1. I personally routinely include in my consent discussion, for arthroplasties, the rare risk of arterial injury. I don't know if everyone does since:
2. Albeit very severe, from what I've reviewed, the risk of iatrogenic axillary injury is definitely rare... here is a 2017 JBJS review on the subject.
Good find on the paper, thank you! I'm going to include above. Sounds like just a few isolated case reports of this issue during this specific surgery.
I guess we’re splitting hairs with the definition of rare, because I have been involved in evaluating (as an expert) several cases in my region, so can’t be that rare. Also, my understanding of the case was that as soon as he placed the retractor (ie prior to bone cuts) the arterial bleeding started. I absolutely agree that if the cuts were already done and then the arterial bleed began, the best conduct would be to place the components first, then definitely deal w the bleed. Like I said, I understood that no bone cuts had been performed, in which case the steps should be 1) abandon the arthroplasty 2) control the bleed 3) repair or bypass the artery 4) close up and observe for compartment syndrome, loss of pulse distally etc. I think we pretty much are in agreement.
Excellent points, I do pretty much agree with you hehe! Although, after thinking about it, I think the humeral head resection/bone cuts were already done at the time of arterial injury.
The antero-inferior retractor directly adjacent to the glenoid is usually placed when exposing for glenoid preparation. This step is usually done after humeral head resection and humeral preparation.
This would make sense with the decision to finish the arthroplasty before doing the definitive bypass. In any case, I certainly would be very curious to read the operative report !!
Surprised that the vascular surgeon told him to complete the arthroplasty. That extra hour or so of ischemia time was critical to her eventual poor outcome. The Orthopod did very little wrong. The vascular surgeon should be the one sued. Axillary artery injuries are infrequent during shoulder arthroplasty procedures, but I would not say that they are rare.
Yes, that struck me as well (as a non-ortho or vascular expert). An ischemic limb seems like an acute emergency... that being said a Reddit commenter noted that apparently the standard teaching is that you have up to 2 hours to resolve this before there is any real risk of damage.
Tough to say exactly why they decided to complete the arthroplasty before doing the revascularization, especially without knowing all the specifics...
but maybe it is because they wanted to avoid doing the bypass in an incomplete arthroplasty with shortened and floppy shoulder/arm that would soon after be pulled and yanked in all directions in order to finish the reverse shoulder.
I suppose it could be argued that getting the final length/stability/alignement right first (if ischemia time is short) could be preferable so that the vascular repair could be undertaken in a stable environment? Then again, feel free to correct me, I would be curious to know a vascular surgeon's opinion on the matter/order of procedure!
Like in knee fracture/dislocation cases with vascular injury for example. Common to first perform a quick reduction and temporarily stabilize the limb with an external fixator to maintain reduction/length/alignement/create a stable environment, followed by the vascular procedure.
1. I personally routinely include in my consent discussion, for arthroplasties, the rare risk of arterial injury. I don't know if everyone does since:
2. Albeit very severe, from what I've reviewed, the risk of iatrogenic axillary injury is definitely rare... here is a 2017 JBJS review on the subject.
https://journals.lww.com/jbjsreviews/fulltext/2017/06000/evaluation_and_management_of_axillary_artery.3.aspx
Good find on the paper, thank you! I'm going to include above. Sounds like just a few isolated case reports of this issue during this specific surgery.
I guess we’re splitting hairs with the definition of rare, because I have been involved in evaluating (as an expert) several cases in my region, so can’t be that rare. Also, my understanding of the case was that as soon as he placed the retractor (ie prior to bone cuts) the arterial bleeding started. I absolutely agree that if the cuts were already done and then the arterial bleed began, the best conduct would be to place the components first, then definitely deal w the bleed. Like I said, I understood that no bone cuts had been performed, in which case the steps should be 1) abandon the arthroplasty 2) control the bleed 3) repair or bypass the artery 4) close up and observe for compartment syndrome, loss of pulse distally etc. I think we pretty much are in agreement.
Excellent points, I do pretty much agree with you hehe! Although, after thinking about it, I think the humeral head resection/bone cuts were already done at the time of arterial injury.
The antero-inferior retractor directly adjacent to the glenoid is usually placed when exposing for glenoid preparation. This step is usually done after humeral head resection and humeral preparation.
This would make sense with the decision to finish the arthroplasty before doing the definitive bypass. In any case, I certainly would be very curious to read the operative report !!
Surprised that the vascular surgeon told him to complete the arthroplasty. That extra hour or so of ischemia time was critical to her eventual poor outcome. The Orthopod did very little wrong. The vascular surgeon should be the one sued. Axillary artery injuries are infrequent during shoulder arthroplasty procedures, but I would not say that they are rare.
Yes, that struck me as well (as a non-ortho or vascular expert). An ischemic limb seems like an acute emergency... that being said a Reddit commenter noted that apparently the standard teaching is that you have up to 2 hours to resolve this before there is any real risk of damage.
Tough to say exactly why they decided to complete the arthroplasty before doing the revascularization, especially without knowing all the specifics...
but maybe it is because they wanted to avoid doing the bypass in an incomplete arthroplasty with shortened and floppy shoulder/arm that would soon after be pulled and yanked in all directions in order to finish the reverse shoulder.
I suppose it could be argued that getting the final length/stability/alignement right first (if ischemia time is short) could be preferable so that the vascular repair could be undertaken in a stable environment? Then again, feel free to correct me, I would be curious to know a vascular surgeon's opinion on the matter/order of procedure!
Like in knee fracture/dislocation cases with vascular injury for example. Common to first perform a quick reduction and temporarily stabilize the limb with an external fixator to maintain reduction/length/alignement/create a stable environment, followed by the vascular procedure.