Avulsive axillary artery injury in reverse total shoulder arthroplasty.

In addition to neurologic injuries such as peripheral nerve palsy, axillary vessel injury should be recognized as a possible complication of reverse total shoulder arthroplasty. Limb lengthening associated with Grammont-type reverse total shoulder arthroplasty places tension across the brachial plexus and axillary vessels and may contribute to observed injuries. The Grammont-type reverse total shoulder arthroplasty prosthesis reverses the shoulder ball and socket, shifts the shoulder center of rotation distal and medial, and lengthens the arm. This alteration of native anatomy converts shearing to compressive glenohumeral joint forces while augmenting and tensioning the deltoid lever arm. Joint stability is enhanced; shoulder elevation is enabled in the rotator cuff­deficient shoulder. Arm lengthening associated with reverse total shoulder arthroplasty places a longitudinal strain on the brachial plexus and axillary vessels. Peripheral nerve palsies and other neurologic complications of reverse total shoulder arthroplasty have been documented. The authors describe a patient with rotator cuff tear arthropathy and a history of radioulnar synostosis who underwent reverse total shoulder arthroplasty complicated by intraoperative injury to the axillary artery and postoperative radial, ulnar, and musculocutaneous nerve palsies. Following a seemingly unremarkable placement of reverse shoulder components, brisk arterial bleeding was encountered while approximating the incised subscapularis tendon in preparation for wound closure. Further exploration revealed an avulsive-type injury of the axillary artery. After an unsuccessful attempt at primary repair, a synthetic arterial bypass graft was placed. Reperfusion of the right upper extremity was achieved and has been maintained to date. Postoperative clinical examination and electromyographic studies confirmed ongoing radial, ulnar, and musculocutaneous neuropathies.

Reverse total shoulder arthroplasty in obese patients.

PURPOSE: To determine function and complications after reverse total shoulder arthroplasty (RTSA) in obese patients compared with a control group of nonobese patients. METHODS: Between 2005 and 2011, we performed 76 RTSAs in 17 obese, 36 overweight, and 23 normal weight patients, based on World Health Organization body mass index classification. We reviewed the charts for age, sex, body mass index, date of surgery, type of implant, type of incision, length of stay, comorbidities, surgical time, blood loss, American Society of Anesthesiologists score, shoulder motion, scapular notching, and postoperative complications. Complications and outcomes were analyzed and compared between groups. RESULTS: Reverse total shoulder arthroplasty in obese patients was associated with significant improvement in range of motion. Complication rate was significantly greater in the obese group (35%), compared with 4% in the normal weight group. We found no significant differences between scapular notching, surgical time, length of hospitalization, humeral component loosening, postoperative abduction, forward flexion, internal and external rotation, pain relief, or instability between groups. CONCLUSIONS: Our results show that obese patients have significant improvement in motion after RTSA but are at an increased risk for complication. Obesity is not a contraindication to RTSA, but obese patients need to understand fully the increased risk of complication with RTSA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Benign nerve tumors of the hand and the forearm.

We used a hand surgeon's 1978-1994 pathology reports to retrospectively review the incidence, preoperative and postoperative diagnoses, and presenting signs and symptoms of benign nerve tumors. Twenty-four (11.5%) of our series of 208 soft-tissue tumors of the hand and the forearm were benign nerve tumors. Nerve tumors were the third most common tumor after giant cell tumors of tendon sheath and inclusion cysts. Correct preoperative diagnosis was made in only 1 (4.2%) of the 24 cases. Schwannomas and neurofibromas were equally distributed (12 each), and 2 cases of neurofibromatosis (8.3%) were documented. Two (16.7%) of the 12 patients with schwannomas and 4 (33.3%) of the 12 patients with neurofibromas had neurologic symptoms. Six (85.7%) of the 7 digital tumors were dorsally located. In the literature, incidence of benign nerve tumors is much lower (ie, 1%-5%), and preoperative diagnosis consistently incorrect in our study. Incidence of neurologic symptoms (numbness, paresthesia) as presenting symptoms was higher in our study than previously documented. Although benign nerve tumors are most often located on the volar surface of the hand, 25% of the lesions we found were on the dorsal surface of the fingers.