons’ perceptions of interscalene nerve blocks and a review of complications rates in the literature. Phys Sportsmed. 2013;41:77–84. 5. Mall NA, Chahal J, Heard WM, et  al. Outcomes of arthroscopic and open surgical repair of isolated subscapularis tendon tears. Arthroscopy. 2012;28:1306–14. 6. Bartl C, Salzmann GM, Seppel G, et al. Subscapularis function and structural integrity after arthroscopic repair of isolated subscapularis tears. Am J Sports Med. 2011;39:1255–62. 7. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am. 2007;89:1184–93. 8. Elhassan BT, Cox RM, Shukla DR, et al. Management of failed rotator cuff repair in young patients. J Am Acad Orthop Surg. 2017;25:e261–e71. 9. Wellmann M, Wiebringhaus P, Lodde I, et  al. Biomechanical evaluation of a single-row versus double-­ row repair for complete subscapularis tears. Knee Surg Sports Traumatol Arthrosc. 2009;17:1477–84. 10. Grueninger P, Nikolic N, Schneider J, et  al. Arthroscopic repair of traumatic isolated subscapularis tendon lesions (Lafosse Type III or IV): a prospective magnetic resonance imaging-controlled case series with 1 year of follow-up. Arthroscopy. 2014;30:665–72. 11. Ide J, Karasugi T, Okamoto N, Taniwaki T, Oka K, Mizuta H.  Functional and structural comparisons of

71 the arthroscopic knotless double-row suture bridge and single-row repair for anterosuperior rotator cuff tears. J Shoulder Elbow Surg. 2015;24:1544–54. 12. Lee BG, Cho NS, Rhee YG. Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises. Arthroscopy. 2012;28:34–42. 13. Weishaupt D, Zanetti M, Tanner A, Gerber C, Hodler J. Lesions of the reflection pulley of the long biceps tendon. MR arthrographic findings. Invest Radiol. 1999;34:463–9. 14. Vastamaki H, Vastamaki M. Postoperative stiff shoulder after open rotator cuff repair: a 3- to 20-year follow-­up study. Scand J Surg. 2014;103:263–70. 15. Denard PJ, Ladermann A, Burkhart SS.  Prevention and management of stiffness after arthroscopic rotator cuff repair: systematic review and implications for rotator cuff healing. Arthroscopy. 2011;27:842–8. 16. Vezeridis PS, Goel DP, Shah AA, Sung SY, Warner JJ.  Postarthroscopic arthrofibrosis of the shoulder. Sports Med Arthrosc Rev. 2010;18:198–206. 17. Gerber C, Hersche O, Farron A.  Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am. 1996;78:1015–23. 18. Neviaser AS, Hannafin JA.  Adhesive capsulitis: a review of current treatment. Am J Sports Med. 2010;38:2346–56. 19. Hughes JD, Hughes JL, Bartley JH, Hamilton WP, Brennan KL.  Infection rates in arthroscopic versus open rotator cuff repair. Orthop J Sports Med. 2017;5:2325967117715416. 20. Kwon YW, Kalainov DM, Rose HA, Bisson LJ, Weiland AJ. Management of early deep infection after rotator cuff repair surgery. J Shoulder Elbow Surg. 2005;14:1–5. 21. Boyle KK, Duquin TR.  Antibiotic prophylaxis and prevention of surgical site infection in shoulder and elbow surgery. Orthop Clin North Am. 2018;49:241–56. 22. Jameson SS, James P, Howcroft DW, et  al. Venous thromboembolic events are rare after shoulder surgery: analysis of a national database. J Shoulder Elbow Surg. 2011;20:764–70. 23. Desai VS, Southam BR, Grawe B.  Complications following arthroscopic rotator cuff repair and reconstruction. JBJS Rev. 2018;6:e5. 24. Yamamoto T, Tamai K, Akutsu M, Tomizawa K, Sukegawa T, Nohara Y.  Pulmonary embolism after arthroscopic rotator cuff repair: a case report. Case Rep Orthop. 2013;2013:801752.

8

Complications in Posterosuperior and Three Tendon Rotator Cuff Repair Stefan Pauly and Markus Scheibel

8.1

Preoperative Complications

Rather than the term preoperative “complications”, it seems more appropriate to summarize critical issues and pitfalls beforehand a possible RC repair such as incomplete appreciation or mis-interpretation of preoperatively available information, thus leading to suboptimal or bad indications for any subsequent arthroscopy. Among those preoperative information, radiographic and clinical findings are of utmost relevance.

8.1.1 Radiographic/Diagnostic Tools Radiographic tools allow for assessment of several prognostic factors or predictors of RC repair outcomes. In particular, the MRI represents the

S. Pauly (*) Department for Special Orthopaedics and Trauma Surgery, Vivantes AVK, Berlin, Germany Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany e-mail: [email protected] M. Scheibel Center for Musculoskeletal Surgery, Charité Universitaetsmedizin Berlin, Berlin, Germany Schulthess Clinic, Zurich, Switzerland e-mail: [email protected]

gold standard in detecting and quantifying RC tears and RC muscle status. Parameters such as fatty muscle infiltration [1] can be estimated [2–5] and help anticipating a decreased outcome with increasing muscle atrophy or fatty infiltration. With longer standing RC tears, not just the muscle, but also the remaining tendon stump shorten over time. This remaining tendon stump length in combination with muscle fatty infiltration as determined in MRI can be useful to predict the fate of a reconstruction: While a low fatty infiltration and a tendon stump of >15  mm showed a retear rate below 25%, this value increased to over 90% of failure in cases of higher fatty infiltration with a short tendon stump (60–65 years [7, 14–16]. However, to date, patients from different age groups with arthroscopically manageable RC lesions are submitted to RC repair, and favorable clinical results have recently been described for RC repairs in elderly patients, even beyond the age of 65–70 years [17–20]. The same conflict of results is found when it comes to further demographic factors such as patients gender: a sex-related effect was advocated by some authors [10, 21], but others have found no such association [11, 13, 22, 23]. Beyond non-healing of the tendon, the risk of direct medical complications and hospital readmission is increased for male gender, increased age and medical comorbidities [24–27], which will be discussed later in the respective subchapter.

8.1.3 Approach, Indications, Informed Consent Choosing the surgical approach for indicated RC-repair, it should be noted that—despite comparable clinical outcomes—the general complication rate is significantly higher after (mini-) open compared to arthroscopic (ASC) procedures. In two studies with more than 10,000 patients each, the benefits of the ASC-group were a significantly lower rate of superficial and deep infection, a lower incidence of return to the operating room within 30  days, and a lower risk of hospital readmission [24, 25]. Ignoring clinical problems and concomitant side pathologies, such as AC-arthritis, subacromial impingement, LHB instability, concomitant stiffness, etc. before ASC will most likely lead to their insufficient therapy, possibly resulting in deteriorated overall patient satisfaction postoperatively. Finally, incomplete patient information and/or incomplete written informed consent regarding treatment of such concomitant pathologies (such as LHB tenotomy or partial RC repair) should be avoided before scheduled RC repair.

8.2

Intraoperative Complications

Many intra- and postoperative complications during RC repair are overlapping with general complications during and following arthroscopic

8  Complications in Posterosuperior and Three Tendon Rotator Cuff Repair

shoulder surgery and have been introduced over the respective chapters in this book. As stated earlier, these occur in 5–10% of cases and include— among the acute ones—instrument breakage, hardware failure, fluid extravasation [28]. Further intraoperative factors are incorrect portal placement, iatrogenic lesions to cartilage or bone, or even to the suprascapular nerve during scope introduction or extensive RC tendon mobilization. Some other complications are more specific to RC-repair and therefore should be regarded more detailed: Suture anchor pullout strength generally depends on quality of the bone, the inclination of the anchor and the friction of the anchor-bone interface [29]. Acute anchor loosening may occur in cases of severe osteopenia/osteoporosis of the trabecular structures underneath the footprint. For RC-intact

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shoulders, age >70 years and female gender predispose for tuberosity osteopenia [30]. But particularly in long(er) standing retracted RC tears and ongoing chronicity, significantly higher osteopenic changes occur in the greater tuberosity [31], which negatively affect anchor pullout strength. Caution should be exerted during tuberosity decortication with a burr, since matched-pair analyses revealed a significantly decreased pullout strength after this procedure [32]. This fact should also be remembered before microfracturing (or “Crimson duvet”-techniques) at the footprint. If weak bone is assumed, the surgeon can establish the bone socket for the anchor by pushing the awl manually to get a feel for the bone strength. To finally assess the anchor stability before RC-perforation, a sincere pull on the suture tails in the direction of load may help to verify a stable setting (Fig. 8.2).

a

b

c

d

e

f

Fig. 8.2  Large posterolateral RC tear following an infection and previous anchor removal (a), with (b) a remaining crater-like bone socket. (c, d) During revision, a new threaded suture anchor is applied in a new 90° angle adjacent to the lateral border of the previous socket, however,

did not provide enough stability under tension. (e) Dimension of the medial-row crater after breakout; (f) final RC re-reconstruction with a knotless single-row construct laterally fixed

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If the awl for anchor socket placement was used too firmly or in a wrong direction, it is possible to break into humeral head cartilage (if the insertion angle is oriented too horizontal) or to cause an iatrogenic fracture of the greater tuberosity (if the insertion angle is too vertical). For several reasons, mostly for load transmission after RC refixation, an insertion angle of about 45° was proposed (“deadman’s angle”) [33]. However, Itoi et  al. suggested that this calculation is not always applicable because of bone deformation and that a threaded anchor should be inserted at 90° [29]. Recent biomechanical analyses suggest that the use of all-suture anchors in the setting of RC repair and possibly weaker bone at the tuberosity is associated with high rates of anchor pullout, decreased failure load and increased displacement when compared to traditional threaded suture anchors [34]. These results suggest the use of other than all-suture anchors for RC repair or to restrict their use for the medial-row. Another potentially fatal iatrogenic complication is mis-placement of suture anchors, obviously by mis-understanding “extraanatomical medialization” of anchor placement. Figure  8.3 shows MRI- and intraoperative pictures of a patient with ongoing complaints following a “RC repair” with metal anchor placed centrally in the humeral head cartilage. Proper suture management is one key to successful RC repair. Bundles of suture limbs

originating from the same anchor should be kept together with external clamps etc. to maintain overview over their respective relations and for prevention of bacterial adherence (see the later section low-grade infections). In order to avoid eyelet-pullout during suture passages, the anchor bottom should be visualized during suture strand pull in order to confirm handling the appropriate end of it. A lost suture usually cannot be reinserted to the anchor. Hence, the anchor must be used with the remnant suture as “single-loaded” and/or be replaced with a new one. Tendon-suture interface cut-out can occur with current strong synthetic suture materials placed through rather weak and degenerative RC tendon tissue. To prevent such, it is safer to resign tying down sliding knots with long suture limb travelling distances through the tendon, and to rather tie direct knots using a knot pusher/sixth finger®.

Fig. 8.3  MRI scans and intraoperative finding of a patient with ongoing problems after allegedly ASC RC-repair 6 months before. The anchors were applied in the central

portion of the humeral cartilage. It was removed with no option of re-repair given the meanwhile irreparable character of the cuff tear

8.3

Immediate Postoperative Complications

Among summarized shoulder arthroscopy complications in general (5–10% of cases), infection, stiffness, deep venous thrombosis are typically postoperative ones [28]. As summarized before, factors such as higher age, female gender and particularly chronic RC-tears predispose for osteopenic tuberosities

8  Complications in Posterosuperior and Three Tendon Rotator Cuff Repair

with higher rates of suture anchor loosening. In this setting, not just acute, but also subacute or postoperative anchor loosening may occur. Very early metal anchor loosening (as assessed by X-ray in >5700 patients) revealed a rate of 0.1%, however, follow up was done at the day of surgery [35]. Depending on the duration of follow-­up, others found rates between 0.01% and 3% of anchor loosening [36]. Ongoing patientreported discomfort and/or scratching noise should lead to further diagnostics. Depending on the anchor body material, ultrasound, X-ray or MRI will help to identify a displaced anchor (Fig.  8.4). While in the majority of cases simple anchor removal is sufficient (Figs.  8.5 and 8.6), re-repair of the non-healed RC-tendon can become necessary. Acute infections are among the most adverse surgery-related complications. With this regard, arthroscopic RC surgery generally shows a better complication profile than (mini-) open RC

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repair by means of a lower rate of superficial and deep infection as well as a generally lower incidence of return to the operating room within 30  days [24, 25]. Further risk factors for complications include patient age >65 and operative time >90 min [24]. The early surgical complication rate following ca. 3000 ASC RC repairs was 0.9%, with superficial- and deep infection in 0.1%, respectively [25]. Yeranosian et al. analyzed >165,000 shoulder arthroscopies and found significantly different risks of postoperative infections within 30 days between different ASC procedures, with the highest incidence following RC repair in 0.29% of cases [27]. Other authors describe the incidence of deep infections following RC repair in 0.3–1.9% of cases, suggesting a possibly even higher rate since many cases may remain undetected or unreported [37]. The most frequently detected pathogens are Propionibacterium acnes, Staphylococcus epidermidis, and Staphylococcus

a

b

c

d

e

f

Fig. 8.4 (a) Ultrasound-proof of a partially dislocated resorbable suture anchor, (b, c) subsequent ASC identification and removal with an intact previously repaired RC-tendon. (d) MRI-proof of a dislocated anchor, (e)

intraoperative finding of a partially resorbed bio-anchor; (f) X-ray proof of a dislocated lateral-row suture anchor with a metal core

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a

b

c

d

e

f

g

h

Fig. 8.5 (a) Initial intraoperative pictures of a bursal sided flap tear at the time of repair with a knotless technique: (b) four suture strands are passed and fixed with (c) a knotless anchor, resulting in (d) an anatomic repair. Four months later, the patient suffered sudden pain and a scratching sensation in her shoulder. (e) Re-MRI showed

a

b

loosening of the anchor towards the deltoid fascia. (f) Intact reconstruction and integrated sutures at 4  months after RC repair. Suture material was left in place, samples for microbiological analysis were obtained. (g, h) Meanwhile, the threaded anchor had migrated into the deltoid facia and was retrieved

d

c

Fig. 8.6 (a) The prominence of one metal suture anchor had caused secondary impingement and erosion to the lateral acromion edge. (b, c) Intraoperative pictures show the integrity of the surrounding RC, hence, only the promi-

nent anchor was removed and the lateral acromion gently decompressed. (d) Final situation under intraoperative fluoroscopy control without any remaining mechanical conflict

aureus. Management in these cases involves thorough surgical debridement, removal of artificial materials (such as suture anchors), extensive lavage and usually long-term intravenous antibiotic treatment fitted to the identified pathogen. Although deep shoulder infection

after RCR is usually successfully treated with few lavage(s), complications of this condition can be ­devastating. Prolonged course of intravenous antibiotic treatment, extensive soft-tissue destruction and adhesions may result in substantially diminished functional outcomes [37].

8  Complications in Posterosuperior and Three Tendon Rotator Cuff Repair

Several other authors have assessed large datasets of RC repair cases for their complication profile within the first 30  days after surgery. Schairer et  al. overlooked >23,000 patients, 1.39% of which experienced at least 1 complication (0.85% major vs. 0.66% minor complications). Again, infection was the most common surgery-related complication (in 0.3% of patients) and was the most common reason for return to the operating room. Other major complications had a non-surgical focus, such as urinary tract infection, pulmonar embolism and pneumonia) [26]. Following more than 18,000–20,000 outpatient RC repairs, 0.7–1% of these patients needed readmission to the hospital for cardiovascular, infectious, and respiratory indications. Factors such as higher age (>80), COPD, hypertension and an ASA classification of >2 were identified as major prognosticators for readmission [38, 39]. With these circumstances in mind, (out-)patients for RC repair should be selected carefully.

8.4

Middle-/Long Term Complications

The rates of anchor dislocations and acute infections following ASC RC repair has been introduced in the previous section. Almost every immobilization period following RC repair is followed by a temporary stiffness of the shoulder. But what exactly is a “stiffness”, how long could it physiological and acceptable and when should it be overcome? Beyond stiffness—what can be considered (yet) normal) in the postoperative course, and where does a complication begin? As stated in the introduction, there is no reliable definition of a surgical complication. The literature does not consistently define and report on items such as “stiffness” or “infection” following RC repair, which hinders objective comparison of their incidence in the available literature [40]. Brislin et  al. assessed n = 263 patients following RC repair with a specific complication rate of 10.6%, whereas pro-

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longed stiffness was the key symptom [28]. At the same time, prolonged stiffness can be the clinical key finding in cases of low-­grade infections, that are (1) poorly defined and (2) do typically not develop the symptoms of obvious deep infections. There is a smooth transition between both pathologies and therefore certainly a high rate of undetected cases. Horneff et  al. revised n = 68 patients for ongoing pain or stiffness following shoulder ASC and found proof of p. acnes in 23.5% of cases. An own series over 169 revision cases >12  months after index arthroscopy patients revealed the highest incidence of bacteria after application of synthetic materials suture materials and in cases of non-specific shoulder pain or stiffness (50–63%) when compared to a recurrent pathology of the shoulder (such as a re-tear) (Pauly et al. SECEC 2017). This seems plausible since strong bacterial adherence and biofilm formation has been reported with regard to currently available synthetic suture materials [41]. For these cases, the same treatment as for acute infections seems reasonable: thorough irrigation, removal of synthetic materials if possible, and biofilm-targeting antibiotic treatment for 6–12 weeks. The knowledge of low-grade infections, even though still limited, should have implications on the intraoperative handling of any synthetic suture or anchor applied. Numerous studies have assessed the percentage of re-tears following single- or double row RC repairs. In summary, retear rates of 5–95% were described and must be anticipated in the range of 23–30%, depending on several intrinsic and extrinsic factors. Despite the improved footprint reconstruction [42–44] and improved biomechanical properties as obtained with double row repairs [45–50], the operating time and expenses are higher than for single row repairs. Currently available clinical studies have not demonstrated significantly improved results of this approach [51– 57]. Improved radiographic integration, but not ­superior clinical results were reported for double row repairs in massive tears [51, 58–61].

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Re-tears following Double row repairs may occur as 1. tendon elongation (”failure in continuity” [62]), 2. real re-tears or non-healing to the point of anatomic refixation [53, 63] as well as 3. “medial cuff failure” adjacent to the medial row anchor [64–66], which was observed after introduction of double row repairs. Of importance, RC re-tears do not preclude positive functional results [9], even though improved function in patients with complete healing has been reported [67]. Recent studies and meta-analyses found no significant differences in clinical scores between intact and non-healed groups, but did identify increased muscle strength for the healed repairs [68–70]. It seems possible that the effect of subacromial decompression, bursectomy or additional long head biceps management alone may contribute to clinical improvement by way of pain relief and improved active motion in these patients. This should be considered before indication re-repair of the RC.

References 1. Goutallier D, Postel JM, Bernageau J, et  al. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994:78–83. 2. Fuchs B, Weishaupt D, Zanetti M, et  al. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8:599–605. 3. Gladstone JN, Bishop JY, Lo IK, et al. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med. 2007;35:719–28. 4. Goutallier D, Postel JM, Gleyze P, et al. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg. 2003;12:550–4. 5. Shen PH, Lien SB, Shen HC, et al. Long-term functional outcomes after repair of rotator cuff tears correlated with atrophy of the supraspinatus muscles on magnetic resonance images. J Shoulder Elbow Surg. 2008;17:1S–7S.

S. Pauly and M. Scheibel 6. Meyer DC, Farshad M, Amacker NA, et  al. Quantitative analysis of muscle and tendon retraction in chronic rotator cuff tears. Am J Sports Med. 2012;40:606–10. 7. Boileau P, Brassart N, Watkinson DJ, et  al. Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. 2005;87:1229–40. 8. Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury. 2008;39:1338–44. 9. Defranco MJ, Bershadsky B, Ciccone J, et  al. Functional outcome of arthroscopic rotator cuff repairs: a correlation of anatomic and clinical results. J Shoulder Elbow Surg. 2007;16:759–65. 10. Grasso A, Milano G, Salvatore M, et  al. Single-row versus double-row arthroscopic rotator cuff repair: a prospective randomized clinical study. Arthroscopy. 2009;25:4–12. 11. Milgrom C, Schaffler M, Gilbert S, et al. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br. 1995;77:296–8. 12. Sorensen AK, Bak K, Krarup AL, et al. Acute rotator cuff tear: do we miss the early diagnosis? A prospective study showing a high incidence of rotator cuff tears after shoulder trauma. J Shoulder Elbow Surg. 2007;16:174–80. 13. Yamaguchi K, Ditsios K, Middleton WD, et  al. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88:1699–704. 14. Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained? Am J Sports Med. 2011;39:2108–16. 15. Gumina S, Carbone S, Campagna V, et al. The impact of aging on rotator cuff tear size. Musculoskelet Surg. 2013;97(Suppl 1):69–72. 16. Kamath G, Galatz LM, Keener JD, et  al. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am. 2009;91:1055–62. 17. Flurin PH, Hardy P, Abadie P, et  al. Rotator cuff tears after 70 years of age: a prospective, randomized, comparative study between decompression and arthroscopic repair in 154 patients. Orthop Traumatol Surg Res. 2013;99:S371–8. 18. Pauly S, Stahnke K, Klatte-Schulz F, et al. Do patient age and sex influence tendon cell biology and clinical/ radiographic outcomes after rotator cuff repair? Am J Sports Med. 2015;43:549–56. 19. Robinson PM, Wilson J, Dalal S, et  al. Rotator cuff repair in patients over 70 years of age: early outcomes and risk factors associated with re-tear. Bone Joint J. 2013;95-B:199–205. 20. Verma NN, Bhatia S, Baker CL 3rd, et al. Outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older. Arthroscopy. 2010;26:1273–80.

8  Complications in Posterosuperior and Three Tendon Rotator Cuff Repair 21. Chung SW, Oh JH, Gong HS, et al. Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors. Am J Sports Med. 2011;39:2099–107. 22. Osti L, Papalia R, Del Buono A, et  al. Comparison of arthroscopic rotator cuff repair in healthy patients over and under 65 years of age. Knee Surg Sports Traumatol Arthrosc. 2010;18:1700–6. 23. Tashjian RZ, Hollins AM, Kim HM, et  al. Factors affecting healing rates after arthroscopic double-­ row rotator cuff repair. Am J Sports Med. 2010;38:2435–42. 24. Day M, Westermann R, Duchman K, et  al. Comparison of short-term complications after rotator cuff repair: open versus arthroscopic. Arthroscopy. 2018;34:1130–6. 25. Owens BD, Williams AE, Wolf JM.  Risk factors for surgical complications in rotator cuff repair in a veteran population. J Shoulder Elbow Surg. 2015;24:1707–12. 26. Schairer WW, Nwachukwu BU, Fu MC, et  al. Risk factors for short-term complications after rotator cuff repair in the united states. Arthroscopy. 2018;34:1158–63. 27. Yeranosian MG, Arshi A, Terrell RD, et al. Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery. Am J Sports Med. 2014;42:437–41. 28. Brislin KJ, Field LD, Savoie FH 3rd. Complications after arthroscopic rotator cuff repair. Arthroscopy. 2007;23:124–8. 29. Itoi E, Nagamoto H, Sano H, et al. Deadman theory revisited12. Biomed Mater Eng. 2016;27:171–81. 30. Clavert P, Bouchaib J, Sommaire C, et al. Does bone density of the greater tuberosity change in patients over 70? Orthop Traumatol Surg Res. 2014;100:109–11. 31. Cadet ER, Hsu JW, Levine WN, et al. The relationship between greater tuberosity osteopenia and the chronicity of rotator cuff tears. J Shoulder Elbow Surg. 2008;17:73–7. 32. Hyatt AE, Lavery K, Mino C, et al. Suture anchor biomechanics after rotator cuff footprint decortication. Arthroscopy. 2016;32:544–50. 33. Burkhart SS. The deadman theory of suture anchors: observations along a south Texas fence line. Arthroscopy. 1995;11:119–23. 34. Nagra NS, Zargar N, Smith RD, et  al. Mechanical properties of all-suture anchors for rotator cuff repair. Bone Joint Res. 2017;6:82–9. 35. Skaliczki G, Paladini P, Merolla G, et al. Early anchor displacement after arthroscopic rotator cuff repair. Int Orthop. 2015;39:915–20. 36. Desai VS, Southam BR, Grawe B.  Complications following arthroscopic rotator cuff repair and reconstruction. JBJS Rev. 2018;6:e5. 37. Atesok K, Macdonald P, Leiter J, et al. Postoperative deep shoulder infections following rotator cuff repair. World J Orthop. 2017;8:612–8. 38. Heyer JH, Kuang X, Amdur RL, et  al. Identifiable risk factors for thirty-day complications following

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arthroscopic rotator cuff repair. Phys Sportsmed. 2018;46:56–60. 39. Kosinski LR, Gil JA, Durand WM, et  al. 30-Day readmission following outpatient rotator cuff repair: an analysis of 18,061 cases. Phys Sportsmed. 2018;46:466–70. 40. Audige L, Blum R, Muller AM, et al. Complications following arthroscopic rotator cuff tear repair: a systematic review of terms and definitions with focus on shoulder stiffness. Orthop J Sports Med. 2015;3:2325967115587861. 41. Masini BD, Stinner DJ, Waterman SM, et  al. Bacterial adherence to high-tensile strength sutures. Arthroscopy. 2011;27:834–8. 42. Brady PC, Arrigoni P, Burkhart SS.  Evaluation of residual rotator cuff defects after in vivo single- versus double-row rotator cuff repairs. Arthroscopy. 2006;22:1070–5. 43. Mazzocca AD, Millett PJ, Guanche CA, et  al. Arthroscopic single-row versus double-row suture anchor rotator cuff repair. Am J Sports Med. 2005;33:1861–8. 44. Meier SW, Meier JD. Rotator cuff repair: the effect of double-row fixation on three-dimensional repair site. J Shoulder Elbow Surg. 2006;15:691–6. 45. Ma CB, Comerford L, Wilson J, et al. Biomechanical evaluation of arthroscopic rotator cuff repairs: double-­ row compared with single-row fixation. J Bone Joint Surg Am. 2006;88:403–10. 46. Meier SW, Meier JD.  The effect of double-row fixation on initial repair strength in rotator cuff repair: a biomechanical study. Arthroscopy. 2006;22:1168–73. 47. Pauly S, Fiebig D, Kieser B, et  al. Biomechanical comparison of four double-row speed-bridging rotator cuff repair techniques with or without medial or lateral row enhancement. Knee Surg Sports Traumatol Arthrosc. 2011;19:2090–7. 48. Pauly S, Kieser B, Schill A, et al. Biomechanical comparison of 4 double-row suture-bridging rotator cuff repair techniques using different medial-row configurations. Arthroscopy. 2010;26:1281–8. 49. Smith CD, Alexander S, Hill AM, et al. A biomechanical comparison of single and double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am. 2006;88:2425–31. 50. Waltrip RL, Zheng N, Dugas JR, et  al. Rotator cuff repair. A biomechanical comparison of three techniques. Am J Sports Med. 2003;31:493–7. 51. Chen M, Xu W, Dong Q, et al. Outcomes of single-­ row versus double-row arthroscopic rotator cuff repair: a systematic review and meta-analysis of current evidence. Arthroscopy. 2013;29:1437–49. 52. Dehaan AM, Axelrad TW, Kaye E, et al. Does double-­ row rotator cuff repair improve functional outcome of patients compared with single-row technique? A systematic review. Am J Sports Med. 2012;40:1176–85. 53. Pauly S, Gerhardt C, Chen J, et  al. Single versus double-row repair of the rotator cuff: does double-row repair with improved anatomical and biomechanical

82 characteristics lead to better clinical outcome? Knee Surg Sports Traumatol Arthrosc. 2010;18:1718–29. 54. Perser K, Godfrey D, Bisson L.  Meta-analysis of clinical and radiographic outcomes after arthroscopic single-­ row versus double-row rotator cuff repair. Sports Health. 2011;3:268–74. 55. Prasathaporn N, Kuptniratsaikul S, Kongrukgreatiyos K.  Single-row repair versus double-row repair of full-thickness rotator cuff tears. Arthroscopy. 2011;27:978–85. 56. Saridakis P, Jones G.  Outcomes of single-row and double-row arthroscopic rotator cuff repair: a systematic review. J Bone Joint Surg Am. 2010;92:732–42. 57. Sheibani-Rad S, Giveans MR, Arnoczky SP, et  al. Arthroscopic single-row versus double-row rotator cuff repair: a meta-analysis of the randomized clinical trials. Arthroscopy. 2013;29:343–8. 58. Denard PJ, Jiwani AZ, Ladermann A, et al. Long-term outcome of arthroscopic massive rotator cuff repair: the importance of double-row fixation. Arthroscopy. 2012;28:909–15. 59. Duquin TR, Buyea C, Bisson LJ.  Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic review. Am J Sports Med. 2010;38:835–41. 60. Xu C, Zhao J, Li D.  Meta-analysis comparing single-­row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears. J Shoulder Elbow Surg. 2014;23:182–8. 61. Zhang Q, Ge H, Zhou J, et al. Single-row or double-­ row fixation technique for full-thickness rotator cuff tears: a meta-analysis. PLoS One. 2013;8:e68515.

S. Pauly and M. Scheibel 62. Mccarron JA, Derwin KA, Bey MJ, et  al. Failure with continuity in rotator cuff repair “healing”. Am J Sports Med. 2013;41:134–41. 63. Scheibel M.  Recurrent defects of the rotary cuff: causes and therapeutic strategies. Oper Orthop Traumatol. 2012;24:458–67. 64. Hayashida K, Tanaka M, Koizumi K, et  al. Characteristic retear patterns assessed by magnetic resonance imaging after arthroscopic double-row rotator cuff repair. Arthroscopy. 2012;28:458–64. 65. Trantalis JN, Boorman RS, Pletsch K, et  al. Medial rotator cuff failure after arthroscopic double-row rotator cuff repair. Arthroscopy. 2008;24:727–31. 66. Yamakado K, Katsuo S, Mizuno K, et  al. Medial-­ row failure after arthroscopic double-row rotator cuff repair. Arthroscopy. 2010;26:430–5. 67. Charousset C, Bellaiche L, Kalra K, et al. Arthroscopic repair of full-thickness rotator cuff tears: is there tendon healing in patients aged 65 years or older? Arthroscopy. 2010;26:302–9. 68. Kim KC, Shin HD, Lee WY.  Repair integrity and functional outcomes after arthroscopic suturebridge rotator cuff repair. J Bone Joint Surg Am. 2012;94:e48. 69. Russell RD, Knight JR, Mulligan E, et al. Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis. J Bone Joint Surg Am. 2014;96:265–71. 70. Slabaugh MA, Nho SJ, Grumet RC, et  al. Does the literature confirm superior clinical results in radiographically healed rotator cuffs after rotator cuff repair? Arthroscopy. 2010;26:393–403.

9

Complications of Superior Capsular Reconstruction Stefan Greiner and Leonard Achenbach

9.1

Introduction

Management of symptomatic non-reparable rotator cuff tears in young patients is extremely challenging and treatment options are still discussed controversial. Therapeutic options for joint preservation include surgical and nonsurgical treatment options. Several surgical techniques have been proposed to address this condition, such as arthroscopic debridement, biceps tenotomy or tenodesis, partial rotator cuff repair, patch augmentation, tendon transfers, superior capsular reconstruction and reverse total shoulder arthroplasty. Of these, the option of superior capsular reconstruction (SCR) represents a new technique to address non-reparable postero-superior tears of the rotator cuff. It first has been described by Mihata et al. in 2013 and it aims to reconstruct the posterosuperior capsule and thereby re-center the humeral head in the glenoid fossa during shoulder movements. First subjective and objective results of this technique have been promising, however no long-term follow-up study evaluating patient outcome exists so far [1–3]. The purpose of this chapter is to indicate complications regarding this treatment option. S. Greiner (*) · L. Achenbach Sporthopaedicum Regensburg-Straubing, Regensburg, Germany e-mail: [email protected]

9.2

Preoperative Complications/ Failure Because of Patient Selection

No consensus has yet been found which patients are suitable and will benefit the most from this operation technique. The technique with its respective indication was first described in 2013 and different authors have presented different indications for this technique. However, possible complications and failure of these techniques are likely associated with wrong patient selection. In case of shoulder pain in presence of a non-­ reparable postero-superior rotator cuff tear, SCR can be considered as a treatment of choice. However, preoperative X-rays should be checked in order to determine signs of advanced osteoarthritis, which represents a contraindication for this technique. Surgeons should be aware that, although current literature has shown promising results also in patients with complete tear of the infraspinatus muscle, superior results could be achieved in patients with partially intact infraspinatus tendons [1]. An intact teres minor muscle is mandatory for clinical success of this technique. Accordingly, clinical examination should not show a positive hornblower sign or an external rotation lag of more than 20°. Since the SCR addresses only the postero-superior part of the

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_9

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capsule, the anterior structures, the subscapularis muscle should be intact or at least reparable. To avoid failure as a result of wrong patient selection the following requirements should be assured: Clinical examination: Preoperatively there should be no pseudoparalysis of the shoulder. External rotation lag sign 20° – Concomitant non-repairable subscapularis tear – Pseudoparalysis of the shoulder

for

superior

capsular

Initially described indication [1] Non-reparable RC tear: “torn tendon cannot reach to the original footprint” during shoulder arthroscopy

– Every bone deformity (Mihata grade 5) – Severe superior migration of the humeral head that does not move by traction of the arm – Cervical or axillary nerve palsy – Deltoid muscle dysfunction – Infection

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9.3.1 Preparation of Glenoid and Humerus The patient is positioned in the beach-chair position. The arm is maintained comfortably at the patient’s side (“neutral abduction”) and in neutral rotation. At the beginning of the operation, arthroscopic portals are established to evaluate the status of the glenohumeral joint and to confirm clinical and MRI findings. An attempt is made to repair as much of the rotator cuff as possible, i.e. the infraspinatus and subscapularis tendons. Since the long head of the biceps tendon or pulley complex is usually involved, a biceps tenodesis or tenotomy is performed. First, the superior scapular bone medial to the superior glenoid rim is debrided using the shaver and the burr in order to create a bony bed for medial fixation of the patch graft. Second, the insertion zone of the torn rotator cuff tendons of the major tuberosity is debrided and prepared. Possible complications can be an injury to the suprascapular nerve while debriding the superior scapular bone. Care must be taken to visualize the instruments during debridement and to avoid to be to medial in order to protect the nerve. Excessive bony debridement in combination with poor bone quality can lead to later anchor pull out and should be avoided. According to the anatomy of the scapula, patient-individual approaches are used for placing two 3.0 double loaded suture anchors in the superior scapular bone in front of the base of the coracoid and at the medial border of the still intact posterior rotator cuff. According to the patients’ individual anatomy, the ideal approaches can be an anterosuperior approach, the Neviaser portal or a posterosuperior portal. Possible complications can be anchor malpositioning and pull out. The authors recommend to simulate each Portal with a spinal needle and to check for later anchor insertion angle in order to prevent these complications. Care must be taken

Fig. 9.2  Perforation of the cartilaginous surface of the glenoid due to drilling in a too much lateral directed way for the glenoidal anchors

to place the drill holes of the anchors in a medial towards the bone of the scapula directed way in order to prevent perforation of the cartilaginous surface of the glenoid (Fig. 9.2). Then two 4.75-mm Anchors loaded with both, FiberTapes and 2.0 Fibre wires are placed at the cartilage bone junction of the greater tuberosity both anteriorly and posteriorly. The anterior anchor is placed posterior to the biceps groove. After evaluation of the flexibility of the remaining posterior cuff, the posterior anchor is placed in the posterior part of the greater tuberosity in order to allow repair and shift of the upper part of the remaining infraspinatus tendon. The Fibre wire of this anchor is then used to partially repair and shift the infraspinatus tendon to the greater tuberosity and thereby decrease the size of the tear. By use of an intra-articular measurement device the distance between each of the anchors is measured (Fig. 9.3a–c). The individual anchors serve hereby as landmarks to determine the size of the patch in coronal plane and in sagittal plane both medially and laterally. Laterally 1.0  cm

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a

b

c

Fig. 9.3 (a–c) Arthroscopic view: measurement for graft sizing and preparation

patch length is added in order to cover the footprint of the major tuberosity. Arm positioning during measurement of the medio-lateral distance plays an important role. Excessive abduction can lead to an undersized measurement and thereby later to overtensioning of the patch and failure of the reconstruction. The author recommends an abduction angle between 10° and 30° and neutral rotation in order to prevent this problem.

All suture strands are then retreated through the same lateral portal. Possible complications of this step may be soft tissue bridges and suture tangling which will make passing of the patch in the joint impossible (Fig.  9.4). It is therefore important to check that no soft-tissue has been twisted into the suture strands to allow the patch to be pulled through the lateral portal. Moreover it is crucial to avoid suture tangling (Fig. 9.5).

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According to the arthroscopic measurement, a doubled acellular dermal porcine xenograft patch is prepared. The two layers are then sewed together by means of a continuous absorbable suture (Fig. 9.6a, b). Since this acellular dermal graft is very rigid, needle breakage can occur while suturing the both layers together. Each suture end of the medial double loaded anchors is then shuttled through the patch. This will result in two fiber pairs for each medial anchor. The FiberTape suture strands from the placed anchors are then shuttled through the lateral edge of the patch according to the measured distance of the medial anchors to the cartilage bone border of the major tuberosity. Again, the most common complication of this step may be suture tangling. Fig. 9.4  Arthroscopic view of all anchors and corresponding sutures in place

Fig. 9.5  Suture management after insertion of all anchors

9.3.2 Patch Preparation Different patches have been described for use to reconstruct the superior capsule. Mihata et  al. described a fascia lata autograft [1]. To decrease the morbidity of the donor site, recent literature reports the use of a synthetic patch, dermal allograft or long head of biceps autograft [1, 7, 8]. The authors’ choice is either a porcine xenograft or dermal allograft, which will be explained in detail.

9.3.3 Medial Fixation The two most central suture strands of each medial anchor are then tied together in order to create a pulley to shuttle the graft into the joint. The patch is rolled upwards and then introduced into the joint with help of a blunt hemostat and by pulling at the free ends of each suture forming the pulley at the same time. This is best visualized placing the arthroscope in the antero-superior portal. The patch is then flattened out by help of a grasper. The remaining sutures from each corner of the patch are retrieved through the corresponding portals and are tied together, fixing the patch to the medial glenoid rim. Finally, the free suture limbs of the pulley are tied together forming a double pulley in the middle. This can be a very complicated step. Soft tissue bridges, suture tangling, anchor failure and pullout or an over or undersized graft may now lead to failure of the technique and each of these complication may lead to the impossibility to continue with the procedure (Fig. 9.7).

9.3.4 Lateral Fixation The Fibre Tapes are tensioned and the graft is thereby pressed to the footprint area of the greater

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a

b

Fig. 9.6 (a, b) Graft preparation

Fig. 9.7  Suture passing and graft preparation

tuberosity. One tape of each anchor is criss crossed and pulled over the remaining lateral stump of the graft pressing the graft thereby to the prepared footprint. Using two additional 4.75 knotless anchors, the tapes are fixed laterally to the graft at the major tuberosity. Finally, the remnants of the infraspinatus tendon are fixed to the posterior border of the graft in a side to side fashion using 2.0 Fibre wires (Fig. 9.8).

Fig. 9.8  Arthroscopic view of a left shoulder from posterior portal. Lateral fixation of the SCR

9.4

Postoperative Management

After surgery, patients must be provided basic postoperative management, which includes wound check, removal of sutures and prescrip-

9  Complications of Superior Capsular Reconstruction

tion of pain medication, if needed. Patients should remain in a sling with 30° shoulder abduction for 6 weeks with no active shoulder motion allowed. Starting from the 4th week, passive assisted mobilisation can be started with flexion and abduction limited to 60°. The sling can be removed at 6 weeks and free passive and active assisted mobilisation is initiated. External rotation strength exercises should be trained from 12  weeks on. This management scheme has to be adapted to the profile of the patient and possible changes of the operation, such as subscapularis reattachments and biceps tenodesis or tenotomy.

Fig. 9.9  MRI of a left shoulder with intact patch graft

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9.5

Complications

Besides standard complications such as infection, shoulder stiffness and re-tear (Fig.  9.10), specific complications may include penetration of the glenoid fossa due to wrong angle positioning while drilling the medial glenoidal anchors. Care must be taken to avoid this complication by optimal angulation of the drill and optimal portal positioning for drilling the medial anchors according to the patients individual anatomy. Postoperative MRI evaluation remains difficult due to the double layer technique and the thickness of the graft (Fig. 9.9), however a clear tear of the patch can easily be diagnosed (Fig. 9.10).

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References

Fig. 9.10  MRI of a right shoulder with lateral tear of the patch graft and subsequent cranialization of the humeral head

9.6

Conclusion

The superior capsular reconstruction represents a promising new technique that offers a treatment option for young patients with non-reparable postero-superior rotator cuff tears. It reliably decreases pain and restores functionality. However, midterm and long-term results are still lacking due to its recent introduction and more research is needed to confirm the promising first results.

1. Mihata T, Lee TQ, Watanabe C, et  al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013;29(3):459–70. 2. Mihata T, McGarry MH, Pirolo JM, et  al. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears. Am J Sports Med. 2012;40(10):2248–55. 3. Mihata T, McGarry MH, Kahn T, et al. Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon. Am J Sports Med. 2016;44(6):1423–30. 4. Bayne O, Bateman J.  Long-term results of surgical repair of full-thickness rotator cuff tears. In: Bateman JE, Welsh R, editors. Surgery of the shoulder. Philadelphia: CV Mosby; 1984. 5. Patte D.  Classification of rotator cuff lesions. Clin Orthop. 1990;(254):81–6. 6. Goutailler D, Postel J, Bernageau J, et  al. Fatty muscle degeneration in cuff ruptures: pre and postoperative evaluation by CT scan. Clin Orthop. 1994;(304):78–83. 7. Gupta AK, Hug K, Boggess B, et  al. Massive or 2-­tendon rotator cuff tears in active patients with minimal glenohumeral arthritis: clinical and radiographic outcomes of reconstruction using dermal tissue matrix xenograft. Am J Sports Med. 2013;41:872–9. 8. Boutsiadis A, Chen S, Jiang C, et  al. Long head of biceps as a suitable available local tissue autograft for superior capsular reconstruction: “the Chinese way”. Arthrosc Tech. 2017;6(5):e1559–66.

Complications in Tendon Transfers

10

Daniel Henderson and Simon Boyle

10.1 Introduction

As the field of shoulder surgery has progressed, so too has the understanding of the role of tendon There has been a resurgence of interest in upper transfers around the shoulder. This has led to the limb tendon transfers in recent years despite the wider consideration of different donor tendons for long history of their use in the treatment of shoul- cases of rotator cuff deficiency. Encouraging early der pathology. One of the first descriptions of a results have been described for the use of both pectransfer was by L’episcopo in 1934 [1]. He uti- toralis major and minor transfers for irreparable lised the teres major tendon for the treatment of subscapularis tears although Elhassan & colleagues obstetric brachial-plexus palsies. This was later have suggested that the latissimus dorsi tendon is a modified by Zachary in 1947 [2] who combined more suitable transfer for the treatment of subscapthe transfer of the teres major with the latissimus ularis deficiency. Alongside the greater awareness dorsi tendon. It was Gerber however, in 1988, of the role of transfers, surgical techniques have who recognised that the same treatment princi- advanced such that many of these newer procedures ples used to treat “neurological cuff deficiencies” can be performed both arthroscopically assisted or from suprascapular nerve palsies seen in brachial all-arthroscopically [7–11]. Gerber’s open two inciplexus birth injuries could be applied to the cuff-­ sion technique for the transfer of the latissimus deficient shoulder. In managing these massive dorsi tendon for the treatment of postero-superior irreparable postero-superior rotator cuff tears he cuff deficiency has been shown to deliver good described the transfer of the latissimus dorsi ten- long-term outcomes. This transfer has subsequently don with promising results [3–5]. Similarly, in been modified to be performed as a single incision 1997, Wirth & Rockwood described the transfer open transfer, an arthroscopic-­assisted transfer and of the pectoralis major tendon for treatment of an all-arthroscopic procedure [5, 12–14]. irreparable subscapularis tears [6]. The development of these techniques for managing the difficult problem of irreparable massive rotator cuff tears has given us a valuable new tool in the armamentarium of the modern shoulder D. Henderson (*) surgeon. They are however not without their pitLeeds Teaching Hospitals NHS Trust, The University falls, particularly in view of the complex nature of Leeds, & NIHR Leeds Biomedical Research Centre (BRC), Leeds, UK of the surgery, but also the diverse nature of this e-mail: [email protected] group of patients. Many of the patients for whom S. Boyle a transfer may be indicated have undergone York Teaching Hospitals NHS Trust, York, UK numerous previous procedures making further e-mail: [email protected]

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_10

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surgery more challenging. Furthermore, these patients have often developed and adapted complex movement patterns to compensate for their rotator cuff deficiencies. In this chapter, we will review the potential complications of performing arthroscopic and arthroscopically assisted tendon transfer procedures for the treatment of irreparable rotator cuff tears with regards to patient selection as well as the surgery itself.

D. Henderson and S. Boyle

basic principles of the role of force-couples in the rotator cuff and therefore on shoulder function. It has been demonstrated in numerous studies that a latissimus dorsi transfer for postero-superior cuff deficiency, in the absence of an intact subscapularis, leads to poorer functional outcomes, despite what may seem to be a technically well-­performed transfer. This poorer outcome is thought to be a result of the absent force couple which requires subscapularis function [4, 18, 21]. Given this principle, extreme care in planning surgical intervention in patients with both anterior and poste10.2 Pre-Operative Complications rior cuff deficiency should be taken. Consideration in these cases must be made for the repair of the (Indications) subscapularis where a tendon transfer is being One of the mainstays of avoiding poor post-­ used for an irreparable postero-superior cuff operative outcomes lies with careful and appropri- tears. Irreparable anterior and posterior tears ate patient selection. This is particularly true for present a particularly difficult clinical scenario tendon transfer procedures around the shoulder. for the surgeon. Though some improvement of Traditional indications for a tendon transfer function and symptoms is described in some are those patients with a mobile shoulder with a series with a single tendon transfer, a guarded painful irreparable cuff tear associated with poor prognosis should be given, and it is these cases function. Many authors suggest that “irreparabil- that may be appropriate for consideration of a ity” may be determined pre-operatively based on double tendon-transfer in an attempt to restore a clinical examination and duration of symptoms functional force couple. combined with the findings on cross-sectional Ultimately, choosing the optimal tendon transimaging such as level of retraction, degree of fer procedure for the correct patient is the most atrophy and fatty infiltration. Other surgeons take important determinant of a positive outcome. the more pragmatic approach of reserving judge- What determines the “best” transfer for a particument until intra-operative arthroscopic evaluation lar clinical scenario is likely to remain a source of may be performed allowing a full assessment of debate and discussion as the science and practice the retraction as well as tissue quality [15–17]. progresses. Currently, latissimus dorsi appears to Further factors which must be considered as provide the best available substitute for the absent potential contra-indications are patients who postero-superior rotator cuff in restoring external have undergone prior failed surgery, disruption of rotation, but also an element of forward flexion, the coracoacromial arch (and with it the potential as demonstrated by long term follow-up series [5, risk of antero-superior escape of the humeral 18, 22]. Equally, some centres have seen promishead), deficiency of the deltoid, glenohumeral ing results with alternatives such as lower trapejoint stiffness and a pre-existing nerve injury. zius transfers [23–25]. Beyond these factors, subgroup analysis has Though less established, and so with a smaller shown in several follow-up studies that although evidence base, it would also seem that the latisimprovement is seen, poorer functional outcomes simus dorsi provides a functional transfer for the are found in revision cases, particularly follow- treatment of irreparable subscapularis tears both ing failure of a prior tendon repair [4, 15, 18–20]. from a biomechanical perspective but also in As such these patients should be counselled terms of outcomes, although there remain propocautiously. nents of pectoralis major and minor as alternative Prior to embarking on surgery of this nature, it donor tendons with clinical series also demonis important that the surgeon understands the strating clinical improvements [7–11, 26–28].

10  Complications in Tendon Transfers

10.3 Per-Operative Complications

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Josser and and colleagues’ arthroscopic assisted series (n = 2, 6.6%). In all of these reported inciTendon transfer procedures around the shoulder dences, the neuropraxias resolved spontaneously are highly technically demanding and all the without any long-term sequelae [5, 19, 20]. more so when carried out arthroscopically, One of the key principles of successful tendon requiring an advanced level of arthroscopic skill. transfer procedures is the selection of a donor Potential intra-operative difficulties and compli- tendon with a similar excursion to the origications with such procedures include all the chal- nal musculotendinous unit. Having selected an lenges of arthroscopic shoulder surgery as appropriate transfer, one of the potential pitfalls discussed in earlier chapters and particularly the of arthroscopic tendon transfer, is the failure to need for good visualisation. The key to the suc- sufficiently release the donor tendon, therefore cessful completion of an arthroscopic tendon limiting its subsequent excursion. This can lead transfer procedure revolves around an under- to problems for fixation of the tendon intra-­ standing, appreciation and intra-operative visu- operatively, but may also limit the function of alisation of the three dimensional anatomy the transferred musculotendinous unit if this is around the shoulder. Clear identification of the tethered by native connections to surrounding tisrelevant anatomical structures allows for safe sues. This is especially true for transfers that sigharvesting, passage and fixation of the donor ten- nificantly alter the path of the donor tendon, such don, without causing damage or compromise to as the transfer of the latissimus dorsi tendon for nearby nerves. This will result in a transferred postero-superior cuff deficiency. Failure to comtendon having good excursion and alignment pletely release the latissimus dorsi tendon, and along its new functional axis. some of its muscular portion, can make its new The latissimus dorsi tendon harvest requires passage to the greater tuberosity very difficult a sound working knowledge of the anterior com- and may lead to excessive tension on the transpartment of the shoulder. It is advisable to care- ferred portion of the tendon. This can potentially fully identify and protect the axillary nerve as it compress surrounding structures including the passes anterior and inferior to the subscapularis— axillary nerve. Moreover, excessive tension on the nerve lies above the latissimus dorsi during the tendon fixation may pose a risk to successful harvest. The radial nerve can be found as it passes tendon-to-bone healing and should be avoided. anteriorly overlying the musculo-­tendinous juncThe fixation of a transferred tendon creates a tion of the latissimus dorsi. Similarly, these new soft tissue bone interface and as such is an nerves should be identified and protected when area of weakness and prone to complications. In transferring the latissimus dorsi superiorly to principle the same goals apply here as in the optiaddress subscapularis deficiency. misation of tendon healing in rotator cuff repairs; When working posteriorly, or in the axilla, for namely high initial fixation strength, good contransfers addressing a postero-superior cuff defi- tact area and pressure between graft and bone and ciency, the axillary nerve must be protected as it minimal gap formation [29–33]. Therefore optiemerges from the quadrilateral space posteriorly, mal mechanical and biological stability is needed and likewise the radial nerve as it passes through until tendon-to-bone healing is achieved. As the triangular space posteriorly. such, comparisons can be made between the fixaIntra-operative nerve injuries are usually tran- tion of transferred tendons and repairs of rotator sient and well described in the literature. These cuff tendons. Most arthroscopic and complications are largely described in published arthroscopically-­ assisted techniques use suture series of open tendon transfers and can affect anchors or trans-osseous sutures in single or almost any nerve around the shoulder; from the double-­row configurations [14, 24, 34, 35]. For a two (3.6%) ulna nerve injuries in Gerber’s open surgeon, these techniques confer the technical transfer series, to the axillary nerve dysfunction advantages of being a familiar and do not require in the cohorts of Moursy et al. (n = 1) and Nove-­ any specialist implants or equipment. The use of

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knotless suture anchors in combination with a tendon which has undergone whip-stitch sutures allows a solid suture hold with good control of graft tension during fixation. Although there is little clinical evidence to support one method of suture fixation over another in tendon transfers, most surgeons apply the principles of repair of massive rotator cuff tears, and therefore use a double-row technique. In theory, this maximises the contact area for tendon to bone healing and minimises graft lift-off during range of motion [36–38]. At the same time, incorporation of a partial repair of any remaining cuff tendon to the graft fixation should also be considered, particularly where tendon-to-tendon healing may reinforce tendon-to-bone healing of the graft to the humerus. Alternative graft fixation methods have also been reported, with techniques described by Grimberg and Kany with use of bone tunnels and interference screws, as well as button fixation for latissimus dorsi transfers. These have been employed for both postero-superior and subscapularis cuff tears with promising biomechanical and early clinical results [11, 39, 40]. Caution, however, should be exercised with use of interference screw fixation not to under-size the bone tunnel, with Grimberg et al. describing a 10.5% intra-operative fracture rate during screw insertion in their initial series [40].

10.4 Immediate Postoperative Complications Immediate post-operative complications include those complication inherent to all complex arthroscopic surgery around the shoulder, namely wound infection, haematoma, wound dehiscence (in the case of arthroscopically-assisted techniques) and early failure of graft fixation. Grimberg et  al., in their initial series of an arthroscopically-assisted technique using interference screw fixation, report a 5.4% (n = 3) incidence of post-operative haematoma formation requiring revision surgery, with a 3.6% (n  =  2) incidence of infection (P. acnes in both cases)

D. Henderson and S. Boyle

[40]. Likewise, in the same series, 7.2% (n = 4) of patients were found to already have failure of their graft fixation on “immediate” post-operative MRI imaging, although it must be noted that despite this, 50% of these graft failures remained satisfied with the outcome of their surgery in the longer term [40]. Castricini et al. described a similar arthroscopically assisted tendon transfer technique making use of knotless suture anchors. They reported a series of 27 patients with one early wound infection and an 11% incidence of haematoma, though none required surgical intervention. Elhassan et  al., in their series of 33 patients who underwent lower trapezius transfer, with interposition of an achilles tendon allograft and knotless suture anchor fixation, describe a 12% incidence of post-operative seroma formation. None of these cases required revision surgery, however one case (3%) of post-operative infection did require a debridement [25]. Elhassan further reported one patient who suffered a fall post-operatively, resulting in stretching of the graft fixation and so rendering the transfer dysfunctional clinically and radiologically [25].

10.5 Mid-Term Complications Mid-term complications (1–6  months post-­ operatively) of tendon transfer procedures again include the general sequelae of complex arthroscopic shoulder procedures, and these mirror the literature and experience with rotator cuff repair. The most significant of these are cases of post-operative adhesive capsulitis and failure of graft healing. Although much of this is pre-determined by the intra- and immediate post-operative factors already discussed, use of an appropriate post-­ operative rehabilitation regimen minimises the risk of the development of these complications. The aim of this crucial rehabilitation is to allow tendon graft healing without tension, whilst using gentle passive mobilisation to prevent undue adhesion and reducing the risk of a florid capsulitis.

10  Complications in Tendon Transfers

Warner, in his instructional course lecture regarding open tendon transfers for postero-­ superior cuff deficiency, recommends the strict use of an abduction brace (45° abduction and 30° external rotation) for 6  weeks post-operatively, whilst commencing passive mobilisation and avoiding internal rotation and adduction [15]. Only after 6  weeks is active muscle re-training initiated [15]. Likewise, in reporting their arthroscopically assisted technique, Grimberg et al. recommend 4 weeks of immobilisation (30° abduction and neutral rotation), with passive mobilisation from day 3. Castricini et  al. also advocated four weeks of immobilisation, although in 15° abduction and 15° external rotation [41, 42]. Despite the lack of evidence base and surgeon consensus, it seems sensible to treat each patient on the individual merits of their surgery and the nature of their graft fixation. This should afford adequate time and conditions for tendon to bone healing and to minimise gapping during the inflammatory and proliferative phases of tendon healing, during the first 6 weeks post-­ repair [43, 44]. Ultimately, there is minimal data in the current literature regarding healing rates and outcomes specific to tendon transfer procedures. This is even more deficient for arthroscopic procedures, however is seems logical to apply the principles we have learned from cuff repair studies. As such the intra-operative security of graft attachment and tension of the repair is likely to be a key factor in successful healing. Nonetheless, it also appears that successful functional outcomes can still be achieved in many cases despite failure of tendon healing [40, 41, 45, 46].

10.6 Long Term Complications The long-term complications of tendon transfer procedures centre on the ability of newly transferred tendon to limit the progression of arthropathy in the cuff deficient shoulder, which can be a feature of the natural history of massive cuff tears. Long-term follow-up studies largely report

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on the results of open tendon transfer. Gerber’s original series of 46 latissimus dorsi tendon transfers at ten years reported that although degenerative cuff arthropathy was seen to progress, it appeared to be at a slower rate than that which might have been expected from comparable studies of non-operatively managed massive cuff tears [5, 47]. Similarly, El-Azab and colleagues publication of 93 shoulders which underwent latissimus dorsi transfer, at a mean follow-up of 9.3  years, describe significant reduction in mean acromiohumeral distance. This represents an increase in Hamada grade, but interestingly without any correlation to functional or pain score outcomes [22]. This data does however exclude the 5% (n = 6) patients of the original series of 115 operated shoulders who underwent joint-sacrificing revision surgery within the follow up period (reverse arthroplasty or fusion). Similar patterns are also reported by Moroder et al. in their series of 27 cases of pectoralis major transfer for anterosuperior cuff deficiency at 10 years. They observed a similar progression of arthropathy, but again without correlation with functional outcome or pain. One patient (5%) underwent a procedure revision to a reverse shoulder arthroplasty within the followup period [48]. Overall, despite these longer-term follow-up studies revealing a progression of arthropathy and an approximate 5% rate of revision to reverse shoulder arthroplasty, there was a significant and sustained improvement in clinical functional and patient satisfaction [5, 22, 48, 49].

10.7 C  ase Study 1: All Arthroscopic Latissimus Dorsi Transfer for Left Shoulder Postero-Superior Cuff Deficiency 10.7.1 Patient • 57 year old male. • Right hand dominant restaurant owner and keen trail-runner

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10.7.2 History • Fall on ice, onto left shoulder one year ago. • Pain, weakness and limited active range of motion in elevation since. • VAS pain score 8/10 day & night • SSV 60%

10.7.3 Examination (Left/Right) • Active (passive) RoM: Forward flexion: 90 (120)/180, Abduction: 80 (110)/180, Ext. rotation: 0 (45)/45, Int. rotation: L2/T12 • Power: ER 2/5, Jobe 3/5, Palm-up 3/5, Belly press 4/5, Bear-hug 4/5 • ER lag-sign +, Portillon sign +, Hornblower + • Constant score: 25/100 (Pain 5/15, Activity 6/20, Motion 12/40, Power 2/25)

D. Henderson and S. Boyle

tion to the glenoid (Figs. 10.2 and 10.3), but an intact subscapularis tendon (Fig. 10.4).

10.7.5 Clinical Summary • 57 year old fit and active patient with a delayed presentation of a massive retracted postero-­ superior cuff tear. • Pain, weakness and restricted active range of motion in elevation and external rotation. • No stiffness on passive mobilisation.

10.7.4 Imaging Plain radiographs demonstrated no gross abnormalities, specifically no arthritic changes or cuff arthropathy, with no apparent superior migration of the humeral head (Fig. 10.1). MRI Arthrogram demonstrated a massive tear of the postero-superior rotator cuff, with retracFig. 10.2  MRI Arthrogram: T2 FS Coronal slice demonstrating complete supraspinatus tear with retraction to the glenoid

Fig. 10.1  AP radiograph demonstrating no significant superior migration of the humeral head

Fig. 10.3  MRI Arthrogram: T1 FS Sagittal slice demonstrating extent of postero-superior cuff defect

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Fig. 10.5  Arthroscopic view from lateral portal demonstrating a massive retracted and irreparable postero-­ superior rotator cuff tear Fig. 10.4  MRI Arthrogram: T1 FS Axial slice demonstrating intact subscapularis

• Positive Lag- and Hornblower sign. Clinically and radiologically intact subscapularis. • No progression of cuff-tear arthropathy on radiographs

10.7.6 Intra-Operative Diagnostic scope: confirmation of irreparability of tear (Fig. 10.5). Posterior space preparation for tendon passage: Axillary nerve identified emerging from the quadrilateral space and protected (Fig. 10.6). Anterior compartment preparation and Latissimus Dorsi tendon harvest (Fig. 10.7). Graft fixation, following shuttling of the donor tendon through the previously prepared posterior space, using knotless suture anchors and combined with repair to residual posterior cuff (Fig. 10.8).

Fig. 10.6  Preparation of the posterior space, with exposure and protection of the axillary nerve in the quadrilateral space

10.8 C  ase Study 2: All-­ Arthroscopic Latissimus Dorsi Transfer for Subscapularis Deficiency 10.8.1 Patient • 53 year old male, • Right hand dominant construction-site foreman

Fig. 10.7  Detachment of the latissimus dorsi tendon from its insertion on the anterior humerus

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Fig. 10.8  Fixation of the transferred latissimus dorsi tendon to the greater tuberosity

10.8.2 History • Fall directly onto right shoulder from 2  m height 4 years previously • Arthroscopy some months later—irreparable complete subscapularis tear seen • Ongoing mechanical pain and weakness since • VAS pain score 5/10 day/6/10 night • SSV 80%

Fig. 10.9 AP radiograph demonstrating no superior migration of the humeral head or features of arthritis or arthropathy of the glenohumeral joint

10.8.3 Examination (Right/Left) • Active (passive) RoM: Forward flexion: 180/180, Abduction: 180/180, Ext. rotation: 70/70, Int. rotation: LS/T12 • Power: ER 5/5, Jobe 5/5, Palm-up 5/5, Belly press 4/5, Bear-hug 3/5, lift-off NA • IR lag-sign +, ER lag-sign −, Hornblower − • Constant score: 74/100 (Pain 5/15, Activity 15/20, Motion 32/40, Power 22/25)

10.8.4 Imaging Plain radiographs were largely unremarkable, without any features of arthritic change, cuff arthropathy or superior humeral head migration (Fig. 10.9).

Fig. 10.10  MRI Arthrogram: T1 FS Axial slice demonstrating complete retracted subscapularis tear

MRI Arthrogram demonstrated a complete tear of the subscapularis tendon, with retraction beyond the glenoid rim (Fig.  10.10) and fatty infiltration of the muscle belly (Fig. 10.11). The postero-superior rotator cuff was seen to be intact (Fig. 10.12).

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10.8.6 Intra-Operative Diagnostic scope and 360° release of the subscapularis tendon with the assistance of traction sutures-confirmation of irreparability (Fig. 10.13). Latissimus dorsi tendon clearance from surrounding adhesions and attachments, with visualisation and protection of the radial nerve (Fig. 10.14).

Fig. 10.11  MRI Arthrogram: T1 sagittal slice demonstrating fatty infiltration of the subscapularis muscle belly

Fig. 10.13  View from an antero-lateral portal of the retracted subscapularis tendon, still irreducible despite full release

Fig. 10.12  MRI Arthrogram: T2 coronal slice demonstrating intact postero-superior cuff

10.8.5 Clinical Summary • 53  year old fit and active patient, presenting with a previously diagnosed 4 year old irreparable isolated subscapularis tear. • Mechanical pain and weakness • No stiffness. • Positive internal rotation lag-sign. Clinically and radiologically intact postero-superior cuff. • No anterior glenoid wear, or escape, on imaging.

Fig. 10.14  Release of anterior adhesions to the latissimus dorsi tendon. The radial nerve is visualised running anterior to the musculotendinous portion of the tendon

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Arthroscopic whip-stitches placed on the superior and inferior borders of the latissimus dorsi tendon (Fig. 10.15). Latissimus dorsi tendon harvest from its humeral attachment (Fig. 10.16). Superior transfer of the harvested graft and fixation, using knotless anchors, to the subscapularis insertion on the lesser tuberosity (Fig. 10.17).

Fig. 10.17  Fixation of the superiorly transferred latissimus dorsi tendon, to the lesser tuberosity, using knotless anchors

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Fig. 10.15  Arthroscopic whip-stitch to the superior border of the latissimus dorsi tendon

Fig. 10.16  Detachment of the Latissimus dorsi tendon from its humeral attachment

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101 rable posterior-superior rotator cuff tear. J Shoulder Elbow Surg. 2016;25(8):1346–53. 26. Valenti P, et al. Transfer of the clavicular or sternocostal portion of the pectoralis major muscle for irreparable tears of the subscapularis. Technique and clinical results. Int Orthop. 2015;39(3):477–83. 27. Wirth MA, Rockwood CA Jr. Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg. 1997;79(5):722–31. 28. Goutallier D, et  al. Is the trapezius transfer a useful treatment option for irreparable tears of the subscapularis? Orthop Traumatol Surg Res. 2011;97(7): 719–25. 29. Apreleva M, et al. Rotator cuff tears: the effect of the reconstruction method on three-dimensional repair site area. Arthroscopy. 2002;18(5):519–26. 30. Park MC, et al. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007;16(4):461–8. 31. Park MC, et  al. Part II: Biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-­ row repair technique. J Shoulder Elbow Surg. 2007;16(4):469–76. 32. Ahmad CS, et al. Tendon-bone interface motion in transosseous suture and suture anchor rotator cuff repair techniques. Am J Sports Med. 2005;33(11):1667–71. 33. Park MC, et al. Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques. Am J Sports Med. 2005;33(8):1154–9. 34. Petriccioli D, et  al. Arthroscopically assisted latissimus dorsi transfer with a minimally invasive harvesting technique: surgical technique and anatomic study. Musculoskelet Surg. 2011;96(Suppl 1):S35–40. 35. Gervasi E, et al. Arthroscopic latissimus dorsi transfer. Arthroscopy. 2007;23(11):1243.e1–4. 36. Baums MH, et  al. Biomechanical characteristics of single-row repair in comparison to double-row repair with consideration of the suture configuration and suture material. Knee Surg Sports Traumatol Arthrosc. 2008;16(11):1052–60. 37. Ozbaydar M, et  al. A comparison of single-versus double-row suture anchor techniques in a simulated repair of the rotator cuff: an experimental study in rabbits. J Bone Joint Surg Br. 2008;90(10):1386–91. 38. Lo IK, Burkhart SS. Double-row arthroscopic rotator cuff repair: re-establishing the footprint of the rotator cuff. Arthroscopy. 2003;19(9):1035–42. 39. Diop A, et  al. Tendon fixation in arthroscopic latissimus dorsi transfer for irreparable posterosuperior cuff tears: an in  vitro biomechanical comparison of interference screw and suture anchors. Clin Biomech. 2011;26(9):904–9.

102 40. Grimberg J, et  al. Arthroscopic-assisted latissimus dorsi tendon transfer for irreparable posterosuperior cuff tears. Arthroscopy. 2014;31(4):599–607.e1. 41. Grimberg J, Kany J.  Latissimus dorsi tendon transfer for irreparable postero-superior cuff tears: current concepts, indications, and recent advances. Curr Rev Musculoskelet Med. 2014;7(1):22–32. 42. Castricini R, et  al. Arthroscopic-assisted latissimus dorsi transfer for the management of irreparable rotator cuff tears: short-term results. J Bone Joint Surg Am. 2014;96(14):e119. 43. Pandey V, Jaap Willems W.  Rotator cuff tear: a detailed update. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2015;2(1):1–14. 44. Gulotta LV, Rodeo SA. Growth factors for rotator cuff repair. Clin Sports Med. 2009;28(1):13–23. 45. Chung SW, et  al. Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors

D. Henderson and S. Boyle associated with healing failure or poor postoperative function. Am J Sports Med. 2013;41(7):1674–83. 46. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82(4):505–15. 47. Zingg PO, et al. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am. 2007;89(9):1928–34. 48. Moroder P, et al. Long-term outcome after pectoralis major transfer for irreparable anterosuperior rotator cuff tears. J Bone Joint Surg Am. 2017;99(3):239–45. 49. Marra G. Latissimus dorsi transfer results endure over time: commentary on an article by Christian Gerber, MD, FRCSEd(Hon), et al.: “Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears. Long-term results at a minimum follow-up of ten years”. J Bone Joint Surg Am. 2013;95(21):e169.

Complications in Biceps Tendon Management: Long Head of Biceps Tenotomy and Tenodesis

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Johannes Plath

11.1 Introduction Long head of the biceps (LHB) pathologies are a frequent source of anterior shoulder pain and dysfunction. Amongst these, partial and complete LHB tears, tendinosis, SLAP (superior labrum anterior to posterior) tears as well as biceps instability due to antero-superior rotator cuff or biceps pulley lesions are commonly seen. If conservative treatment fails, LHB tenotomy and tenodesis are the primary surgical options. LHB tenotomy is an easy, fast, safe and cost-­ effective procedure that does not require any specific post-operative rehabilitation. A “popeye deformity” (Fig.  11.1) and biceps muscle-belly cramping, however, are regularly seen following tenotomy. Many surgeons therefore perform LHB tenodesis to avoid these drawbacks, especially in younger patients and those involved in athletics or manual labour, or in those who wish to avoid a cosmetic deformity. The numbers of LHB tenodeses have increased dramatically in recent years [1]. With this increase in numbers, more and more technical options for LHB tenodesis have been described. The surgeon now needs to consider where to fix the LHB tendon (high, suprapectoral or subpectoral), how to fix the tendon (suture anchor, tenoJ. Plath (*) Department of Trauma, Orthopaedic, Hand and Plastic Surgery, University Hospital of Augsburg, Augsburg, Germany

Fig. 11.1  Apparent “Popeye” deformity in a young and highly active athlete

desis screw, endobutton, auto-tenodesis and other soft-tissue techniques) and if (s)he wants to perform it in an open or an arthroscopic fashion [2, 3]. Numerous clinical and biomechanical studies on different techniques have been published over the last decade to elucidate these questions with somewhat controversial results. Most studies are, however, level III and IV studies, and limited by methodological deficiencies such as retrospective design, lack of randomization and a low statistical power. Furthermore, the vast heterogenity of patient cohorts, in diagnoses and concomitant procedures (i.e. rotator cuff repair), makes it difficult to give clear recommendations on isolated biceps tenodesis cases. While the debate regarding LHB tendon pathology management continues to evolve and

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_11

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is unlikely ever to resolve completely, complications during LHB tendon management are generally uncommon and each specific technique carries its own potential risks [2]. In this chapter we want to discuss general complications in LHB tendon tenotomy and tenodesis as well as potential complications of some specific tenodesis techniques.

11.2 Pre-Operative Complications (Indications) A thorough diagnosis is imperative for successful surgical treatment and so patient satisfaction. An accurate diagnosis may be made through a comprehensive history, physical examination and appropriate imaging studies. Patients with biceps pathology commonly complain of an anterior shoulder pain that may radiate distally and display tenderness to palpation over the bicipital groove itself. Biceps instability often causes additional mechanical symptoms, typically during rotation with the arm in abduction. Specific clinical tests such as Yergason’s, Speed’s, ARES and O’Brien’s test should be performed and the non-affected shoulder should be examined for symmetry, as many of these examinations often produce a certain degree of discomfort, even in the non-pathological shoulder. Concomitant shoulder pathologies are more the rule than the exception when it comes to LHB tendon pathologies. A comprehensive shoulder examination, including the cervical spine, must, therefore, be performed. In our practice, plain radiographs and magnetic resonance imaging (MRI) are routinely performed prior to surgery. In younger patients with shoulder instability or if an isolated LHB pathology, including SLAP or Pulley lesion, is suspected MR arthrogram is the imaging of choice due to its higher diagnostic accuracy compared to non-contrast MRI [4–6]. Ultrasonography can be very helpful in the diagnosis of LHB tendon pathology as it allows dynamic testing, but with the limitation of being highly operator dependent [7].

J. Plath

During diagnostic arthroscopy the intraarticular portion of the biceps tendon must be assessed thoroughly, from its insertion site at the supraglenoid tubercle, to the biceps reflection pulley and intertubercular groove. By pulling the LHB tendon into the joint with a probe, more distal portions of the tendon may be examined, however the surgeon must be aware that even by this manoeuvre not all lesions of the LHB tendon within the groove will be visualized [8–10]. Patient history, clinical examination as well as imaging should be taken into account in deciding whether or not to perform a LHB tenotomy or tenodesis. If a patient is complaining of typical biceps-related symptoms and has positive provocation tests but no obvious structural lesions during an arthroscopic procedure, LHB tenotomy or tenodesis should be considered nonetheless [11]. Conversely, we do not recommend routine LHB management in patients with a rotator cuff lesion in the absence of biceps signs. If there are no focal biceps symptoms, nor positive signs on physical examination or diagnostic arthroscopy, the LHB tendon can be safely left alone during cuff repair [12–14]. When the surgeon has decided on performing LHB tendon surgery, tenotomy and tenodesis are the two primary options. As mentioned earlier, LHB tenotomy does carry the risk of “Popeye deformity” and potentially of post-operative muscle belly cramping. While the latter is usually self-limiting, cosmetic deformity of the upper-­ arm may be of concern for certain patients, especially for young and slim patients [15]. When it comes to post-operative functional outcomes, however, tenotomy and tenodesis show comparably favourable results in large systematic reviews [16–20]. Likewise, elbow flexion and forearm supination strength have also been found to be comparable between these techniques [15, 17, 18, 20–22]. Given the potential side-effects of tenotomy, we believe that counselling patients appropriately prior to surgery, and considering their specific demands and expectations is absolutely vital in order to enable shared-decision making and avoid patient dissatisfaction.

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during tenodesis. Options include high, close to the articular margin of the humeral head, suprapectoral and subpectoral. While high and suprapectoral LHB tenodeses are nowadays usually performed arthroscopically, subpectoral tenodesis is an open procedure. Potential benefits and complications of the location of fixation, as well as of the different options for fixation, will be discussed in the following sections.

11.3 Per-Operative Complications By its nature biceps tenotomy is an easier, quicker and safer procedure than any tenodesis technique, without any clear direct potential complications. Even for a novice shoulder arthroscopist intra-­ operative complications such as neurovascular, cartilage and soft-tissue injuries are fairly uncommon. While the same is true for the above mentioned “Y-tenotomy” technique, care must be taken not injure the suprascapular nerve, which lies at the spinoglenoid notch approximately Fig. 11.2  Y-Tenotomy: The LHB is detached from the 11 to 1 o‘clock glenoid insertion site. The cut bulky end-­ 19  mm medial to the glenoid, during posterior piece of the “Y-shape” lodges underneath the transverse labral dissection [23]. ligament in the bicipital groove, thereby performing an When considering LHB tenodesis techniques, auto-tenodesis the most straightforward technique to perform arthroscopically is probably the high LHB tenodeWe generally recommend LHB tenodesis in sis, at the articular margin. High LHB tenodeses younger and more physically active patients as do not require any further arthroscopic dissection well as those concerned about cosmesis. and are usually performed with the scope in the In all others we perform a so-called standard posterior visualisation portal (Fig. 11.3a– “Y-tenotomy” technique, as popularised by d). Major complications to neurovascular strucLaurent Lafosse. For this technique the LHB tures are not described. Fixation may be achieved insertion site is detached from the 11 to 1 o’clock using suture anchor, tenodesis screw or an endoglenoid position. The cut labrum and LHB ten- button system, and remaining sutures may be don form the shape of a “Y”, which gives this used for antero-superior rotator cuff repair if technique its name (Fig. 11.2). The bulky labral applicable [24]. end-piece of the “Y-shape” lodges underneath Suprapectoral tenodesis, on the other hand, the transverse ligament in the bicipital groove, needs additional dissection and a release of the thereby performing an auto-tenodesis. In our transverse ligament at the intertubercular groove. own experience this technique is easy, fast, Visualization is typically obtained via a lateral effective and results in deformity that is very extra-articular portal. Clearly, a higher degree of subtle, if present at all. Clinical outcome studies arthroscopic skill is needed to perform this techare, however, pending. nique. Despite a cadaveric study demonstrating Probably the most debated question in LHB the close proximity of the low anterolateral pormanagement is the “Where?” to fix the tendon tal, needed for suprapectoral LHB tenodesis, to a

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small distal branch of the axillary nerve, to our knowledge no neurovascular complications have been reported in the current literature [25–27]. By contrast, a major criticism of the open subpectoral LHB tenodesis is the proximity of the brachial plexus to the tenodesis site, which may place neurovascular structures at risk. This has been investigated previously in cadaveric studies [28, 29]. In the current literature several clinical reports of iatrogenic brachial plexus injuries during open subpectoral biceps tenodesis have been published [25, 30–34]. If one decides to perform a subpectoral LHB tenodesis in conjunction with an arthroscopic procedure, consider performing it early in the surgery as swelling of the arm may distort the anatomy and relations, and may increase the risk of neurovascular injuries.

Fixation can be achieved with a tenodesis screw, suture anchors or an endobutton system. When using tenodesis screws, make sure that the prepared tunnel for the interference screw is drilled large enough to fit tendon and screw. Consider drilling the bone socket 0.5 mm larger than the screw and smooth the bony edges with a shaver to avoid damage to the tendon by the pressure of the threads or sharp edges during screw insertion. The importance of this point is underlined by the findings of a case series of three failures of LHB interference screw tenodesis, that showed all failures to have occurred at the tendon-­screw interface, implying some damage to the tendon during insertion [35]. Furthermore, rotation of the graft around the screw during insertion may also weaken the construct and alter graft tension [36]. The importance of preserv-

a

b

c

d

Fig. 11.3  Long head of biceps tenodesis high in the bicipital groove (right shoulder, visualisation from the posterior portal). A suture is passed through the tendon

(a). A socket hole is drilled high in the groove at the articular margin (b) and the tendon is fixed into the bone with an interference screw (c, d)

11  Complications in Biceps Tendon Management: Long Head of Biceps Tenotomy and Tenodesis

ing the correct length-tension-relation in LHB tenodesis has been stressed previously [37, 38]. We tend to perform a LHB tenodesis with rather less tension as we believe that this reduces LHB irritation and so post-operative pain, and in our experience does not cause appreciable deformity. Overtensioning, however, should be avoided at all costs. In a current cadaveric study, Werner et  al. [38] found that in interference screw tenodeses there is a tendency to over-tension the tendon, with a significantly greater over-­ tensioning in arthroscopic suprapectoral, as compared with open subpectoral LHB tenodeses (2.15 vs. 0.78 cm). Use of suture anchors may reduce the risk of the above-mentioned issues with tendon tension, however, when using a suture anchor for fixation, tapping of the cortical bone is recommended to avoid anchor breakage during insertion, as the bone at the intertubercular groove is usually very solid. For all techniques, clear arthroscopic cannulas may be used to avoid injury to the surrounding soft tissue during drilling.

11.4 Immediate Postoperative Complications Immediate post-operative complications of LHB management include infection and early failure of fixation. Wound infections following biceps management are rare. Open subpectoral tenodesis is thought to carry the highest risk of deep wound infection as this technique requires a separate incision close to the armpit. This hypothesis is supported by an analysis of a large private-payer database of 33,481 patients undergoing a rotator cuff repair with biceps tenodesis/tenotomy. The infection rate was highest in the open biceps tenodesis group and the lowest in the tenotomy group [12]. Nho et al. [33], however, reported a generally low rate of complications following open subpectoral LHB tenodesis of 2.0% in 353 patients; only one patient (0.28%) presented with a deep wound infection. Gottschalk et al. [39] described two cases with superficial infection among 29 patients and Abtahi et al. [30] similarly found four superficial

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infections in 103 patients (4%) treated with open subpectoral LHB tenodesis. Gombera et al. [25] compared open subpectoral and all-arthroscopic suprapectoral tenodesis and reported complications in two of 23 patients (8.7%) in the open tenodesis group including one superficial wound erythema that resolved with oral antibiotics, and one patient with transient brachial plexopathy. The group of all-arthroscopic suprapectoral LHB tenodesis (23 patients) had no complications. Brady et al. [40] published the outcomes of 1083 patients that underwent a high biceps tenodesis at the articular margin with an interference screw and found a revision rate of 4.1% overall and a biceps related revision rate of 0.4%. No infections were reported by the authors. Early failure of LHB fixation is rare and may be explained by an inappropriate surgical technique, trauma or non-compliance. Usually, LHB tenodesis techniques allow an early post-­ operative functional treatment and the post-­ operative treatment is rather dictated by concomitant procedures, i.e. rotator cuff repair. Strengthening of the biceps is usually forbidden for 3 months post-operatively.

11.5 Mid-Term Complications Residual groove pain is a typical mid-term complication following biceps tenodesis and is thought to be particularly associated with high LHB tenodesis at the articular margin [41, 42]. Advocates of an open subpectoral technique argue that only by subpectoral fixation of the LHB tendon, can the degenerative and inflamed superior portion be completely removed from the pathological intertubercular groove, and so eliminate persistent post-operative pain [3]. This approach is supported by Moon et al. [9], who found, in a retrospective evaluation, that most LHB tendon lesions extend beyond the bicipital groove, to the distal extra-articular portion of the LHB. Advocates of high fixation claim, however, that even in patients with substantial inflammation and degeneration in the intertubercular groove, a high tenodesis eliminates the motion

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within the groove and thereby effectively treats any biceps related pain [40]. Others stress the importance of releasing the biceps sheath during tenodesis. Sanders et  al. [42] demonstrated that techniques which release the biceps sheath had a significantly lower revision rate when compared to techniques that did not (6.8% vs. 20.6%). Considering the prior cited publication of Brady et  al. [40] on “high in the groove” LHB tenodesis, who had a biceps related revision rate of only 0.4% in 1083 patients without releasing the biceps sheath, the revision numbers of Sanders et  al. appear surprisingly high however. In comparative studies between arthroscopic suprapectoral and open subpectoral LHB tenodesis, Gombera et  al. [25] as well as Werner et  al. [27] found no significant differences regarding pain relief or clinical outcomes between both groups. Regarding the kind of fixation, Millett et  al. [43] described a significantly higher likelihood of persistent bicipital groove pain when suture anchors were used for open subpecoral tenodesis compared to tenodesis screws. As discussed earlier, “popeye deformity” is probably the most significant downside of LHB tenotomy, occuring in 17–70% of cases following LHB tenotomy [15, 16, 19–21, 44]. For many patients the superior cosmesis compared to tenotomy is the primary reason to undergo a LHB tenodesis. Therefore, a deformity that occurs after a LHB tenodesis must be regarded as a failure of treatment. Multiple biomechanical studies have shown that tenodesis with an interference screw provides a superior primary stability when compared to single suture anchor, endobutton or bone tunnel fixation [45–49], however, Mazzocca et  al. [46] demonstrated that two suture anchors are biomechanically equivalent to interference screw fixation. Most clinical reports of LHB tenodesis show a low incidence of failure and popeye deformity, equally so for all current techniques. Nho et al. [33] noted a failure rate of 0.57% in 353 patients that underwent open subpectoral tenodesis with interference screw. Werner et  al. [27] and Gombera et al. [25] in their comparative studies

J. Plath

of arthroscopic suprapectoral and open subpectoral biceps tenodesis with screws, reported no failures in either group. Castricini et al. [15], however, reported a popeye deformity in 20.8% of cases of LHB tenodesis (suprapectoral with interference screw fixation) compared to 58.1% of LHB tenotomy at 24 months follow-up. Friedman et al. [21] found a popeye deformity in 18.2% of patients that had an open subpectoral LHB tenodesis with suture anchor fixation, compared to 35% of tenotomy patients. All patients in this study were active patients, younger than 55 years old, which may explain the high rates of failures in this particular population. Despite the previously mentioned biomechanical evidence in favour of interference screw fixation, comparative clinical studies of interference screws vs. suture anchor fixation are scarce. Park and colleagues [50] compared both fixation modalities in a prospective randomized controlled study using MRI imaging. Interestingly, anatomic failure on MRI examination was significantly higher in the interference screw group (21.2%) compared to the suture anchor group (5.8%), however, both groups showed similar outcomes with regard to popeye deformity. This divergent definition of clinical failure, makes a comparison to the above mentioned studies difficult. Anatomic failure in this study was also significantly affected by more physically demanding levels of work. Further reported mid-term complications in the current literature are reflex-sympathetic-­ dystrophy and post-operative shoulder stiffness [33, 51–53]. While reflex-sympathetic-dystrophy is a rare finding irrespective of open or arthroscopic techniques, Werner et al. [54] found post-­operative shoulder stiffness to be the only significant complication in 249 patients that underwent LHB tenodesis. Interestingly, stiffness was notably increased after arthroscopic suprapectoral biceps tenodesis as compared to open subpectoral biceps tenodesis (17.9% vs. 5.6%). The authors explained this finding as being a result of the necessary arthroscopic dissection around the tenodesis site during arthroscopic suprapectoral tenodesis, with potentially increased fluid extravasation and bleeding in the region of the bicipital sheath, or a

11  Complications in Biceps Tendon Management: Long Head of Biceps Tenotomy and Tenodesis

potential overtensioning of the biceps tendon. Further risk factors for stiffness found in this study were female sex and smoking. Stiffness following biceps tenodesis is, however, almost always self-limiting and large study cohorts show extremely low revision rates for shoulder stiffness for all tenodesis techniques [12, 40]. A further complication, unique to subpectoral tenodesis, is humeral fracture at the cortical drill hole. Sears and colleagues [55] published a case report of two patients that suffered a proximal humerus fracture 4 and 6  months, respectively, after subpectoral biceps tenodesis. While one patient had a fall down a small hill, the second patient reported no specific trauma. Both patients underwent open reduction and plate fixation. Euler et  al. [56] stressed the importance of central screw placement during subpectoral tenodesis to avoid this specific complication. The authors found in a biomechanical study, that an eccentrically drilled 8 mm bone socket will significantly reduce bone stability by 25% compared to 10% if the biceps tenodesis is placed concentrically. When using a subpectoral biceps tenodesis technique, surgeons should be aware of this technical error.

11.6 Long Term Complications We are not aware of any specific long-term complications of LHB management. While failure of fixation with popeye deformity as well as humeral fracture may also occur in the long-term, usually following trauma, these are complications more usually occurring during the mid-term period. In the literature no specific long-term complications for LHB management have been reported.

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Musculoskelet Med. 2016;9:378–87. https://doi. org/10.1007/s12178-016-9362-7. 3. Patel KV, Bravman J, Vidal A, Chrisman A, McCarty E. Biceps tenotomy versus tenodesis. Clin Sports Med. 2016;35:93–111. https://doi.org/10.1016/j. csm.2015.08.008. 4. Holzapfel K, Waldt S, Bruegel M, Paul J, Heinrich P, Imhoff AB, Rummeny EJ, Woertler K.  Inter- and intraobserver variability of MR arthrography in the detection and classification of superior labral anterior posterior (SLAP) lesions: evaluation in 78 cases with arthroscopic correlation. Eur Radiol. 2009;20:666– 73. https://doi.org/10.1007/s00330-009-1593-1. 5. Razmjou H, Fournier-Gosselin S, Christakis M, Pennings A, ElMaraghy A, Holtby R.  Accuracy of magnetic resonance imaging in detecting biceps pathology in patients with rotator cuff disorders: comparison with arthroscopy. J Shoulder Elbow Surg. 2016;25:38– 44. https://doi.org/10.1016/j.jse.2015.06.020. 6. Zappia M, Reginelli A, Russo A, D’Agosto GF, Di Pietto F, Genovese EA, Coppolino F, Brunese L. Long head of the biceps tendon and rotator interval. Musculoskelet Surg. 2013;97(Suppl 2):S99–108. https://doi.org/10.1007/s12306-013-0290-z. 7. Armstrong A, Teefey SA, Wu T, Clark AM, Middleton WD, Yamaguchi K, Galatz LM. The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg. 2006;15:7–11. https://doi.org/10.1016/j.jse.2005.04.008. 8. Godenèche A, Nové-Josserand L, Audebert S, Toussaint B, Denard PJ, French Society for Arthroscopy (SFA), Lädermann A.  Relationship between subscapularis tears and injuries to the biceps pulley. Knee Surg Sports Traumatol Arthrosc. 2017;25:2114–20. https://doi.org/10.1007/ s00167-016-4374-9. 9. Moon SC, Cho NS, Rhee YG.  Analysis of “hidden lesions” of the extra-articular biceps after subpectoral biceps tenodesis: the subpectoral portion as the optimal tenodesis site. Am J Sports Med. 2015;43:63–8. https://doi.org/10.1177/0363546514554193. 10. Taylor SA, Khair MM, Gulotta LV, Pearle AD, Baret NJ, Newman AM, Dy CJ, O’Brien SJ.  Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex. Arthroscopy. 2015;31:215–24. https://doi.org/10.1016/j.arthro.2014.10.017. 11. Holtby R, Razmjou H.  Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004;20:231–6. https://doi. org/10.1016/j.arthro.2004.01.008. 12. Erickson BJ, Basques BA, Griffin JW, Taylor SA, O’Brien SJ, Verma NN, Romeo AA.  The Effect of Concomitant Biceps Tenodesis on Reoperation Rates After Rotator Cuff Repair: A Review of a Large Private-Payer Database From 2007 to 2014. Arthroscopy. 2017;33:1301–1307.e1. https://doi. org/10.1016/j.arthro.2017.01.030. 13. Godenèche A, Kempf J-F, Nové-Josserand L, Michelet A, Saffarini M, Hannink G, Collin P.

110 Tenodesis renders better results than tenotomy in repairs of isolated s­upraspinatus tears with pathologic biceps. J Shoulder Elbow Surg. 2018;27:1939– 45. https://doi.org/10.1016/j.jse.2018.03.030. 14. Saccomanno MF, Sircana G, Cazzato G, Donati F, Randelli P, Milano G. Prognostic factors influencing the outcome of rotator cuff repair: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016;24:3809– 19. https://doi.org/10.1007/s00167-015-3700-y. 15. Castricini R, Familiari F, De Gori M, Riccelli DA, De Benedetto M, Orlando N, Galasso O, Gasparini G. Tenodesis is not superior to tenotomy in the treatment of the long head of biceps tendon lesions. Knee Surg Sports Traumatol Arthrosc. 2018;26:169–75. https://doi.org/10.1007/s00167-017-4609-4. 16. De Carli A, Vadalà A, Zanzotto E, Zampar G, Vetrano M, Iorio R, Ferretti A.  Reparable rotator cuff tears with concomitant long-head biceps lesions: tenotomy or tenotomy/tenodesis? Knee Surg Sports Traumatol Arthrosc. 2012;20:2553–8. https://doi.org/10.1007/ s00167-012-1918-5. 17. Frost A, Zafar MS, Maffulli N.  Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med. 2009;37:828–33. https://doi. org/10.1177/0363546508322179. 18. Gurnani N, Deurzen DFP, Janmaat VT, Bekerom den MPJ.  Tenotomy or tenodesis for pathology of the long head of the biceps brachii: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2015;24:3765–71. https://doi.org/10.1007/ s00167-015-3640-6. 19. Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg. 2011;20:326–32. https://doi. org/10.1016/j.jse.2010.08.019. 20. Slenker NR, Lawson K, Ciccotti MG, Dodson CC, Cohen SB. Biceps tenotomy versus tenodesis: clinical outcomes. Arthroscopy. 2012;28:576–82. https://doi. org/10.1016/j.arthro.2011.10.017. 21. Friedman JL, FitzPatrick JL, Rylander LS, Bennett C, Vidal AF, McCarty EC. Biceps tenotomy versus tenodesis in active patients younger than 55 years: is there a difference in strength and outcomes? OJSM. 2015;3:1– 6. https://doi.org/10.1177/2325967115570848. 22. García-Rellán JE, Sánchez-Alepuz E, Mudarra-­ García J. Increased fatigue of the biceps after tenotomy of the long head of biceps tendon. Knee Surg Sports Traumatol Arthrosc. 2018;89:1001. https://doi. org/10.1007/s00167-018-5007-2. 23. Bigliani LU, Dalsey RM, McCann PD, April EW. An anatomical study of the suprascapular nerve. Arthroscopy. 1990;6:301–5. 24. Lafosse L, Shah AA, Butler RB, Fowler RL. Arthroscopic biceps tenodesis to supraspinatus tendon: technical note. Am J Orthop. 2011;40:345–7. 25. Gombera MM, Kahlenberg CA, Nair R, Saltzman MD, Terry MA.  All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the

J. Plath biceps brachii. Am J Sports Med. 2015;43:1077–83. https://doi.org/10.1177/0363546515570024. 26. Knudsen ML, Hibbard JC, Nuckley DJ, Braman JP. The low-anterolateral portal for arthroscopic biceps tenodesis: description of technique and cadaveric study. Knee Surg Sports Traumatol Arthrosc. 2014;22:462–6. https://doi.org/10.1007/s00167-013-2444-9. 27. Werner BC, Evans CL, Holzgrefe RE, Tuman JM, Hart JM, Carson EW, Diduch DR, Miller MD, Brockmeier SF. Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of minimum 2-year clinical outcomes. Am J Sports Med. 2014;42:2583– 90. https://doi.org/10.1177/0363546514547226. 28. Dickens JF, Kilcoyne KG, Tintle SM, Giuliani J, Schaefer RA, Rue J-P. Subpectoral biceps tenodesis: an anatomic study and evaluation of at-risk structures. Am J Sports Med. 2012;40:2337–41. https://doi. org/10.1177/0363546512457654. 29. Jarrett CD, McClelland WB, Xerogeanes JW. Minimally invasive proximal biceps tenodesis: an anatomical study for optimal placement and safe surgical technique. J Shoulder Elbow Surg. 2011;20:477– 80. https://doi.org/10.1016/j.jse.2010.08.002. 30. Abtahi AM, Granger EK, Tashjian RZ. Complications after subpectoral biceps tenodesis using a dual suture anchor technique. Int J Shoulder Surg. 2014;8:47–50. https://doi.org/10.4103/0973-6042.137527. 31. Ma H, Van Heest A, Glisson C, Patel S. Musculocutaneous nerve entrapment: an unusual complication after biceps tenodesis. Am J Sports Med. 2009;37:2467–9. https:// doi.org/10.1177/0363546509337406. 32. McCormick F, Nwachukwu BU, Solomon D, Dewing C, Golijanin P, Gross DJ, Provencher MT.  The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs. Am J Sports Med. 2014;42:820–5. https://doi. org/10.1177/0363546513520122. 33. Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Mazzocca AD, Romeo AA.  Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery. J Shoulder Elbow Surg. 2010;19:764–8. https://doi.org/10.1016/j. jse.2010.01.024. 34. Rhee PC, Spinner RJ, Bishop AT, Shin AY. Iatrogenic brachial plexus injuries associated with open subpectoral biceps tenodesis: a report of 4 cases. Am J Sports Med. 2013;41:2048–53. https://doi. org/10.1177/0363546513495646. 35. Koch BS, Burks RT. Failure of biceps tenodesis with interference screw fixation. Arthroscopy. 2012;28:735– 40. https://doi.org/10.1016/j.arthro.2012.02.019. 36. Saithna A, Chizari M, Morris G, Anley C, Wang B, Snow M.  An analysis of the biomechanics of interference screw fixation and sheathed devices for biceps tenodesis. Clin Biomech (Bristol, Avon). 2015;30:551–7. https://doi.org/10.1016/j. clinbiomech.2015.04.006. 37. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS. Anatomy of the biceps tendon: implications for restoring physiological length-tension relation dur-

11  Complications in Biceps Tendon Management: Long Head of Biceps Tenotomy and Tenodesis ing biceps tenodesis with interference screw fixation. Arthroscopy. 2012;28:1352–8. https://doi. org/10.1016/j.arthro.2012.04.143. 38. Werner BC, Lyons ML, Evans CL, Griffin JW, Hart JM, Miller MD, Brockmeier SF. Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of restoration of length-tension and mechanical strength between techniques. Arthroscopy. 2015;31:620–7. https://doi.org/10.1016/j.arthro.2014.10.012. 39. Gottschalk MB, Karas SG, Ghattas TN, Burdette R. Subpectoral biceps tenodesis for the treatment of type II and IV superior labral anterior and posterior lesions. Am J Sports Med. 2014;42:2128–35. https:// doi.org/10.1177/0363546514540273. 40. Brady PC, Narbona P, Adams CR, Huberty D, Parten P, Hartzler RU, Arrigoni P, Burkhart SS. Arthroscopic proximal biceps tenodesis at the articular margin: evaluation of outcomes, complications, and revision rate. Arthroscopy. 2015;31:470–6. https://doi. org/10.1016/j.arthro.2014.08.024. 41. Lutton DM, Gruson KI, Harrison AK, Gladstone JN, Flatow EL.  Where to tenodese the biceps: proximal or distal? Clin Orthop Relat Res. 2011;469:1050–5. https://doi.org/10.1007/s11999-010-1691-z. 42. Sanders B, Lavery KP, Pennington S, Warner JJP.  Clinical success of biceps tenodesis with and without release of the transverse humeral ligament. J Shoulder Elbow Surg. 2012;21:66–71. https://doi. org/10.1016/j.jse.2011.01.037. 43. Millett PJ, Sanders B, Gobezie R, Braun S, Warner JJ.  Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: does it matter? BMC Musculoskelet Disord. 2008;9:121. https://doi. org/10.1186/1471-2474-9-121. 44. Kelly AM, Drakos MC, Fealy S, Taylor SA, O’Brien SJ. Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results. Am J Sports Med. 2005;33:208–13. https://doi. org/10.1177/0363546504269555. 45. Kilicoglu O, Koyuncu O, Demirhan M, Esenyel CZ, Atalar AC, Ozsoy S, Bozdag E, Sunbuloglu E, Bilgic B.  Time-dependent changes in failure loads of 3 biceps tenodesis techniques: in vivo study in a sheep model. Am J Sports Med. 2005;33:1536–44. https:// doi.org/10.1177/0363546505274716. 46. Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA.  The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy. 2005;21:1296–306. https://doi. org/10.1016/j.arthro.2005.08.008. 47. Patzer T, Kircher J, Krauspe R.  All-arthroscopic suprapectoral long head of biceps tendon tenodesis

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with interference screw–like tendon fixation after modified lasso-loop stitch tendon securing. Arthrosc Tech. 2012;1:e53–6. https://doi.org/10.1016/j. eats.2012.01.003. 48. Richards DP, Burkhart SS.  A biomechanical analysis of two biceps tenodesis fixation techniques. Arthroscopy. 2005;21:861–6. https://doi. org/10.1016/j.arthro.2005.03.020. 49. Sethi PM, Rajaram A, Beitzel K, Hackett TR, Chowaniec DM, Mazzocca AD.  Biomechanical performance of subpectoral biceps tenodesis: a comparison of interference screw fixation, cortical button fixation, and interference screw diameter. J Shoulder Elbow Surg. 2012;22:451–7. https://doi. org/10.1016/j.jse.2012.03.016. 50. Park JS, Kim SH, Jung HJ, Lee YH, Oh JH. A prospective randomized study comparing the interference screw and suture anchor techniques for biceps tenodesis. Am J Sports Med. 2017;45:440–8. https://doi. org/10.1177/0363546516667577. 51. Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C, Trojani C.  Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007;89:747–57. https://doi.org/10.2106/ JBJS.E.01097. 52. Boileau P, Krishnan SG, Coste J-S, Walch G.  Arthroscopic biceps tenodesis: a new technique using bioabsorbable interference screw fixation. Arthroscopy. 2002;18:1002–12. 53. Walch G, Edwards TB, Boulahia A, Nové-Josserand L, Neyton L, Szabó I. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg. 2005;14:238–46. https://doi. org/10.1016/j.jse.2004.07.008. 54. Werner BC, Pehlivan HC, Hart JM, Carson EW, Diduch DR, Miller MD, Brockmeier SF. Increased incidence of postoperative stiffness after arthroscopic compared with open biceps tenodesis. Arthroscopy. 2014;30:1075–84. https://doi.org/10.1016/j.arthro.2014.03.024. 55. Sears BW, Spencer EE, Getz CL.  Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients. J Shoulder Elbow Surg. 2011;20:e7– 11. https://doi.org/10.1016/j.jse.2011.02.020. 56. Euler SA, Smith SD, Williams BT, Dornan GJ, Millett PJ, Wijdicks CA.  Biomechanical analysis of subpectoral biceps tenodesis: effect of screw malpositioning on proximal humeral strength. Am J Sports Med. 2015;43:69–74. https://doi. org/10.1177/0363546514554563.

Complications in Arthroscopic Fracture Management

12

Philipp Moroder, Maximilian Haas, and Markus Scheibel

12.1 Glenoid Fractures 12.1.1 Introduction Glenoid fractures are usually seen in younger patients as a result of a high energy trauma and are present in about one third of all scapular fractures [1]. While extra-articular scapular fractures can often be treated conservatively, fractures involving the glenoid must be considered on their own merits [2]. Glenoid rim fractures are associated with recurrent shoulder dislocations [3, 4] and because they affect the articular surface of the glenohumeral joint, potential complications also include early-onset degenerative joint disease [5]. Hence, surgical treatment results in higher functional outcome scores when compared with conservative measures [2] and is therefore considered golden standard for larger P. Moroder Center for Musculoskeletal Surgery, Campus Virchow, Charité–Universitaetsmedizin Berlin, Berlin, Germany e-mail: [email protected] M. Haas Paracelsus Medical University, Salzburg, Austria e-mail: [email protected] M. Scheibel (*) Center for Musculoskeletal Surgery, Campus Virchow, Charité–Universitaetsmedizin Berlin, Berlin, Germany Schulthess Clinic, Zurich, Switzerland e-mail: [email protected]

displaced fractures involving the glenoid cavity. Notwithstanding, conservative treatment also yields satisfying results with high subjective shoulder scores and a good shoulder function, even in displaced fractures with large fragments [6, 7]. However, it is necessary that the glenohumeral joint is concentrically reduced in order to achieve those results [7]. Although anatomical reduction and secure fixation of fracture fragments can be achieved with open surgical approaches, open techniques bear the potential for complications such as extensive surgical trauma, soft tissue dissection with resulting subscapularis insufficiency, blood loss, and prolonged postoperative recovery [8]. Arthroscopic treatment options, on the other hand, are minimally invasive procedures and offer excellent intra-articular visualization of the fracture, as well as satisfying cosmetic and functional results with a smaller risk of complications than seen with open surgical procedures [8, 9].

12.1.2 Classification A classification for acute glenoid rim fractures that is quite common and widely used today was introduced by Bigliani et al. [10]. Scheibel et al. further subdivided the acute glenoid fractures into bony Bankart lesions (Type Ia), solitary ­fractures (Type Ib), and multi-fragmentary fractures (Type Ic) [11].

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12.1.3 Surgical Technique The following options for the arthroscopic treatment of acute glenoid fractures have been described in the literature: The patient can be positioned either in beach chair position [12–14] or in lateral decubitus position [8, 9, 15, 16]. The lateral decubitus position with vertical and horizontal traction improves visualization of the glenoid rim and the working space. In addition to posterior, antero-superior, and antero-inferior portals, an additional deep antero-inferior portal is created [16] and a diagnostic arthroscopy is performed prior to fracture reduction [12, 13]. The first step is evacuation of fracture hematoma, followed by mobilization of the fracture fragment and subsequent fracture reduction using elevators [12, 17], rasps [12, 15, 16], shavers [12, 13], or a radiofrequency instrument [12]. After satisfying fracture alignment and fracture

reduction is achieved, the fragment is fixed with cannulated screws [13] or darts [8, 17, 18] for large defects (type Ib) (Figs. 12.1 and 12.2), or suture anchors for smaller lesions (Type Ia) [9, 12, 15, 16] and multifragmented fractures (Type Ic) [9, 12, 16]. Accompanying labral defects may be addressed using suture anchors, as well [13, 16].

12.1.4 Results Arthroscopic treatment of glenoid fractures shows excellent clinical and radiological results with healing of the glenoid fracture and restored stability in the majority of patients up to 2 years after the procedure [12, 13, 16, 18]. Accordingly, patient satisfaction and subjective shoulder scores were also considerably high [9, 12, 13, 16, 19]. While postoperative range of motion was excellent in most direc-

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Fig. 12.1  Arthroscopic fixation of a large glenoid fracture (Type 1b). (a) Direct visualization via the anterosuperior portal. (b) Cleaning of the fracture site using a shaver. (c) Improved visualization of the fracture line after

removal of the hematoma. (d) Mobilization of the fracture fragment using an elevator. (e) Reduction attempts of the fracture fragment

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Fig. 12.2 (a) View of the fracture gap via the anterosuperior portal. (b) Insertion of a K-wire which helps to temporarily fix the fragment. (c) Position of the fragment after reduction. (d) Image of a resorbable screw used for frag-

ment fixation. (e) Visualization of the reduced fracture. (f) Insertion of a knotless suture anchor to refix the labrum to the glenoid superior to the fragment

tions, several studies found a mild restriction of external rotation when compared to the uninjured side [13, 16, 18].

smaller or multiple fragments (Type Ia or Type Ic) eventually require indirect fixation with a suture anchor system, because the size of the fracture fragments may not be large enough for screw fixation [15, 16].

12.1.5 Complications 12.1.5.1 Pre-Operative/Indication Preoperative evaluation of a glenoid fracture is essential in order to choose the right treatment strategy and to avoid possible complications associated with different techniques. Generally, glenoid fractures with a large fragment, gross displacement, or associated instability should be treated surgically [12]. More specifically, fractures with a large and solitary fracture fragment (Type Ib), a step formation of more than 2 mm, and without concomitant neurological injuries such as brachial plexus lesions are suitable for fixation with an arthroscopic screw osteosynthesis or osteochondral darts [13]. Fractures with

12.1.5.2 Intra-Operative One of the main reasons for intraoperative challenges and complications can be as simple as the lack of availability of instruments specifically dedicated to arthroscopic fracture fixation. If the K-wire drills or screw drivers are too short for arthroscopic use, a definitive fixation is impossible [17]. Another potential complication arises from the goal to insert screws perpendicularly to the fracture orientation. Fractures with an oblique direction are especially demanding to treat, because they might require a deep antero-inferior portal with risk of neurovascular injury [17]. In general, anterior and anteroinferior portals need to be carefully placed in order to avoid damage of

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Fig. 12.3  Hardware conflict with protruding screws in a 65  year old female patient. (a) Anteroposterior view. (b) Lateral view. (c) Axial view

relevant neurovascular structures including the axillary nerve, the cephalic vein, the musculocutaneous nerve, the brachial plexus, and the brachial artery [19]. The risk of axillary nerve damage is particularly high when placing the portal in a 5.00–5.30 o’clock position [20, 21]. A portal placed in a 3.00–4.00 o’clock position, on the other hand, bears less potential of neurovascular damage [21]. In addition, cannulas or percutaneous drill sleeves should be used to avoid any direct contact with relevant neurovascular structures. In case metallic screws are used for fragment fixation, attention has to be paid to insert them almost parallel to the joint line and not too close to the articular surface in order to avoid mechanical impingement and damage to the cartilage of the humeral head which make screw removal necessary [13]. Also, it is recommended to tighten the screws with caution, because overtightening may lead to fragment comminution during fixation. A good alternative are screws or darts with a headless profile that can be inserted without being parallel to the joint line. If fragments are temporarily reduced with K-wires and subsequently fixed indirectly with suture anchors by reattaching the labrum, care must be taken to avoid secondary medial displacement of the fragments after K-wire removal. When using the indirect fixation technique, it is advantageous to keep the labrum in continuity

with the fragments attached, since indirect fixation might otherwise become very difficult. In case of highly comminuted free floating fragments, arthroscopic or even open fixation may become impossible and thus an intraoperative switch to an open or arthroscopic glenoid reconstruction procedure using a bone graft may become necessary [13].

12.1.5.3 Post-Operative Specific complications include hardware conflicts with resulting humeral impingement (Figs.  12.3 and 12.4), restricted range of motion, secondary loss of reduction of the fragments, mal-union/non-union, and fragment absorption. Additionally, post-traumatic osteoarthritis with humeral osteophytes has been observed in patients after glenoid fracture treatment [9, 12, 13, 16].

12.2 Greater and Lesser Tuberosity Fractures 12.2.1 Introduction The greater tuberosity (GT) is fractured in 13% to 33% of all proximal humeral fractures [22]. Despite their frequent occurrence, isolated fractures of the greater tuberosity are scarce and often a consequence of shoulder dislocations [23].

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Fig. 12.4  Hardware conflict with protruding screws in a 65 year old female patient. (a) Coronal plane, (b) axial plane

Depending on the mechanism of injury, GT-fractures can be divided into impaction fractures, avulsion/shearing injuries, and bony rotator cuff avulsions with only small bony fracture fragments. While impaction fractures most commonly result from a direct fall on the shoulder or a hyperabduction with impaction of the GT, avulsion or shearing injuries are associated with anterior shoulder dislocations and subsequent shearing off the GT by contact against the glenoid [3, 23, 24]. With the postero-superior parts of the rotator cuff being attached, the greater tuberosity is an integral and eminently important part for shoulder function and is therefore particularly sensitive to traumatic changes. Accordingly, a biomechanical study found even small amounts of GT fragment displacement to alter the balance of forces required to elevate the arm [25]. The already confined anatomical conditions in the subacromial space may further be narrowed by cranial displacement of the GT fracture fragment and subsequently lead to massive limitations of shoulder mobility and pain [26]. In order to avoid these adverse consequences, the indication for conservative or operative treatment must be closely evaluated. Open surgical approaches are associated with a higher morbidity due to the more invasive surgical approach involving splitting of the deltoid muscle. However, arthroscopic frac-

ture treatment may be difficult in severely displaced fractures, multi-­fragmentary fractures, or patients with poor bone quality and as a consequence, an open surgical approach may be preferred [26]. Isolated fractures of the lesser tuberosity with intact humeral head are rare injuries, predominantly affecting young males. A high energy abduction external rotation trauma with a bony avulsion of the lesser tuberosity is causative in most cases [27–30]. Similar to greater tuberosity fractures, even slight displacement of the lesser tuberosity can have a negative effect on functional outcome and therefore surgical treatment is the preferred method for patients with displaced avulsion fractures [28, 30, 31]. However, due to the rare incidence of this injury, there is no general rule which fractures need surgical treatment.

12.2.2 Surgical Technique 12.2.2.1 Greater Tuberosity Fractures The patient is positioned in beach chair position [26, 32–34], which is preferred by the authors, or in lateral decubitus position [35, 36]. It is reasonable to perform a diagnostic arthroscopy not only focused on the footprint of the rotator cuff but also including the pulley system of the long biceps tendon [26], capsulo-ligamentous s­ tructures, labrum

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and cartilage, since greater tuberosity fractures are frequently accompanied by other injuries of the glenohumeral joint [23]. After debridement of the fracture site the arthroscope is moved to the subacromial space [35]. It may be useful to make the incision for the scope more superior and lateral to the classical posterior soft spot to allow a better vision of the greater tuberosity and the rotator cuff when inspecting the subacromial space [34]. Based on the underlying operative technique, several different tools and methods for fracture reduction have been introduced. The range extends from a blunt trochar [26, 34, 35], a probe hook [36], to a suture lasso device [32], or different arthroscopic retrieval devices. After successful fracture reduction, K-wires [34, 37] or a forceps [37] may be beneficial to successfully maintain fracture reduction. In general, there are three different ways for arthroscopic refixation of a fractured greater tuberosity described in the literature. In the beginning, cannulated screws were the method of choice [34, 37]. The screws are inserted over the K-wire and preferably aligned at an angle of 45° to the humeral diaphysis [37]. Although firm, compressive fixation of the tuberosity can be achieved with this approach [34], this technique is not ideal in multi-fragmentary fractures or patients with poor bone quality [26]. Later, double row suture anchor constructs were proposed as an alternative way of fracture fixation (Fig. 12.6). With this technique anchors are inserted medially at the footprint with sutures then being pulled over the fragment and fixed laterally using further suture anchors. While the medial-row anchors are tied as mattress sutures to restore the medial footprint of the rotator cuff, the lateral-row anchors are used to buttress the fractured fragments on the humeral surface area [35, 36, 38]. The lateral anchors should ideally be inserted in line with the medial anchors and about 5–10 mm distal to the lateral edge of the fracture fragment (Fig. 12.5).

12.2.2.2 Lesser Tuberosity Fractures The patient is positioned in beach chair position and a diagnostic arthroscopy is performed

with inspection of the subscapularis insertion zone including the long head of the biceps and the reflection pulley from superior to inferior. Visualization of the inferior parts of the subscapularis tendon can be achieved with further internal rotation of the arm. A mattress stitch formation is achieved anterior to the subscapularis tendon. For that purpose, two suture anchors are inserted into the fracture site. The threads are retrieved via the anterosuperior portal, thereby shuttling the sutures through the subscapularis tendon, which is perforated at the most inferior aspect adjacent to the bone-tendon-interface. The avulsed lesser tuberosity is reduced with a sliding knot. In addition to medial row suture anchor fixation, a second (lateral) row can be used to improve fixation.

12.2.3 Results 12.2.3.1 Greater Tuberosity Fractures Results after screw fixation are scarce in the literature. However, there are various studies on techniques using suture anchor fixation. Postoperative pain level is low, especially when compared to the preoperative situation [36]. Patient reported outcome scores including the UCLA score [36], the ASES score [36], and the Subjective Shoulder Value [26] are comparatively high, indicating great patient satisfaction. Most patients also regained satisfying mobility including a mean abduction ranging from 153° to 157° [36]. 12.2.3.2 Lesser Tuberosity Fractures The available literature on arthroscopical treatment of isolated lesser tuberosity fractures is limited to case reports. However, in a case report, the Constant Score improved from 61.4 points to 91.3 points. The patient was completely pain free with a negative lift off test and a negative Napoleon/belly-press test. Radiographic evaluation revealed an anatomical consolidation of the lesser tuberosity [30].

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a

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Fig. 12.5  Arthroscopically assisted surgical treatment of a displaced isolated greater tuberosity fracture. (a) Arthroscopic intra-articular view of the displaced greater tuberosity fracture from a posterior portal. (b) Visualization of the fracture fragment from a lateral portal. (c) Insertion of a suture anchor on the medial aspect of

the footprint. (d–f) Use of a suture passing device to pass all sutures through the rotator cuff medial to the bone fragment. (g) Lateral fixation of the sutures by inserting a knotless suture anchor distal to the fracture site. (h, i) Subacromial and intra-articular view of the successfully reduced fracture

12.2.4 Complications

intervention and justify its conveyed risks. Neer et al. proposed to only treat proximal humerus fractures with displacement of more than 1cm or 45° of angulation surgically [39]. However, as mentioned above, even small amounts of GT fragment displacement can alter the balance of forces required to elevate the arm [25] and

12.2.4.1 Pre-Operative/Indication In all cases it is necessary not only to consider the morphology of the fracture but also functional demands of the individual patient in order to determine the actual necessity for surgical

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further narrow the already confined subacromial space leading to massive limitations of shoulder mobility and pain [26]. Additionally, a study investigating epidemiological characteristics of proximal humeral fractures found major differences between isolated fractures of the greater tuberosity and proximal humeral fractures in general. More precisely, patients with isolated GT fractures were found to be comparatively young, predominantly male, and suffered from less comorbidities. Additionally, isolated greater tuberosity fractures were more frequently associated with traumatic shoulder dislocations [40]. Thus, the authors suggested to consider treatment and classification of isolated GT fractures separately from that for proximal humeral fractures in general [40]. The current recommendation is to treat greater tuberosity fractures with a displacement of more than 5  mm surgically [41]. In athletes and heavy laborers who are involved in overhead activity this threshold is lowered to 3 mm [42]. However, no randomized trials have confirmed these recommendations. Additionally, the chronicity of the fracture must be respected. There are no general recommendations for the surgical treatment of isolated lesser tuberosity fractures due to the rare occurrence of this injury.

12.2.4.2 Intra-Operative Certain fracture characteristics increase the risk of possible complications regardless of the arthroscopic technique used for re-fixation. Extensive hematoma, a contused and thickened bursa, or a far inferiorly extending fracture are factors that make surgical treatment substantially more difficult [36]. Chronic bony avulsions of the rotator cuff may show extensive tendon retraction without any chance to reduce the bony fragments and cuff to their former insertion on the humeral head (Fig. 12.6). In the case of far inferiorly extending GT fractures, appropriate caution has to be paid not to damage the axillary nerve, as it runs near the inferior aspect of the fracture [36]. In all cases, exact preoperative imaging and intraoperative examination is necessary to detect GT comminution which might prevent screw fixation.

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Fig. 12.6  Arthroscopic visualization of a chronic avulsion of the posterosuperior rotator cuff with retraction of the tendon and attached bony fragments from a lateral portal

Each technique for arthroscopic treatment of GT fractures has inherent strengths and weaknesses. For all fixation techniques, it is essential to have good primary fixation strength to avoid secondary displacement of the GT due to pull of the rotator cuff. For screw fixation, good bone purchase can be found in the far cortex of the calcar area and close to the subchondral bone of the articular surface. However, attention must be paid to avoid protrusion of the screws into the joint. It is therefore recommended to re-insert the arthroscope into the glenohumeral joint to double check whether the cartilage is intact or not after the fracture is successfully reduced [34]. In patients with poor bone quality of the lateral cortex, the use of a washer can be beneficial in order to improve fixation strength. However, over-reduction of the fracture in the region of the bicipital groove should be avoided as it can cause pain from tendon irritation [33]. Several possible complications are described with the use of sutures and suture anchors for fracture fixation. To lower the risk of anchor cut-­ through or pull-out, the insertion point of the anchor should be located at least 5 mm from the fracture margin [33]. In far-inferiorly extending

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Fig. 12.7  Secondary loss of reduction after arthroscopic fixation of a greater tuberosity fracture using a screw fixation system. (a) Initial postoperative X-ray. (b, c) Secondary displacement of the greater tuberosity

fractures the insertion side of the lateral-row suture anchors might be in the diaphyseal ­transition zone and therefore lack sufficient spongious bone for anchor fixation. If suture anchor insertion anterior to the fracture site is desired in order to counteract secondary posterior displacement, care must be taken not to injure the biceps tendon or the bicipital sulcus. The fractured GT fragment and the rotator cuff can be injured during insertion of the medial row anchors. Ji et al. therefore recommend to insert the anchors via an anterior portal [35]. In case a fracture is located in the bare area of the humeral head, it may be difficult to insert suture anchors in that area through the infraspinatus tendon. Also, if a fragment is displaced far postero-inferiorly, as seen with an avulsion fracture by the infraspinatus or teres minor tendons, arthroscopic access may be difficult. Hence, conversion into an open approach eventually becomes necessary [36].

12.2.4.3 Post-Operative Specific postoperative complications include secondary displacement and implant loosening (Fig. 12.7), mal-union, non-union, adhesive capsulitis, avascular osteonecrosis, and iatrogenic neurovascular injuries with resulting functional deficits and pain. To avoid postoperative shoulder stiffness, adequate physical therapy should be recommended while keeping in mind the primary stability of the surgical construct. Regular radio-

graphic follow-up is recommended to rule out secondary displacement. Avascular osteonecrosis of the humeral head is a complication that can occur after an isolated fracture of the greater tuberosity. The reason is believed to be either the initial trauma or an iatrogenic vascular injury produced during surgery rather than the fracture itself [43].

12.3 Lateral Clavicular Fractures 12.3.1 Introduction Clavicular fractures have an incidence of up to 44% of all fractures of the shoulder girdle [44] and most commonly result of a direct injury to the shoulder [45]. Although distal clavicular fractures account for only 10–17% of all clavicular fractures [44, 46–48], their treatment is particularly challenging because the fracture fragments and the acromioclavicular joint are subject to high mechanical loads during arm movement which can lead to secondary displacement after fracture reduction. Various open [49– 51], minimally invasive [52, 53], and arthroscopically assisted techniques [54–58] have been introduced to provide a stable primary fixation. A major advantage of an arthroscopically assisted technique is the possibility to evaluate the glenohumeral joint and consequently to

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identify potential accompanying injuries, especially given that concomitant injuries are detected in up to 29% in patients with unstable lateral clavicular fractures [54].

12.3.2 Surgical Technique The surgery is performed in beach chair position. Prior to addressing the clavicular fracture, a diagnostic glenohumeral and subacromial arthroscopy is performed [54–60]. The surgical principle is similar to the arthroscopic treatment of acromioclavicular joint dislocations. First the undersurface of the coracoid process is exposed. Then a cannulated drill system is utilized to create a transclavicular and transcoracoidal drill hole just medial to the fracture edge of the clavicle in the direction of the conoid ligament. Then a combination of strong sutures and a metal flip-button is shuttled through the drill hole and flipped under the coracoid process. Fracture reduction can be performed using a periosteal elevator [56] or manual pressure. Additionally, exerting an upward force with the humerus can help to reduce the fracture [55]. Finally, the suture is tightened on the clavicle and fluoroscopic control of successful fracture reduction is performed. An additional suture shuttled trough the drill hole and through a second vertical drill hole through the lateral fragment can be used to improve compression forces between the fragments [56]. (Fig. 12.8)

12.3.3 Results In most cases, radiographic healing of the clavicular fracture can be achieved by arthroscopically assisted surgical treatment [55, 58]. Patient satisfaction is also considerably high with low pain levels and high subjective functional outcome scores [58, 59]. In addition to subjective outcomes, evaluation of shoulder mobility showed that range of motion typically does not differ significantly from the healthy contralateral side [56, 58].

12.3.4 Complications 12.3.4.1 Pre-Operative/Indication Based on a classification originally introduced by Neer [47, 61], Jäger and Breitner further developed a classification for lateral clavicular fractures that is widely used and accepted today [62]. Type I fractures are located laterally of the coracoclavicular (CC) bands. They are considered stable with the CC-bands still being intact [62]. Fractures with injury to the coracoclavicular bands are referred to as type II fractures and further subdivided into type IIa (ruptured conoid ligament) and type IIb (ruptured trapezoid ligament), respectively [62]. As a consequence, cranial dislocation of the medial fracture fragment is typically seen with type IIa fractures due to tension of the sternocleidomastoid muscle [63]. Fractures located medially of the CC ligaments are referred to as type III fractures and type IV fractures are seen in children with avulsion of the periosteal sleeve [62]. 12.3.4.2 Intra-Operative The presented method of arthroscopic fracture fixation is an indirect method of fixation with closed or percutaneous fracture reduction. An issue can be the achievement of adequate reduction and retention of the fragments. Also, interposition of the trapezius muscle and its fascia can further complicate reduction and healing of the fracture [58]. The goal of this surgical procedure should be to achieve anatomical or nearly anatomical reduction with sufficient primary stability to allow fracture healing. Another complication can be button slippage if the drill tunnels are placed too close to the edges of the respective bone or if too many drill attempts are made leading to fracture of either the clavicle or the coracoid process [58, 64]. Some authors even suggest that tightening of the sutures should be performed very carefully, because otherwise fixation failure or a fracture of the coracoid process could occur [60]. 12.3.4.3 Post-Operative Specific complications like secondary displacement, malunion, nonunion, adhesive capsulitis,

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Fig. 12.8  Arthroscopically assisted re-fixation of a displaced lateral clavicular fracture using a double endo-­ button device. (a) Arthroscopic view of the undersurface of the coracoid process with a K-wire protruding through the bone. (b) Anteroposterior X-ray showing positioning of the transclavicular transcoracoidal K-wire and cannulated drill. (c) Insertion of a nitinol suture passing wire through the cannulated drill after removal of the K-wire. (d) Positioning of the metal flip-button on the undersur-

face of the coracoid process along with a strong synthetic suture. (e) Drilling through the lateral fragment. (f) Insertion of a second nitinol suture passing wire via the transfragmentary drill bit (g) to shuttle the strong synthetic suture. (h, i) After tensioning of the double button device and tying of the sutures adequate fracture reduction and fixation is achieved. (j) Postoperative X-ray showing satisfying fracture alignment

or even iatrogenic neurovascular injuries may potentially occur with the presented arthroscopic procedure. Excessive coracoclavicular ossification, can occasionally be observed on follow-up

X-rays, mostly without clinical consequences [56, 64]. Another frequently encountered complication is hardware and suture material irritation of the often only thin soft-tissue layer on top of

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the clavicle which can lead to wound healing problems and infections. Therefore, it is recommended to cover the implant and suture knots by as much soft tissue as possible during wound closure. Migration of the metal buttons is another specific complication of this procedure (Fig.  12.9). At best, it has no clinical consequences, but it can also lead to fracture displacement or non-union. [58] Non-union, in general, is a common complication seen with lateral cla-

a

vicular fractures (Fig. 12.10) [56, 59, 64]. Even though this indirect lateral clavicle fracture fixation technique has certain advantages it offers only limited primary stability. In order to avoid secondary displacement (Fig. 12.11) and button sintering before fracture healing occurs it is recommended to follow a rather conservative postoperative physiotherapy protocol including immobilization in an abduction pillow for 6 weeks.

b

Fig. 12.9  Tunnel widening and slight button migration seen on postoperative X-rays ((a) neutral, (b) 30° tilt) after arthroscopic reconstruction of a lateral clavicle fracture using a double button system

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Fig. 12.10  Non-union of a lateral clavicular fracture after arthroscopically assisted fixation. (a) Preoperative, (b) postoperative, (c) follow-up X-rays, (d) follow-up CT scans

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Fig. 12.11  Secondary loss of reduction after arthroscopically assisted fixation of a lateral clavicle fracture (Type IIa). (a) Preoperative X-ray, (b, c) intra-operative fluoros-

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6. Kraus N, Gerhardt C, Haas N, Scheibel M. Conservative therapy of antero-inferior glenoid fractures. Unfallchirurg. 2010;113(6):469–75. 7. Maquieira GJ, Espinosa N, Gerber C, Eid K. Non-­ operative treatment of large anterior glenoid rim fractures after traumatic anterior dislocation of the shoulder. J Bone Joint Surg Br. 2007;89(10):1347–51. 8. Carro LP, Nuñez MP, Llata JIE. Arthroscopic-assisted reduction and percutaneous external fixation of a displaced intra-articular glenoid fracture. Arthroscopy. 1999;15(2):211–4. 9. Bauer T, Abadie O, Hardy P. Arthroscopic treatment of glenoid fractures. Arthroscopy. 2006;22(5):569. e1–6. 10. Bigliani LU, Newton PM, Steinmann SP, Connor PM, McIlveen SJ.  Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med. 1998;26(1):41–5.

126 11. Scheibel M, Kraus N, Gerhardt C, Haas NP. Anteriore Glenoidranddefekte der Schulter. Orthopade. 2009;38(1):41–53. 12. Sugaya H, Kon Y, Tsuchiya A. Arthroscopic repair of glenoid fractures using suture anchors. Arthroscopy. 2005;21(5):635.e1–5. 13. Tauber M, Moursy M, Eppel M, Koller H, Resch H. Arthroscopic screw fixation of large anterior glenoid fractures. Knee Surg Sports Traumatol Arthrosc. 2008;16(3):326–32. 14. Tauber M, Resch H, Forstner R, Raffl M, Schauer J.  Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. 2004;13(3):279–85. 15. Krüger D, Kraus N, Gerhardt C, Scheibel M. Technik und Grenzen arthroskopischer Versorgung von Glenoid- und Skapulafrakturen. Obere Extremität. 2013;8(2):78–86. 16. Scheibel M, Hug K, Gerhardt C, Krueger D. Arthroscopic reduction and fixation of large solitary and multifragmented anterior glenoid rim fractures. J Shoulder Elbow Surg. 2016;25(5):781–90. 17. Frush TJ, Hasan SS. Arthroscopic reduction and cannulated screw fixation of a large anterior glenoid rim fracture. J Shoulder Elbow Surg. 2010;19(3):e16–e9. 18. Cameron SE.  Arthroscopic reduction and internal fixation of an anterior glenoid fracture. Arthroscopy. 1998;14(7):743–6. 19. Marsland D, Ahmed HA.  Arthroscopically assisted fixation of glenoid fractures: a cadaver study to show potential applications of percutaneous screw insertion and anatomic risks. J Shoulder Elbow Surg. 2011;20(3):481–90. 20. Davidson PA, Tibone JE.  Anterior-inferior (5 o’clock) portal for shoulder arthroscopy. Arthroscopy. 1995;11(5):519–25. 21. Meyer M, Graveleau N, Hardy P, Landreau P.  Anatomic risks of shoulder arthroscopy portals: anatomic cadaveric study of 12 portals. Arthroscopy. 2007;23(5):529–36. 22. Kristiansen B, Barfod G, Bredesen J, Erin-Madsen J, Grum B, Horsnaes MW, et  al. Epidemiology of proximal humeral fractures. Acta Orthop Scand. 1987;58(1):75–7. 23. Bahrs C, Lingenfelter E, Fischer F, Walters EM, Schnabel M.  Mechanism of injury and morphology of the greater tuberosity fracture. J Shoulder Elbow Surg. 2006;15(2):140–7. 24. Green A, Izzi J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder Elbow Surg. 2003;12(6):641–9. 25. Bono CM, Renard R, Levine RG, Levy AS. Effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder. J Bone Joint Surg Br. 2001;83(7):1056–62. 26. Greiner S, Scheibel M.  Knöcherne Rotatorenmanschettenausrisse: Arthroskopische Konzepte. Orthopade. 2011;40 27. Paschal SO, Hutton KS, Weatherall PT. Isolated avulsion fracture of the lesser tuberosity of the humerus in

P. Moroder et al. adolescents. A report of two cases. J Bone Joint Surg Am. 1995;77(9):1427–30. 28. Robinson CM, Teoh KH, Baker A, Bell L. Fractures of the lesser tuberosity of the humerus. J Bone Joint Surg Am. 2009;91(3):512–20. 29. Ross GJ, Love MB. Isolated avulsion fracture of the lesser tuberosity of the humerus: report of two cases. Radiology. 1989;172(3):833–4. 30. Scheibel M, Martinek V, Imhoff AB.  Arthroscopic reconstruction of an isolated avulsion fracture of the lesser tuberosity. Arthroscopy. 2005;21(4):487–94. 31. Ogawa K, Takahashi M. Long-term outcome of isolated lesser tuberosity fractures of the humerus. J Trauma. 1997;42(5):955–9. 32. Cadet ER, Ahmad CS.  Arthroscopic reduction and suture anchor fixation for a displaced greater tuberosity fracture: a case report. J Shoulder Elbow Surg. 2007;16(4):e6–9. 33. Song HS, Williams GR Jr. Arthroscopic reduction and fixation with suture-bridge technique for displaced or comminuted greater tuberosity fractures. Arthroscopy. 2008;24(8):956–60. 34. Taverna E, Sansone V, Battistella F.  Arthroscopic treatment for greater tuberosity fractures: rationale and surgical technique. Arthroscopy. 2004;20(6):e53–7. 35. Ji JH, Kim WY, Ra KH. Arthroscopic double-row suture anchor fixation of minimally displaced greater tuberosity fractures. Arthroscopy. 2007;23(10):1133.e1–4. 36. Ji JH, Shafi M, Song IS, Kim YY, McFarland EG, Moon CY.  Arthroscopic fixation technique for comminuted, displaced greater tuberosity fracture. Arthroscopy. 2010;26(5):600–9. 37. Carrera EF, Matsumoto MH, Netto NA, Faloppa F. Fixation of greater tuberosity fractures. Arthroscopy. 2004;20(8):e109–11. 38. Kim K-C, Rhee K-J, Shin H-D, Kim Y-M. Arthroscopic fixation for displaced greater tuberosity fracture using the suture-bridge technique. Arthroscopy. 2008;24(1):120.e1–3. 39. Neer CS 2nd. Displaced proximal humeral fractures. I.  Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077–89. 40. Kim E, Shin HK, Kim CH. Characteristics of an isolated greater tuberosity fracture of the humerus. J Orthop Sci. 2005;10(5):441–4. 41. McLaughlin HL.  Dislocation of the shoulder with tuberosity fracture. Surg Clin North Am. 1963;43:1615–20. 42. Park TS, Choi IY, Kim YH, Park MR, Shon JH, Kim SI.  A new suggestion for the treatment of minimally displaced fractures of the greater tuberosity of the proximal humerus. Bull Hosp Jt Dis. 1997;56(3):171–6. 43. Gruson KI, Ruchelsman DE, Tejwani NC.  Isolated tuberosity fractures of the proximal humeral: current concepts. Injury. 2008;39(3):284–98. 44. Postacchini F, Gumina S, De Santis P, Albo F.  Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11(5):452–6.

12  Complications in Arthroscopic Fracture Management 45. Stanley D, Trowbridge EA, Norris SH.  The mechanism of clavicular fracture. A clinical and biomechanical analysis. J Bone Joint Surg Br. 1988;70(3):461–4. 46. Craig E. Fractures of the clavicle. In: Rockwood CA, Matsen FA, editors. The shoulder. Philadelphia: WB Saunders; 1990. p. 367–412. 47. Neer CS 2nd. Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma. 1963;3:99–110. 48. Nordqvist A, Petersson C.  The incidence of frac tures of the clavicle. Clin Orthop Relat Res. 1994;(300):127–32. 49. Herrmann S, Schmidmaier G, Greiner S. Stabilisation of vertical unstable distal clavicular fractures (Neer 2b) using locking T-plates and suture anchors. Injury. 2009;40(3):236–9. 50. Kashii M, Inui H, Yamamoto K.  Surgical treatment of distal clavicle fractures using the clavicular hook plate. Clin Orthop Relat Res. 2006;447:158–64. 51. Lee SK, Lee JW, Song DG, Choy WS. Precontoured locking plate fixation for displaced lateral clavicle fractures. Orthopedics. 2013;36(6):801–7. 52. Nandra R, Kowalski T, Kalogrianitis S.  Innovative use of single-incision internal fixation of distal clavicle fractures augmented with coracoclavicular stabilisation. Eur J Orthop Surg Traumatol. 2017;27(8):1057–62. 53. Teoh KH, Jones SA, Robinson JD, Pritchard MG. Long-term results following polydioxanone sling fixation technique in unstable lateral clavicle fracture. Eur J Orthop Surg Traumatol. 2016;26(3):271–6. 54. Beirer M, Zyskowski M, Cronlein M, Pforringer D, Schmitt-Sody M, Sandmann G, et  al. Concomitant intra-articular glenohumeral injuries in displaced fractures of the lateral clavicle. Knee Surg Sports Traumatol Arthrosc. 2017;25(10):3237–41. 55. Checchia SL, Doneux PS, Miyazaki AN, Fregoneze M, Silva LA.  Treatment of distal clavicle fractures

127 using an arthroscopic technique. J Shoulder Elbow Surg. 2008;17(3):395–8. 56. Kraus N, Stein V, Gerhardt C, Scheibel M.  Arthroscopically assisted stabilization of displaced lateral clavicle fractures with coracoclavicular instability. Arch Orthop Trauma Surg. 2015;135(9):1283–90. 57. Nourissat G, Kakuda C, Dumontier C, Sautet A, Doursounian L.  Arthroscopic stabilization of Neer type 2 fracture of the distal part of the clavicle. Arthroscopy. 2007;23(6):674.e1–4. 58. Motta P, Bruno L, Maderni A, Tosco P, Mariotti U.  Acute lateral dislocated clavicular fractures: arthroscopic stabilization with TightRope. J Shoulder Elbow Surg. 2014;23(3):e47–52. 59. Ranalletta M, Rossi LA, Barros H, Nally F, Tanoira I, Bongiovanni SL, et al. Minimally invasive double-­ button fixation of displaced lateral clavicular fractures in athletes. Am J Sports Med. 2017;45(2):462–7. 60. Takase K, Kono R, Yamamoto K.  Arthroscopic stabilization for Neer type 2 fracture of the distal clavicle fracture. Arch Orthop Trauma Surg. 2012;132(3):399–403. 61. Neer CS 2nd. Fractures of the distal third of the clavicle. Clin Orthop Relat Res. 1968;58:43–50. 62. Jager M, Breitner S.  Therapy related classifica tion of lateral clavicular fracture. Unfallheilkunde. 1984;87(11):467–73. 63. Breitner S, Theisen C, Schneider K, Kösters C, Raschke M.  Die laterale Klavikulafraktur  – Grundlagen, OP-Indikationen, Versorgungstechniken. Obere Extremität. 2014;9(3):222–8. 64. Loriaut P, Moreau PE, Dallaudiere B, Pelissier A, Vu HD, Massin P, et  al. Outcome of arthroscopic treatment for displaced lateral clavicle fractures using a double button device. Knee Surg Sports Traumatol Arthrosc. 2015;23(5):1429–33.

Vascular Complications in Shoulder Arthroscopy

13

Laurent Lafosse and Thibault Lafosse

13.1 Introduction Vascular complications are extremely rare in shoulder arthroscopy but can be catastrophic. The purpose of this chapter is to expose vascular difficulties risk and complications in the different field of shoulder’s arthroscopic surgery. General and surgical tips are described in order to avoid the major complications as well as their treatment. Out of the description and evaluation of difficulties risk and complications described in literature, out of the box vascular complications and solutions based on personal experience are exposed as well as the tips and tricks to avoid as much as possible to be in bad situation.

13.2 General Complications 13.2.1 Deep Venous Thrombosis (DVT) DVT has been described as one of shoulder arthroscopic complications [1–5]. Burkhart SS was the first who described a DVT of the upper limb after a shoulder arthroscopy [6]. In that L. Lafosse ∙ T. Lafosse (*) Department of Orthopedics, Clinique Générale, Annecy, France

case the patient had a compression of the vessels by ganglions due to lymphoma and the DVT was inaugural. Even if extremely rare (0.31% of shoulder arthroscopy according Kuresmski) [7], to a more recent review about 14 publication reported by Dattani which shows the incidence of VTE as 0.038% from 92,440 shoulder arthroscopic procedures [8]. Diagnosis is not obvious, based on ultrasound as soon as an edema is felt by the patient and/or visible mostly at the level of the hand. DVT can happen few days or weeks after shoulder arthroscopy, the risk is possibly increased by the necessary high pressure during the arthroscopy and the immobilization after repair. There is no influence of patient positioning during the arthroscopy. It is sometime difficult to differentiate an algodystrophic syndrome to a DVT and an ultrasound must be required as soon as there is a suspicion for adequate treatment. DVT can lead to venous superior cave syndrome, to post thrombotic venous syndrome and to venous thromboembolism (VTE) [9, 10], sometime fatal [11].

13.2.2 Venous Air Embolism First lethal air embolism during arthroscopy was described by R. Habegger in 1989 [12]. It was a knee diagnostic arthroscopy for an acute trauma which was managed under air without

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fluid. The author used a pressure 5–10 times higher than the venous system and air may have escape through the intra-articular fracture. First air embolism during shoulder arthroscopy was described by E.  Faure [13]. In a 40  years old healthy lady, 60 mL of air where injected at the beginning of the arthroscopy followed by saline. Three minutes after the scope introduction, End Tidal carbon (ET CO2) decreased to less than 10  mmHg, Oxygen Saturation Sp 02 decrease to less than 90% before the signal was lost, sinus rhythm was 90. Patient was saved by discontinuing the surgery and anesthesia, performing manual ventilation with 100% oxygen, 1 mg epinephrine was injected, and the patient was moved to supine position. Same situation happened during a shoulder arthroscopy in a young shoulder 28-year-old man unless any sequalae [14]. Other cases where lethal [14, 15]. In the case described by Zmistowski [15], air entered by mistake in the saline poach and patient had a 14  days recovery before fatal issue. Beach chair position as well as left lateral decubitus may be one of the factors which facilitates the tricuspid atrium failure due to venous air inflation. It looks obvious today that air should not be inflated into a shoulder arthroscopy, more specifically for acute cases. Particular attention should be paid by the nurse to control that the fluid bag does not remain empty of fluid while the arthroscopic pump is running.

13.3 Local Complications 13.3.1 Venous Aneurysm Venous pseudo aneurysm after a shoulder arthroscopy was described by Cameron in 1996 [16]. The patient with a renal failure which required a long history of vascular fistula developed a delated high flow cephalic vein. The vascular cyst appeared 3 months after surgery and was removed without sequlae.

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13.3.2 Arterial Pseudoaneurysm Arterial pseudoaneurysm developed from the Acromial branch of the acromio-thoracic artery after shoulder arthroscopy was first described by ISHIDA in 2015 [17]. A 5  mm diameter vascular mass appeared at day 5, increased to 20  mm diameter at 6  weeks after surgery and was successfully removed at that time. Another case from the same artery’s branch was efficiently treated by embolization by coils [18].

13.3.3 Anatomic Risk of Shoulder Arthroscopy Portals Portals at risk has been described by Meyers in 2007 [19], who made a cadaver study about six different portals commonly used during shoulder arthroscopy. Only two portals are at risk: • 5 o’clock portal at risk for axillary artery (1.3 cm) • Neviaser at risk for suprascapular artery (2.5 cm)

13.4 Personal Experience Today development of most advanced and out of the box surgeries are exposing to more risk than usual arthroscopic surgeries. As shoulder exploration and treatment does not remain intra articular for surgeries developed for massive rotator cuff repair, shoulder instability and plexus treatment, shoulder arthroscopy moves to shoulder endoscopy. We described three compartments of the shoulder (Fig. 13.1). (Rockwood Book Third edition) the anterior, the postero-superior and the inferior shoulder. • Postero-Superior shoulder is corresponding mainly to the sub acromial area and contain supra spinatus, infra spinatus and teres minor as well as the superior vessels and supra scapular nerve. The lateral limit is the end of the

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Fig. 13.1  The three sectors of the shoulder

Fig. 13.3  Superior periarticular vessels at the acromion spine area

Fig. 13.2  Supra scapular nerve and artery

subacromial bursae under which the axillary nerve gives its deltoid branch. • Anterior sector starts superiorly at the anterior border of the subacromial bursae and ends at the inferior border of the subscapularis muscle. It contains the coracoid process and its inferior extension represented by the conjoint tendon which determines a limit between the lateral and the medial anterior sector. • Inferior sector is the axillary area which starts superiorly at the level of the quadrilateral space and ends inferiorly at the inferior border of the latissimus dorsi.

13.4.1 Postero-Superior Area No voluminous vascular structures are at risk in this area, except the suprascapular artery

(Fig.  13.2). During arthroscopic supra scapular nerve release, it is important to protect the artery medially during the transverse ligament release or to coagulate it as its leakage may create voluminous postoperative hematoma with secondary fibrosis around the suprascapular nerve. Vascular clips can sometime be necessary. It is even important to pay attention of the periarticular vascular structures around the base of the acromion (Fig. 13.3) during postero-­superior cuff release in order to avoid bleeding during and after arthroscopic rotator cuff repair. These vessels are giving branches toward the sub acromial tissues and most of the time surrounded by fat, which make the coagulation somehow difficult.

13.4.2 Anterior Area This area contains subscapularis muscle, plexus, sub-clavicular and axillary vessels. As previously described, coracoid and conjoint tendon determine two subareas: • A lateral space extended to the sub coracoid bursae (Fig. 13.4), in which there is no major vascular structure at risk. The only vascular structures are: –– superiorly the terminal branch of the Acromio-­ Thoracic artery which can be involved as soon as the Coraco-Acromial

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Fig. 13.4  Intact subcoracoid bursae

(CA) ligament is detached. It is located between the deltoid muscle and the CA ligament. Meticulous hemostasis has to be performed while acromioplasty and Acromio-­Clavicular joint is performed. Inferiorly the sisters at the inferior border of the subscapularis which may be responsible of consequent bleeding in case of damage. As long as the sub coracoid bursae is intact, there is no vascular and no neurologic risk on this area. Subscapularis repair allows very medial intra-articular release and extra articular retro coracoid and behind the conjoint tendon as long as the subcoracoid medial bursae limit is respected. • The medial area is the most dangerous area of the shoulder. –– The subcoracoid area As soon as the medial border of the sub coracoid bursae is open (Fig. 13.5), we can during the shoulder endoscopy looking form lateral identified the plexus and the axillary vessels (Fig. 13.6). Axillary artery is located anterior to the posterior cord just behind the musculo-­ cutaneous nerve. During axillary nerve or subscapularis nerve release necessary for subscapularis repair with massive retraction, it is dramatically important to pay attention to the axillary artery and to the axillary vein.

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Fig. 13.5  Opened subcoracoid bursae

Fig. 13.6  Plexus and axillary vessels. Lateral view

–– The subclavicular area Vascular vessels and plexus are located behind the clavicle and the sub-clavicle muscle in front of the thorax at the level of the first ribs. More inferiorly the nerve vascular structures are behind the pectoralis minor. During anterior shoulder endoscopic procedures, (Arthroscopic Latarjet mainly), under the level of the clavicle, as long as the pectoralis minor is intact, there is no vascular or nerve structure at risk.

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Fig. 13.7  Axillary vein. (a) Vertical tear. (b) Hemostasis with vascular clips

As soon as the pectoral minor is detached, the nerve and vascular structures are at risk. Under the clavicle, at the upper level, vascular and nerve structures are already included in the same aponeurosis. In case of endoscopic plexus release, particular attention must be paid for axillary artery and vein. We experimented an axillary vein injury during a plexus release for a 44-year-old woman case of persistent outlet syndrome after a first rib resection. During the endoscopic release of the plexus at the level of the retro clavicle area, the vein which was included in a fibrotic tissue was damaged (Fig. 13.7a). It was possible to control the bleeding by adapted pressure of the pump avoiding to inflating air by water tightening the portals and by paying great attention to the fluid management of the pump (no air entry). The tear of the vein was longitudinal and long about 2  cm. We performed a watertight hemostasis by using endoscopically vascular clips (Fig. 13.7b). The plexus release procedure was terminated efficiently, and the patient went back to the recovery room in good conditions. –– The retro Pectoralis Minor area • In case of plexus release, some transversal horizontal artery may cross the anterior plexus and be responsible of compression. Vascular clips may be necessary to insure accurate hemostasis in order to cut this transversal vessels

Fig. 13.8  Plexus exposure during arthroscopic Latarjet

• Arthroscopic Latarjet as well as open Latarjet is a procedure which is located in a sensible area due to the proximity of vessels and nerves (Fig.  13.8). Particular attention must be paid during these procedures for a step by step hemostasis in order to avoid per operative bleeding and post-operative hematoma. Since end 2003, we performed more than 800 arthroscopic Latarjet. Five patients needed endoscopic revision for lavage of hematoma without any sequalae. On the top of these five cases, one case presented a post-operative hematoma which was not efficiently treated by a simple lavage. A 23 year-old man was operated for left shoulder instability by arthroscopic Latarjet. During surgery, hemostasis was difficult, patient was slightly bleeding and the pressure of the pump had to remain high to

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achieve the surgery but not obvious vessel was injured. Despite a particular attention was given to the axillary vessels area. Post operatively at Day 1 it was hard to differentiate hematoma

from swelling (Fig. 13.9a). Hemoglobin when down too 7 gr at Day 2 and lavage was managed with endoscopic assistance. No major bleeding origin could be found. Persistent

a

b

c

d

Fig. 13.9  Artery damage during arthroscopic Latarjet. (a) Day 1 hematoma. (b) Ultrasound of bleeding artery. (c, d) Angio-CT. (e) Unsuccessful hemostasis by Coil. (f, g) Stent. (h) Hematoma diffusion. (I, j) Good final result

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f

g h

i

Fig. 13.9 (continued)

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reconstruction of postero-superior RCT and of Subscapularis deficiency. Today, differently to neurological complications which may happen, no vascular complication has been reported in the new field of endoscopic tendon transfer.

j

13.5 Conclusion Vascular complications are extremely rare in shoulder arthroscopy but can be terrible. It is important to avoid DVT by systematic prevention and not to use any endoscopic air inflation by syringe or by mistake during the pump management in order to avoid air embolism catastrophic complications. Perfect knowledge of anatomy.

References Fig. 13.9 (continued)

bleeding at Day 3 leaded to ultrasound which confirmed the origin of a persistent bleeding from a small branch of the axillary artery into a pseudo aneurysm (Fig.  13.9b) as well as by Angio CT (Fig. 13.9c, d) but with integrity of the axillary artery. An attempt of hemostasis with a Coil by the vascular radiologist was unsuccessful (Fig. 13.9e). Vascular endoscopic surgeons could finally obtain an accurate hemostasis by endovascular stent at the origin (Fig. 13.9f, g). After a massive diffused hematoma (Fig. 13.9h), the patient totally recovered normal vascularization and presented at 6 months post op an excellent clinical and functional result. He remained under anti-coagulant for 6 months (Fig. 13.9i, j). There is no vascular sequalae, pulse and ultrasound control are 100% normal.

13.4.3 Inferior Area In case of irreparable rotator cuff tear (RCT), Latissimus Dorsi transfer can be indicated for

1. McFarland EG, O’Neill OR, Hsu CY. Complications of shoulder arthroscopy. J South Orthop Assoc. 1997;6(3):190–6. 2. Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic shoulder surgery. Arthroscopy. 2002;18(2 Suppl 1):88–95. 3. Polzhofer GK, Petersen W, Hassenpflug J.  Thromboembolic complication after arthroscopic shoulder surgery. Arthroscopy. 2003;19(9):E129–32. 4. Kommareddy A, Zaroukian MH, Hassouna HI. Upper extremity deep venous thrombosis. Semin Thromb Hemost. 2002;28(1):89–99. 5. Creighton RA, Cole BJ. Upper extremity deep venous thrombosis after shoulder arthroscopy: a case report. J Shoulder Elbow Surg. 2007;16(1):e20–2. 6. Burkhart SS. Deep venous thrombosis after shoulder arthroscopy. Arthroscopy. 1990;6(1):61–3. 7. Kuremsky MA, Cain EL, Fleischli JE.  Thromboembolic phenomena after arthroscopic shoulder surgery. Arthroscopy. 2011;27(12):1614–9. 8. Dattani R, Smith CD, Patel VR. The venous thromboembolic complications of shoulder and elbow surgery: a systematic review. Bone Joint J. 2013;95-B(1):70–4. 9. Hariri A, Nourissat G, Dumontier C, Doursounian L. Pulmonary embolism following thrombosis of the brachial vein after shoulder arthroscopy. A case report. Orthop Traumatol Surg Res. 2009;95(5):377–9. 10. Cortés ZE, Hammerman SM, Gartsman GM. Pulmonary embolism after shoulder arthroscopy: could patient positioning and traction make a difference? J Shoulder Elbow Surg. 2007;16(2):e16–7. 11. Kim SJ, Yoo KY, Lee H-G, Kim W-M, Jeong CW, Lee H-J. Fatal pulmonary embolism caused by thrombosis

13  Vascular Complications in Shoulder Arthroscopy of contralateral axillary vein after arthroscopic right rotator cuff repair: a case report. Korean J Anesthesiol. 2010;59(Suppl):S172–5. 12. Habegger R, Siebenmann R, Kieser C.  Lethal air embolism during arthroscopy. A case report. J Bone Joint Surg Br. 1989;71(2):314–6. 13. Faure EA, Cook RI, Miles D.  Air embolism during anesthesia for shoulder arthroscopy. Anesthesiology. 1998;89(3):805–6. 14. Hegde RT, Avatgere RN.  Air embolism during anaesthesia for shoulder arthroscopy. Br J Anaesth. 2000;85(6):926–7. 15. Zmistowski B, Austin L, Ciccotti M, Ricchetti E, Williams G.  Fatal venous air embolism during ­shoulder arthroscopy: a case report. J Bone Joint Surg Am. 2010;92(11):2125–7.

137 16. Cameron SE. Venous pseudoaneurysm as a complication of shoulder arthroscopy. J Shoulder Elbow Surg. 1996;5(5):404–6. 17. Ishida Y, Chosa E, Taniguchi N. Pseudoaneurysm as a complication of shoulder arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2015;23(5):1549–51. 18. Choo H-J, Kim J-H, Kim D-G. Arterial pseudoaneurysm at the arthroscopic portal site as a complication after arthroscopic rotator cuff surgery: a case report. J Shoulder Elbow Surg. 2013;22(12):e15–9. 19. Meyer M, Graveleau N, Hardy P, Landreau P.  Anatomic risks of shoulder arthroscopy portals: anatomic cadaveric study of 12 portals. Arthroscopy. 2007;23(5):529–36.

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Thibault Lafosse and Laurent Lafosse

14.1 Introduction Shoulder arthroscopy is widely performed by most upper limb surgeons and has become a gold standard regarding many different procedures ranging from rotator cuff repairs to instability. Most of the surgical procedure addressing post traumatic or degenerative conditions of the shoulder can be performed arthroscopically. Many acute traumatic cases can be managed with arthroscopy as well, particularly glenoid or humeral tuberosity fractures. Arthroscopy is in many aspects performed out of the box and can be considered rather as endoscopy. With the expansion of the procedures outside of the joint, the space of work becomes closer to the brachial plexus, and to all its branches. Therefore, neurologic complications occur. They are not only linked to the proximity of the nerves, which can be damaged by the surgeon during dissection, but are also often secondary to patient positioning, and sometimes to implants. A wide range of neurologic complications are reported, and most of them can be avoided by either a cautious dissection of the nerves around T. Lafosse (*) Department of Hand, Upper Limb, and Peripheral Nerve Surgery, Clinique Générale, Annecy, France L. Lafosse Department of Orthopedics, Clinique Générale, Annecy, France

the shoulder or care during the patient’s set up. However, some remain unexpected, and patients as well as surgeons should be informed and aware about them before surgery. We describe those complications and the way to manage it in this chapter. As making a scientific article around this matter was not the proper way of explaining the most interesting issues, we alternatively describe common patterns and case reports. The idea and goal of this chapter is to find answers to problems that one may encounter as a surgeon. The main aim is to give clues about what went wrong and led to complications, but mostly and overall, how to deal with it.

14.2 Anatomy of the Shoulder (Fig. 14.1) In understanding nerves, around the shoulder, it is easier to visualize them as comparted in the shoulder. We describe three compartments of the arthroscopic shoulder. The anterior, the inferior shoulder, and the posterosuperior shoulder. Each one of these compartments has a certain amount of nerves that should be expected, and seeked when working in this space. The anterior compartment contains the Cords and the distal divisions of the brachial plexus (Musculocutaneous, median, ulnar, radial nerves).

© Springer Nature Switzerland AG 2020 L. Lafosse et al. (eds.), Complications in Arthroscopic Shoulder Surgery, https://doi.org/10.1007/978-3-030-24574-0_14

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of the surrounding nerves even though they might be considered as protected during the procedures.

14.3.2 Non-Surgical Complications

Fig. 14.1  Representation of the arthroscopic anatomy of the shoulder divided into anterior, superior and posterior compartments

The posterosuperior compartment regroups the SupraScapular nerve (SSN), and the Trunks (superior middle and inferior). The inferior compartment contains the axillary nerve and the branches to the long head of the triceps from the radial nerve.

14.3 Types of Complications 14.3.1 Expected and Less Expected Complications As soon as the surgery is performed out of the limits of the joint, it becomes risky for the nerves. This principle is widely accepted and most surgeons prefer to remain inside the joint to prevent neurologic complications. However, it remains possible to damage nerves during exclusively arthroscopic procedures. Particularly the axillary nerve and the SSN. The main risk for the axillary nerve is related to its proximity with the inferior capsule. During Bankart procedures, the inferior suture, if tighten too widely after grabbing too much capsular tissue is at risk of transecting the axillary nerve and damaging it. During SLAP repair procedures, an ancre placed too high and through the coracoid notch might damage the SSN. Therefore again, it is tremendously important to always keep in mind the anatomy and take care

The set-up of the patient can be a great source of complications around the nerves. The literature has described palsy in almost all peripheral nerve territory after the set up was neglected, particularly at the lower limb and the ulnar nerve with compression points. However, we recently faced a severe complication caused by the set up in beach chair and a compression of the cranial nerves at the neck. The 9th, 10th and 12th cranial nerve pairs were compressed and paralyzed during a beach chair position set up with a stabilizing strapping around the head of the patient, who woke up with a palsy of the tong, and suffering dysphonia and dysphagia. Those symptoms spontaneously recovered within the first 2 months. The first emergency to look for in such a situation is a basilar trunk stroke. Therefore an Angio MRI should be performed in emergency. An MRI of the cervical spine should shortly be made in order to eliminate decompensation of peripheral nerve tumors. When the paraclinical examination is normal, the diagnose is clinical and confirmed by the ENT physicians. It is most likely the compression of the cranial nerves at the neck while the surgery was performed in a beach chair position, by the strapping of the head. However such symptoms have also been described following a wrong management of the intubation and air management by the anesthesiology team and is called the Tapia’s syndrome [1, 2]. This rare complication reminds us not only of the importance of positioning during anesthesia and surgery, but also of the need for careful and correct airway management. It could be probably prevented by careful insertion of an appropriate size LMA, and the use of low intracuff pressures and/or volumes.

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Anesthesiology complications are also described regarding loco regional anesthesia. Cases of intraneural injections have been described, causing severe damage to any nerves in the area where the block was made. The typical presentation is a neurological pain and weakness in the territory of the SSN, that can be extended to the upper trunk territory after an interscalenic block. Patient suffers from pain for many months, which resigns and leaves a permanent weakness and atrophy. Electromyographic studies are not very specific but show an absence of complete nerve block, and only an increase of latencies. After a few months an MRI can be performed and will show signs of scaring within the nerve. It is not yet perfectly well defined if the best solution is to leave the situation to spontaneous healing, or perform an intraneural neurolysis in order to remove the scar tissue and provide better and faster healing. This situation has also been described in axillary blocks, with symptoms in the median and ulnar nerve.

14.3.3 Positioning Complications The patients set up, may lead to several nerve complications. The main injuries occurring because of the set up are traction or compression injuries. Either beach chair or lateral decubitus can be responsible for nerve injuries when associated to a simple traction or an arm holder. The traction aiming mostly inferiorly, produces a stretch on the superior trunk and on the musculocutaneous nerve [3]. Though mostly transitory, traction injuries due to positioning of the patient may occur if the weigh put on the arm is too heavy, or during certain steps of the procedures [4]. Traction injuries to the cervical brachial plexus have been described as well, with permanent lesion of the auricular branches of C5.

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14.3.4 Surgical Complication Working in the anterior space of the shoulder outside of the joint is more frequent in many shoulder surgeons’ practice. Procedures such as arthrolysis, massive subscapularis tears, Latarjet procedures, and revisions, lead to working in a space close to the brachial plexus and its division branches. Therefore, not knowing exactly during some steps of the procedures where the nerves stand, put them at risk. Examples of axillary and musculocutaneous nerve palsies occur even in experienced surgeons’ hands. Working in the posterosuperior area of the shoulder, far from the limit of the joints (i.e. rotator cuff release) may lead to SSN damage particularly at the spinoglenoid notch. As described previously, the inferior shoulder is an area where very few procedures occur exept for the stabilization procedure such as Bankarts with a need of a very inferior reattachment of the labrum. The axillary nerve is there again at risk. Mechanism of the lesion is frequently clean cuts in case of surgical mistakes, but also hot water burns with the use of radio frequency around nerves. During arthroscopic procedures, compression injuries secondary to retractor placement are less frequent.

14.4 Paraclinical Investigations We now tend to preform MRI of the brachial plexus with a specific protocol targeting the nerves, in order to visualize the level of the lesion. It is possible to localize the area of the damage on the nerve, and we can determine if the nerve is still in continuity or if there is a rupture or a fresh cut. The interest of the MRI is also to show signs of denervation of the muscles and thus identify the nerve damage indirectly (Fig. 14.2). There isn’t any real interest in performing an electromyographic study before 3  weeks. The

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14.5.2 General Management of Nerves During Shoulder Arthroscopy

Fig. 14.2  MRI representation of the denervation oedema of the deltoid, following an axillary nerve injury. This sagittal reconstruction also shows a denervation oedema of the Teres minor, indicating a lesion of the nerve proximal to the division of the axillary nerve into its anterior and posterior branches innervating respectively the deltoid and the Teres minor

surgeon must specifically ask for the study of every nerve suspected of palsy, and also ask the neurologist if the lesion is proximal or distal. It is possible to determine if the nerve is still in continuity, functionally or anatomically speaking, and therefore to precise the prognosis of recovery. The interest of the EMG study is also to help follow the recovery, and decide to perform a surgery when it is to slow, and incomplete.

14.5 Management 14.5.1 Nerve Injuries and Management In this chapter we describe the most common nerve injuries, their clinical consequences, the hypothetical surgical situations at risk of creating such a trauma, and the expected management of this situation.

The best way to avoid nerve damages during shoulder arthroscopy is to either remain in a space where there is no risk (i.e. glenohumeral joint laterally to the glenoid, anterior shoulder, laterally to the conjoint tendon, above the inferior limit of the subscapularis). In any other situation, we recommend to be able to dissect around the nerve and identify the location of the nerve in order to visualize it and protect it. Recently described advanced arthroscopic procedures such as arthroscopic Latarjet, can be harmful to the brachial plexus and the axillary nerve. When the nerve is visualized, it can be protected, and surgeons should not perform this procedure if afraid of identifying it. For the same reasons, Latissimus dorsi transfers passed arthroscopically through the posterior space, between the deltoid and the posterior cuff may threaten the axillary nerve. Therefore, the long head of the triceps and the posterior part of the nerves must be strictly dissected and identified before passing the transfer. The management of a nerve palsy requires to be initially conservative, and to follow the potential recovery. The pattern of the palsy, allows to identify most frequently the level of the lesion. Associated palsies will indicate cords or trunks lesions, and isolated muscle palsy will orientate rather toward a distal branches lesion. The association of a sensitory and motor deficit, is in favor of a severe lesion and a potential risk of no recovery. On the other hand, when the deficit is only motor, without any sensitory deficit, the chances of recovery are good. During the follow up, an EMG should be performed between 3 and 6  weeks. It enables to verify the absence of complete transient lesion of the nerves. However, the interpretation of the EMG cannot stand alone in the therapeutic decision. We recommend that if any doubt exists at 3  weeks post op, a surgical exploration should be performed. It seems reasonable to contact

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specialized peripheral nerve surgeons for this step of the management, and if one is not confident into dealing with nerve exploration, the patient should be referred.

14.5.3 Conservative Treatment In most of the cases the recovery is complete, but it should be fast. The common attitude is to wait for six months until there is a recovery of the palsy and perform surgery if it doesn’t happen. We believe that the “wait and see” attitude should be shorter since an early exploration of the nerve enables an identification and most frequently a direct suture of the nerve when possible.

14.5.4 Suprascapular Nerve Any procedure taking place in the area of the coracoid and spinoglenoid notch put the SSN at risk. Few surgeons work around the coracoid notch, except for those who perform SSN release. During SSN release, the Supra spinatus must not be retracted too much posteriorly to expose the nerve, since distal lesion can occur to the branches penetrating the muscle at the level of the coracoid notch. Another risk is linked to the anatomic variations of the SSN, which can divide into a proximal branch aiming for the supra spinatus. It often accompanies the artery above the transverse ligament and can be damaged when the transverse ligament is cut. Care must therefore be taken before resecting the ligament, by dissecting the nerve proximally and distally, ensuring there is no anatomical variation. The spinoglenoid notch is frequently approached during arthroscopic procedures. Wide release of the supra - and infraspinatus at the spine in massive cuff tears, can cause SSN lesions. On the articular side, any procedure approaching the superior labrum can be responsible for iatrogenic injuries to the SSN. The release of the labrum, and the debridement of the bone is frequently a source of nerve lesion, along with drilling and anchors placements [5, 6]. Lesions to the SSN are also observed in cases of too long and ascending latarjet screws, or with

Fig. 14.3  Drawings on the shoulder of a patient suffering from a distal SSN and axillary nerve lesion, requiring a posterior approach for a transfer from the Spinal accessory nerve to the SSN and the long head of the triceps motor branch to the anterior branch of the deltoid

ancres misplaced ayt the superior part of the glenoid during SLAP repair. The management of a severe lesion of the SSN at the coracoid or glenoid notch is possible with nerve procedures, such as neurolysis or nerve transfers when addressed soon enough. However, in case a nerve transfer is needed, the lesion is frequently too distal to be addressed by a proximal and classic Spinal accessory nerve transfer. The approach must be posterior and enable an end to end anastomosis distally to the coracoid or glenoid notch, using either the Spinal accessory nerve or the dorsal scapular nerve (Fig. 14.3) [7–10]. When nerve procedures are no longer available, the palliative techniques include lower trapezius transfer to reanimate external rotation, and Latissimus dorsi transfer to reanimate forward elevation. Those transfers have a good functional outcome as long as the deltoid is still efficient [11].

14.5.5 Musculocutaneous Nerve A musculocutaneous nerve palsy can occur particularly while surgery is performed in the anterior space of the shoulder. Many cases of lesions are described during Latarjet procedures. Even if the nerve is visualized and protected, traction injuries can be responsible for elbow flexion palsies.

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Fig. 14.4  Clinical examination of a patient suffering from a musculocutaneous nerve palsy. Despite a conserved elbow flexion, the biceps and brachialis muscle do not contract, and the palpation of those two muscles show a permanent flaccidity

The Musculocutaneous nerve innervates the biceps and the brachialis muscles. Elbow flexion however, can be achieved by the brachioradialis, and medial epicondylar muscles. Therefore, a musculocutaneous nerve deficit can remain undetected if one doesn’t focus on the observation on the contraction of the biceps and brachialis muscles (Fig. 14.4). If the level of the lesion is accurately identified, an early suture of the nerve section remains the best option, however, distal nerve transfers give excellent results, within the first 6 months, as described by Oberlin [12]. Indeed, a direct transfer from a fascicle of the ulnar and median nerves to the branches of the biceps and the brachialis respectively allows a fast growth of the nerves into the muscles as the distance to reach the motor plates is short. If the delay for nerve surgery is not respected, palliative options include bipolar pedicled Latissimus dorsi, or Pectoralis major transfers, with good results expected [13–15].

14.5.6 Axillary Nerve Axillary nerve lesions are within the most common neurological lesions encountered in shoulder arthroscopy. It can be provoked by anterior dissections, inferior capsular manipulations, and posterior shoulder approach.

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Fig. 14.5  Cadaveric dissection representing a double nerve transfer to the motor branches of the axillary nerve (i.e. Long head of the triceps motor branch to the anterior axillary nerve branch, and ulnar nerve fascicle to the Teres minor motor branch)

A deltoid palsy doesn’t imply a paralytic shoulder but is however responsible for a lack of strength, and threatens the long-term function of the shoulder. As in any nerve injury, the best option to restore the function is to explore, identify the lesion and to perform a direct suture and repair. However, the dissection of the axillary nerve is a complex procedure as this nerve is both in the anterior and posterior shoulder. A deltopectoral approach allows to address anterior lesions but will not allow to visualize distal damages at the entry of the nerve in the deltoid and teres minor muscles. Nerve transfers are described to reanimate the axillary nerve, and are based on the transfer from a branch of the radial nerve for the long head of the triceps to the anterior motor branch of the axillary nerve as described by Leechavengvongs [16, 17]. Such nerve transfers can either be performed through a posterior or anterior axillary approach. An ideal management of an axillary nerve lesion includes a transfer on the motor branch of the Teres minor muscle to ensure reanimation of the external rotation (Fig. 14.5). When nerve procedures are not available, palliative surgery include pectoralis major and latissimus dorsi transfers, or glenohumeral joint fusion [18, 19].

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14.5.7 Posterior Cord Again, the best option remains to identify and suture the lesion. When the direct suture is not possible or when the delay puts the viability of the motor plates at risk, nerve transfers give reasonable results. In this situation, it is impossible to use the branch from the long head of the triceps, since it is also paralyzed. Two functions must be reanimated: the deltoid, and the extension of the elbow and posterior plan of the forearm. The condition is mostly managed with a twostage surgery. Nerve surgery targets the deltoid palsy and the triceps palsy with the use of fascicles of the ulnar nerve to the axillary nerve, and intercostal nerves to the branch of the long head of the triceps. Tendon transfers are performed after proximal recovery to reanimate the extension of wrist and fingers, as in typical low radial nerve palsy (i.e Flexor carpi ulnaris to finger extension, Pronator teres to wrist extensors, Palmaris longus to extensor pollicis brevis, and abductor pollicis longus).

14.5.8 Hand Palsy It occurs in lesion of the medial cord, ulnar or median nerve. These structures can be threatened in any procedure taking place into the retrocoraa

Fig. 14.7 (a) Intraoperative view of the dissection of the distal branches of the radial and median nerve at the forearm, before transfers of the median nerve to the radial nerve for a radial nerve lesion. (b) Intraoperative view of

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coid space, or medially to the coracoid [20]. It is however rarely directly damaged as the posterior cord will first be encountered when coming from laterally (Fig.  14.6). Nevertheless, a traction or compression injury can be observed. When the recovery is partial and the hand remains paralyzed because of a median or ulnar nerve palsy, the strategy must combine nerve and tendon transfers. Distal nerve transfers are possible using branches of the radial nerve to the Anterior Interosseous nerve [21–23] (Fig. 14.7a, b).

Fig. 14.6  Endoscopic representation of the posterior cord dividing into the axillary, and radial nerves, visualized from a retrocoracoid approach anteriorly from the subscapularis muscle (left of the picture) and the conjoint tendon (right of the picture)

b

the branches of Flexor Digiti Superficialis (FDS) and Flexor Carpi Radialis (FCR) the Extensor carpi radialis brevis (ECRB) and Posterior interosseous (PIN) nerves, respectively

T. Lafosse and L. Lafosse

146 Fig. 14.8 (a) Intraoperative view of the dissection of the ulnar motor branch and quadratus pronator branches before nerve transfers in a case of proximal ulnar nerve lesion. (b) Intraoperative view of the branches of the quadratus pronator branch transferred to the ulnar motor branch

a

Sensitive branche to the 4th 5th digit

Motor branche

Aion for QP

Ulnar nerve

Median nerve

b

End to end suture of the aion for QO to the ulnar motor bracnhe

Proximal nerve transfers can be performed to the ulnar nerve from the radial or median nerve at the level of the brachial canal, and distal transfers can be performed on the motor branch of the ulnar nerve from the anterior Interosseous when the median nerve is intact (Fig. 14.8a, b) Combined median and ulnar nerve palsies are difficult to manage, and when nerve transfers are performed, care must be taken not to sacrifice the functions of muscles needed for tendon transfers [24].

14.6 Conclusion Nerve complications around shoulder arthroscopy are frequent. Their consequences can be severe. A good way of preventing them is to perfectly know the anatomy. Dissections of the nerves around the shoulders have been described, and without taking risks, it is possible and sometimes mandatory to visualize, dissect the nerve and protect them before going on to the next step of a procedures.

14  Neurological Complications in Shoulder Arthroscopy

Even when care is taken to prevent such complications, situations can occur where, it is important to identify the lesion and quickly address the condition, either oneself or by referring the patient to a peripheral nerve surgeon. In peripheral nerve complications, it remains of major importance to first eliminate a central neurological impairment. We must keep in mind that the longer a nerve suffers, the harder it will be to recover completely. As soon as a neurological complication is found, it should be managed, since the chances of recovery can be very high when addressed on time, and managed with the proper techniques.

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