Extensive subcutaneous emphysema complicating a percutaneous Mumford procedure Shanmugasundaram Saseendar, Si Heng Sharon Tan, Sandeep Vijayan, Aditya Pawaskar & Veerasingam Prem Kumar Knee Surgery, Sports Traumatology, Arthroscopy ISSN 0942-2056 Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3183-2
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Author's personal copy Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3183-2
Shoulder
Extensive subcutaneous emphysema complicating a percutaneous Mumford procedure Shanmugasundaram Saseendar · Si Heng Sharon Tan · Sandeep Vijayan · Aditya Pawaskar · Veerasingam Prem Kumar
Received: 9 June 2014 / Accepted: 10 July 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Subcutaneous emphysema may be a part of a life-threatening pneumomediastinum or pneumothorax and usually does not occur alone. A case of a 75-year-old lady who underwent a percutaneous Mumford procedure for acromioclavicular osteoarthrosis has been reported. She developed extensive subcutaneous emphysema of the neck, chest, bilateral shoulders, and upper arms, in the absence of pneumomediastinum or pneumothorax, during the procedure. Isolated subcutaneous emphysema as a complication of a percutaneous Mumford procedure has not been reported so far in the English literature. The possible mechanism of this complication is discussed. Understanding the mechanism is essential in avoiding this preventable complication. Level of evidence IV. Keywords Subcutaneous emphysema · Shoulder surgery · Mumford procedure
Introduction Subcutaneous emphysema is the clinical state where air is present in the subcutaneous tissue [3]. The phenomenon
S. Saseendar (*) · S. Vijayan · A. Pawaskar Department of Orthopaedic Surgery, University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Health System (NUHS), 5 Lower Kent Ridge Road, Singapore 119074, Singapore e-mail:
[email protected] S. H. S. Tan · V. P. Kumar Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
may occur suddenly and without apparent explanation and may be progressive or may simply disappear as quietly as it came [11]. It usually occurs in association with pneumomediastinum and/or pneumothorax depending on the pathogenesis [11]. Isolated subcutaneous emphysema is rare. A case of extensive subcutaneous emphysema of the neck, chest, bilateral shoulders, and upper arms following a percutaneous Mumford procedure has been reported. There has been no such report of surgical emphysema following a non-arthroscopic shoulder surgery in the English literature.
Case report A 75-year-old, right-hand-dominant woman, who was wheelchair bound, presented with pain in the right shoulder for 2 years. Past medical history included adrenal hyperplasia, type II diabetes mellitus, hyperlipidemia, hypertension, stroke, Parkinsonism, and iron deficiency anemia. She had undergone surgery earlier for malignant gastrinoma, bilateral knee replacement, and an open Mumford procedure on the left side. On clinical examination, the acromioclavicular joint was tender. The shoulder joint and rotator cuff were normal. There was no clinical sign of rotator cuff impingement. Antero-posterior radiograph of the shoulder revealed osteoarthritis of the acromioclavicular joint (Fig. 1). On ultrasonographic examination, the rotator cuff and the long head of biceps were found to be normal. As conservative therapy was unsuccessful, a percutaneous Mumford procedure was planned. With the patient on a beach chair position, under general anesthesia and an ultrasound-guided suprascapular nerve block, the acromioclavicular joint was localized with the help of an 18-G spinal needle under image guidance. Through a 1-cm skin incision anterior to the
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Fig. 1 Antero-posterior radiograph of the right shoulder showing osteoarthrosis of the right acromioclavicular joint
Knee Surg Sports Traumatol Arthrosc
Fig. 3 Immediate postoperative chest radiograph demonstrating extensive surgical emphysema over the chest and both shoulders
pneumothorax. The vitals of the patient were stable, and oxygen saturation was always maintained. The patient recovered uneventfully with supportive care in the high-dependency unit and was fit for discharge the next day. She had significant relief of symptoms on the first postoperative day. She achieved full shoulder range of movements postoperatively, and there was no recurrence of emphysema.
Discussion
Fig. 2 Intra-operative radiograph showing adequate resection of the lateral end of the clavicle. Radiolucent striations are visible over the shoulder
acromioclavicular joint, a Zimmer 5 mm burr was inserted percutaneously and 5 mm of the lateral end of the clavicle was excised. An intra-operative post-resection radiograph (Fig. 2) confirmed the excision. However, the radiograph also showed radiolucent striations raising the suspicion of subcutaneous emphysema. A chest radiograph (Fig. 3) was immediately obtained, and it demonstrated subcutaneous emphysema of the chest, neck, shoulders and upper arms, without any evidence of a pneumomediastinum or
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A literature search in PubMed, Medical Literature Analysis, and Retrieval System Online (MEDLINE) and Scopus with the keywords (subcutaneous emphysema) and (shoulder surgery) or (shoulder arthroscopy) gave 54 results. All reports of subcutaneous emphysema following shoulder surgery were included. Articles were excluded if they were not in the English language. The results of the keyword search were narrowed down using the inclusion and exclusion criteria. Only five of these 54 results reported subcutaneous emphysema following any shoulder surgery (percutaneous, open or arthroscopic). The full texts of these reports were retrieved and analyzed. In all, there were five reports (seven patients) with subcutaneous emphysema following shoulder surgery. All followed arthroscopic surgery of the shoulder—six were subacromial procedures (subacromial decompression or rotator cuff repair), while one was a debridement of the glenoid labrum. There were no reports of subcutaneous emphysema following open or percutaneous shoulder surgery.
Author's personal copy Knee Surg Sports Traumatol Arthrosc
None of the patients had isolated subcutaneous emphysema. While four patients had additional pneumomediastinum, three patients reported by Lee et al. [10] demonstrated pneumomediastinum and a tension pneumothorax along with subcutaneous emphysema. Six patients were operated under general anesthesia with endotracheal intubation; one patient underwent a scalene brachial plexus block [2]. While six of the seven patients were operated in a sitting position, the intra-operative positioning of one patient is not known. Subcutaneous emphysema is an extremely rare complication of surgery of the shoulder. Subcutaneous emphysema associated with pneumomediastinum was first reported in 1850 in a patient following violent coughing [7, 12]. The first case of spontaneous isolated subcutaneous emphysema was reported in 1900 in a bugler who returned to work following a tooth extraction [4]. This was re-emphasized by Parker et al. [12]. Lee et al., in their report of three patients with subcutaneous emphysema, pneumomediastinum and pneumothorax during arthroscopic subacromial decompression, speculated that due to transient changes of pressure in the subacromial space relative to atmospheric pressure, air was drawn in through the lateral portal and extended into the surrounding tissues. The air then penetrated into the axillary sheath and extended through the prevertebral space of the neck, resulting in a pneumomediastinum. Further rise in the mediastinal pressure caused the mediastinal parietal pleura to rupture, leading to pneumothorax [10]. Kim et al. [6], in their report of one patient who had subcutaneous and intermuscular emphysema on the face and neck and pneumomediastinum, proposed the same mechanism as the cause of the aberrant air. Lau [9] implicated a loose junction between the collapsible plastic bags of saline solution and the inflow tubing as the portal of entry of air. Henderson and Hopson also postulated the same hypothesis for pneumoscrotum following knee arthroscopy [5]. Calvisi et al. [2] hypothesized that inadvertent puncture of the prevertebral fascia during a scalene block sucked in air and caused subcutaneous and mediastinic emphysema. Pneumomediastinum as a complication of brachial plexus block has been reported earlier [13]. In addition, the authors proposed that air gets sucked in due to negative pressure created by a Bernoulli effect [2]. A 22 mm tear in the trachea was reported as the cause for the subcutaneous emphysema in a patient undergoing arthroscopic shoulder surgery [8]. The clinical scenario in the present case differs from these reports in two ways—arthroscopy was not used in the present case, and there was no pneumomediastinum or pneumothorax associated with the subcutaneous emphysema. A 1-cm anterior skin incision was used to approach
the acromioclavicular joint with a 5 mm burr percutaneously. It has been shown that only 5 mm of distal clavicle needed to be resected to ensure that no bone-to-bone contact existed between the acromion and clavicle with movements postoperatively [1]. Hence, it was decided to excise only 5 mm of the lateral end of the clavicle through a percutaneous approach. The mechanisms proposed in the arthroscopic procedures described previously were not existent in our case. Further, the patient had no pneumothorax or pneumomediastinum ruling out the possibility of air leak from the alveoli or the upper airway. The mechanism proposed in this study is as follows—the power burr, with its in-built spiral flutes, acts as a propeller, and when used in a tight space through a percutaneous incision, forces air into the surrounding subcutaneous tissues. The fragility of the subcutaneous tissues in an elderly female favors easy dissection of air in between the layers. The excess heat produced from burring bone expands the air and assists the dissection into the tissues. In addition, the sagging soft tissues of the elderly act as a one-sided valve forcing movement of aberrant air in one direction. Once air is forced in through the tissues, more air could be sucked in by the combination of inspiratory and expiratory chest movements coupled with a collapsible subcutaneous airway path acting as a one-sided valve. This method of lateral clavicle resection has been used in this institute in other patients. However, this is the first incidence of surgical emphysema associated with the procedure. The percutaneous method of lateral clavicle excision is recommended only for patients with isolated acromioclavicular joint arthritis, in the absence of subacromial stenosis or impingement. An arthroscopic burr, with simultaneous suction, has been used by the authors ever since, to avoid collection of air in the tissues. A suprascapular nerve block was used in the present case, in addition to general anesthesia. While a scalene block has been shown to be associated with subcutaneous emphysema [2, 13], there is no report or evidence to suggest the possibility of subcutaneous emphysema developing from an ultrasound-guided suprascapular nerve block.
Conclusion The report emphasizes a preventable complication of a percutaneous Mumford procedure—extensive surgical emphysema, arising from use of a power burr percutaneously, raising serious concerns of possible pneumothorax. This complication has not been reported so far in the English literature. Understanding the mechanism and an awareness of the complication are essential in preventing this postoperative morbidity.
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Author's personal copy Acknowledgments None of the authors, or any member of their family, received any financial remuneration related to the subject of the article.
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