Avulsive Axillary Artery Injury in Reverse Total Shoulder Arthroplasty

Abstract

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 cuff–deficient 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.

Delayed Axillary Artery Occlusion after Reverse Total Shoulder Arthroplasty

“…The axillary artery and the brachial plexus originate in the posterior triangle of the neck, bound by sternocleidomastoid and trapezius muscles and the clavicle. They enter the axilla deep to the pectoralis minor muscle and run 5–20 mm medial to the anterior glenoid rim of the glenohumeral joint and therefore are susceptible during shoulder injury [ 1 ]. Although rare, vascular injury from shoulder trauma has been previously described in the literature [ 2 , 4 , 5 ].…”

“…Nonetheless, most of the reported cases of axillary artery injury appear to be secondary to anterior shoulder dislocation [ 2 ]. Shoulder surgery can lead to axillary artery injury as well as both acute arterial thrombosis and arterial avulsion which has been described [ 1 , 4 ]. This is attributable to the position of the shoulder during the arthroplasty producing torsional forces on the axillary artery similar to that seen with anterior glenohumeral dislocation [ 6 ].…”

“…The anatomic location of the axillary artery renders it susceptible to injury after shoulder surgery or dislocation [ 1 ]. Although uncommon, most of the reported cases of axillary artery injury appear to be secondary to anterior shoulder dislocation [ 2 ].…”

“…On the other hand, the relatively new reverse total shoulder arthroplasty (RTSA) has been linked to vascular complications of which hematoma and phlebitis seem to be the most common. However, these complications are typically mild and transient [ 1 ]. We present a case of delayed axillary artery occlusion after RTSA.…”

Management of complications after reverse shoulder arthroplasty

“…The patient had incomplete resolution of symptoms at 30 months follow-up. Wingert et al [10] reported 1 patient with p ersiste nt ra dial, ulnar, a nd musculocutaneous nerve injury after intraoperative axillary artery avulsion and placement of synthetic arterial graft. Fortunately, most of these neurological complaints are transient and should be treated with observation alone.…”