Delayed tension pneumothorax 2 days after shoulder arthroscopic rotator cuff repair: a case report

Abstract

Background

The report of tension pneumothorax after shoulder arthroscopy is very rare, and it is easy to be misdiagnosed and missed clinically, thus delaying the treatment of patients and endangering their lives.

Case presentation

A 68-year-old woman was admitted to the joint surgery department. Chief complaint: left shoulder joint pain with limited movement for 6 months. Physical examination: lateral acromial tenderness (+), significant shoulder tenderness, Job sign (+), Hapolen sign (+), Lift off sign (+), forward flexion about 80°, abduction about 80°, external rotation about 30°, internal buckle and hip level. Magnetic resonance imaging(MRI) revealed a tear of the left supraspinatus muscle and edema in the rotator cuff space. Left rotator cuff repair and joint capsule release under arthroscope in lateral position were arranged for the patient. The patient’s vital signs were stable during the operation and she returned to the ward safely. At 13:27 PM on the second day of the operation, sudden shortness of breath, sweating, poor spirit, able to respond to breathing, able to act as instructed, shortness of breath, both lungs and sporadic dry and wet rale, heart rhythm, not heard and obvious pathological murmurs were immediately treated with mask oxygen inhalation and sputum aspiration, and a small amount of white frothy sputum could be aspirated. Please consult the intensive care department immediately. Subsequently, the Peripheral oxygen saturation. (SPO2) of the patient gradually decreased to 60%, and the patient was lethargic and given balloon assisted ventilation, the oxygen saturation remained between 57% and 65%. The patient’s vital signs were stable after immediate emergency treatment with endotracheal intubation. A physical examination on ward round the next morning revealed fullness of the chest and widening of the thorax. Tympanic sound was found on right thoracic percussion, but no respiratory sound was found on auscultation. The diagnosis was tension pneumothorax. The cardiothoracic surgeon immediately performed closed thoracic drainage in the third intercostal space on the right midline of the clavicle with a 20-gauge needle. Two days later, the right lung returned to normal. There was no lung discomfort during the six-month follow-up. She has returned to her pre-injury athletic level.

Conclusion

Delayed tension pneumothorax after arthroscopic rotator cuff repair is a very rare condition with no clear cause. Special attention should be paid to patients with sudden dyspnea after shoulder arthroscopy, and early diagnosis and treatment should be conducted according to the symptoms, signs and imaging examinations of patients to avoid misdiagnosis and missed diagnosis.

Background

Tension pneumothorax is secondary to different pulmonary diseases, such as chronic obstructive pulmonary disease, tuberculosis, silicosis, pulmonary fibrosis, etc., as well as patients with ventilator-assisted breathing, but it is very rare to have tension pneumothorax after shoulder arthroscopy [1,2,3]. Tension pneumothorax will cause significant reduction of effective lung respiration, reduced ventilation function, resulting in severe respiratory disorders, reduced cardiac output under pressure of the heart and large blood vessels, blocked return blood flow, and circulatory failure. If it cannot be effectively treated in time, the disease will develop rapidly and lead to death. This article reports a case of delayed tension pneumothorax 2 days after shoulder arthroscopic rotator cuff repair, which was diagnosed and treated in time to avoid catastrophic consequences. Our patient has been informed that information about the case will be submitted for publication.

Case presentation

A 68-year-old female was admitted to joint surgery. Chief complaint: left shoulder joint pain with limited movement for 6 months. Physical examination: Visual: left shoulder joint no surgical scar: shoulder joint swelling (-), local skin no pigmentation, no petechiae, local skin no redness: shoulder supraspinata muscle, deltoid muscle no atrophy. Contact: The skin temperature of the affected shoulder joint is not high, tenderness of the lateral acromion (+), and obvious tenderness of the shoulder joint. Movement: affected shoulder joint: Neer sign (-), Hamkin sign (-), Bear hug sign (-), Jab sign (+), Hapolen sign (+): Drop arm test (-); Lift off sign (+). Internal rotation resistance limit force (-), external rotation resistance (+). Quantity: Anterior flexion of the affected shoulder joint about 80°, abduction about 80°, external rotation about 30°, internal buckle and hip level. X-rays of the shoulder joint were normal. Magnetic resonance imaging revealed A partial tear of the left supraspinatus muscle, edema of the rotator cuff space, thickening of the joint capsule, and disappearance of the axillary capsule (Figures 1 A and B). Previous history: No surgical history, no smoking history. History of hypertension for 20 years, usually take amlodipine besylate tablets to control blood pressure, blood pressure control is stable. History of diabetes for 8 years, usually take dimethyl double pulse + gliclazide to control blood sugar, blood sugar level control is better. The patient was stocky and had no family history of disease. Preoperative CT examination of the chest showed no abnormality(Figures C, D), and then arthroscopic repair of the left rotator cuff and joint capsule release were arranged for her. Before operation, the anesthesiologist performed brachial plexus block by interscalene approach. After general anesthesia, the lateral position was taken, arm abduction 30°, forward flexion 15 °, and axial traction of 5 kg. Routine shoulder arthroscopy showed that there was obvious hyperemia and edema in the rotator cuff space, hyperplasia and hypertrophy of the joint capsule, hyperplasia and hyperemia and edema of the descendal acromial sac, partial tear of the bursa layer about 5 mm in length could be seen in the anterior edge of the supraspinatus tendon, and no retract of the broken end. The rotator cuff was repaired with one edge to edge suture of Sharp and high strength suture. The patient’s vital signs were stable during operation and returned to the ward safely after operation. 2 days after the operation, sudden shortness of breath, heavy sweating, oxygen inhalation immediately, ECG monitoring: P: 130 times/min, R: 30 times/min, BP: 175/90mmHg, SPO2: 80%( nasal catheter oxygen status), poor mental state, response to exhalation, activity as instructed, shortness of breath, both lungs and scattered dry and wet rales, heart rhythm, no obvious pathological murmur, abdominal softness, no obvious edema of both lower limbs, four dressings clean and dry, limbs as instructed. A small amount of white frosty sputum could be aspirated immediately after oxygen inhalation and sputum aspiration, and the patient was immediately referred to ICU for urgent consultation. The oxygen saturation of the patient subsequently decreased gradually, P: 135 times/min, R: 32 times/min, BP: 185/94mmHg, SPO2: 60% (nasal catheter oxygen status), the patient was lethargy, balloon assisted ventilation was given, oxygen gown and degree remained between 57 and 65%, and after immediate emergency treatment with tracheal intubation, the patient’s vital signs were stable, and physical examination showed that the chest was full and widened. Tympanic sound was found on right thoracic percussion, but no respiratory sound was found on auscultation. CT examination of the lungs revealed tension pneumothorax (Figures E, F). The cardiothoracic surgeon immediately performed a closed thoracic drainage in the third intercostal space on the right midline of the clavicle using a 20-gauge needle. After 15 min of emergency surgery, intrathoracic drainage tube was placed, and the symptoms were significantly relieved. After 2 days, the right lung returned to normal (Figure G), and the subcutaneous emphysema basically disappeared within 1 week (Figure H). There was no lung discomfort during the six-month follow-up. She has since returned to her pre-injury athletic level.

Fig. 1

A and B. Left supraspinatus muscle was partially torn, rotator cuff space edema, joint capsule thickened, and axillary capsule disappeared. C and D. Preoperative pulmonary CT showed no significant abnormalities. E and F. Lung CT scan showed severe atrophy of the left lung, suggesting pneumothorax. G and H. Reexamination after closed thoracic drainage showed that the pressurized right lung basically recovered to normal

Discussion

Arthroscopy has become a major diagnostic tool and treatment option for shoulder diseases. The main advantages are less trauma and faster recovery. However, there are some complications associated with shoulder arthroscopic surgery, such as anesthesia related complications such as infection, bleeding, postoperative pain, joint stiffness, rotator cuff tear, deep vein thrombosis [4], decreased cerebral oxygenation [5], sitting quadriplegia [6], adrenergic-induced arrhythmia [7], negative pressure pulmonary edema [8], airway complications, and pneumothorax. Pneumothorax after shoulder arthroscopy is a very rare respiratory complication. In previous studies on pneumothorax after shoulder arthroscopy, most of the patients had respiratory diseases or smoking history, but the patients had no respiratory diseases such as asthma, chronic obstructive pulmonary disease, bullosa, no smoking history, no body type prone to pneumothorax, no family history of disease, and no abnormalities were found in preoperative chest CT. In our case, the intubation was performed under direct vision, remained stable throughout the operation, and was successfully extubed and returned to the ward.

There is evidence that the effect of the pressure gradient below the peak may be the underlying mechanism [9,10,11,12,13]. Due to the transient change in subacromial space pressure relative to atmospheric pressure, air is inhaled through an approach from the front door of the arthroscope. When suction is turned off during surgery, the positive pressure created by pumping may push air into the prevertebral space around the trachea and esophagus due to temporary changes in subacromial pressure. When the mediastinal pleura ruptures, mediastinal emphysema and pneumothorax can result [13]. The total time of subacromial operation in this operation was only 30 min, and no significant swelling of the patient’s chest was found on the first day after surgery. We speculated that this factor would not cause tension pneumothorax in the patient. It is worth considering that the possible reason is that the anesthesiologist conducted the ultrasound-guided brachial plexus block by the intermuscular groove approach before surgery, and the whole process of the block was very smooth. It has been shown that accidentally puncturing the fascia or direct lung injury during the block may lead to pneumothorax [14, 15]. Even ultrasound does not completely prevent pneumothorax. Therefore, the success of ultrasound-guided interscalene nerve block is highly dependent on the operative operator [14,15,16]. According to most literature reports [17,18,19], if tension pneumothorax occurred due to acupuncture, it should have occurred early and was very urgent. However, the patient’s emergency occurred 2 days after surgery, and it was found in the pulmonary CT review on the second day after tracheal intubation, so it was not necessarily nerve block that caused tension pneumothorax.The position of shoulder arthroscope may also be related to pneumothorax. Lee et al. [11] reported three extensive cases of subcutaneous emphysema, mediastinal emphysema, and tension pneumothorax in a semi-upright beach chair position with subacromial decompression during or immediately after shoulder arthroscopy. The authors speculate that these complications are the result of the transient development of negative pressure relative to atmospheric pressure in the subacromial space caused by the use of a planer blade with suction in the upright position [20, 21]. Laura Sacrista et al. [22] reported a iatrogenic case of pleural injury caused by sharp trocar during arthroscopic surgery to establish a posterior approach. In our case, we reviewed video recordings of shoulder arthroscopic surgery in the lateral position, but no procedures that might have induced pneumothorax were observed. Similar to what was reported by Lee et al. [11] In our patients, temporary excessive negative pressure on the pleural cavity due to arm traction during shoulder arthroscopy may lead to pleural injury, which may be associated with the occurrence of pneumothorax. However, to date, there is no objective evidence to support a causal relationship between any patient position and respiratory complications in arthroscopic joint surgery [21].

In summary, we presented a patient with no chest trauma and no history of lung disease who developed delayed tension pneumothorax 2 days after shoulder arthroscopic rotator cuff repair under general anesthesia. Tension pneumothorax generally occurs in the early stage of injury, delayed tension pneumothorax is rare, due to the lack of vigilance to this disease, no preventive measures, most of the rescue measures are not effective, and lead to death [2, 3, 12, 19]. The patient occurred 2 days after surgery. During anesthesia, positive pressure ventilation may lead to the rupture of pulmonary bulla, and unidirectional valve is formed after gas enters the pleural cavity, resulting in delayed tension pneumothorax. However, the patient did not find pulmonary bulla on preoperative CT, which can basically be ruled out. The chance of puncturing the pleura directly with blunt piercers is also low when the anterior-lower surgical approach is established. In addition, the intraoperative fluid inflow and outflow were controlled by pressure pumps, and this cause of pneumothorax could also be ruled out. Delayed tension pneumothorax occurred in the patient without direct trauma, which pointed to iatrogenic pneumothorax as the cause. The most likely cause was that the patient mistakenly punctured the chest during cervical plexus block, causing the puncture needle to damage the lung surface and form a valve. Gas slowly accumulated in the pleural cavity and gradually formed tension pneumothorax 2 days after surgery. Secondly, the local tissue necrosis caused by contusion of trachea or esophagus and blood supply obstruction caused by tracheal intubation during anesthesia is not completely excluded. After 2 days, a flap is formed due to the rupture of the necrotic area due to cough and force, etc. After the formation of pneumothorax, the wound is closed under the action of pressure, resulting in simple pneumothorax. However, in the case of poor healing of the local injured tissue, When coughing and straining increase the pressure in the lungs, the valve changes to open to the pleural cavity, resulting in tension pneumothorax. However, we suggest that clinicians reduce the occurrence of pneumothorax complications in patients undergoing shoulder arthroscopic surgery from the following considerations: First, carefully examine the patient’s lung CT before surgery to exclude risk factors such as bullosa and lung disease, and ask the anesthesiologist to fully evaluate; Second, careful operation during the operation, the correct placement of the approach, especially the placement of the anterior-lower approach, is very important to avoid air entry; Third, during the operation, the changes of outflow and inflow should be kept in balance, and pump irrigation fusion must be used as little as possible to avoid large fluctuations in subacromial pressure. Fourth, if the patient’s lung discomfort is found after surgery, carefully check the body and auscultate the lungs, timely review the lung CT to confirm the diagnosis, accurate and timely treatment, and even routine imaging review.

Table 1 Summarizes the cases of respiratory complications following shoulder arthroscopy

Conclusion

Based on the literature review, shoulder arthroscopy appears to be a safe and effective technique. Complications such as pneumothorax are very rare, but can be life-threatening if left untreated. Surgery itself appears to be the most common cause, while risk factors for perioperative pneumothorax still need to be highly considered and fully evaluated. Strengthening nursing observation and timely treatment after operation can reduce the death rate of tension. In any case, patients must be informed of possible later complications. Both surgeons and anesthesiologists should be prepared to deal with such rare events.