Raffy Mirzayan, MD

Disclosures

July 18, 2006

Editorial Collaboration

Medscape &

Shoulder arthroscopy is a rapidly expanding field, and arthroscopic shoulder procedures are increasing in frequency and popularity. Complications exist but are considered by the community to be relatively rare compared with open procedures. Severe glenohumeral chondrolysis is a severe, life-altering complication that has been seen following shoulder arthroscopy. Several theories as to the cause of this devastating complication have been put forward. No etiology has been firmly identified and treatment options are limited. The use of thermal devices has been implicated as a possible cause in most published cases. At the American Academy of Orthopaedic Surgeons 2006 Annual Meeting, March 22-26, Chicago, Illinois, M.W. Larsen, MD, and coworkers[1] presented a paper entitled "Severe Glenohumeral Chondrolysis Following Shoulder Arthroscopy Resulting in Arthroplasty." Between 2002 and 2004, 6 patients were referred to the orthopaedic department at Duke University Medical Center, Durham, North Carolina, for severe chondrolysis following shoulder arthroscopy performed at outside institutions. All of the previous cases were performed by experienced shoulder surgeons. The patients were between the ages of 15 and 32 years of age and had previously undergone either 1 or 2 arthroscopic shoulder procedures for labral pathology or instability. On the basis of the information gained from the operative reports or intraoperative photographs, 4 of the 6 patients had undergone thermal treatment of the shoulder. All presented to Duke with severe pain and loss of motion after the arthroscopic procedures. X-rays demonstrated concentric, global glenohumeral cartilage loss with bone on bone contact between the humeral head and glenoid. All patients failed treatment of activity modifications, anti-inflammatory medications, and physical therapy. Following discussion of treatment options, all patients requested arthroplasty. After surgical exposure demonstrated the absence of any cartilage within the glenohumeral joint space, 2 patients underwent hemiarthroplasty of the shoulder and 4 underwent a humeral head resurfacing. One of the patients with humeral head resurfacing also underwent an interpositional arthroplasty with an Achilles tendon allograft. The study authors concluded that severe glenohumeral chondrolysis can occur after shoulder arthroscopy and may be associated with use of thermal devices. However, some patients developed chondrolysis after minimal or no use of the thermal devices. Therefore, surgeons should be judicious in their use of thermal devices in the shoulder until the link between chondrolysis and shoulder arthroscopy has been better established. Also, the young age of all of these patients and those reported in the literature is cause for concern.

Alternative Viewpoints on Chondrolysis

Another theory as to the cause of chondrolysis is the association of this side effect of surgery with the use of postoperative intra-articular pain pump catheters. B. Hansen and colleagues[2] presented a paper entitled "Post-arthroscopic Shoulder Chondrolysis With Associated Intra-articular Pain Pump Catheter Use." This group of investigators reviewed the charts of 152 patients who underwent 177 shoulder arthroscopies by the senior author between January 1, 2003 and December 31, 2005 for postarthroscopic chondrolysis. Demographic information, procedure, implant and suture type, thermal probe use, and intra-articular pain catheter use were evaluated. All cases who developed chondrolysis also underwent rheumatologic and infection work-ups. Twelve shoulders in 10 patients who underwent arthroscopic stabilization developed chondrolysis. Eighty-three percent of these required a subsequent procedure. All patients who developed chondrolysis had been treated postoperatively with an intra-articular pain pump catheter with bupivacaine 0.25% with epinephrine 1:200,000. Seven other patients treated with intra-articular pain pump catheters had not developed chondrolysis at the time of review. None of the other patients developed chondrolysis in this group. No other factors were found to be in common. All chondrolysis cases occurred after beginning the use of a larger pain pump, which infused this medication at 4.16 cc/hour over 2 or 3 days. Although the exact etiology and mechanism of chondrolysis are still unknown, the study authors believe that there is a significant and previously unrecognized risk associated with the use of intra-articular pain pump catheters and bupivacaine with epinephrine. One of the possible reasons is that the pH of bupivacaine with epinephrine is between 3.5 and 5.5 and that the low pH may play a role. The study authors conclude that intra-articular pain pump catheters should be used with caution until the safety of constantly infusing local anesthetics intra-articularly is better defined.

Portal of Wilmington: More Harm Than Good?

The Portal of Wilmington is an accessory portal used in shoulder arthroscopy, primarily in the repair of superior labrum, anterior-posterior (SLAP) lesions. This portal has become popular because it provides access to the superior labrum and glenoid. Improper placement of this portal can result in damage to the rotator cuff near its attachment to the greater tuberosity. J. Hurt, MD, and S.D. Mair[3] presented the paper entitled "Rotator Cuff Tears Associated With the Port of Wilmington" to stress the importance of proper placement of this portal and the potential for complications with its use. Five patients were referred to the study authors' clinic after previous shoulder arthroscopy with SLAP repair. The mean age of the patients was 34.2 years (range, 17-44 years). There were 4 males and 1 female. The American Shoulder and Elbow Surgeons (ASES) scores at time of presentation averaged 46.0 (range, 34-60). Four of 5 reported that their symptoms were worse after the index surgery. Operative reports were reviewed and showed that the rotator cuff had been described as normal in 4 patients at the time of the first surgery. The other patient had a mild partial supraspinatus tear. All patients underwent repeat shoulder arthroscopy at a mean of 15.8 months (range, 10-22 months) from the index surgery. All 5 patients had significant rotator cuff tears associated with portal placement from their first surgery. A spinal needle was placed through the skin at the site of the previous portal to confirm the portal as the source of the rotator cuff tear. Revision SLAP repair was performed in 3 of 5 patients. All 5 underwent a rotator cuff repair: 2 with side-to-side repair and 3 with suture anchor repair to bone. All patients improved after revision surgery. Postoperative ASES scores averaged 91.2 (range, 77-100). Mean follow-up was 13.4 months (range, 4-26 months). The Portal of Wilmington is an accepted portal in shoulder arthroscopy. Its proper use involves careful placement in order to traverse the rotator cuff medial to the muscle-tendon junction. This report highlights the potential for injury to the rotator cuff tendons with improper placement of this portal. In patients with persistent pain after previous SLAP repair, where the Portal of Wilmington was used, consideration should be given to rotator cuff injury as the source of symptoms. Revision surgery with rotator cuff repair provided improvement.

Managing Postoperative Infections

Infections following shoulder surgery are very uncommon because the shoulder has an ample blood supply. Two papers were presented with regard to postoperative shoulder infections. There are no reported series on the outcomes of patients treated for infection after surgery for proximal humerus fractures. G. Athwal, MD, and colleagues[4] presented a paper entitled "Acute Deep Infection Following Surgical Fixation of Proximal Humerus Fractures." The study authors reviewed the presentation, incidence, treatment, and outcomes of patients with proximal humerus fractures complicated with infection. Between 1993 and 2003, 5 patients with acute, deep infection following open reduction internal fixation (ORIF) of proximal humerus fractures were identified. The medical records, laboratory data, and x-rays were examined retrospectively. The mean age of the patients at the time of diagnosis of infection was 50 years. The mean interval from proximal humerus fracture fixation to the time of infection diagnosis was 27 days. All patients were available for follow-up evaluation at a mean of 6.4 years (range, 32 months to 8.3 years). Four of 5 patients (80%) with acute infection following surgical treatment of proximal humerus fractures developed a nonunion requiring surgery. Propionibacterium and coagulase-negative Staphylococcus species were the most common organisms isolated. A mean of 3.3 surgical debridements were necessary for the eradication of infection. At a mean of 6.4 years final follow-up, the ASES score averaged 53 points and the Simple Shoulder Test score averaged 6.2 points. The study authors concluded that acute deep infection following ORIF of proximal humerus fractures is a devastating complication. They recommended that patients should be counseled that the results of deep infection have high complication rates, which lead to a poor functional outcome and a high nonunion rate.

Outcomes Following Rotator Cuff Infections

Little information is available concerning the outcomes of patients with infection following rotator cuff repair. G. Athwal, MD, and colleagues[5] presented a paper entitled "Deep Infection After Rotator Cuff Repair." The second paper presented during this session by this group of study authors reviewed the incidence, management, and outcomes of patients with rotator cuff repair complicated with deep infection. Between 1975 and 2003, 39 cases of deep infection following rotator cuff repair were identified. The medical records and x-rays were examined retrospectively. At a mean follow-up of 8.2 years, 7 patients had died and 2 patients had been lost to follow-up, leaving 30 cases for outcomes evaluation. The incidence of deep infection after rotator cuff repairs that were performed at our institution was 0.43% (21 of 4886 cases). The mean interval from rotator cuff repair to the time of diagnosis of infection was 49 days. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated in only 60% and 50% of patients, respectively. Propionibacterium was the most common organism isolated, infecting 51% of cases. This is consistent with a previous report by R. Mirzayan, MD, and colleagues.[6] A mean of 3.3 surgical debridements were necessary for the eradication of infection. At final follow-up, the mean active abduction was 121° and mean external rotation was 44°. The ASES score averaged 67 points and the Simple Shoulder Test score averaged 7.3 points. The study authors concluded that the eradication of deep infection following rotator cuff repair is possible; however, substantial functional limitations are to be expected. Additionally, a minimum of 7 days is necessary for the cultures to grow in order to identify Propionibacterium.

References
  1. Larsen MW, Basamania CJ, Higgins LD. Severe glenohumeral chondrolysis following shoulder arthroscopy resulting in arthroplasty. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 284.

  2. Hansen BP, Beck CL, Townsley RW. Post-arthroscopic shoulder chondrolysis with associated intraarticular pain pump catheter use. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 360.

  3. Hurt JH, Mair SD. Rotator cuff tears associated with the Port of Wilmington. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 435.

  4. Athwal G, Sperling JW, Rispoli DM, Cofield RH. Acute deep infection following surgical fixation of proximal humerus fractures. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 430.

  5. Athwal G, Sperling JW, Rispoli DM, Cofield RH. Deep infection after rotator cuff repair. Program and abstracts of the American Academy of Orthopaedic Surgeons 2006 Annual Meeting; March 22-26, 2006; Chicago, Illinois. Paper 166.

  6. Mirzayan R, Itamura JM, Vangsness CT Jr, Holtom PD, Sherman R, Patzakis MJ. Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am. 2000;82A:1115-1121.

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