Complications of Arthroscopic Shoulder Surgery: Miscellaneous Shoulder Conditions

Abstract

Overall rate of complications after arthroscopic shoulder surgery was once believed to be quite low.^1–3 For instance, Ellman reported no major complications, one localized hematoma at a portal site, and three transient dysesthesias in the thumb (attributed to inadequate padding on the traction device) in his review of 50 consecutive subacromial decompressions.⁴ Subsequently, a report from the Committee on Complications of the Arthroscopy Association of North America in the 1980s documented a wider range and scope of complications after arthroscopic shoulder surgery, and noted rates as low as 0.76% for subacromial space procedures and as high as 5.3% for arthroscopic anterior staple capsulorrhaphy.⁵ Even for the “experienced” surgeons, the committee noted a fairly high complication rate of 5.2% after arthroscopic shoulder surgery.⁶ More recent retrospective review studies noted even higher complication rates, between 6.5 and 10.5%, with adhesive capsulitis being the most common complication.^7,8 In 2002, Weber and colleagues reviewed the available literature and found the overall complication rates after shoulder arthroscopy to be between 5.8 and 9.5%.⁹ Thus, complications after arthroscopic shoulder surgery may be more common than once believed and warrant particular attention to increase awareness and to provide appropriate treatment.

Editors’ Comments: Miscellaneous Shoulder Conditions

Adhesive Capsulitis

Although forward elevation can often be improved with manipulation alone, full external and particularly internal rotation is much more difficult to achieve without surgical release of the capsule. In addition, in postsurgical adhesive capsulitis, particularly after a repair, controlled release is greatly preferable to blind manipulation, to avoid disrupting the repaired tissue. In addition, in postsurgical adhesive capsulitis, adhesions are also often found in the subacromial space and subscapularis bursa which are most amenable to direct surgical release.

We recommend direct release of the inferior capsule as well as anterior and inferior capsule. This can be facilitated by the use of an accessory posterior inferior portal while viewing from the standard posterior portal. Capsule is released with an electrocautery device facing the glenoid just off the labral surface. The axillary nerve is >1.5 cm away from the inferior glenoid margin, and should be safe as long as the release is performed adjacent to the inferior labrum and inferior glenoid margin. A complete release has been obtained when muscle fibers are visible through the release. The rotator interval and coracohumeral ligament will also usually need to be released to obtain full external rotation. It is also important to release adhesions around the rotator cuff including those in the subscapularis bursa. In rare cases, usually after open shoulder surgery, some of the adhesions are extramuscular and will not be accessible arthroscopically. If imp-aired motion persists intraoperatively after adequate arthroscopic releases, the surgeon may want to consider open extramuscular releases. Beware of patients who have had previous radiation about the shoulder, since their scarring is quite extensive, thus making full motion as a final outcome extremely difficult even with open releases.

Patients who develop postoperative adhesions often are timid with their subsequent physical therapy and have some psychological barriers to believing they will ever get their motion back. We have found benefit to photographing the patients arm in full range of motion after the surgery, which we show to the patients postoperatively as encouragement, and will occasionally even leave the patients arm in full foward flexion until they are awake in the recovery room and can visualize the success of the procedure.

Some surgeons use CPM machines postrelease, but we have found these cumbersome and unpredictable We prefer to start the patient on physical therapy post-op day #1, 3–5 times a week. If adhesions seem to be recurring at 6 weeks, we will schedule a repeat manipulation at this point, before the adhesions become thick enough to require additional surgical release. We place all patients on a nonsteroidal for at least 1 month post-op, and will also use Medrol dose packs on occasion.

The best way to treat postoperative adhesions is to avoid them. We being pendulum exercises day one post-op for all shoulder surgery patients, and emphasize external rotation to avoid scarring of the anterior capsule and coracohumeral ligament. We also utilize an abduction/external rotation pillow along with a sling to avoid capsular scarring. Patients are advised to take pain medication 1 h prior to their physical therapy sessions which begin 7 days post-op. Proper physical therapy is also essential in avoiding other complications. If patients do not receive glenohumeral joint mobilization, they will often compensate with scapulothoracic motion. To the inexperienced therapist, the patient will appear to be meeting range of motion milestones, but in fact they are getting a stiff glenohumeral joint, and straining their AC joints due to transference of force to this joint and then to the scapula to obtain arm elevation. This is a common cause for secondary AC joint pain following previous unrelated shoulder surgery. To truly test your patients recovery of motion, stabilize their scapula with your hand, or have them stand leaning backward against a wall to stabilize their scapula and then have them raise their arm. This will accurately test glenohumeral motion.

Nerve Injury

The exact etiology of reported neuropraxias after shoulder arthroscopy is not clear. In our experience, the most likely culprit is from the distal holding devices. We avoid use of rigid gauntlets which can easily compress superficial nerves, and take care not to wrap the distal traction devices too tightly. Traction up to 15 lbs appears to be well tolerated, and we have not had a neuropraxia in thousands of cases using this technique. However, it should be noted that most cases are under an hour or hour and a half and in general excessively long surgical times even with lighter traction should be avoided. Interscalene anesthesia blocks can also cause neuropraxia, and should be carefully considered as a cause when evaluating the etiology of a postoperative complication. When performing shoulder instability surgery, care must be taken when utilizing suture hooks in the inferior pouch, since the axially nerve can be injured if an overly aggressive bite of tissue is taken. Avoid going too deep, or more than 1 cm inferior to the inferior labrum.

Others

Always place a gauze or ABD pad under the patient’s axilla postoperatively, especially in warm humid climates. This will avoid secondary fungal infections which will slow recovery and lead to a very unhappy patient.

Encourage elbow wrist and hand motion immediately postoperatively. This will help avoid distal edema and secondary joint stiffness.

Encourage patients to sleep in a lounge chair or use multiple pillows so that they are in a beach chair position while sleeping for several weeks after reconstructive shoulder surgery. This will prevent them rolling onto the surgical site and potentially disrupting your repair.