Complications in Shoulder Arthroscopy

Fig. 13.1

The three sectors of the shoulder

13.4.1 Postero-Superior Area

No voluminous vascular structures are at risk in this area, except the suprascapular artery (Fig. 13.2). During arthroscopic supra scapular nerve release, it is important to protect the artery medially during the transverse ligament release or to coagulate it as its leakage may create voluminous postoperative hematoma with secondary fibrosis around the suprascapular nerve. Vascular clips can sometime be necessary.

../images/437034_1_En_13_Chapter/437034_1_En_13_Fig2_HTML.png — Fig. 13.2

Supra scapular nerve and artery

It is even important to pay attention of the periarticular vascular structures around the base of the acromion (Fig. 13.3) during postero-superior cuff release in order to avoid bleeding during and after arthroscopic rotator cuff repair. These vessels are giving branches toward the sub acromial tissues and most of the time surrounded by fat, which make the coagulation somehow difficult.

../images/437034_1_En_13_Chapter/437034_1_En_13_Fig3_HTML.png — Fig. 13.3

Superior periarticular vessels at the acromion spine area

13.4.2 Anterior Area

This area contains subscapularis muscle, plexus, sub-clavicular and axillary vessels. As previously described, coracoid and conjoint tendon determine two subareas:

A lateral space extended to the sub coracoid bursae (Fig. 13.4), in which there is no major vascular structure at risk.
The only vascular structures are:
- superiorly the terminal branch of the Acromio-Thoracic artery which can be involved as soon as the Coraco-Acromial (CA) ligament is detached. It is located between the deltoid muscle and the CA ligament. Meticulous hemostasis has to be performed while acromioplasty and Acromio-Clavicular joint is performed.
  
  Inferiorly the sisters at the inferior border of the subscapularis which may be responsible of consequent bleeding in case of damage. As long as the sub coracoid bursae is intact, there is no vascular and no neurologic risk on this area. Subscapularis repair allows very medial intra-articular release and extra articular retro coracoid and behind the conjoint tendon as long as the subcoracoid medial bursae limit is respected.
The medial area is the most dangerous area of the shoulder.
- The subcoracoid area
  
  As soon as the medial border of the sub coracoid bursae is open (Fig. 13.5), we can during the shoulder endoscopy looking form lateral identified the plexus and the axillary vessels (Fig. 13.6). Axillary artery is located anterior to the posterior cord just behind the musculo-cutaneous nerve. During axillary nerve or subscapularis nerve release necessary for subscapularis repair with massive retraction, it is dramatically important to pay attention to the axillary artery and to the axillary vein.
- The subclavicular area
  
  Vascular vessels and plexus are located behind the clavicle and the sub-clavicle muscle in front of the thorax at the level of the first ribs. More inferiorly the nerve vascular structures are behind the pectoralis minor. During anterior shoulder endoscopic procedures, (Arthroscopic Latarjet mainly), under the level of the clavicle, as long as the pectoralis minor is intact, there is no vascular or nerve structure at risk.
  
  As soon as the pectoral minor is detached, the nerve and vascular structures are at risk.
  
  Under the clavicle, at the upper level, vascular and nerve structures are already included in the same aponeurosis. In case of endoscopic plexus release, particular attention must be paid for axillary artery and vein.
  
  We experimented an axillary vein injury during a plexus release for a 44-year-old woman case of persistent outlet syndrome after a first rib resection. During the endoscopic release of the plexus at the level of the retro clavicle area, the vein which was included in a fibrotic tissue was damaged (Fig. 13.7a). It was possible to control the bleeding by adapted pressure of the pump avoiding to inflating air by water tightening the portals and by paying great attention to the fluid management of the pump (no air entry). The tear of the vein was longitudinal and long about 2 cm. We performed a watertight hemostasis by using endoscopically vascular clips (Fig. 13.7b). The plexus release procedure was terminated efficiently, and the patient went back to the recovery room in good conditions.
- The retro Pectoralis Minor area
In case of plexus release, some transversal horizontal artery may cross the anterior plexus and be responsible of compression. Vascular clips may be necessary to insure accurate hemostasis in order to cut this transversal vessels
Arthroscopic Latarjet as well as open Latarjet is a procedure which is located in a sensible area due to the proximity of vessels and nerves (Fig. 13.8). Particular attention must be paid during these procedures for a step by step hemostasis in order to avoid per operative bleeding and post-operative hematoma. Since end 2003, we performed more than 800 arthroscopic Latarjet. Five patients needed endoscopic revision for lavage of hematoma without any sequalae. On the top of these five cases, one case presented a post-operative hematoma which was not efficiently treated by a simple lavage. A 23 year-old man was operated for left shoulder instability by arthroscopic Latarjet. During surgery, hemostasis was difficult, patient was slightly bleeding and the pressure of the pump had to remain high to achieve the surgery but not obvious vessel was injured. Despite a particular attention was given to the axillary vessels area. Post operatively at Day 1 it was hard to differentiate hematoma from swelling (Fig. 13.9a). Hemoglobin when down too 7 gr at Day 2 and lavage was managed with endoscopic assistance. No major bleeding origin could be found. Persistent bleeding at Day 3 leaded to ultrasound which confirmed the origin of a persistent bleeding from a small branch of the axillary artery into a pseudo aneurysm (Fig. 13.9b) as well as by Angio CT (Fig. 13.9c, d) but with integrity of the axillary artery. An attempt of hemostasis with a Coil by the vascular radiologist was unsuccessful (Fig. 13.9e). Vascular endoscopic surgeons could finally obtain an accurate hemostasis by endovascular stent at the origin (Fig. 13.9f, g). After a massive diffused hematoma (Fig. 13.9h), the patient totally recovered normal vascularization and presented at 6 months post op an excellent clinical and functional result. He remained under anti-coagulant for 6 months (Fig. 13.9i, j). There is no vascular sequalae, pulse and ultrasound control are 100% normal.