Open shoulder: the deltopectoral approach for glenohumeral joint preservation surgery

The pursuit of ‘best practice’, health economic planning, the increasing awareness and expectations of patients, pressure from politicians and the media, and the emergence of league tables for surgeons are some of the reasons why orthopaedic surgeons are encouraged to adopt evidence-based

Introduction Progress in shoulder surgery is associated with improved operating rooms equipment, advanced surgical products and minimally invasive techniques. There are rare injuries to nerves and vessels being intersected or pulled into the sutures. However, marginal tears, compression and nerve entrapment of trunks during access retraction, catheterization, inadequate correct of the patient on the operating table and errors in rehabilitation can be common.The purpose was to identify factors predisposing to peripheral nerve injury to the upper limb during shoulder surgery and offer prevention options.Material and methods Major studies in the field of shoulder anatomy and surgery published between 1984 and 2023 were reviewed to identify anatomical, biomechanical and perioperative factors leading to peripheral nerve injuries. The original literature search was conducted on key resources including GoogleScholar, PubMed, ScienceDirect, RSCI, Scopus. Four approaches were used for structuring and informative presentation of the data to include types of the peripheral nerve injury in the upper limb.Results and discussion Factors predisposing to the peripheral nerve injury in the upper limb during shoulder surgery were identified in the review. Prevention measures include the patient positioned on the operating table with adequate fixation of the head and torso, regardless of the chosen position; traction of the involved upper limb with a load of not greater than 9 kg using a specialized clamp; preoperative marks of the surgical field and staining of bone landmarks; the arthroscopic ports 1–2 cm to be shifted more distally minimizing the fluid flow into the joint during a long operation. Postoperative consultation with rehabilitation specialists is essential to develop an early activation program and assess the risks of neurological disorders.Conclusion The shoulder anatomy and the localization of unsafe zones of the shoulder, the risks associated with a particular manipulation were explored for effective preoperative planning and prevention of neurological complications in the treatment of surgical pathology of the shoulder joint.

Background: Shoulder injuries from repetitive baseball pitching continue to be a serious, common problem. Purpose: To determine whether passive range of motion of the glenohumeral joint was predictive of shoulder injury or shoulder surgery in professional baseball pitchers. Study Design: Cohort study; Level of evidence, 2. Methods: Passive range of motion of the glenohumeral joint was assessed with a bubble goniometer during spring training for all major and minor league pitchers of a single professional baseball organization over a period of 8 successive seasons (2005-2012). Investigators performed a total of 505 examinations on 296 professional pitchers. Glenohumeral external and internal rotation was assessed with the pitcher supine and the arm abducted to 90° in the scapular plane with the scapula stabilized anteriorly at the coracoid process. Total rotation was defined as the sum of internal and external glenohumeral rotation. Passive shoulder flexion was measured with the pitcher supine and the lateral border of the scapula manually stabilized. After examination, shoulder injuries and injury durations were recorded by each pitcher’s respective baseball organization and reported to the league as an injury transaction as each player was placed on the disabled list. Results: Highly significant side-to-side differences were noted within subjects for each range of motion measurement. There were 75 shoulder injuries and 20 surgeries recorded among 51 pitchers, resulting in 5570 total days on the disabled list. Glenohumeral internal rotation deficit, total rotation deficit, and flexion deficit were not significantly related to shoulder injury or surgery. Pitchers with insufficient external rotation (<5° greater external rotation in the throwing shoulder) were 2.2 times more likely to be placed on the disabled list for a shoulder injury (P = .014; 95% CI, 1.2-4.1) and were 4.0 times more likely to require shoulder surgery (P = .009; 95% CI, 1.5-12.6). Conclusion: Insufficient shoulder external rotation on the throwing side increased the likelihood of shoulder injury and shoulder surgery. Sports medicine clinicians should be aware of these findings and develop a preventive plan that addresses this study’s findings to reduce pitchers’ risk of shoulder injury and surgery.

ESRA19-0518 Strategies to reduce hemidiaphragmatic paresis and related risks after blocks/for shoulder surgery

Malpractice trends in shoulder and elbow surgery.

A commentary on “Efficacy and safety of suprascapular nerve block combined with axillary nerve block for arthroscopic shoulder surgery: A systematic review and meta-analysis of randomized controlled trials” [Int. J. Surg. 94 (2021) 106111

Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?

One of the surgical procedures most commonly performed in North America is arthroscopic repair of the shoulder joint. In the United States, approximately two-thirds of these patients undergo anesthesia and surgery in the sitting or beach chair position (BCP). Although the BCP offers several advantages for the surgeon, including reduced risk of neurovascular trauma, ease of conversion to an open approach, and excellent intra-articular visualization, the sitting position introduces several challenges for the anesthesiologist and potential risks to the patient. Recent reports have described catastrophic neurologic injuries occurring in otherwise healthy patients during shoulder surgery in the sitting position. The authors of these reports hypothesized that improper blood pressure management resulted in reductions in cerebral perfusion pressure which led to central nervous system ischemia and injury. At the present time, however, several important questions about ‘‘best practices’’ for blood pressure management in the BCP remain unanswered. In this issue of the Journal, the investigations by YaDeau et al. and Trentman et al. provide important data in this ongoing debate about the prevalence, risk factors, and potential consequences of hypotension during shoulder surgery in the sitting position. The incidence of ischemic brain or spinal cord injury following shoulder surgery in the BCP is unknown. In 2003, Bhatti and Enneking reported that a patient developed visual loss and ophthalmoplegia after shoulder surgery. In 2005, Pohl and Cullen described four cases of severe brain and spinal cord injury in this patient population. In a 2009 survey of 287 members of the American Shoulder and Elbow Surgeons Society (93 responses), eight cases of cerebral vascular events after shoulder surgery were reported, all of which occurred in the sitting position. An analysis of the American Society of Anesthesiologists Closed Claims database for new onset cervical cord injuries published this year revealed that 24% of the events occurred in patients having surgery in the sitting position. It is likely that the incidence of these complications is significantly underreported, as surgeons and anesthesiologists may be reluctant to publish cases where otherwise healthy patients suffered severe neurologic injuries. Through personal communications, the authors of this editorial are aware of eight additional cases of central nervous system injury following BCP surgery that have not been reported in the literature. The Anesthesia Patient Safety Foundation (APSF) has now funded a national registry, the Neurologic Injury after Non-Supine Shoulder Surgery (NINSS) registry (http://depts.washington.edu/asaccp/NINS/ index.shtml), to establish the incidence of central nervous system injury and determine probable causative factors. The adverse neurologic events reported thus far were attributed most commonly to inadequate cerebral perfusion secondary to intraoperative hypotension. Significant hemodynamic changes occur when the patient’s position is changed from supine to sitting. In awake subjects, upright positioning activates the sympathetic nervous system, producing increases in systemic vascular resistance (3040%) and systemic blood pressure (10-15%) and reductions in cardiac output (15-20%). Under general anesthesia, baroreceptor responses are blunted, resulting in an attenuated increase in systemic vascular resistance, a decrease in mean arterial pressure, and a greater reduction in cardiac output compared with the awake state. Not surprisingly, G. S. Murphy, MD (&) J. W. Szokol, MD Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Evanston, IL 60201, USA e-mail: dgmurphy2@yahoo.com

ABSTRACTObjective:To evaluate the choice of surgical approach among Brazilian orthopedists and whether shoulder surgery specialty training or duration of experience influences the decision-making.Methods:A questionnaire on the preferred approach and complications was administered to orthopedic surgeons with and without shoulder specialization training. The chi-square test or Fisher's exact test was applied.Results:We interviewed 114 orthopedists, 49 (43.0%) traumatologists, 36 (31.5%) specialist surgeons, and 29 (25%) shoulder surgery specialist residents. In cases of fracture without dislocation, specialized training and duration of experience did not influence the approach used (primarily deltopectoral). In cases of fracture/dislocation, 97.2% of the specialists versus 82.1% of the traumatologists opted for the deltopectoral approach (p = 0.034). In cases of fractures/dislocation, 92.5% of surgeons with more than 5 years of experience and 78.7% with less than 5 years of experience opted for the deltopectoral approach (p = 0.032).Conclusion:Specialization in shoulder surgery did not influence surgeons' approaches to manage fractures without dislocation. In cases of fracture/dislocation, shoulder surgery specialization training and duration of experience were associated with selection of the deltopectoral approach. Level of Evidence V, Expert opinion.

Determining anatomic accuracy of shoulder field injection: triangular injection technique does adequately reach pain transmitters

Recovery of overhead mobility after shoulder surgery is time-consuming and important for patient satisfaction. Overhead stretching and mobilization of the scapulothoracic and glenohumeral (GH) joints are common treatment interventions. The isolated GH range of motion (ROM) of flexion, abduction, and external rotation required to move above 120° of global shoulder flexion in the clinical setting remains unclear. This study clarified the GH ROM needed for overhead mobility. The timely development of shoulder ROM in patients after shoulder surgery was analyzed. Passive global shoulder flexion, GH flexion, abduction, and external rotation ROM were measured using goniometry and visually at 2-week intervals starting 6-week postsurgery until the end of treatment. Receiver operating characteristic curves were used to identify the GH ROM cutoff values allowing overhead mobility. A total of 21 patients (mean age 49 years; 76% men) after rotator cuff repair (71%), Latarjet shoulder stabilization (19%), and arthroscopic biceps tenotomy (10%) were included. The ROM cutoff value that accurately allowed overhead mobility was 83° for GH flexion and abduction with the area under the curve (AUC) ranging from 0.90 to 0.93 (p < 0.001). The cutoff value for GH external rotation was 53% of the amount of movement on the opposite side (AUC 0.87, p < 0.001). Global shoulder flexion above 120° needs almost full GH flexion and abduction to be executable. External rotation ROM seems less important as long as it reaches over 53% of the opposite side.

The purpose of this study was to assess the functional results, quality of life, and complications in two groups of Charcot-Marie-Tooth (CMT) patients according to the type of surgical operations, joint preserving, or joint sacrificing surgery. Fifty-two feet in forty-six patients with CMT who had undergone surgical deformity correction were divided into two groups based on the main surgical procedure for the correction: Class I (joint preserving surgery) and class II (joint sacrificing surgery). Foot ankle disability index (FADI) and short form 12 version 2 (SF12V2) were documented pre-operative and 12 months post-operative. The complications of both groups were monitored with a mean follow-up time of 20.5 months (range, 13-71.5). After surgical treatment, FADI scores showed differences (p=0.005) between both groups. The functional improvement was 29 (20-46; p<0.001) in class I and 10 (2-36; p=0.001) in class II. The patients in both groups acquired a better quality of life as demonstrated in physical component summary of SF12 but without statistically difference. Three feet needed reintervention in class I (two for cavovarus recurrence and one for hallux flexus) at the end of follow-up. In contrast, five feet needed a new operation for cavovarus recurrence, claw toes recurrence, and ankle osteoarthritis after the progression of the condition. An early surgical intervention to neutralize the deforming forces in CMT patients could be a useful strategy to delay or prevent the need for extensive reconstruction and potential future complications. Based on the type of surgical intervention in CMT patients, the joint preserving surgery in addition to soft tissue balancing procedures obtained better functional outcomes and lower rate of complications when compared to the group of joint sacrificing surgery.

Chronological changes in the rate of surgical field contamination in the shoulder joint

In the era of outpatient shoulder surgery, bundled payment, safe, predictable, and time-efficient pain management strategies for shoulder arthroplasty (SA) are important. Ultrasound-guided interscalene blocks (ISBs), currently the gold standard for postoperative pain management after shoulder surgery, can be highly operator dependent, time-consuming, and not without complications. We developed a new surgical technique of surgeon-administered intraoperative brachial plexus block in patients undergoing SA open shoulder surgery using the deltopectoral approach. This procedure could be performed after the exposure, either at the beginning or end of the bony work. This procedure is simple, safe, and effective. We did not notice any complications that are typically seen with ISB-like respiratory depression secondary to phrenic nerve palsy, rebound pain after the block wore off, and pain related conversion of outpatient SA to inpatient, over the period of four years (2018-2022). This technique has additional advantages over the established "gold standard" ISB in terms of time and cost savings and improved operating room efficiency.

What's New in Shoulder and Elbow Surgery.