The volume of Arthroscopic Shoulder Surgery

1. The volume of Arthroscopic Shoulder Surgery

2. The volume of arthroscopic surgery performed: 2003 E.Wolfson Med Center: 470 Arthroscopic surgical procedures 208 Knee (44.25%) 168 Hand and Wrist (35.74%) 74 Shoulder (15.7%) 18 Ankle (3.8%) 2 Other

3. Complications Associated With Arthroscopic Shoulder Surgery E.Adar M.D Arthroscopic surgery Unit E.Wolfson Medical Center H O L O N

4. Literature First report : 5.3% complication rate Small NC Arthroscopy 1986 2:253-258 = Relatively SAFE procedure 1990 – 2001 57 articles discussing complications 1) Review articles 2) Studies dealing with specific type of complications

5. Review articles: early 90th Bigiliani Orthop Rev 1991 20(9): 743-751 Curtis Arthroscopy 1992 8(3):395 (660 procedures – 6.5% comp ) late 90th

6. McFarland J South Orthop Assoc 1997;6(3):190-196 Neurologic comp 0-30% Infection rate 0.04-0.23% Berjano (179 patients) Arthroscopy 1998 ; 14(8) : 785-788 9.49% complication rate

7. These reviews generally correlate the complexity of the procedure with increased complication rates

8. General surgical complications: Infections 0-3.4% Anesthesia : Air embolism Tracheal compression Temporary blindness Pneumothorax Quadriparesis (sitting) Airway obstruction (fluid) Pneumomediastinum

9. Shoulder A-sc complications: Vascular injury (DVT, Vein laceration) Neurological injury Fluid extrvasation Stiffness (ONE OF THE MOST COMMON PROBLEMS UP TO 15%) Tendon injury (RARE )

10. Complications related to specific procedures: • Subacromial surgery • i. Inadequate resection • ii. Fracture • iii. ACJ symptoms • iiii. Heterotopic ossification

11. Complications related to specific procedures: b. A-sc R.C repair i. Failed repair ii. Hardware problems iii. Captured shoulder

12. Complications related to specific procedures: c. Instability surgery i. Recurrence ii. Hardware problems (1) Metal (2) Resorbable iii. Thermal (nerve injury) (capsular necrosis)

13. We are going to discuss the possibility of complications related to the portals and patient’s position during arthroscopy of the shoulder joint

14. Nerve Injuries Commonly, the nerve injuries occur secondary to traction or contusion. These are avoided best by careful attention to patient positioning, and arm manipulation during surgery. Nerve injuries are reported to occur in 1% to 2% of patients undergoing rotator cuff surgery and in 1% to 8% of patients undergoing surgery for anterior instability

15. Vascular Injuries Mainly portal bleeding Major vascular injury ?

16. Structural Injuries Chondral and Rotator cuff iatrogenic injuries

17. Complications related to Patient's Position

18. COMFORTABLE FOR BEGINNERS COMFORTABLE FOR GHJ PROCEDURES COMFORTABLE FOR TOOLS SWITCHING UNCOMFORTABLE FOR MINI OPEN R.C REPAIR UNCOMFORTABLE FOR OPEN PROCEDURES Patient's Position

19. Possible complications Brachial Plexus on the operated side Brachial Plexus on the opposite side Peroneal Nerve on the opposite side Fluid distention to the neck and mediastinum Patient's Position

20. Less COMFORTABLE FOR BEGINNERS COMFORTABLE FOR GHJ PROCEDURES Less COMFORTABLE FOR TOOLS SWITCHING COMFORTABLE FOR MINI OPEN R.C REPAIR COMFORTABLE FOR OPEN PROCEDURES Patient's Position

21. Possible complications Brachial Plexus on the operated side Ulnar Nerve on the opposite side DVT (legs) Patient's Position

22. Technical modifications to avoid some of the complications: The use of beach chair position, limits the fluid distention to the neck and mediastinum

23. Application of limited amount of traction (less than 3 kg) Lateral traction/ Less longitudinal traction Technical modifications to avoid some of the complications:

24. Technical modifications to avoid some of the complications: Limiting the degrees of arm flexion and abduction. Careful neck position

25. Technical modifications to avoid some of the complications: Avoiding prolong surgical time

26. Careful hemostasis Technical modifications to avoid some of the complications:

27. Controlled Fluid Pressure Technical modifications to avoid some of the complications:

28. Portal related complications of Shoulder Arthroscopy

29. Posterior Portal הסבר

30. Posterior Portal הסבר

31. SupraScapular Nerve and Artery Supra Spinatus Axillary Nerve Posterior Circumflex artery Teres Minor Infra Spinatus Teres Major

32. 2 CM DISTALLY TO THE POSTERIOR ACROMIAL CORNER Axillary Nerve Posterior Circumflex artery EXCELLENT FOR SUB ACROMIAL BURSOSCOPY SUPRA SCAPULAR NERVE IS IN DANGER Postero-Lateral Portal ROTATOR CUFF IS IN DANGER

33. GOOD FOR ARTHROSCOPIC EXCISION OF DISTAL CLAVICLE Postero-Medial Portal

34. Superior Portal

35. POSITIONED PROXIMALLY TO THE ACROMION POSTERIORELY TO THE CLAVICULAR HEAD PASSES THROUGH THE MUSCLE FIBERS OF SUPRASPINATUS May assist in S.L.A.P. LESIONS REPAIR A.S.C ASSISTED # FIXATION RC REPAIR BRACHIAL PLEXUS IS IN DANGER SUPRA SCAPULAR NERVE IS IN DANGER Superior Portal

36. 10-11 mm DRILL IN THE MIDPORTION OF THE ACROMION IMPORTANT IN S.L.A.P. LESIONS REPAIR Instruments may damage the tendon of supra spinatus # of Acromion Trans-Acromial Portal

37. ASSISTING PORTAL FOR R.C. REPAIR MAY BE USED FOR G.H.J INSPECTION THROUGH THE R.C. TEAR Instruments may damage the tendon of supra spinatus High-Lateral Portal

38. Assisting portal for sub-acromial procedures Axillary Nerve is in danger Lateral Portal

39. Assisting portal for anterior instability repair Thoraco-Acromial Artery is in danger High-Anterior Portal

40. Main portal for anterior instability repair F.I.O F.I.O F.I.O F.I.O Musculo-Cutaneous Nerve Is in danger Anterior Portal

41. Assisting portal for Distal Claviculectomy Thoraco-Acromial Artery is in danger Anterior-Medial Portal

42. SHOULDER ARTHROSCOPY PORTALS SUMMARY

43. Although shoulder arthroscopic procedures are not free of complications, we still consider them to be safe because few of the complications recorded have compromised the clinical outcome of the patients.

44. THANK YOU!!!