Department of Orthopedic Surgery and Hand Surgery, Mayo Clinic, Rochester, MN, USA.
Department of Orthopedic Surgery and Hand Surgery, Mayo Clinic, Rochester, MN, USA.
J Shoulder Elbow Surg. 2022 Oct;31(10):2128-2133. doi: 10.1016/j.jse.2022.03.018. Epub 2022 Apr 30.
Peripheral nerve injuries associated with reverse total shoulder arthroplasty (rTSA) are rarely reported and are often dismissed as neuropraxias, particularly in the setting of perioperative nerve blocks. The purpose of this study was to evaluate nerve injuries following rTSA to determine if there is a pattern of injury and to evaluate outcomes of patients who sustain an intraoperative nerve injury.
A retrospective review was performed identifying patients who underwent rTSA and had a concomitant major nerve injury who were referred to a multidisciplinary peripheral nerve injury clinic. Demographic data, preoperative nerve block use, physical examination, electrodiagnostic studies, injury pattern, and time from injury to referral was collected. Radiographs, Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score, and outcomes surveys were obtained at final follow-up.
Twenty-two patients were identified with postoperative nerve injuries. Average time from injury to referral was 9.0 months, with 18.8 months' follow-up. Eight patients had undergone prior shoulder surgery, and 11 patients had prior shoulder trauma. Injury patterns were variable and involved diffuse pan-plexopathies with severity localized to the posterior and medial cords (11), the upper trunk (5), lateral cord (2), and axillary nerve (4). The average postoperative acromiohumeral distance (AHD) was 3.7 cm, with an average change of 2.9 cm. The average postoperative lateral humeral offset (LHO) was 1.1 cm, with an average change of 0.2 cm. Seventeen patients were confirmed to have undergone preoperative nerve blocks, which were initially attributed as the etiology of nerve injury. Eighteen patients were initially treated with observation: 11 experienced residual debilitating neuropathic pain and/or disability, and 7 had substantial improvement. One patient underwent nerve transfers, whereas the others underwent procedures for hand dysfunction improvement. The average QuickDASH score was 53.5 at average of 4 years post rTSA.
Although uncommon, permanent peripheral nerve injuries following rTSA do occur with debilitating effects. Preoperative regional blocks were used in most cases, but none of the blocks could be directly attributed to the nerve injuries. Nerve injuries were likely secondary to traction at the time of arthroplasty and/or substantial distalization and lateralization of the implants. Patients with medial cord injuries had the most debilitating loss of hand function. Surgeons should be cognizant of these injuries and make a timely referral to a peripheral nerve specialist.
与反式全肩关节置换术（rTSA）相关的周围神经损伤很少见，通常被认为是神经病变，尤其是在围手术期神经阻滞的情况下。本研究旨在评估 rTSA 后的神经损伤情况，以确定是否存在损伤模式，并评估发生术中神经损伤的患者的治疗效果。
回顾性分析接受 rTSA 并伴有主要神经损伤的患者，这些患者被转诊至多学科周围神经损伤诊所。收集了患者的人口统计学数据、术前神经阻滞使用情况、体格检查、电诊断研究、损伤模式以及从损伤到转诊的时间。在最终随访时获得了影像学检查、快速上肢功能障碍问卷（QuickDASH）评分和结果调查问卷。
共 22 例患者术后发生神经损伤。从损伤到转诊的平均时间为 9.0 个月，随访时间为 18.8 个月。8 例患者曾接受过肩部手术，11 例患者曾有肩部创伤史。损伤模式多种多样，包括弥漫性全臂丛神经病，严重程度局限于后侧和内侧束（11 例）、上干（5 例）、外侧束（2 例）和腋神经（4 例）。术后肩峰肱骨头间距（AHD）平均为 3.7cm，平均变化 2.9cm。术后外侧肱骨偏移（LHO）平均为 1.1cm，平均变化 0.2cm。17 例患者术前接受过神经阻滞，最初认为这些神经阻滞是神经损伤的病因。18 例患者最初接受观察治疗：11 例患者仍存在严重的神经病理性疼痛和/或残疾，7 例患者有明显改善。1 例患者接受神经转移治疗，其余患者接受手部功能改善手术。术后平均 QuickDASH 评分为 53.5，平均随访时间为 rTSA 术后 4 年。
尽管罕见，但 rTSA 后确实会发生永久性周围神经损伤，并伴有致残影响。大多数情况下，患者术前都接受过区域阻滞，但没有一种阻滞可以直接归因于神经损伤。神经损伤可能是由于关节置换时的牵引以及植入物的显著远移和侧移引起的。内侧束损伤的患者手部功能丧失最严重。外科医生应该认识到这些损伤，并及时转介给周围神经专家。
