Abstract
Analysis of orthopaedic malpractice claims has shown that highest impact allegations (highest payment dollars per claim) were those that were related to failure to protect anatomic structures in surgical fields. The prevalence of subclinical peripheral neurologic deficit following reverse and anatomic shoulder arthroplasty has been reported to be 47% and 4%, respectively. We propose the following five rules in order to avoid neurovascular injury during shoulder arthroplasty cases:
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Pre-operative planning would assure a smooth operation without intra-operative difficulties. Adequate planning would include appropriate imaging, obtaining previous operative reports, complete pre-operative neurovascular examination and requesting the necessary operative equipment.
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Tug test: It is crucial to palpate the axillary nerve and be aware of its location. The tug test is a systematic technique for locating and protecting the axillary nerve.
Neuromonitoring has been utilised in shoulder surgery in the past. Nagda et al showed that nerve alerts during shoulder arthroplasty occurred 56.7% of the time and 50% of the events were with the arm in abduction, external rotation and extension; 76.7% of signals returned to normal with retractor removal and change in arm positioning. We recommend removing all retractors and returning the arm to neutral position several times during surgery, especially during the glenoid exposure when the arm is in abduction and external rotation.
Newer commercially available nerve stimulators are extremely useful in locating and protecting neurovascular structures. We recommend brachial plexus exploration and axillary nerve dissection with the aid of a nerve stimulator in all revision cases.
Availability of a nerve/microvascular surgeon as an assistant in revision cases for brachial plexus exploration using a microscope is crucial for successful revision surgery.
