Shoulder/Arm Surgery

Amy L. Ladd MD¹

Andrew C. Karich MD¹

Emilie V. Cheung MD¹

Lindsey Vokach-Brodsky MB, ChB, FFARCSI²

¹SURGEONS

²ANESTHESIOLOGIST

ARTHROSCOPIC SHOULDER SURGERY

SURGICAL CONSIDERATIONS

Description: The role of arthroscopy in shoulder surgery has advanced tremendously in the past decade and is now routinely performed by most shoulder surgeons. Arthroscopic procedures include subacromial decompression (SAD), distal clavicle resection (Mumford procedure), debridement (for labral tear, infection, or synovitis), rotator cuff (RC) repair, anterior capsule-labral repair for recurrent dislocation (Bankart repair), capsular plication for multidirectional instability (MDI), capsular release for frozen shoulder, and repair of SLAP lesions (superior labral anterior-posterior tears).

Procedures done arthroscopically are less painful postoperatively than open procedures because they produce less trauma to normal tissues. Rehabilitation is, therefore, facilitated. Interscalene block has been shown to provide good postop analgesia of shorter duration, but its clinical application with arthroscopic procedures is surgeon-dependent because the postoperative pain is usually moderate to mild. Some surgeons prefer only a general anesthesia for shoulder arthroscopy. The use of indwelling intra-articular pain catheters has fallen out of favor in the past few years due to multiple case reports of chondrolysis, a devastating complication characterized by end-stage arthrosis of the glenohumeral joint.

Arthroscopic shoulder surgery may be performed in the beachchair or lateral decubitus position. Beachchair positioners are available with a trough for the head and a breakaway shoulder pad to provide important access to the posterior shoulder. The lateral decubitus position utilizes distal traction of 5-10 lbs, with the arm abducted 30-45°. Both are safe positions for the brachial plexus because the shoulder is not excessively abducted. The “down” arm in the lateral position is placed in forward flexion, and an axillary roll is placed underneath the upper chest wall.

Initially, an 18-ga spinal needle is inserted into the glenohumeral joint, passing through the posterior deltoid and infraspinatus muscle and the posterior capsule of the joint (see shoulder anatomy, Fig. 10.2-1). Placement is verified by injecting saline to inflate the joint capsule. A stab incision is made using a No. 11 blade in the direction previously defined by the finder needle. Sharp, then blunt trocars are used to gain access to the joint and permit insertion of the arthroscopic device. Improper insertion of the instruments can injure the axillary or suprascapular nerves and the cartilage of the glenohumeral joint. Initial diagnostic arthroscopy is carried out through the posterior portal. Bupivacaine 0.5% with epinephrine 1:200,000 often is infiltrated into portals and the joint or subacromial space at the onset of surgery to help with hemostasis. An anterior portal is used for instrumentation within the glenohumeral joint. After joint arthroscopy, the scope is placed into the subacromial space, where a direct lateral portal is used for instrumentation. Accessory portals are established as needed, depending on the procedure performed. Joint debridement and anterior capsulolabral stabilization are usually performed through anterior portals. RC repair, subacromial bursectomy, acromioplasty, and distal clavicle resection are done within the subacromial space (deep to the deltoid and superficial to the RC). Epinephrine (1 mg/3 L) in the irrigation fluid and maintaining MAP < 80 mm Hg help control bleeding, thus enhancing visualization during surgery.

Usual preop diagnosis: Rotator cuff tear; subacromial impingement; glenohumeral instability; AC arthritis; labral tear

▪ SUMMARY OF PROCEDURE

Position	Lateral decubitus or beachchair
Incision	Posterior arthroscopic portal, anterior instrumentation portal, lateral instrumentation portal for visualizing subacromial bursa; superior portal for semisitting position
Special instrumentation	Arthroscope; power burrs; arthroscopic shavers; suture-passing instruments; bone anchors; radiofrequency cautery
Unique considerations	Rigid eye patch over ipsilateral eye, to prevent corneal abrasion, suggested. Positioning of the head with appropriate support, removing upper section of operating table, if possible, for better access with semisitting position. ETT taped to opposite side of face. MAP ≤ 80.
Antibiotics	Cefazolin 1 g iv preop, particularly if bone work performed
Surgical time	Positioning the patient is time-intensive; can add as much as 45 min. Reconstructive: 1-4 h Diagnostic: < 1-1.5 h
EBL	Minimal: < 200 mL (less with use of epinephrine, electrocautery, and laser)
Postop care	Frequently outpatient; may be overnight if interscalene or supraclavicular block is given or reconstructive procedure performed. Intraarticular pain catheter commonly used.
Mortality	Rare
Morbidity	VAE possible Extravasation of fluid (NS or LR): > 50% Brachial plexus injury (lateral decubitus position): Rare Breakage of instruments: < 1% Infection: 0-3%
Pain score	4 (diagnostic); 5-7 (reconstruction)

Figure 10.2-1. Anatomy of the shoulder joint, anterior. (Reproduced with permission from Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, 2nd edition. Lippincott Williams & Wilkins: 1994.)

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Surgery for Shoulder Instability, p. 966.

Suggested Readings

1. Baechler MF, Kim DH: Patient positioning for shoulder arthroscopy based on variability in lateral acromion morphology. Arthroscopy 2002; 18(5):547-9.

2. Bigliani LU, Flatow EL, Deliz ED: Complications of shoulder arthroscopy. Orthop Rev 1991; 20(9):743-51.

3. 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.

4. Pearsall AW IV, Osbahr DC, Speer KP: An arthroscopic technique for treating patients with frozen shoulder. Arthroscopy 1999; 15(1):2-11.

5. Ruotolo C, Nottage WM, Flatow EL, et al: Controversial topics in shoulder arthroscopy. Arthroscopy 2002; 18(2 Suppl 1):65-75.

6. Salazar D, Sears BW, Andre J, Tonion P, Marra G: Cerebral desaturation during shoulder arthroscopy: a prospective observational study. Clin Orthop Relat Res 2013; 471(12):4027-34.

SURGERY FOR ACROMIAL IMPINGEMENT, ROTATOR CUFF TEARS, AND ACROMIOCLAVICULAR JOINT ARTHRITIS

SURGICAL CONSIDERATIONS

Description: Subacromial impingement is a common degenerative condition of middle age. It may be related to extrinsic anatomic factors (e.g., hooked acromion), a traumatic episode, or intrinsic factors (e.g., tissue degeneration). The subacromial space (space between the acromion and humeral head) is occupied by the supraspinatus (superior rotator cuff [RC]) muscle and tendon and the bursa, which allows for smooth gliding of the cuff tendon under the acromion. Trauma produces hemorrhage and inflammation in the bursa; swelling of the bursa decreases the space available under the acromion. These tissues may then be “pinched” between the greater tuberosity of the humerus and the lateral aspect of the acromion (Fig. 10.2-2) with forward elevation or abduction of the arm. This further increases the inflammation, producing a vicious cycle.

Impingement of the anterolateral acromion on the insertion of the supraspinatus (along with poor vascularity of this part of the cuff) is a leading hypothesis for the etiology of degenerative RC tears.

AC joint arthritis is a common radiographic finding in adults, but it is often asymptomatic. Distal clavicle excision is performed for clinically symptomatic AC joint arthritis.

Subacromial impingement: Surgical treatment of subacromial impingement is indicated when nonoperative treatment (e.g., cortisone injection, physical therapy) fails. Surgery involves shaving of the anterolateral aspect of the undersurface of the acromion (creating a flat surface and providing more room in the subacromial space). This may be accomplished with open techniques in combination with open RC repair, but it is more commonly done arthroscopically. The bursa is usually inflamed and quite vascular. Bleeding may obscure arthroscopic visualization and is controlled with electrocautery, with epinephrine in the irrigant, and by maintaining relative ↑ BP (MAP < 80 mm Hg).

Figure 10.2-2. Abduction of the arm can impinge the subacromial bursa between the greater tuberosity and the undersurface of the acromion and coracoacromial ligament (between arrows). (Reproduced with permission from Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, 2nd edition. Lippincott Williams & Wilkins: 1994.)

Rotator cuff tears: RC (Fig. 10.2-3) repair may be performed using the direct lateral open approach, the mini-open (deltoid-splitting) approach in conjunction with arthroscopy, or all arthroscopically. If a deltoid-splitting incision is used, care is taken not to extend the split more than 5 cm distal to the acromion because of possible injury to the axillary nerve, which innervates the deltoid 5 cm or more from the lateral aspect of the acromion. If the beachchair position is used for open RC surgery or arthroscopy, the upper limb is draped free. The arm is manipulated, and traction is frequently applied. It is important that the head is secured (the head may be taped to the table or special beachchair positioner), the eyes are protected, and the anesthesiologist frequently checks to see that the surgeon is not pulling the patient off the table (not always apparent from the surgeon’s side of the drape). Traction on the brachial plexus is more likely in the lateral decubitus position 2° arm traction.

Open RC repair involves suturing the cuff insertion back to the greater tuberosity through drill holes or with suture anchors. Arthroscopic repair requires percutaneous anchor placement and arthroscopic suture-passing and knottying. Bleeding is minimal with the arthroscopic technique, but may approach 400 mL with an open procedure. Both require that the patient remain relaxed until all dressings are applied and he/she is fitted with an abduction sling. Patients typically are admitted for 24 h for pain control or if a drain is used.

AC joint disease: Surgery for AC joint arthritis is usually performed in conjunction with SAD and/or RC repair and may be done open or arthroscopically. It involves simple resection of the distal 5 mm of the clavicle through an incision directly over the joint or through an accessory anterior portal. Again, relative ↓ BP is required for the arthroscopic procedure.

Repair of AC joint dislocation (“shoulder separation”) is uncommon. Most AC separations are treated nonoperatively because long-term functional results are the same or better than those treated surgically. Severe AC separations occasionally require surgery, when the dislocated clavicle is buttonholed posteriorly through the trapezius, the deltoid origin has been avulsed from the clavicle, or the clavicle is displaced inferiorly below the cricoid process. Repair is performed in the beachchair position with the incision carried out over the AC joint and distal third of the clavicle. The clavicle is reduced and held in place with a large screw into the base of the coracoid, a large suture wrapped around the coracoid, or with K-wires across the AC joint. The coracoclavicular ligament often is repaired or reconstructed with tendon graft, or the coracoacromial ligament is transferred from the edge of the acromion to the clavicle. Following reduction and fixation, the deltoid is reattached to the clavicle if it has been avulsed, and the patient is placed in an immobilizer after skin closure. The operation is technically challenging, and the brachial plexus and subclavian vessels are at risk with screw placement and with inferior dislocations.

Figure 10.2-3. Lateral view of the right shoulder showing a rotator cuff repair. (Reproduced with permission from Lafosse L, Brozska R, Toussaint B, et al: The outcome and structural integrity of arthroscopic rotator cuff repair with use of the double-row suture anchor technique. J Bone Joint Surg 2007; 89(7):1533-41.) A: Rotator cuff tear. B: Rotator cuff repair with suture anchors.

Usual preop diagnosis: RC tears (partial or complete); AC arthritis; impingement; bursitis; bicipital tendinitis; AC separation

▪ SUMMARY OF PROCEDURE

Position	Beachchair; semisitting, ˜40-70°; or lateral decubitus
Incision	Oblique, saber-type incision anteriorly over distal acromion; lateral or deltopectoral incision for wider exposure; deltoid-splitting incision for RC tears
Special instrumentation	Power equipment for bone work; self-retaining retractors for cuff repairs; suture anchors
Unique considerations	Rigid eye protection for ipsilateral eye and careful head positioning
Antibiotics	Cefazolin 1 g iv preop
Surgical time	1-3 h
Closing considerations	Muscle relaxation when mobilizing cuff and during closure. Arm in sling and swathe, or abduction pillow for large tears. Immobilizer should be positioned prior to awakening patient to minimize potential for rupture of repair.
EBL	200-400 mL
Postop care	Maintenance of position in sling and swathe; no active motion of shoulder girdle for 2 d-6 wk, depending on procedure.
Mortality	Rare
Morbidity	Infection: 1-5% Axillary nerve damage: < 2% Musculocutaneous nerve damage: < 2% Breakage of instruments: < 1% Brachial plexus damage (position-dependent) Suprascapular nerve at risk for RC mobilization
Pain score	5-8

▪ PATIENT POPULATION CHARACTERISTICS

Age range	Rotator cuff tears > 40 yr (younger for athletes)
Male:Female	3:1
Incidence²	5-30% of general population affected by RC and acromial conditions, depending on age, thickness of tear, associated conditions
Etiology	Age-related; trauma (70% involved in light work)
Associated conditions	Bursitis; tendinitis; impingement; RC disease (especially in first-time glenohumeral dislocations > 40 yr); diabetes and renal failure; hypermobility

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Surgery for Shoulder Instability, p. 966.

Suggested Readings

1. Chelly JE, Greger J, Al-Samsam T, et al: Reduction of operating and recovery room times and overnight hospital stay with interscalene blocks as sole anesthetic technique for rotator cuff surgery. Minerva Anestesiol 2001; 67(9):613-9.

2. Cofield RH, Parvizi J, Hoffmeyer PJ, et al: Surgical repair of chronic rotator cuff tears. A prospective long-term study. J Bone Joint Surg Am 2001; 83A(1):71-7.

3. Hata Y, Saitoh S, Murakami N, et al: A less invasive surgery for rotator cuff tear: mini-open repair. J Shoulder Elbow Surg 2001; 10(1):11-16.

4. Martin SD, Baumgarten TE, Andrews JR: Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression. J Bone Joint Surg Am 2001; 83A(3):328-35.

5. Yamaguchi K, Ball CM, Galatz LM: Arthroscopic rotator cuff repair: transition from mini-open to all-arthroscopic. Clin Orthop 2001; 390:83-94.

SURGERY FOR SHOULDER INSTABILITY

SURGICAL CONSIDERATIONS

Description: Shoulder instability is classified as multidirectional (MDI)/atraumatic, or unidirectional/traumatic.

MDI is associated with generalized ligamentous laxity (e.g., Ehlers Danlos or Marfan syndromes, or idiopathic), and is treated primarily nonoperatively with physical therapy. Open or arthroscopic capsular shift is performed for recalcitrant cases. This involves “plication” of the capsule and/or labrum to decrease the capsular volume of the shoulder. Patients with MDI, known as “voluntary dislocators,” frequently have psychiatric disorders and are very poor candidates for surgery.

Traumatic instability is usually anterior and is quite common in the young, active population. The shoulder is the most commonly dislocated joint. Recurrent dislocation in young, active patients is common (80-90%) and is associated with avulsion of the capsule/labrum from the anterior-inferior glenoid rim (Bankart lesion). The population undergoing a Bankart repair is almost invariably young and healthy. Older first-time dislocators (age > 50 yr) more commonly sustain rotator cuff (RC) tears or fractures, which do not result in chronic instability, but may require operative reduction and RC repair or fracture fixation. Posterior traumatic dislocation is much less common and is associated with high-energy trauma, seizures, or electrocution.

Instability surgery is often preceded by exam under anesthesia and arthroscopic examination, either in the beachchair or lateral decubitus position. The essential feature of instability surgery, whether arthroscopic or open, is the reattachment of the anterior inferior capsulolabral complex back to the rim of the glenoid, thus reestablishing the normal “bumper” effect of the anterior-inferior labrum and decreasing the capsular volume of the shoulder. Nonanatomic procedures (reconstructive) are much less common, but are still performed occasionally. These include transfer of the coracoid process to the anterior glenoid rim (Bristow or Latarjet procedure).

The open Bankart repair is performed in the beachchair position using the deltopectoral approach, with the interval between the deltoid and pectoralis major. The subscapularis (anterior RC muscle) lies just anterior to the joint capsule (Fig. 10.2-4), and this is either detached from its insertion or split. The capsule may then be opened to visualize the joint and rim of the glenoid. The glenoid rim is decorticated, providing bleeding bone to promote healing, and the anterior capsule is reattached through drill holes in the glenoid or with suture anchors. The capsule often is imbricated (overlapping folds) if it is redundant.

The shoulder and deltoid are highly vascular; however, bleeding is usually slight, with careful surgical technique. Major nerves are close but out of the plane of the operative field. The musculocutaneous nerve may be stretched by excessive medial retraction of the coracobrachialis (especially if a coracoid osteotomy is used) and the axillary nerve may be injured if the surgeon strays too far inferiorly.

If a subscapularis-releasing technique is used, the muscle is reattached and must be protected postop. External rotation of the shoulder is prevented for several weeks while the repair heals, and the surgeon prefers that the patient remain anesthetized until a shoulder immobilizer is applied.

The arthroscopic Bankart repair is similar to the open procedure but is performed through two anterior portals with the scope coming in posteriorly. This procedure is less painful postop and allows for more rapid rehabilitation, because the subscapularis is not detached.

Open surgery for posterior dislocation is similar to the open Bankart repair, but it is done in the lateral position and utilizes the interval between the infraspinatus and teres minor. The RC attachment is preserved, but the posterior deltoid is detached and must be protected postop.

Usual preop diagnosis: Recurrent traumatic anterior or posterior instability; MDI; fracture dislocation

▪ SUMMARY OF PROCEDURES

	Open	Arthroscopic
Position	Beachchair for anterior; lateral decubitus for posterior	Lateral decubitus or beachchair
Incision	Deltopectoral (anterior); posterior approach (posterior)	Multiple small portals
Special instrumentation	Arthroscopic shaver; suture anchors; glenoid and humeral instrumentation	⇚ + arthroscopic instruments for suture passing and knot-tying
Antibiotics	Cefazolin 1 g iv preop if bone work performed	⇚
Surgical time	2-4 h	⇚
Closing considerations	Continuous anesthesia until application of sling and swathe or abduction pillow	⇚
EBL	200-400 mL	Minimal
Postop care	No active motion for 6 wk	⇚
Mortality	Minimal	⇚
Morbidity	Axillary nerve palsy: 15% (may be preexisting) Suprascapular nerve injury
Pain score	8	5

Figure 10.2-4. Cross section of the joint: The joint capsule is redundant inferiorly to allow abduction. The long head of the biceps tendon traverses the joint. The tendon is surrounded by synovium and, therefore, is anatomically intracapsular but extrasynovial. (Reproduced with permission from Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, 2nd edition. Lippincott Williams & Wilkins: 1994.)

ANESTHETIC CONSIDERATIONS

(Procedures covered: shoulder arthroscopy; surgery for acromial impingement, RC tears, and AC disease; surgery for shoulder dislocations or instability)

PREOPERATIVE

Typically, three patient populations present for repair of RC tears or shoulder arthroscopy: (a) healthy posttrauma, (b) nonrheumatoid arthritic, and (c) rheumatoid arthritic. Individuals presenting for repair of shoulder dislocations also may include those with a joint hypermobility syndrome (e.g., Marfan or Ehlers-Danlos) or Sz disorder patients.

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Tags: Anesthesiologist's Manual of Surgical Procedures

May 23, 2016 | Posted by drzezo in ANESTHESIA | Comments Off

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Respiratory	Arthritic patients may exhibit Sx of pleural effusion or pulmonary fibrosis. Hoarseness may indicate cricoarytenoid joint (CAJ) involvement → difficult intubation. (See Anesthetic Considerations for Wrist Procedures, p. 936.) Seizure disorder patients who suffer from recurrent shoulder dislocation as a result of frequent grand mal Sz also may suffer from occult aspiration pneumonia or pneumonitis. Tests: Consider CXR; PFTs; ABGs in debilitated rheumatoid patients.
Cardiovascular	Arthritic patients may suffer from chronic pericardial effusions, valvular disease, and cardiac conduction defects. Patients presenting for shoulder stabilization because of joint hypermobility syndromes are likely to have valvular dysfunction and are vulnerable to aortic dissection 2° HTN. These patients may require antibiotic prophylaxis for bacterial endocarditis. Tests: Consider ECG, ECHO in patients with severe rheumatoid arthritis. Recent ECHO to assess valve function and aortic root size indicated in most patients with Marfan syndrome.
Neurological	Arthritic patients may have cervical or lumbar radiculopathies that should be documented carefully preop. For example, head flexion may cause cervical cord compression. Patients with severe Sz disorders can suffer from recurrent shoulder dislocations 2° frequent violent grand mal Sz. Such patients should be treated maximally for Sz disorder prior to elective surgery. Be aware that as many as 15% of shoulder dislocations can be accompanied by axillary nerve palsy, which should be documented carefully preop. Tests: Consider C-spine radiographs to r/o occult subluxations in arthritic patients with neck complaints or upper extremity radiculopathy. Verify therapeutic levels of antiepileptic medication in Sz disorder patients.
Musculoskeletal	Arthritic patients may have limited neck and jaw ROM and may require fiberoptic intubation techniques. Bony deformities or muscle contractures may necessitate special attention to positioning. Patients with joint hypermobility syndromes presenting for shoulder surgery also may suffer other joint dislocations 2° positioning problems.
Hematologic	Virtually all patients will be on some type of anti-inflammatory medication that may result in anemia or Plt inhibition. Ideally, patients should D/C NSAIDs at least 5 d preop; aspirin, 7 d. In addition, selected patients with Ehlers-Danlos are known to have severe coagulation defects that may preclude the use of regional anesthesia. Tests: A coag profile is mandatory in Ehlers-Danlos patients.
Endocrine	Rheumatoid patients may be on oral corticosteroids and may require supplemental perioperative steroids (e.g., 100 mg hydrocortisone q 8 h iv) to treat adrenal suppression, although the routine use of “stress-dose steroids” has been questioned.
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