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Exposure of the brachial plexus in complex revisions to reverse total shoulder arthroplasty

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Abstract

Background

Excision of extensive scar tissue (EEST) may be required in certain cases of revision reverse total shoulder arthroplasty (RTSA). Neurovascular structures are at a higher risk of iatrogenic direct injury in these cases. We describe a technique to expose and protect the musculocutaneous and axillary nerves in a series of revision RTSA cases that required EEST.

Methods

Between 2004 and 2013, 83 revision RTSA procedures were identified in our database. Of these, 18 cases (22%) who underwent concomitant nerve exploration for EEST preventing glenoid exposure, preventing reduction of the humeral component, or causing instability of the implanted RTSA, were included. All patients were observed for a minimum of two  years or until reoperation. Patient-reported outcome scores (PROMs), range of motion (ROM), and complication rates were analyzed.

Results

Patients had significant pain relief and improvement in PROMs post-operatively. Two patients (11%) required another revision surgery because of infection (one patient with glenoid loosening; one patient with stem loosening). Two patients (11%) had instability successfully managed with closed reduction. Two patients (11%) had a clinically evident post-operative nerve injury. Both cases were neurapraxias (1 partial brachial plexopathy and 1 partial isolated axillary nerve injury) and experienced complete neurologic recovery at last follow-up.

Conclusions

Complete permanent nerve injuries resulting from direct surgical trauma during revision RTSA requiring EEST can be avoided using the technique presented here. Despite proper exposition of the nerves, partial temporary neurapraxic injuries may occur. Patients who underwent this procedure experienced significant improvements in shoulder pain and function with complication rates consistent to those previously reported in revision RTSA.

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Authors and Affiliations

  1. Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 10753 Falls Road, Suite 215, Pavilion II, Lutherville, Baltimore, MD, 21093, USA

    Jorge Rojas, Filippo Familiari, Amrut U. Borade, Jacob Joseph & Edward G. McFarland

  2. Division of Hand Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline, Baltimore, MD, 21287, USA

    E. Gene Deune & Jack V. Ingari

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  1. Jorge Rojas
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Corresponding author

Correspondence to Edward G. McFarland.

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Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional research board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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This study, NA_00074209, was approved by the Johns Hopkins Medicine institutional review board.

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Level IV, Case Series, Treatment Study.

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Rojas, J., Familiari, F., Borade, A.U. et al. Exposure of the brachial plexus in complex revisions to reverse total shoulder arthroplasty. International Orthopaedics (SICOT) 43, 2789–2797 (2019). https://doi.org/10.1007/s00264-019-04349-3

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