Orthopedics

Sports Medicine Update 

Complications in Shoulder Arthroscopy

Geoffrey S. Marecek, MD; Matthew D. Saltzman, MD

  • Orthopedics. 2010;33(7)
  • Posted July 1, 2010

Abstract

Shoulder arthroscopy is performed in either the sitting beach chair or the lateral decubitus position. Each of these positions has relative merits for the technical performance of procedures; however, each is also associated with a relatively different complication profile that must also factor into the surgeon’s preference for patient positioning.

In the lateral decubitus position, the patient’s operative extremity is suspended from a traction device (Figure 1). This potentially places the brachial plexus under tension. Paresthesias and nerve palsies have been reported in 10% to 30% of cases performed in this position.8-10 The optimal position for reducing strain on the brachial plexus while preserving arthroscopic visibility is approximately 45° of forward flexion and either 0° or 90° of abduction.11 Internal rotation of the humerus with forward flexion will also decrease brachial plexus strain.12 The surgeon should be careful to pad all bony prominences on the down leg, use an axillary roll to protect the down arm, and use no more than 15 to 20 lbs of traction.13

In the beach chair position, the patient sits upright with the operative extremity supported by an assistant or mechanical arm-holder (Figure 2). Although this position provides the anesthesiologist greater access to the airway, anesthesia-related complications are more common in this position than in the lateral decubitus position, including spinal and cerebral ischemia and death.14,15

Impaired venous return from the dependent lower extremities and vasodilation from anesthetic agents may contribute to impaired cerebral blood flow. Hypotensive anesthesia is commonly used during arthroscopic shoulder surgery to decrease bleeding and improve visualization. If such measures are used, careful monitoring of the patient’s blood pressure is essential to avoid extreme hypotension.

Blood pressure cuffs should be placed at the level of the heart, as using a dependent lower extremity will cause the readings to be falsely elevated.15 The head and neck should be placed in a neutral position to avoid alterations in cerebral blood flow15 and palsies of the hypoglossal and superficial nerves.16,17 Visual loss has also been reported in the beach chair position; however, it is unclear what role positioning may have played.18 There is also a theoretical risk of air embolus,13 which has been reported following neurosurgical cases performed in the upright position.15

Interscalene nerve blocks are commonly used for arthroscopic shoulder surgery as they generally provide good muscle relaxation as well as intra- and postoperative analgesia. However, complication rates of 0.7% to 4%7,19-22 have been reported, and additional anesthetic methods are frequently necessary. Complications following interscalene nerve blocks include pneumothorax, pseudoaneurysm, respiratory distress from phrenic nerve palsy, seizure, hematoma, cardiovascular collapse, spinal or epidural anesthesia, peripheral neuropathy, and complex regional pain syndrome.7,19-25

Postarthroscopic glenohumeral chondrolysis is an increasingly recognized entity. Although the cause is unknown, much attention has focused on the use of radiofrequency or thermal devices and intra-articular pain pumps during cases in which chondrolysis occurs.26-40 Young patient age, instability surgery, articular cartilage damage, bioabsorbable implants, type of anesthetic, type of irrigant fluid, and use of an intra-articular bolus of local anesthetic have also been implicated as risk factors.26,37,41,42 Patients undergoing arthroscopy for instability may have some degree of preexisting damage to the articular cartilage that predisposes them to postarthroscopic glenohumeral chondrolysis.37 Solomon et al37 proposed a multifactorial pathway in which articular cartilage damage combines with a secondary thermal, mechanical, or chemical insult to produce chondrolysis (Figure 3).

Figure 3: Intraoperative photograph of postarthroscopic glenohumeral chondrolysis. Image courtesy of Frederick Matsen III, MD. Figure 4: Superior view of arthroscopic portals on a right shoulder in the lateral decubitus position: standard lateral portal (A), Kim posterolateral portal (B), standard posterior portal (C), Neviaser portal…

Whether the beach chair or lateral decubitus position is used in shoulder arthroscopy, careful patient positioning and vigilant anesthesia monitoring are essential.
Cover illustration © Jennifer E. Fairman
Cover illustration © Jennifer E. Fairman

Shoulder arthroscopy is generally a safe and effective method for treating a wide variety of shoulder pathology. Fortunately, complications following shoulder arthroscopy are rare, with reported rates between 4.6% and 10.6%.1-7 These rates may be underestimated, as underreporting of complications and varying definitions of the term complication are likely. During shoulder arthroscopy, complications may occur at numerous points. The surgeon must be aware of potential problems and take necessary measures to prevent them.

This article describes common complications after arthroscopic shoulder surgery. Although failure of treatment and postoperative stiffness are undesirable outcomes, they are not described.

Patient Positioning and Anesthesia

Shoulder arthroscopy is performed in either the sitting beach chair or the lateral decubitus position. Each of these positions has relative merits for the technical performance of procedures; however, each is also associated with a relatively different complication profile that must also factor into the surgeon’s preference for patient positioning.

In the lateral decubitus position, the patient’s operative extremity is suspended from a traction device (Figure 1). This potentially places the brachial plexus under tension. Paresthesias and nerve palsies have been reported in 10% to 30% of cases performed in this position.8-10 The optimal position for reducing strain on the brachial plexus while preserving arthroscopic visibility is approximately 45° of forward flexion and either 0° or 90° of abduction.11 Internal rotation of the humerus with forward flexion will also decrease brachial plexus strain.12 The surgeon should be careful to pad all bony prominences on the down leg, use an axillary roll to protect the down arm, and use no more than 15 to 20 lbs of traction.13

Figure 1: A patient in the lateral decubitus position Figure 2: A patient in the beach chair position
Figure 1: A patient in the lateral decubitus position for right shoulder surgery. Figure 2: A patient in the beach chair position for left shoulder surgery.

In the beach chair position, the patient sits upright with the operative extremity supported by an assistant or mechanical arm-holder (Figure 2). Although this position provides the anesthesiologist greater access to the airway, anesthesia-related complications are more common in this position than in the lateral decubitus position, including spinal and cerebral ischemia and death.14,15

Impaired venous return from the dependent lower extremities and vasodilation from anesthetic agents may contribute to impaired cerebral blood flow. Hypotensive anesthesia is commonly used during arthroscopic shoulder surgery to decrease bleeding and improve visualization. If such measures are used, careful monitoring of the patient’s blood pressure is essential to avoid extreme hypotension.

Blood pressure cuffs should be placed at the level of the heart, as using a dependent lower extremity will cause the readings to be falsely elevated.15 The head and neck should be placed in a neutral position to avoid alterations in cerebral blood flow15 and palsies of the hypoglossal and superficial nerves.16,17 Visual loss has also been reported in the beach chair position; however, it is unclear what role positioning may have played.18 There is also a theoretical risk of air embolus,13 which has been reported following neurosurgical cases performed in the upright position.15

Interscalene nerve blocks are commonly used for arthroscopic shoulder surgery as they generally provide good muscle relaxation as well as intra- and postoperative analgesia. However, complication rates of 0.7% to 4%7,19-22 have been reported, and additional anesthetic methods are frequently necessary. Complications following interscalene nerve blocks include pneumothorax, pseudoaneurysm, respiratory distress from phrenic nerve palsy, seizure, hematoma, cardiovascular collapse, spinal or epidural anesthesia, peripheral neuropathy, and complex regional pain syndrome.7,19-25

Chondrolysis

Postarthroscopic glenohumeral chondrolysis is an increasingly recognized entity. Although the cause is unknown, much attention has focused on the use of radiofrequency or thermal devices and intra-articular pain pumps during cases in which chondrolysis occurs.26-40 Young patient age, instability surgery, articular cartilage damage, bioabsorbable implants, type of anesthetic, type of irrigant fluid, and use of an intra-articular bolus of local anesthetic have also been implicated as risk factors.26,37,41,42 Patients undergoing arthroscopy for instability may have some degree of preexisting damage to the articular cartilage that predisposes them to postarthroscopic glenohumeral chondrolysis.37 Solomon et al37 proposed a multifactorial pathway in which articular cartilage damage combines with a secondary thermal, mechanical, or chemical insult to produce chondrolysis (Figure 3).

Figure 3: Postarthroscopic glenohumeral chondrolysis Figure 4: Superior view of arthroscopic portals

Figure 3: Intraoperative photograph of postarthroscopic glenohumeral chondrolysis. Image courtesy of Frederick Matsen III, MD. Figure 4: Superior view of arthroscopic portals on a right shoulder in the lateral decubitus position: standard lateral portal (A), Kim posterolateral portal (B), standard posterior portal (C), Neviaser portal (D), direct acromioclavicular portal (E), anterosuperior portal (F), and 5 o’clock portal (G).

Postarthroscopic glenohumeral chondrolysis often presents initially as a deep ache that progresses to severe pain and loss of motion.26 Patients typically present between 3 and 12 months after their index procedure.26,30,31,36 Radiographs demonstrate loss of the glenohumeral joint space without significant osteophytosis or subchondral sclerosis.26 Treatment of this problem is challenging, with many authors proposing nonsteroidal anti-inflammatory drugs, intra-articular corticosteroids, hyaluronic acid, and ultimately some form of arthroplasty with or without biologic resurfacing.26,28-30,32,33,36,43 Most authors now suggest avoiding thermal capsulorrhaphy and intra-articular pain pumps until more definitive studies are performed.31,38

Neurologic Complications

Nerve damage after shoulder arthroscopy is fortunately rare, with reported rates of <3%,44,45 with larger series reporting rates <0.2%.5,6,46 Paresthesias have been reported in 10% to 30% of cases.8-11,47 Injuries to the median,45,48 axillary,5 musculocutaneous,10,44,46 medial antebrachial cutaneous,49 radial,10 ulnar,44 medial pectoral,50 and anterior interosseous nerves,50 as well as cutaneous hypoesthesias51 have all been reported. These injuries are generally transient, although permanent damage requiring tendon transfers has been described.45 Positioning,8-11,47,52 traction,11 joint distention and fluid extravasation,10 and direct injury from portal placement45 have all been implicated in postoperative nerve injuries.

A thorough knowledge of shoulder anatomy is essential to avoid nerve injury while placing arthroscopic portals (Figure 4). Neurovascular structures are most at risk during placement of anterior portals. In particular, the dangers of the 5 o’clock (right shoulder) anteroinferior portal are well described, with some authors cautioning against placement of anteroinferior portals altogether.53,54

Davidson and Tibone55 described an inside-out technique that established the portal at the leading edge of the inferior glenohumeral ligament and the glenoid rim. Resch et al56 described an outside-in technique in which they placed the 5 o’clock portal 2 cm below the palpable tip of the coracoid. In the beach chair position, the axillary nerve is an average of 12 to 33 mm away53,54,57 and the musculocutaneous nerve is an average of 18 to 28 mm away from this portal.54,57 These structures are even more at risk when placing an anteroinferior portal in the lateral decubitus position as they move nearer the portal site.58 Placement of an anteroinferior portal also puts the cephalic vein and axillary artery at risk and may cause chondral injuries.53,54,57 Caution should be used when placing instrumentation inferiorly as the axillary nerve is 10 to 25 mm from the glenoid rim at the 5:30 to 6 o’clock position in the right shoulder. Abduction with neutral rotation moves the axillary nerve maximally away from the glenoid rim.59 Increasing abduction in the lateral decubitus position brings the lateral cord of the brachial plexus closer to the coracoid, so care should be taken when working around this structure.60

The placement of posterior, lateral, and Neviaser supraclavicular portals imparts less risk to adjacent structures than anteriorly based portals, but care must still be taken.53,54 The standard posterior central or “soft point” portal is placed 2 cm medial and 2 cm inferior to the posterolateral corner of the acromion.53 Lateral portals are established 2 cm below the lateral edge of the acromion, between the anterior and posterior edges of the acromion.53 The Neviaser portal is created in the soft spot bounded by the acromion, clavicle, and scapular spine. A skin incision is made 1 cm medial to the medial acromion and the cannula is advanced slightly posteriorly and 30° laterally.53 The axillary nerve is at least 30 mm away from standard posterior portals53,57 and standard lateral portals.53,57 The suprascapular nerve is at least 20 mm medial to the Neviaser supraclavicular portal,53,61 making nerve injury unlikely. Care should be taken to avoid abducting or flexing the arm during portal placement to minimize musculotendinous damage.61 The posterolateral Kim portal is created 2.5 cm inferior to the posterolateral corner of the acromion and places the axillary nerve, suprascapular nerve, and nerve branch to the teres minor at less risk than posteroinferior portals when accessing the inferior glenohumeral recess.62

Infection

Deep infection after arthroscopic or mini-open shoulder surgery is rare, with rates reported between 0.16% and 1.9%.46,63-65 Preoperative antibiotics should be used to reduce the incidence of postoperative infection.65,66 Surgical site preparation with 2% chlorhexidine gluconate and 70% isopropyl alcohol (ChloraPrep; Enturia, El Paso, Texas) is more efficacious than 0.7% iodophor and 74% isopropyl alcohol (DuraPrep; 3M, Minneapolis, Minnesota) or providone-iodine scrub and paint (0.75% iodine scrub and 1.0% iodine paint; Tyco Healthcare Group, Springfield, Massachusetts) in eliminating bacteria from the shoulder region prior to surgery.67

Patients with postoperative shoulder infection typically present with erythema and wound drainage.63,64 The erythrocyte sedimentation rate is typically elevated,63,64 but fever and malaise are relatively uncommon.64 It is important to distinguish between superficial and deep infections. Although the incidence of superficial infections is not known, these infections do not extend deep to the deltoid, and they can generally be treated with oral antibiotics alone.63,64 However, patients with deep infections will typically require multiple debridements and intravenous antibiotics.63,64 Consultation with an infectious disease specialist may be helpful when selecting an antibiotic regimen.

Propionibacterium acnes is a frequent cause of postoperative shoulder infections.63,64,68,69 Because this organism can be difficult to isolate, cultures should be monitored for at least 1 week and up to 3 weeks. Shoulder function after infection is generally decreased compared to patients who do not experience infection.64 The amount of intact cuff at final debridement may be an important factor in determining outcome.63

Thromboembolic Complications

Deep venous thrombosis (DVT) and pulmonary embolus are rare events after shoulder arthroscopy, with reported rates between 0.06% and 0.42%.65,70-72 The literature consists primarily of case reports with only a few case series. The lateral decubitus position increases the risk of thromboembolic complications,70,72-75 as traction causes decreased limb perfusion.9,76 However, thromboembolic complications have been reported after use of the beach chair position as well.71,77,78 Other potential risk factors include prolonged surgical time, use of an interscalene block, and presence of a hypercoagulable state.71,72 In most reported cases, an underlying hypercoagulable state was identified as a contributing factor.70-73,75,77,79 Interestingly, one large series reported several ipsilateral lower extremity DVTs after shoulder arthroscopy.71,72 In another recent series, there was no association between a thromboembolic event and whether the patient had received antithrombotic prophylaxis.65

Conclusion

Despite myriad potential problems, shoulder arthroscopy is generally a safe and effective method for treating a variety of conditions. Whether the beach chair or lateral decubitus position is used, careful patient positioning and vigilant anesthesia monitoring are essential. Thermal devices and intra-articular pain pumps have been implicated in the pathogenesis of postarthroscopic glenohumeral chondrolysis and should be avoided or used with caution. The musculocutaneous and axillary nerves are most at risk during arthroscopic portal placement. The anteroinferior or 5 o’clock portal warrants special caution.

Preoperative antibiotics and proper antisepsis are important to reduce the risk of infection. Thorough debridement and targeted antibiotics are effective treatment measures. Thromboembolic events are rare and usually attributable to a hypercoagulable state. Patients should be informed of these potential complications prior to surgery, and treating surgeons must exercise care to minimize the risk of these potentially debilitating problems.

References

  1. Berjano P, González BG, Olmedo JF, Perez-España LA, Munilla MG. Complications in arthroscopic shoulder surgery. Arthroscopy. 1998; 14(8):785-788.
  2. Brislin KJ, Field LD, Savoie FH III. Complications after arthroscopic rotator cuff repair. Arthroscopy. 2007; 23(2):124-128.
  3. Curtis AS, Snyder SJ, Del Pizzo W, Friedman MJ, Ferkel RD, Karzel RP. Complications of shoulder arthroscopy. Arthroscopy. 1992; 8(3):395.
  4. Müller D, Landsiedl F. Arthroscopy of the shoulder joint: a minimal invasive and harmless procedure? Arthroscopy. 2000; 16(4):425.
  5. Complications in arthroscopy: the knee and other joints. Committee on Complications of the Arthroscopy Association of North America. Arthroscopy. 1986; 2(4):253-258.
  6. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy. 1988; 4(3):215-221.
  7. Weber SC, Jain R. Scalene regional anesthesia for shoulder surgery in a community setting: an assessment of risk. J Bone Joint Surg Am. 2002; 84(5):775-779.
  8. Paulos LE, Franklin JL. Arthroscopic shoulder decompression development and application. A five year experience. Am J Sports Med. 1990; 18(3):235-244.
  9. Phillips BB. Arthroscopy of the upper extremity. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics. 11th ed. Philadelphia, PA: Mosby Elsevier; 2008:2923-2926.
  10. Pitman MI, Nainzadeh N, Ergas E, Springer S. The use of somatosensory evoked potentials for detection of neuropraxia during shoulder arthroscopy. Arthroscopy. 1988; 4(4):250-255.
  11. Klein AH, France JC, Mutschler TA, Fu FH. Measurement of brachial plexus strain in arthroscopy of the shoulder. Arthroscopy. 1987; 3(1):45-52.
  12. Tibone JE. Diagnostic shoulder arthroscopy in the lateral decubitus position. In: Tibone JE, Savoie FHr, Shaffer BS, eds. Shoulder Arthroscopy. New York, NY: Springer-Verlag; 2003:3-8.
  13. Peruto CM, Ciccotti MG, Cohen SB. Shoulder arthroscopy positioning: lateral decubitus versus beach chair. Arthroscopy. 2009; 25(8):891-896.
  14. Papadonikolakis A, Wiesler ER, Olympio MA, Poehling GG. Avoiding catastrophic complications of stroke and death related to shoulder surgery in the sitting position. Arthroscopy. 2008; 24(4):481-482.
  15. Pohl A, Cullen DJ. Cerebral ischemia during shoulder surgery in the upright position: a case series. J Clin Anesth. 2005; 17(6):463-469.
  16. Mullins RC, Drez D Jr, Cooper J. Hypoglossal nerve palsy after arthroscopy of the shoulder and open operation with the patient in the beach-chair position. A case report. J Bone Joint Surg Am. 1992; 74(1):137-139.
  17. Park TS, Kim YS. Neuropraxia of the cutaneous nerve of the cervical plexus after shoulder arthroscopy. Arthroscopy. 2005; 21(5):631.
  18. Bhatti MT, Enneking FK. Visual loss and ophthalmoplegia after shoulder surgery. Anesth Analg. 2003; 96(3):899-902.
  19. Bishop JY, Sprague M, Gelber J, et al. Interscalene regional anesthesia for shoulder surgery. J Bone Joint Surg Am. 2005; 87(5):974-979.
  20. Borgeat A, Ekatodramis G, Kalberer F, Benz C. Acute and nonacute complications associated with interscalene block and shoulder surgery: a prospective study. Anesthesiology. 2001; 95(4):875-880.
  21. Bryan NA, Swenson JD, Greis PE, Burks RT. Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: technique, efficacy, and complications. J Shoulder Elbow Surg. 2007; 16(4):388-395.
  22. Capdevila X, Pirat P, Bringuier S, et al. Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology. 2005; 103(5):1035-1045.
  23. Flowers GA, Meyers JF. Pseudoaneurysm after interscalene block for a rotator cuff repair. Arthroscopy. 2004; (20 Suppl 2):67-69.
  24. Iocolano CF. Total spinal anesthesia after an interscalene block. J Perianesth Nurs. 1997; 12(3):163-168.
  25. Shaffer BS, Tibone JE. Arthroscopic shoulder instability surgery. Complications. Clin Sports Med. 1999; 18(4):737-767.
  26. Bailie DS, Ellenbecker TS. Severe chondrolysis after shoulder arthroscopy: a case series. J Shoulder Elbow Surg. 2009; 18(5):742-747.
  27. Busfield BT, Romero DM. Pain pump use after shoulder arthroscopy as a cause of glenohumeral chondrolysis. Arthroscopy. 2009; 25(6):647-652.
  28. Ciccone WJ II, Weinstein DM, Elias JJ. Glenohumeral chondrolysis following thermal capsulorrhaphy. Orthopedics. 2007; 30(2):158-160.
  29. Good CR, Shindle MK, Kelly BT, Wanich T, Warren RF. Glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy. Arthroscopy. 2007; 23(7):797 e1-5.
  30. Greis PE, Legrand A, Burks RT. Bilateral shoulder chondrolysis following arthroscopy. A report of two cases. J Bone Joint Surg Am. 2008; 90(6):1338-1344.
  31. Hansen BP, Beck CL, Beck EP, Townsley RW. Postarthroscopic glenohumeral chondrolysis. Am J Sports Med. 2007; 35(10):1628-1634.
  32. Levine WN, Clark AM Jr, D’Alessandro DF, Yamaguchi K. Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability. A report of two cases. J Bone Joint Surg Am. 2005; 87(3):616-621.
  33. McNickle AG, L’Heureux DR, Provencher MT, Romeo AA, Cole BJ. Postsurgical glenohumeral arthritis in young adults. Am J Sports Med. 2009; 37(9):1784-1791.
  34. Petty DH, Jazrawi LM, Estrada LS, Andrews JR. Glenohumeral chondrolysis after shoulder arthroscopy: case reports and review of the literature. Am J Sports Med. 2004; 32(2):509-515.
  35. Rapley JH, Beavis RC, Barber FA. Glenohumeral chondrolysis after shoulder arthroscopy associated with continuous bupivacaine infusion. Arthroscopy. 2009; 25(12):1367-1373.
  36. Saltzman M, Mercer D, Bertelsen A, Warme W, Matsen F. Postsurgical chondrolysis of the shoulder. Orthopedics. 2009; 32(3):215.
  37. Solomon DJ, Navaie M, Stedje-Larsen ET, Smith JC, Provencher MT. Glenohumeral chondrolysis after arthroscopy: a systematic review of potential contributors and causal pathways. Arthroscopy. 2009; 25(11):1329-1342.
  38. Lubowitz JH, Poehling GG. Glenohumeral thermal capsulorrhaphy is not recommended—shoulder chondrolysis requires additional research. Arthroscopy. 2007; 23(7):687.
  39. Coobs BR, LaPrade RF. Severe chondrolysis of the glenohumeral joint after shoulder thermal capsulorrhaphy. Am J Orthop (Belle Mead NJ). 2009; 38(2):E34-37.
  40. Jerosch J, Aldawoudy AM. Chondrolysis of the glenohumeral joint following arthroscopic capsular release for adhesive capsulitis: a case report. Knee Surg Sports Traumatol Arthrosc. 2007; 15(3):292-294.
  41. Levy JC, Frankle M. Bilateral shoulder chondrolysis following arthroscopy. A report of two cases. J Bone Joint Surg Am. 2008; 90(11):2546-2547.
  42. Scheffel PT, Clinton J, Lynch JR, Warme WJ, Bertelsen AL, Matsen FA III. Glenohumeral chondrolysis: A systematic review of 100 cases from the English language literature. J Shoulder Elbow Surg. 2010 Apr 24. [Epub ahead of print].
  43. Levy JC, Virani NA, Frankle MA, Cuff D, Pupello DR, Hamelin JA. Young patients with shoulder chondrolysis following arthroscopic shoulder surgery treated with total shoulder arthroplasty. J Shoulder Elbow Surg. 2008; 17(3):380-388.
  44. Andrews JR, Carson WG. Shoulder joint arthroscopy. Orthopedics. 1983; (6):1157-1162.
  45. Matthews LS, Zarins B, Michael RH, Helfet DL. Anterior portal selection for shoulder arthroscopy. Arthroscopy. 1985; 1(1):33-39.
  46. Ogilvie-Harris DJ, Wiley AM. Arthroscopic surgery of the shoulder. A general appraisal. J Bone Joint Surg Br. 1986; 68(2):201-207.
  47. Skyhar MJ, Altchek DW, Warren RF, Wickiewicz TL, O’Brien SJ. Shoulder arthroscopy with the patient in the beach-chair position. Arthroscopy. 1988; 4(4):256-259.
  48. Ellman H. Arthroscopic subacromial decompression: analysis of one- to three-year results. Arthroscopy. 1987; 3(3):173-181.
  49. Morgan CD. Arthroscopic bankart suture repair—2 to 5 year results. Orthopaedic Transactions. 1989; (13):231-232.
  50. Mohammed KD, Hayes MG, Saies AD. Unusual complications of shoulder arthroscopy. J Shoulder Elbow Surg. 2000; 9(4):350-353.
  51. Segmüller HE, Alfred SP, Zilio G, Saies AD, Hayes MG. Cutaneous nerve lesions of the shoulder and arm after arthroscopic shoulder surgery. J Shoulder Elbow Surg. 1995; 4(4):254-258.
  52. Terry MA, Altchek DW. Diagnostic shoulder arthroscopy technique: Beach chair position. In: Tibone JE, Savoie FHr, Shaffer BS, eds. Shoulder Arthroscopy. New York, NY: Springer-Verlag; 2003:9-15.
  53. Meyer M, Graveleau N, Hardy P, Landreau P. Anatomic risks of shoulder arthroscopy portals: anatomic cadaveric study of 12 portals. Arthroscopy. 2007; 23(5):529-536.
  54. Pearsall AW IV, Holovacs TF, Speer KP. The low anterior five-o’clock portal during arthroscopic shoulder surgery performed in the beach-chair position. Am J Sports Med. 1999; 27(5):571-574.
  55. Davidson PA, Tibone JE. Anterior-inferior (5 o’clock) portal for shoulder arthroscopy. Arthroscopy. 1995; 11(5):519-525.
  56. Resch H, Wykypiel HF, Maurer H, Wambacher M. The antero-inferior (transmuscular) approach for arthroscopic repair of the Bankart lesion: an anatomic and clinical study. Arthroscopy. 1996; 12(3):309-319.
  57. Lo IK, Lind CC, Burkhart SS. Glenohumeral arthroscopy portals established using an outside-in technique: neurovascular anatomy at risk. Arthroscopy. 2004; 20(6):596-602.
  58. Gelber PE, Reina F, Caceres E, Monllau JC. A comparison of risk between the lateral decubitus and the beach-chair position when establishing an anteroinferior shoulder portal: a cadaveric study. Arthroscopy. 2007; 23(5):522-528.
  59. Yoo JC, Kim JH, Ahn JH, Lee SH. Arthroscopic perspective of the axillary nerve in relation to the glenoid and arm position: a cadaveric study. Arthroscopy. 2007; 23(12):1271-1277.
  60. Pan WJ, Teo YS, Chang HC, Chong KC, Karim SA. The relationship of the lateral cord of the brachial plexus to the coracoid process during arthroscopic coracoid surgery: a dynamic cadaveric study. Am J Sports Med. 2008; 36(10):1998-2001.
  61. Nottage WM. Arthroscopic portals: anatomy at risk. Orthop Clin North Am. 1993; 24(1):19-26.
  62. Bhatia DN, de Beer JF, Dutoit DF. An anatomic study of inferior glenohumeral recess portals: comparative anatomy at risk. Arthroscopy.2008; 24(5):506-513.
  63. Herrera MF, Bauer G, Reynolds F, Wilk RM, Bigliani LU, Levine WN. Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg. 2002; 11(6):605-608.
  64. Kwon YW, Kalainov DM, Rose HA, Bisson LJ, Weiland AJ. Management of early deep infection after rotator cuff repair surgery. J Shoulder Elbow Surg. 2005; 14(1):1-5.
  65. Randelli P, Castagna A, Cabitza F, Cabitza P, Arrigoni P, Denti M. Infectious and thromboembolic complications of arthroscopic shoulder surgery. J Shoulder Elbow Surg. 2010; 19(1):97-101.
  66. D’Angelo GL, Ogilvie-Harris DJ. Septic arthritis following arthroscopy, with cost/benefit analysis of antibiotic prophylaxis. Arthroscopy. 1988; 4(1):10-14.
  67. Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS, Koh JL. Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am. 2009; 91(8):1949-1953.
  68. Levy PY, Fenollar F, Stein A, et al. Propionibacterium acnes postoperative shoulder arthritis: an emerging clinical entity. Clin Infect Dis. 2008; 46(12):1884-1886.
  69. Sperling JW, Cofield RH, Torchia ME, Hanssen AD. Infection after shoulder instability surgery. Clin Orthop Relat Res. 2003; (414):61-64.
  70. Bongiovanni SL, Ranalletta M, Guala A, Maignon GD. Case reports: heritable thrombophilia associated with deep venous thrombosis after shoulder arthroscopy. Clin Orthop Relat Res. 2009; 467(8):2196-2199.
  71. Kuremsky MA, Cain EL Jr, Fleischli JE. Thromboembolic events after arthroscopic shoulder surgery: a case series of unusual complications. Arthroscopy. 2007; 16(6 Supplement 1):e18-e19.
  72. Kuremsky M, Cain EL Jr, Fleischli JE. Thromboembolic complications after arthroscopic shoulder surgery: a case series. Paper presented at: American Academy of Orthopaedic Surgeons 75th Annual Meeting; March 5-9, 2008; San Francisco, California.
  73. Burkhart SS. Deep venous thrombosis after shoulder arthroscopy. Arthroscopy. 1990; 6(1):61-63.
  74. Hariri A, Nourissat G, Dumontier C, Doursounian L. Pulmonary embolism following thrombosis of the brachial vein after shoulder arthroscopy. A case report. Orthop Traumatol Surg Res. 2009; 95(5):377-379.
  75. Polzhofer GK, Petersen W, Hassenpflug J. Thromboembolic complication after arthroscopic shoulder surgery. Arthroscopy. 2003; 19(9):E129-132.
  76. Hennrikus WL, Mapes RC, Bratton MW, Lapoint JM. Lateral traction during shoulder arthroscopy: its effect on tissue perfusion measured by pulse oximetry. Am J Sports Med. 1995; 23(4):444-446.
  77. Cortés ZE, Hammerman SM, Gartsman GM. Pulmonary embolism after shoulder arthroscopy: could patient positioning and traction make a difference? J Shoulder Elbow Surg. 2007; 16(2):e16-17.
  78. Creighton RA, Cole BJ. Upper extremity deep venous thrombosis after shoulder arthroscopy: a case report. J Shoulder Elbow Surg. 2007; 16(1):e20-22.
  79. Starch DW, Clevenger CE, Slauterbeck JR. Thrombosis of the brachial vein and pulmonary embolism after subacromial decompression of the shoulder. Orthopedics. 2001; 24(1):63-65.

Authors

Drs Marecek and Saltzman are from the Department of Orthopedic Surgery, Northwestern University, Chicago, Illinois.

Drs Marecek and Saltzman have no relevant financial relationships to disclose.

Correspondence should be addressed to: Matthew D. Saltzman, MD, Department of Orthopedic Surgery, Northwestern University, 676 N Saint Clair St, Ste 1350, Chicago, IL 60611 (mdsaltzman@gmail.com).

doi: 10.3928/01477447-20100526-15

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