Complications of shoulder instability surgery

Complications of shoulder instability surgery may results from errors made during the preoperative, intraoperative, or postoperative periods. Some complications are preventable whereas the risk of others can be reduced. A few complications remain unpreventable. Two sources of error in the preoperative period that can lead to complications are an incorrect diagnosis and failure to address a patient's expectations of treatment. These errors and their subsequent complications are preventable. Preventing complications during the intraoperative period begins with proper patient positioning and a thorough knowledge of shoulder anatomy. Understanding the indications and limitations of the various stabilization procedures, as well as applying proper surgical technique, is essential to avoid a surgical misadventure. Complications recognized in the postoperative period include recurrent instability, limitation of motion, inability to return to the previous level of sport, problems related to hardware, pain, development of osteoarthritis, and neurovascular injuries. Infection and hematoma formation may also occur; both need to be recognized and treated early to maximize outcome. A protocol for treating each complication that may occur often is helpful. Knowledge of the complications that can arise is paramount to preventing their occurrence. This knowledge comes through experience, study, and continued research.     

The safety and efficacy of intrabursal oxycodone and bupivacaine in analgesia after shoulder surgery

We experienced three patients with CD30+ diffuse large cell lymphoma having chromosomal abnormalities. The first patient was an 8-year-old girl with bilateral cervical lymphadenopathy. A biopsy of a cervical lymph node revealed diffuse large cell lymphoma (stage III), positive for CD30 and a chromosomal abnormality, t(2;5). She attained a remission and is now in complete remission 108 months after diagnosis, despite frequent relapses. The second patient was a 13-year-old boy with right axillar and supraclavicular lymph-node adenopathy. A biopsy of a cervical lymph node revealed diffuse large cell lymphoma (stage III), positive for CD30 and a chromosomal abnormality, t(2;5). He attained remission and was in continuous first remission 112 months after diagnosis. The third patient was an 11-year-old boy with fever and bilateral cervical lymph node revealed diffuse large cell lymphoma (stage III), positive for CD30 and chromosomal abnormality without t(2;5). He showed a very aggressive clinical course. Only the patients with Ki-1 lymphoma having t(2;5) survived over 100 months from the diagnosis, despite the advanced stage of the disease. These findings and a review of the literature showed that the presence or absence of t(2;5) may influence the outcome of Ki-1 lymphoma.     

Questionnaire on the perceptions of patients about shoulder surgery

We developed a 12-item questionnaire for completion by patients having shoulder operations other than stabilisation. A prospective study of 111 patients was undertaken before operation and at follow-up six months later. Each patient completed the new questionnaire and the SF36 form. Some filled in the Stanford Health Assessment Questionnaire (HAQ). An orthopaedic surgeon assessed the Constant shoulder score. The single score derived from the questionnaire had a high internal consistency. Reproducibility, examined by test-retest reliability, was found to be satisfactory. The validity of the questionnaire was established by obtaining significant correlations in the expected direction with the Constant score and the relevant scales of the SF36 and the HAQ. Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at follow-up. Changes in scores were compared with the patients' responses to postoperative questions about their condition. The standardised effect size for the new questionnaire compared favourably with that for the SF36 and the HAQ. The new questionnaire was the most efficient in distinguishing patients who said that their shoulder was much better from all other patients. The shoulder questionnaire provides a measure of outcome for shoulder operations which is short, practical, reliable, valid and sensitive to clinically important changes.     

Analgesia using continuous axillary block after surgery of severe hand injuries: self-administration versus continuous injection

OBJECTIVE: To compare analgesia produced after surgery for severe hand trauma, by a continuous axillary block obtained either with a continuous injection (CA) or controlled by the patient (PCA). STUDY DESIGN: Prospective, randomized study. PATIENTS: Forty-two ASA physical class 1 and 2 patients were enrolled over a twelve-month period and randomly allocated either into the CA or the PCA group. METHODS: After recovery from the surgical block, the axillary plexus was located using a nerve stimulator and a 20 G catheter (Contiplex B Braun) inserted over 5 centimeters into the axillary sheath. In the CA group (n = 21) patients received 0.1 mL.kg-1.h-1 of 0.25% bupivacaine and in the PCA group (n = 21) patients received 0.1 mL.kg-1 boluses of 0.25% bupivacaine with a one hour lock-out period. Data collected were pain intensity rated according to he visual analog scale (VAS), the total volume of bupivacaine injected, the quantity of nalbuphine administered as 10 mg boluses when VAS was = 5, and the patient's satisfaction after removal of the catheter. Statistical analysis used Student t test, ANOVA and chi 2 test. RESULTS: The mean duration of catheter use was 5 +/- 3 days. During this period the amount of bupivacaine was significantly reduced in the PCA group when compared to the CA group (P < 0.001). Similarly, the PCA group required significantly less nalbuphine. Finally, in this group, the satisfaction index was higher than in the CA group (95 versus 52% respectively, P < 0.01). CONCLUSION: Continuous axillary plexus blockade provides safe and effective postoperative analgesia. With the PCA technique results a lower quantity of bupivacaine is required and patient's satisfaction better.     

Anesthesia case of the month. Analgesia for fractures until surgery can take place

OBJECTIVE: To emphasize a potentially lethal condition that is virtually impossible to diagnose preoperatively. DESIGN: Case report with review of the literature. SETTING: University Hospital. PARTICIPANT: The patient requiring urgent surgery for heart failure related to severe aortic stenosis and mild mitral stenosis with poor ventricular function. The patient was elderly and suffered from atrial fibrillation. INTERVENTIONS: Preoperative transesophageal echocardiography followed by mitral valve repair and aortic valve replacement. MEASUREMENTS: Clinical outcome and pathological results. RESULTS: Although preoperative TEE demonstrated no left atrial appendage abnormality. After cardiac manipulation prior to the institution of cardiopulmonary bypass a large left atrial mural thrombus was mobilized from the atrial wall and was free floating in the left atrium. CONCLUSIONS: For high risk patients TEE should be applied intraoperatively to avoid undiagnosed left atrial clot dislodgement.     

Penetration of cryotherapy in treatment after shoulder arthroscopy

The authors describe the case of a female patient affected with large symptomatic gastric leiomyoma, six centimeters in diameter, who presented to clinical observation referring gastric pain and melena. The first gastroscopy showed massive bleeding from a submucosal gastric lesion. The lesion was not endoscopically resectable and the injective endoscopic treatment of bleeding failed. The patient was surgically treated with laparotomic excision of the leiomyoma. She was back home in ten days. The authors describe this case to discuss the possibility to resect large gastric leiomyomas using endoscopic resection indeed surgical approach. They also enhance the validity of surgical treatment for its safety and radical approach to large lesions.     

Results of anterior shoulder decompression surgery according to Neer for shoulder impingement syndrome; little effect on fitness for work

OBJECTIVE: To evaluate the effect of surgical treatment of the impingement syndrome of the shoulder on the fitness for work. DESIGN: Retrospective. SETTING: Academic Hospital Groningen, department of Orthopaedics, the Netherlands. PATIENTS AND METHODS: A group of 31 patients who had undergone an anterior shoulder decompression between 1 January 1984 and 31 December 1993 because of shoulder symptoms due to impingement lasting more than one year, were subjected in January 1996 to a study of the effect of the treatment on the pain, fitness for work and participation in the labour process. The results were measured using an objectivated score list for pain and function and with a comparison of the labour situations before and after the operation as described by the patients. RESULTS: End results as measured with the score list were fair to good in 97 patients (74%). The numbers of those completely fit for work before operation and at follow-up were identical, viz. 45 out of 131 (34%). Thirty-four patients (26%) had other jobs or adjusted activities and 37 (28%) were completely unfit for work (together 71 patients: 54%); 15 patients (11%) had stopped working for reasons of age. The probability to be definitely rejected for work after the operation was increased significantly by a job causing shoulder overstrain and by having been on sick leave with pay prior to the operation. CONCLUSION: Although the objective results were reasonably good, the percentage of those completely fit for work was not changed appreciably by the surgical treatment.     

Muscle power and shoulder joint function after removal of the latissimus dorsi muscle

Understanding the functional dynamics of the oral cavity helps researchers design methods to predict clinical outcomes. Most information about the oral cavities of companion animals must be drawn from animal studies designed to understand human oral disease and from human studies. Based upon functional criteria for any animal or experimental research study, supragingival plaque and calculus can be assessed within four to six weeks. Although longer studies may be more appealing, such study designs may compromise the oral soft tissue health of the animals and are complicated by oral cavity dynamics. Thus, they are less sensitive and predictive of longer term clinical outcomes. Additional research is necessary to relate tooth surface accumulation phenomena with oral soft tissue health.     

Beta-adrenergic blockers and vasovagal episodes during shoulder surgery in the sitting position under interscalene block

Shoulder surgery is often performed with patients in the sitting position under interscalene block anesthesia. Vasovagal episodes, characterized by a sudden decrease in heart rate and/or blood pressure, have a reported incidence of 17%-24% in this setting. We performed a retrospective study to determine whether there was an association between the use of beta-adrenergic blockers and the incidence of these episodes. Of the 150 patients identified, 20 (13.3%) had a vasovagal event. Similar proportions of patients had received a beta-adrenergic blocker in the group who had a vasovagal event compared with those who did not (20% vs 18%; P = 0.95). No other differences could be identified. We conclude that vasovagal episodes occur frequently in this setting with no identifiable risk factors. Beta-adrenergic blockers were not associated retrospectively with either an increased or decreased incidence of these episodes. The most likely mechanism involves the Bezold-Jarisch reflex. Implications: In this retrospective study of 150 patients who underwent shoulder surgery in the sitting position under interscalene block, we found a 13% incidence of vasovagal episodes. Unlike a previous study, this was not affected by the use of beta-blockers. A randomized, prospective study is necessary to clarify this issue.     

Infection of the urinary tract after anti-reflux surgery

Two hundred twenty-three children who underwent anti-reflux surgery were evaluated. Pyelonephritic scarring was more apt to occur with greater degrees of reflux. Postoperative infection was principally confined to the bladder and occurred primarily in females. The beneficial effect of anti-reflux surgery is discussed.     

Predicting the refractive result after cataract surgery

PURPOSE: To study the accuracy of predicting visual results after cataract surgery using a mathematical model of surgically induced refractive change and a previously published regression formula predicting uncorrected visual acuity as a function of the resulting spherocylinder. SETTING: Outpatient cataract clinic at a university hospital. METHODS: In this prospective study with a 4 month follow-up, 333 patients had phacoemulsification using a 6 or 4 mm scleral tunnel incision. Final refraction and uncorrected visual acuity were predicted based on preoperative and 1 day postoperative measurements, which were compared with the final visual results. RESULTS: A significant correlation was found between the observed and the predicted visual acuity in each eye (P < .01). CONCLUSION: The visual outcome of cataract extraction can be predicted from a theoretical model of the surgically induced refractive change.     

In vitro evaluation of shoulder external rotation after a Bankart reconstruction

The authors report a case of cystic dilatation of the choledochus associated with narrow stenosis at the confluence of the left and right hepatic ducts which was found to be inflammatory on histological examination. This pathology is becoming an increasingly more commonplace clinical finding. The case reported here is particularly interesting owing to the onset of the disease and the way in which it was treated. An attempt was made to treat the patient using a simple operation which was to the least radical possible. The authors take this opportunity of reviewing the literature on the subject.     

Functional evaluation of the shoulder after surgical and nonsurgical treatment of grade III acromio-clavicular dislocation

Fecal specimens from a baby vaccine were collected every day from 1 to 51 days after primary vaccination and from 0 to 15 days after secondary vaccination. Polioviruses were isolated with GMK-2 cell line from 10% emulsion of the feces and titrated the virus contents in the emulsion of the feces. The isolated viruses were tested the reproductive capacity at 39.0 degrees C and 39.5 degrees C by the plaque method with primary cynomologous monkey kidney cells. Viruses were isolated from the feces during 28 days for type 1, 39 days for type 2 and 36 days for type 3 after primary vaccination, however, only type 1 viruses were isolated during 7 days after secondary vaccination. The multiplication of type 3 viruses in the intestine were increased after diminished the multiplication of type 1 and type 2. In plaque formation capacity at 39.0 degrees C and 39.5 degrees C, the isolates had shown to differ clearly among the types of poliovirus. After primary vaccination, type 1 isolates were not produced the plaques at 39.0 degrees C and 39.5 degrees C. Although type 2 isolates were not formed the plaques until the 14th day at 39.5 degrees C, the plaque formation capacity of the these isolates were increased gradually i.e.; on the 20th day (10(0.88) PFU/ml), the 26th day (10(2.00) PFU/ml) and the 39th day (10(2.63) PFU/ml) at 39.5 degrees C, and all of type 2 isolates tested were showed the plaque formation capacity (10(2.88 approximately 10(3.76) PFU/ml) at 39.0 degrees C. Type 3 isolates were formed plaques at 39.0 degrees C and 39.5 degrees C from the 7th day. After the secondary vaccination, type 1 isolates (7th day) was a little changed them. Neutralizing antibody titers were shown that type 1 was 320, type 2 was 110 and type 3 was 60 after 1 year of the second administration. These titers were closely similar the geometric mean titers of 2 year old babies in Japan.     

Analgesia after upper abdominal surgery using extradural administration of a fixed dose of buprenorphine in combination with lignocaine given at two infusion rates: a comparative study

BACKGROUND: Extradural administration of combinations of local anaesthetics and opioids are frequently employed for postoperative pain relief. There is a scarcity of data on the analgesic effects of variations of the dose of local anaesthetic drug admixed to a fixed dose of opioid. METHODS: Twenty-four patients were investigated after elective upper abdominal surgery. During closure of the abdomen, 2% mepivacaine (8 ml) with buprenorphine 0.1 mg (0.5 ml) was given extradurally. After extubation, patients were randomly allocated to receive continuous extradural infusion of a fixed dose of buprenorphine (0.017 mg/h) in combination with 2% lignocaine at either 2.1 ml/h (low rate group, n = 14) or 6.3 ml/h (high rate group, n = 10). Postoperative pain at rest was assessed using visual analogue scale (VAS) scores and pain at movement by Prince Henry Pain Scale (PHPS) scores. Venous plasma lignocaine concentrations were measured. RESULTS: VAS scores at rest were similar in the two groups at 3 h postoperatively, whereas at 6-24 h postoperatively, VAS scores were higher in the low rate group than in the high rate group. PHPS scores were similar in the two groups at 3 h and at 18 h postoperatively, whereas at 6, 9, 12 and 24 h postoperatively, PHPS scores were higher in the low rate group than in the high rate group. Plasma lignocaine concentrations were higher at 23 h postoperatively in the high rate group than at 16 h in both groups, and at 23 h in the low rate group. At 3 h postoperatively, both the systolic and diastolic arterial pressures were higher in the low rate group than control values obtained on admission. Side effects were observed in one patient in the low rate group who complained of dizziness, and in one patient in the high rate group who complained of nausea. CONCLUSIONS: When added to a fixed dose of buprenorphine, continuous extradural infusion of 2% lignocaine at high rate provides better postoperative analgesia than when given at low rate without producing significant side effects.     

Predicting upper limb recovery after stroke: the place of early shoulder and hand movement

We describe a rare case of pleomorphic type of malignant fibrous histiocytoma (MFH) in the buttock that presented a systemic involvement. The case was of a 58-year-old woman presenting hepatic dysfunction and inflammatory reactions including fever, positive C-reactive protein (CRP), an elevated erythrocyte sedimentation rate, and high levels of platelets and ferritin. The fever of 3 months duration subsided on the first postoperative day. The MFH resection also brought rapid normalization in CRP, platelets, and leukocytes. The local and systemic productions of cytokines induced by this tumor were evaluated. In vivo and in vitro production of interleukin (IL)-6, IL-1beta, and tumor necrosis factor alpha by tumor cells were measured using enzyme-linked immunosorbent assay. Blood samples taken preoperatively, tumor tissues, and the primary culture medium showed extraordinarily high IL-6 levels. The plasma IL-6 level was normalized postoperatively. Immunohistochemistry showed the positivity of tumor cells for IL-6. The IL-6 produced by the tumor was concluded to have been responsible for the systemic illness.