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Complications in arthroscopic shoulder surgery
Complications in Arthroscopic Shoulder Surgery Pedro Berjano, M.D., Benjamı´n Garcı´a Gonza´lez, M.D., Jesu´s Ferrer Olmedo, M.D., Luis Alcocer Perez-Espan˜a, M.D., and Miguel Garcı´a Munilla, M.D.
Summary: Arthroscopic surgery of the shoulder is considered a safe technique, yet a variety of complications have been described. There are few published reports on the incidence of these complications. The aim of this study is to evaluate the complication rate of arthroscopic shoulder surgery. We retrospectively evaluated a series of 179 consecutive arthroscopic (n ⫽ 141) and combined (arthroscopic plus open; n ⫽ 38) procedures performed by the same surgeon. The overall complication rate was 9.49%. Combined procedures had a 5.26% complication rate and arthroscopic procedures a 10.63% complication rate. Key Words: Shoulder arthroscopy—Shoulder surgery—Complications.
T
he use of arthroscopic techniques has been a significant advance in the diagnosis and therapy of shoulder injuries.1 Their increasing application is justified by a less invasive surgical approach, a detailed visualization of anatomic structures, the possibility to record images, and the ability to perform therapeutic procedures. However, shoulder arthroscopy is not a technique void of complications.2-14 The information available about the incidence of complications in shoulder arthroscopic surgery is limited. The aim of this study is to report on the rate and type of observed complications after shoulder arthroscopic surgical procedures. MATERIALS AND METHODS Patients We retrospectively evaluated 179 consecutive shoulder arthroscopic procedures (141 arthroscopic and 38 combined arthroscopic and open surgical procedures), performed in 172 patients. The procedures included were those carried out at our institution from January From the Hospital Monogra´fico de Traumatologı´a, Cirugı´a Ortope´dica y Rehabilitacio´n ASEPEYO, Coslada, Madrid, Spain. Address correspondence and reprint requests to Pedro Berjano, M.D., C/ Joaquı´n de Ca´rdenas 2, 28820 Coslada, Madrid, Spain. r 1998 by the Arthroscopy Association of North America 0749-8063/98/1408-1727$3.00/0
of 1988 to August of 1995. All of the procedures were carried out directly or under close supervision of the senior author (J.F.O.), and include his learning curve in shoulder arthroscopy. The sample is summarized in Table 1. Statistics Sample data were recorded in a computer data base with statistic functions (RSigma, Horus Software). Proportions were calculated at a 95% confidence. Surgical Technique The interventions were performed under general anesthesia, interscalenic plexus blockade, or both. Four doses of intravenous antibiotics were given to the patients (the first dose 30 minutes before surgery and then every 6 hours). Cefazolin, 1 g per dose, was the first choice, and in patients with a history of sensitivity, vancomycin was used). There were 156 patients placed in the lateral decubitus position with the operated arm held by 2 to 3 kg of longitudinal traction at 30° of abduction and 15° of flexion; and 23 patients placed in the beach chair position at 15° of flexion using 2 kg of traction. For irrigation inflow, bags were elevated 120 cm above the shoulder. The arthroscopy was performed through a posterior portal. Intra-articular instruments were inserted through an anterior interval portal, made in a retrograde
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 8 (November-December), 1998: pp 785–788
785
786
P. BERJANO ET AL. TABLE 1. Series Description
No. of shoulders No. of patients Side Right Left Anesthesia General Interscalenic Combined No data Patient position Lateral decubitus Beach chair Diagnosis Subacromial syndrome Instability Labral tear/SLAP Displaced staple Operative time (min) Mean Min General 79 25 Arthroscopic 72 25 Combined 110 30 First 50 cases 92 30 Procedures Arthroscopic Subacromial decompression 125 Stabilization 14 Rotator cuff repair 2 Articular debridement 12 Labral reattachment 1 Total shoulders operated on 141
179 172 114 65 129 16 25 9 156 23 142 30 8 2 Max 180 150 170 170 Open 17 16 17 0 1 38
NOTE. In one operation, one shoulder could have had more than one procedure (e.g., subacromial decompression and rotator cuff repair).
fashion. Two portals, 2-cm lateral to the acromial edge, were used for accessory subacromial instrumentation and irrigation. The superior transtendinous portal was avoided. Thus, the standard number of portals was four. The glenohumeral joint was always inspected. In patients with subacromial impingement, a bursoscopy and endoscopic subacromial decompression followed,
as described by Ellman.15 The anteroinferior portion of the lateral clavicle was resected when it was considered necessary. In massive rotator cuff tears, when the defect was not repaired, a subacromial decompression followed by a tendinous debridement was performed to avoid any subacromial impingement. In all cases, a careful hemostasis with electrocautery was done at the end of the operation. Glycine solution was used for irrigation in all of the patients. Postoperatively, the patients were splinted in adduction and internal rotation, with the exception of those patients with a rotator cuff repair that needed immobilization in abduction to avoid suture cutting through the tendon. In the cases of isolated subacromial decompression, the patients were encouraged to perform pendulous exercises from the first postoperative day, and the sling was retired after a week. In this series, arthroscopic stabilization was performed by capsular plicature and fixation with an arthroscopic staple on the decorticated anterior glenoid rim. Reattachment of the labrum was performed with an arthroscopic staple. A glenohumeral joint debridement was performed when necessary with the use of basket forceps or a full radius synoviotome, and electrocautery for control of bleeding. RESULTS Fifteen complications were recorded in 141 shoulder arthroscopic procedures and two complications were recorded out of 38 combined procedures (Table 2). The most serious complication was a case of respiratory distress that required reintubation and intensive care for 24 hours. This event was attributed to liquid diffusion from the subacromial space. The patient improved satisfactorily with no further complications after extubation.
TABLE 2. Complications Arthroscopy n
%
Respiratory distress 1 0.71 Failure to correct instability with arthroscopic techniques 3 2.13 Capsular tear 1 0.71 Hematoma 2 1.42 Excessive bleeding 2 1.42 Infection 1 0.71 Severe postoperative edema 3 2.13 Ulnar nerve neurapraxia 2 1.42 Total 15 10.63
95% CI 0.04-4.48 0.55-6.57 0.04-4.48 0.25-5.55 0.25-5.55 0.04-4.48 0.55-6.57 0.25-5.55
Combined n
%
95% CI
0 0 0 0 1 2.63 0.14-15.43 0 0 1 2.63 0.14-15.43 2 5.26
COMPLICATIONS IN SHOULDER ARTHROSCOPY In three cases of anterior recurrent dislocation, there was failure of adequate arthroscopic stabilization because of the staples breaking or bending. All of these patients had a secondary open procedure. The patient who had a portal infection needed oral antibiotics and topical antiseptics for resolution of symptoms. Three patients had severe postoperative edema, defined as edema extending to the cervical region and requiring special observation to disclose respiratory or circulatory problems that finally did not occur. They were treated with ice application and the condition resolved in the following 24 hours. The cases of postoperative excessive bleeding did not cause hemodynamic failure and were controlled with wound compression or deep portal suture. Three cases of cubital nerve neurapraxia were recorded. Symptoms were self-limited and resolved in 2 to 12 weeks. Cubital nerve impairment is not a frequent complication after shoulder arthroscopy. The excellent review on nerve injuries after shoulder arthroscopy by Stanish and Peterson10 only makes reference to two ulnar nerve neurapraxias.9 In our cases, this complication was probably related to the way that the adhesive traction system was wrapped around the elbow (with an elastic bandage covered by an sterile draping that was secured around the elbow with an adhesive band), since the amount of traction applied was usually 2 kg and never exceeded 3 kg. The diagnosis of ulnar nerve apraxia was confirmed by electrophysiological testing. DISCUSSION Arthroscopic techniques are thought to be minimally invasive and less aggressive than open techniques. Nevertheless, arthroscopic shoulder surgery is not free of complications. A large variety of complications have been previously reported2-14 (Table 3). Curtis et al.16 reported in a series of 711 shoulder arthroscopic procedures an overall 6.0% complication rate (4.6% for arthroscopic and 8.1% for combined procedures, Table 4). They observed the highest complication rate in combined procedures in the subacromial space (11.6%). Rodriguez et al.6 reported a complication rate of 21% in a series of 90 shoulder arthroscopies. A survey by the Arthroscopy Association of North America in 19857 (14,329 cases) suggested a high complication rate associated with anterior staple capsulorrhaphy (5.3%). Subacromial space surgery was found to have a complication rate of
787
TABLE 3. Described Complications in Shoulder Arthroscopy Portal bleeding Chondral and rotator cuff iatrogenic lesions Neurological impairment (transient or permanent) Infection Frozen shoulder Hemolysis Severe postoperative pain Instrument breakage Airway obstruction Phrenic nerve palsy Pleural puncture Subcutaneous emphysema, pneumothorax, pneumomediastinum
0.76%. With the purpose of overcoming the limitations of this study, a prospective study among very experienced arthroscopists was performed.8 It included 1,184 cases, and only 9 complications were reported. Again, anterior staple capsulorrhaphy had the highest complication rate (3.3%). The present study shows a complication rate slightly higher than that reported by Curtis et al.,16 although only a small proportion of these had serious consequences. Our findings are consistent with those of Small7,8 in the high complication rate associated with anterior staple capsulorrhaphy. This modality of stabilization has been discontinued in our center because of the high incidence of complications. Recent studies suggest that other modalities of anterior stabilization may also be associated with significant complications.11-14 The discrepancy in the overall complication rates found in the literature can be at least partially explained on the basis of differences in the diagnostic criteria for a complication. The effect of the learning curve has been addressed in our study. Although the first 50 cases (35 arthroscopic procedures—32 acromioplasties, 2 capsulorrhaphies, and 1 labral reattachment; and 15 combined operations—6 rotator cuff repairs, 1 labral reattachment, and 8 open stabilizations) had longer operative times (Table 1), only three complications were recorded in these cases (infection in one patient undergoTABLE 4. Complication Rate in Previous Series Series
n
Overall
Arthroscopy
Combined
Curtis et al.16 Rodriguez et al.6 Small8 Present report
711 90 1184 179
6.0% 21.0% — 9.5%
4.6% — 0.76% 10.6%
8.1% — — 5.3%
788
P. BERJANO ET AL.
ing arthroscopy and open cuff repair, and edema in two patients—one arthroscopic acromioplasty and one arthroscopic capsulorrhaphy). We did not include as complications shoulder stiffness, instability recurrence, or persistence of the preoperative symptoms, because we considered these as poor results. Other authors have considered ‘‘excessive postoperative pain’’ as a complication. As this was a retrospective study, we found it difficult to reliably assess pain. In a retrospective report on complications, there may exist a bias due to underestimation of the number of complications (it is more likely in a retrospective study that not all the complications are recorded in the clinical chart). This is particularly true for the less serious complications. There is a discrepancy in the literature reviewed, about the relative complication rate in procedures confined to the articular versus subacromial space. Curtis et al.16 found it to be higher in the latter, whereas Small7,8 found it to be higher in the former. Our data cannot resolve this disagreement because of the high incidence of subacromial procedures (only 36 shoulders did not have any) and the high frequency of staple capsulorrhaphy in the remaining. Small number of patients in the interscalenic anesthesia and beach chair position groups preclude further analysis of their influence in complication rates. Several authors have proposed technical modifications to avoid some of the complications related to shoulder arthroscopy1-3,17: the use of beach chair position, which limits fluid diffusion to the neck and mediastinum; palpation of the deltoid mass for prompt detection of fluid diffusion; application of limited amount of traction (less than 3 kg); limiting the degrees of arm flexion and abduction; avoiding prolonged surgical time; and careful hemostasis after tissue resection. Although shoulder arthroscopic procedures are not free of complications, we still consider them to be safe because few of the complications recorded have compromised the clinical outcome of the patients.
REFERENCES 1. Hynson JM, Tung A, Guevara JE, Katz JA, Glick JM, Shapiro WA. Complete airway obstruction during arthroscopic shoulder surgery. Anesth Analg 1993;76:875-878. 2. Moran MC, Warren RF. Development of a synovial cyst after arthroscopy of the shoulder (a brief note). J Bone Joint Surg Am 1989;71:127-129. 3. Lee, HC, Dewan N, Crosby L. Subcutaneous emphysema, pneumomediastinum, and potentially life-threatening tension pneumothorax. Pulmonary complications from arthroscopic shoulder decompression. Chest 1992;101:1265-1267. 4. Mullins RC, Drez D, Cooper J. Hypoglossal nerve palsy after arthroscopy of the shoulder and open operation with the patient in the beach-chair position. J Bone Joint Surg Am 1992;74:137140. 5. Lau KY. Pneumomediastinum caused by subcutaneous emphysema in the shoulder (A rare complication of arthroscopy). Chest 1993;103:1606-1607. 6. Rodriguez JC, Mendoza Lopez M, Cobo Sotes J. Complicaciones en la artroscopia de hombro. Cuadernos de Artroscopia 1994;1:25-29. 7. Small NC. Report of the Committee on Complications of the Arthroscopy Association of North America. Complications in arthroscopy: The knee and other joints. Arthroscopy 1986;253258. 8. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4:215-221. 9. Andrews JR, Carson WG. Shoulder joint arthroscopy. Orthopedics 1983;6:1157-1162. 10. Stanish WD, Peterson DC. Shoulder arthroscopy and nerve injury: Pitfalls and prevention. Arthroscopy 1995;11:458-466. 11. Savoie FH, Miller CD, Field LD. Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique. Arthroscopy 1997;13:201-209. 12. Mormino MA, Gross RM, McCarthy JA. Captured shoulder: A complication of rotator cuff surgery. Arthroscopy 1996;12:457461. 13. Torchia ME, Caspari RB, Asselmeier MA, Beach WR, Gayari M. Arthroscopic transglenoid multiple suture repair: 2 to 8 year results in 150 shoulders. Arthroscopy 1997;13:609-619. 14. Resch H, Povacz P, Wambacher M, Sperner G, Golser K. Arthroscopic extra-articular Bankart repair for the treatment of recurrent anterior shoulder dislocation. Arthroscopy 1997;13: 188-200. 15. Ellman H. Arthroscopic subacromial decompression: Analysis of one to three year results. Arthroscopy 1987;3:173-181. 16. Curtis AS, Del Pizzo W, Ferkle RD, Friedman MJ, Snyder SJ, Karzel RP. Complications of shoulder arthroscopy. Presented at the 59th Annual Meeting of the American Association of Orthopaedic Surgeons, Washington DC, February 1992. 17. Ogilvie-Harris DJ, Boynton E. Arthroscopic acromioplasty: Extravasation of fluid into the deltoid muscle. Arthroscopy 1990;6:52-54.
Summary: Arthroscopic surgery of the shoulder is considered a safe technique, yet a variety of complications have been described. There are few published reports on the incidence of these complications. The aim of this study is to evaluate the complication rate of arthroscopic shoulder surgery. We retrospectively evaluated a series of 179 consecutive arthroscopic (n ⫽ 141) and combined (arthroscopic plus open; n ⫽ 38) procedures performed by the same surgeon. The overall complication rate was 9.49%. Combined procedures had a 5.26% complication rate and arthroscopic procedures a 10.63% complication rate. Key Words: Shoulder arthroscopy—Shoulder surgery—Complications.
T
he use of arthroscopic techniques has been a significant advance in the diagnosis and therapy of shoulder injuries.1 Their increasing application is justified by a less invasive surgical approach, a detailed visualization of anatomic structures, the possibility to record images, and the ability to perform therapeutic procedures. However, shoulder arthroscopy is not a technique void of complications.2-14 The information available about the incidence of complications in shoulder arthroscopic surgery is limited. The aim of this study is to report on the rate and type of observed complications after shoulder arthroscopic surgical procedures. MATERIALS AND METHODS Patients We retrospectively evaluated 179 consecutive shoulder arthroscopic procedures (141 arthroscopic and 38 combined arthroscopic and open surgical procedures), performed in 172 patients. The procedures included were those carried out at our institution from January From the Hospital Monogra´fico de Traumatologı´a, Cirugı´a Ortope´dica y Rehabilitacio´n ASEPEYO, Coslada, Madrid, Spain. Address correspondence and reprint requests to Pedro Berjano, M.D., C/ Joaquı´n de Ca´rdenas 2, 28820 Coslada, Madrid, Spain. r 1998 by the Arthroscopy Association of North America 0749-8063/98/1408-1727$3.00/0
of 1988 to August of 1995. All of the procedures were carried out directly or under close supervision of the senior author (J.F.O.), and include his learning curve in shoulder arthroscopy. The sample is summarized in Table 1. Statistics Sample data were recorded in a computer data base with statistic functions (RSigma, Horus Software). Proportions were calculated at a 95% confidence. Surgical Technique The interventions were performed under general anesthesia, interscalenic plexus blockade, or both. Four doses of intravenous antibiotics were given to the patients (the first dose 30 minutes before surgery and then every 6 hours). Cefazolin, 1 g per dose, was the first choice, and in patients with a history of sensitivity, vancomycin was used). There were 156 patients placed in the lateral decubitus position with the operated arm held by 2 to 3 kg of longitudinal traction at 30° of abduction and 15° of flexion; and 23 patients placed in the beach chair position at 15° of flexion using 2 kg of traction. For irrigation inflow, bags were elevated 120 cm above the shoulder. The arthroscopy was performed through a posterior portal. Intra-articular instruments were inserted through an anterior interval portal, made in a retrograde
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 8 (November-December), 1998: pp 785–788
785
786
P. BERJANO ET AL. TABLE 1. Series Description
No. of shoulders No. of patients Side Right Left Anesthesia General Interscalenic Combined No data Patient position Lateral decubitus Beach chair Diagnosis Subacromial syndrome Instability Labral tear/SLAP Displaced staple Operative time (min) Mean Min General 79 25 Arthroscopic 72 25 Combined 110 30 First 50 cases 92 30 Procedures Arthroscopic Subacromial decompression 125 Stabilization 14 Rotator cuff repair 2 Articular debridement 12 Labral reattachment 1 Total shoulders operated on 141
179 172 114 65 129 16 25 9 156 23 142 30 8 2 Max 180 150 170 170 Open 17 16 17 0 1 38
NOTE. In one operation, one shoulder could have had more than one procedure (e.g., subacromial decompression and rotator cuff repair).
fashion. Two portals, 2-cm lateral to the acromial edge, were used for accessory subacromial instrumentation and irrigation. The superior transtendinous portal was avoided. Thus, the standard number of portals was four. The glenohumeral joint was always inspected. In patients with subacromial impingement, a bursoscopy and endoscopic subacromial decompression followed,
as described by Ellman.15 The anteroinferior portion of the lateral clavicle was resected when it was considered necessary. In massive rotator cuff tears, when the defect was not repaired, a subacromial decompression followed by a tendinous debridement was performed to avoid any subacromial impingement. In all cases, a careful hemostasis with electrocautery was done at the end of the operation. Glycine solution was used for irrigation in all of the patients. Postoperatively, the patients were splinted in adduction and internal rotation, with the exception of those patients with a rotator cuff repair that needed immobilization in abduction to avoid suture cutting through the tendon. In the cases of isolated subacromial decompression, the patients were encouraged to perform pendulous exercises from the first postoperative day, and the sling was retired after a week. In this series, arthroscopic stabilization was performed by capsular plicature and fixation with an arthroscopic staple on the decorticated anterior glenoid rim. Reattachment of the labrum was performed with an arthroscopic staple. A glenohumeral joint debridement was performed when necessary with the use of basket forceps or a full radius synoviotome, and electrocautery for control of bleeding. RESULTS Fifteen complications were recorded in 141 shoulder arthroscopic procedures and two complications were recorded out of 38 combined procedures (Table 2). The most serious complication was a case of respiratory distress that required reintubation and intensive care for 24 hours. This event was attributed to liquid diffusion from the subacromial space. The patient improved satisfactorily with no further complications after extubation.
TABLE 2. Complications Arthroscopy n
%
Respiratory distress 1 0.71 Failure to correct instability with arthroscopic techniques 3 2.13 Capsular tear 1 0.71 Hematoma 2 1.42 Excessive bleeding 2 1.42 Infection 1 0.71 Severe postoperative edema 3 2.13 Ulnar nerve neurapraxia 2 1.42 Total 15 10.63
95% CI 0.04-4.48 0.55-6.57 0.04-4.48 0.25-5.55 0.25-5.55 0.04-4.48 0.55-6.57 0.25-5.55
Combined n
%
95% CI
0 0 0 0 1 2.63 0.14-15.43 0 0 1 2.63 0.14-15.43 2 5.26
COMPLICATIONS IN SHOULDER ARTHROSCOPY In three cases of anterior recurrent dislocation, there was failure of adequate arthroscopic stabilization because of the staples breaking or bending. All of these patients had a secondary open procedure. The patient who had a portal infection needed oral antibiotics and topical antiseptics for resolution of symptoms. Three patients had severe postoperative edema, defined as edema extending to the cervical region and requiring special observation to disclose respiratory or circulatory problems that finally did not occur. They were treated with ice application and the condition resolved in the following 24 hours. The cases of postoperative excessive bleeding did not cause hemodynamic failure and were controlled with wound compression or deep portal suture. Three cases of cubital nerve neurapraxia were recorded. Symptoms were self-limited and resolved in 2 to 12 weeks. Cubital nerve impairment is not a frequent complication after shoulder arthroscopy. The excellent review on nerve injuries after shoulder arthroscopy by Stanish and Peterson10 only makes reference to two ulnar nerve neurapraxias.9 In our cases, this complication was probably related to the way that the adhesive traction system was wrapped around the elbow (with an elastic bandage covered by an sterile draping that was secured around the elbow with an adhesive band), since the amount of traction applied was usually 2 kg and never exceeded 3 kg. The diagnosis of ulnar nerve apraxia was confirmed by electrophysiological testing. DISCUSSION Arthroscopic techniques are thought to be minimally invasive and less aggressive than open techniques. Nevertheless, arthroscopic shoulder surgery is not free of complications. A large variety of complications have been previously reported2-14 (Table 3). Curtis et al.16 reported in a series of 711 shoulder arthroscopic procedures an overall 6.0% complication rate (4.6% for arthroscopic and 8.1% for combined procedures, Table 4). They observed the highest complication rate in combined procedures in the subacromial space (11.6%). Rodriguez et al.6 reported a complication rate of 21% in a series of 90 shoulder arthroscopies. A survey by the Arthroscopy Association of North America in 19857 (14,329 cases) suggested a high complication rate associated with anterior staple capsulorrhaphy (5.3%). Subacromial space surgery was found to have a complication rate of
787
TABLE 3. Described Complications in Shoulder Arthroscopy Portal bleeding Chondral and rotator cuff iatrogenic lesions Neurological impairment (transient or permanent) Infection Frozen shoulder Hemolysis Severe postoperative pain Instrument breakage Airway obstruction Phrenic nerve palsy Pleural puncture Subcutaneous emphysema, pneumothorax, pneumomediastinum
0.76%. With the purpose of overcoming the limitations of this study, a prospective study among very experienced arthroscopists was performed.8 It included 1,184 cases, and only 9 complications were reported. Again, anterior staple capsulorrhaphy had the highest complication rate (3.3%). The present study shows a complication rate slightly higher than that reported by Curtis et al.,16 although only a small proportion of these had serious consequences. Our findings are consistent with those of Small7,8 in the high complication rate associated with anterior staple capsulorrhaphy. This modality of stabilization has been discontinued in our center because of the high incidence of complications. Recent studies suggest that other modalities of anterior stabilization may also be associated with significant complications.11-14 The discrepancy in the overall complication rates found in the literature can be at least partially explained on the basis of differences in the diagnostic criteria for a complication. The effect of the learning curve has been addressed in our study. Although the first 50 cases (35 arthroscopic procedures—32 acromioplasties, 2 capsulorrhaphies, and 1 labral reattachment; and 15 combined operations—6 rotator cuff repairs, 1 labral reattachment, and 8 open stabilizations) had longer operative times (Table 1), only three complications were recorded in these cases (infection in one patient undergoTABLE 4. Complication Rate in Previous Series Series
n
Overall
Arthroscopy
Combined
Curtis et al.16 Rodriguez et al.6 Small8 Present report
711 90 1184 179
6.0% 21.0% — 9.5%
4.6% — 0.76% 10.6%
8.1% — — 5.3%
788
P. BERJANO ET AL.
ing arthroscopy and open cuff repair, and edema in two patients—one arthroscopic acromioplasty and one arthroscopic capsulorrhaphy). We did not include as complications shoulder stiffness, instability recurrence, or persistence of the preoperative symptoms, because we considered these as poor results. Other authors have considered ‘‘excessive postoperative pain’’ as a complication. As this was a retrospective study, we found it difficult to reliably assess pain. In a retrospective report on complications, there may exist a bias due to underestimation of the number of complications (it is more likely in a retrospective study that not all the complications are recorded in the clinical chart). This is particularly true for the less serious complications. There is a discrepancy in the literature reviewed, about the relative complication rate in procedures confined to the articular versus subacromial space. Curtis et al.16 found it to be higher in the latter, whereas Small7,8 found it to be higher in the former. Our data cannot resolve this disagreement because of the high incidence of subacromial procedures (only 36 shoulders did not have any) and the high frequency of staple capsulorrhaphy in the remaining. Small number of patients in the interscalenic anesthesia and beach chair position groups preclude further analysis of their influence in complication rates. Several authors have proposed technical modifications to avoid some of the complications related to shoulder arthroscopy1-3,17: the use of beach chair position, which limits fluid diffusion to the neck and mediastinum; palpation of the deltoid mass for prompt detection of fluid diffusion; application of limited amount of traction (less than 3 kg); limiting the degrees of arm flexion and abduction; avoiding prolonged surgical time; and careful hemostasis after tissue resection. Although shoulder arthroscopic procedures are not free of complications, we still consider them to be safe because few of the complications recorded have compromised the clinical outcome of the patients.
REFERENCES 1. Hynson JM, Tung A, Guevara JE, Katz JA, Glick JM, Shapiro WA. Complete airway obstruction during arthroscopic shoulder surgery. Anesth Analg 1993;76:875-878. 2. Moran MC, Warren RF. Development of a synovial cyst after arthroscopy of the shoulder (a brief note). J Bone Joint Surg Am 1989;71:127-129. 3. Lee, HC, Dewan N, Crosby L. Subcutaneous emphysema, pneumomediastinum, and potentially life-threatening tension pneumothorax. Pulmonary complications from arthroscopic shoulder decompression. Chest 1992;101:1265-1267. 4. Mullins RC, Drez D, Cooper J. Hypoglossal nerve palsy after arthroscopy of the shoulder and open operation with the patient in the beach-chair position. J Bone Joint Surg Am 1992;74:137140. 5. Lau KY. Pneumomediastinum caused by subcutaneous emphysema in the shoulder (A rare complication of arthroscopy). Chest 1993;103:1606-1607. 6. Rodriguez JC, Mendoza Lopez M, Cobo Sotes J. Complicaciones en la artroscopia de hombro. Cuadernos de Artroscopia 1994;1:25-29. 7. Small NC. Report of the Committee on Complications of the Arthroscopy Association of North America. Complications in arthroscopy: The knee and other joints. Arthroscopy 1986;253258. 8. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4:215-221. 9. Andrews JR, Carson WG. Shoulder joint arthroscopy. Orthopedics 1983;6:1157-1162. 10. Stanish WD, Peterson DC. Shoulder arthroscopy and nerve injury: Pitfalls and prevention. Arthroscopy 1995;11:458-466. 11. Savoie FH, Miller CD, Field LD. Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique. Arthroscopy 1997;13:201-209. 12. Mormino MA, Gross RM, McCarthy JA. Captured shoulder: A complication of rotator cuff surgery. Arthroscopy 1996;12:457461. 13. Torchia ME, Caspari RB, Asselmeier MA, Beach WR, Gayari M. Arthroscopic transglenoid multiple suture repair: 2 to 8 year results in 150 shoulders. Arthroscopy 1997;13:609-619. 14. Resch H, Povacz P, Wambacher M, Sperner G, Golser K. Arthroscopic extra-articular Bankart repair for the treatment of recurrent anterior shoulder dislocation. Arthroscopy 1997;13: 188-200. 15. Ellman H. Arthroscopic subacromial decompression: Analysis of one to three year results. Arthroscopy 1987;3:173-181. 16. Curtis AS, Del Pizzo W, Ferkle RD, Friedman MJ, Snyder SJ, Karzel RP. Complications of shoulder arthroscopy. Presented at the 59th Annual Meeting of the American Association of Orthopaedic Surgeons, Washington DC, February 1992. 17. Ogilvie-Harris DJ, Boynton E. Arthroscopic acromioplasty: Extravasation of fluid into the deltoid muscle. Arthroscopy 1990;6:52-54.