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.
2 Complications in Shoulder Arthroscopy
I. Incidence and patient risk factors
Arthroscopic shoulder complications are less prevalent than open shoulder procedures 1
Wide range due to definition of complications and length of follow-up.
Common complications include: 8
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.
II. Patient positioning
No proven difference in complication rates between lateral decubitus and beach chair positions. 8
Lateral decubitus (▶ Fig. 2.1 ):
Increased visualization and access
Lower risk of hypotension, bradycardia, and cerebral hypoperfusion.
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 ):
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:
i. Can be reduced with use of regional anesthesia instead of general anesthesia.
Neuropraxia from head and neck malpositioning. 10
III. Anatomy and nerve injury
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
Deltoid insertion: 6.7 ± 0.47 cm
Upper border of deltoid origin:
i. Anterior: 4.94 ± 0.8 6 cm
ii. Middle: 5.14 ± 0.90 cm
iii. 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 away 12
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:
i. Through anteroinferior or posteroinferior axillary pouch and recesses places the nerve at risk of injury.
i. Capsulolabral sutures of anteroinferior band of the inferior glenohumeral ligament have particular risk
ii. Sutures placed within 1 cm of the anterior glenoid rim are relatively safe.
Arthroscopic axillary nerve release
i. Close proximity of surgical instruments to axillary nerves. 8
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
Unique anatomy of nerve makes it susceptible to injury during various open and arthroscopic shoulder procedures: 8
Transglenoid drilling for instability:
Aggressive mobilization of retracted rotator cuff tear:
i. 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
i. Usually transient injuries.