Summary

Arthroscopic shoulder surgery complications are considered rare occurrences. However, there have been reports in the literature of complication rates as high as 10.6%. It is imperative to evaluate the incidence, severity, and prevention of these complications to improve surgical outcomes. Common complications reported after arthroscopic shoulder surgery are peripheral nerve injury, infections, arthrofibrosis, and thromboembolic events. Careful patient selection, surgical diligence, and extensive knowledge of the shoulder anatomy can prevent these complications.

Keywords: Shoulder arthroscopy, complications, nerve injury, arthrofibrosis, infection

 

Incidence and patient risk factors

Arthroscopic shoulder complications are less prevalent than open shoulder procedures1

Complication rates following arthroscopic shoulder procedures range from 1.0 to 10.6%:2,7

Wide range due to definition of complications and length of follow-up.

Common complications include:8

Arthrofibrosis/stiffness

Infections

Deep vein thrombosis/pulmonary embolism (DVT/PE)

Peripheral nerve injury.

Patient risk factors:1

Age > 80 years

Body mass index (BMI) > 35

Functionally dependent status

American Society of Anesthesiology > 2 (Class III or IV)

Congestive heart failure

History of disseminated cancer

Open wound at time of surgery.

 

Patient positioning

No proven difference in complication rates between lateral decubitus and beach chair positions.8

Lateral decubitus (▶Fig. 2.1):

Theoretical benefits:

Increased visualization and access

Lower risk of hypotension, bradycardia, and cerebral hypoperfusion.

 

Fig. 2.1 (a, b) Patient is in the lateral decubitus position and the surgical arm is held in an abducted position.8‌

 

 

 

Potential complications:

Neuropraxia from arm traction (10–30%)

Higher rate of thromboembolic events

Increased risk of injury to axillary and musculocutaneous nerves when placing anteroinferior portal.9

Beach chair (▶Fig. 2.2):

Theoretical benefits:

Better anatomic orientation

Easier to convert to open procedure

Regional anesthesia is better tolerated than with lateral positions

Decreased risk of neuropathies

Decreased surgical time.

Potential hypoperfusion complications:

Cerebral hypoperfusion:

Can be reduced with use of regional anesthesia instead of general anesthesia.

Neuropraxia from head and neck malpositioning.10

 

Anatomy and nerve injury

Iatrogenic nerve injuries are common due to proximity of the standard portals to the nerves8 and lack of awareness of anatomical variations of the nerves.11

Axillary nerve:

Distance of axillary nerve from:8

Coracoid process tip: 3.56 ± 0.51 cm (immediately before entering the quadrangular space)

Posterolateral acromion: 7.46 ± 0.99 cm

 

Fig. 2.2 Patient is in the beach chair position preoperatively.8

 

 

 

Deltoid insertion: 6.7 ± 0.47 cm

Upper border of deltoid origin:

Anterior: 4.94 ± 0.8 6 cm

Middle: 5.14 ± 0.90 cm

Posterior: 5.44 ± 0.95 cm.

Axillary nerve comes closest to capsule at 5:30–6:30 o’clock positions on the glenoid with the closest distance measuring 10–25 mm away12

Standard posterior portal placement is usually a minimum of 2–3 cm from

the axillary nerve:

Placement is also 2 cm medial and 2 cm inferior to the posterolateral

corner of the acromion.

Lateral working portals placed in the “safe zone” (located within 3 cm of the lateral border of the acromion) avoid the axillary nerve

Anterior portals, particularly anteroinferior portals, are at greater risk of neurovascular injury than posterior portals:

Increasing risk of axillary nerve injury with inferior placement

Placement of anterior portal lateral to the coracoid through the rotator

interval is safe.

 

Specific arthroscopic procedures at higher risk of axillary nerve injury:

Glenohumeral capsular release:

Through anteroinferior or posteroinferior axillary pouch and

recesses places the nerve at risk of injury.

Thermal capsulorrhaphy

Arthroscopic stabilization:

Capsulolabral sutures of anteroinferior band of the inferior glenohumeral ligament have particular risk

Sutures placed within 1 cm of the anterior glenoid rim are relatively safe.

Arthroscopic axillary nerve release

Arthroscopic Latarjet:

Close proximity of surgical instruments to axillary nerves.8

Musculocutaneous nerve:

At risk with anterior working portal (▶Fig. 2.3):

Standard placement of portal is midway between anterolateral corner of the acromion and coracoid

More inferior or medial placement of portal increases chances of injury

Less risk of injury with placement under direct visualization.8

Suprascapular nerve:

Unique anatomy of nerve makes it susceptible to injury during various open and arthroscopic shoulder procedures:8

Transglenoid drilling for instability:

Anchors have shown to decrease this risk.

 

Fig. 2.3 Anterior arthroscopic working portal is placed midway between the coracoid and anterolateral acromion.8

 

 

 

Aggressive mobilization of retracted rotator cuff tear:

Risk is minimized by staying within 2 cm of superior glenoid rim.

Arthroscopic decompression of suprascapular and spinoglenoid notches increases the vulnerability of the nerve to injury

Arthroscopic transglenoid Bankart repair:13

Usually transient injuries.

 

Infection

Deep infection after arthroscopic shoulder procedure is rare but can be devastating:

Overall rate ranges from 0 to 3.4%.7,14,15

Risk for infection increases drastically when converted to open procedure

Risk factors for perioperative infection following arthroscopic shoulder procedure are:

Diabetes mellitus

Smoking

Obesity

Peripheral vascular disease

Immunocompromised

History of prior surgery

Prior joint aspiration or injection.

Propionibacterium acnes has predilection for postoperative shoulder infection:

Gram positive bacillus

Can take up to 2 weeks to grow in culture

Mildly virulent with often benign initial presentation

Usually no systemic symptoms, no laboratory abnormalities, and minimal to no local reaction

Usually penicillin (PCN) sensitive

Vigilance is required to identify this infection in a timely manner.8

Efficacy of surgical preparation solutions in removing bacteria from shoulder

region:16

ChloraPrep is more effective than DuraPrep and povidone-iodine

DuraPrep is more effective than povidone-iodine

Antibiotic prophylaxis can drastically reduce infection rates following arthroscopic shoulder procedures.14

Deep infection is treated successfully with surgical debridement and antibiotic therapy.8

Venous thromboembolic events‌

Venous thromboembolic events (VTE) after arthroscopic shoulder surgery are rare:

Overall pulmonary embolism rate: 0.01%

Overall DVT rate: <0.01%.

Thromboprophylaxis is not particularly useful in preventing VTE after

arthroscopic shoulder procedures.17

 

Athrofibrosis and stiffness

Postarthroscopic athrofibrosis:

Rate of postarthroscopic arthrofibrosis in the shoulder: 1–2.8%

Classic arthrofibrosis is intra-articular adhesions in the glenohumeral joint:

May be present with extra-articular adhesions in multiple periarticular

locations.

General comorbid associations:

Diabetes

History of keloid formation.

Treated initially with physical therapy:

Postsurgical stiffness is more resistant than primary adhesive capsulitis

to conservative measures

Surgical interventions such as capsular release are highly successful.18

Arthroscopic rotator cuff repair (aRCR):

High incidence of stiffness after aRCR: 2.3–8.7%5,18

Stiffness is one of the most common complications after primary aRCR:

Stiffness complication rate is 8.7% compared to overall complication rate

of 10.6%

Stiffness can be defined as more than 90 postoperative days with:

Passive external rotation less than 10 degrees with arm at the side

Passive external rotation less than 30 degrees with arm at 90 degrees

of abduction

Passive forward elevation less than 100 degrees.

Stiffness in most patients is treated successfully with physical therapy:

Arthroscopic release can be performed if nonoperative treatments fail.5

Risk factors for stiffness after aRCR:18

Prolonged immobilization

Noncompliance with physical therapy

Over-tightening of repair

 

Glenohumeral osteoarthritis

Concomitant calcific tendonitis

History of adhesive capsulitis

Single tendon repair or repair of partial, articular-sided tear.

Protective factors for postoperative stiffness in the setting of aRCR:18,19

Larger tears

Multitendon tears

Concomitant coracoplasty.

Arthroscopic labral repair:

Stiffness is one of the most common complications after superior labrum from anterior to posterior (SLAP) tear repair20

Lack of high-quality evidence in the literature to guide successful treatment

of stiffness after arthroscopic SLAP lesion repair:20,21

Increased likelihood of unsuccessful conservative treatment

Recurrent stiffness after operative treatment for postoperative stiffness is

also common.

 

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