Thursday, July 21, 2011

Shoulder arthritis articles from the July issue of the Journal of Bone and Joint Surgery

The July JBJS publishes an article by Gilles Walch and colleagues on Prevalence of Neurologic Lesions After Total Shoulder Arthroplasty. These authors recognize that the nerves of the brachial plexus are at risk in major shoulder surgery. They used electromyography to study patients with reverse total shoulders and with anatomic arthroplasty. Importantly, 9 of 19 shoulders in the reverse group and 13 of 23 shoulders in the anatomic group had neurologic lesions detected BEFORE their joint replacement. At a month after surgery, nine of 19 patients with reverse total shoulders and one of 23 anatomic total shoulders had evidence of new nerve injury, with a rate 10 times higher in the reverse total shoulders. Three additional reverse total shoulder patients had worsening of preoperative nerve deficits. The most commonly involved nerve was the axillary nerve. Eight of these resolved in less than 6 months. They suggested that arm lengthening in reverse total shoulder may be responsible for some of these nerve lesions, although this difference did not appear to be statistically significant with the small number of cases included.

We now understand that there are many possible factors that could contribute to compromised neurological function after shoulder joint replacement, including pre-existing cervical spine or shoulder nerve injuries, nerve injury from brachial plexus block, direct surgical injury, and injury from arm lengthening in reverse total shoulder.  These considerations indicate the need for a complete evaluation of the patient before surgery, a detailed discussion of the risks of nerve injury with the patient, and careful attention to surgical technique.

The observation that one nerve lesion in the 41 shoulders had a new nerve lesion that had not resolved by 6 months is a concern for two reasons. One, if this rate is applied to all of the shoulder arthroplasties performed, it would indicate a rather large number of patients with iatrogenic chronic nerve injury. Secondly, the arthroplasties studied in this paper were performed by one of the most experienced shoulder surgeons in the world. It would seem likely that this nerve injury rate would be much lower than that of less experienced surgeons who perform most of the joint replacements.


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