All right, well, thanks, Matt, and sorry this is IC207, but Matt definitely wants too much information about the shower, so that's great. Okay, well, I'm going to be speaking about shoulder, and I'm going to start, I have nothing to disclose here about this, but so I'm going to start with one with a labor repair. It's a little different than just a shoulder case, but what could really go wrong? It's just a labor repair, and so we're going to talk a little bit about what Matt just mentioned about the importance of the doctor-patient relationship when you have a complication. So this is a patient of mine, 26-year-old, who ended up having an MI in the OR due to something we did in surgery apparently, so very difficult situation. So just a brief history of 26-year-old female playing rugby, subluxated her shoulder, had some instability after that for a time, and then four years later, moving a bed, headboard fell, tried to catch it, subluxated again, so otherwise healthy, very healthy person. So she had an exam that's consistent with anterior instability, otherwise normal exam. X-rays looked quite normal here, really no evidence of dislocation based on X-rays, and you can see some of the key MRI findings here where in addition to labral tear and the hill sacs, like at least a contusion, even a slight depression there. She's also got what looks like a hagel there. And so we looked at that. She had no bony lesion, her hill sacs was really small, was on track, and she had an ALPSA there and a hagel, something that we'd at least look at in the OR and think about how we're going to need to repair that. So that was our plan, we're going to repair this labrum and then see what we need to do about her capsule, including the inferior capsule. So we go to the OR, and sort of a typical thing, most of our surgeries are done with an interscaling block that's done in the pre-op area, and so it was pretty done quite expeditiously, and apparently 1 to 400,000 epinephrine in the block. But we start the surgery at 728, or get in the room at 728, and so we're beginning the incision at 751, get the scope in, and within a couple of minutes of just getting the arthroscope in the joint, anesthesia starts yelling to stop the case. And the reason they said to stop, I'll show you, let's see if we've got a little highlight here, let me go back. So you can't see it so well on the bottom, but essentially the patient's blood pressure went up to like 220 over like 120 suddenly, and tachycardic went up into the 200s. And so looking on her lead, she was having ST depression, like looking like she's having an MI with like extreme hypertension, and so the whole anesthesia team comes running in and then they made a mistake and gave her a beta block or Esmolol, and so then she goes into florid pulmonary edema, and she's 26 years old, having surgery, a little labral repair, and here she is like suddenly nearly coding, and so basically they get her at least in a situation where they've got her heart rate down, blood pressure's at least stabilizing, and so they get her out of the OR and have to transport her by EMS over to our main hospital from our ASC, where she has to go to the CCU because she's ruling in for MI. So I have to go out and meet with the family, and I have no idea why this is really happening. At the time, we're assuming it's some sort of catecholamine situation, epinephrine from some source is causing this, but nobody really knows, and so she goes over to the CCU, and she's really not fully ruling in for MI, but she's still got like depressions, ST depression in her lead, so she's admitted there, has to stay for a couple of days, and essentially, the team decides that it's epinephrine-induced vasospasm due to probably some sort of either the block, there's probably a couple of different sources, they rule out everything else like PE or all these other things and decide that it's epinephrine, and so there's probably a number of different reasons. Again, it's not something else, like she wasn't having anaphylaxis or anything else, but it's just this catecholamine overload, and here are the different sources, and something for everybody here probably does arthroscopy, and so this is a thing, which I never knew about until I had it happen to me, but it could be from the nerve block, and it's just suddenly like, you know, they put a bunch of this, you know, like this bupivacaine or ropivacaine and there's a lot, there's epinephrine there, and it's sort of gradually getting in the tissues, so it can occur from nerve blocks, it could happen when you're doing, apparently, even local for skin infiltration, and something else I didn't know is that it can absorb from the joint from arthroscopy fluid, and there's case reports where that has occurred, and one of the reasons is that the epinephrine, if it's injected into your arthroscopic bags, if you don't shake up the bag, it all concentrates in the bottom of the bag, and there can be like, if you scuff the joint, it can get in the bones or get in the blood supply, it can get in the vasculature from your joint fluid or from your arthroscopic fluid. In this case, I think anesthesia made a mistake and administered an IV without realizing it, and at the time, Ketorolac and epinephrine were in the same size bottle just with a different color cap and were in the dark in the OR. I think the anesthesiologist got the wrong vial and wouldn't admit it, by the way, but in any event, it can occur from our surgery, and certainly something to be aware of. There's case reports, unfortunately some fatal when patients have this develop in the OR, and so it's something for surgeons to be aware of, and so it's happened during arthroscopic shoulder surgery, and it was thought to be, again, like from irrigation fluid here, and another one, you can see, so there's a couple of cases there, and even during ACL, and this is Gus Mazzocca, this is when he was at Rush, and you can see Brian Cole on there, Charles Bush Joseph, and they, same thing happened, that the patient developed this sudden hypertension and tachycardia and Esmolol, a beta blocker, that might be okay in other situations, like is exactly the wrong thing to do because the heart cannot then compensate for what's going on with the catecholamine, and it puts them into florid pulmonary edema, and that's usually what kills the patient, so if someone makes the mistake and gives a beta blocker, which isn't for all of you to really know what to do, but it's a little scary to think that this can happen during arthroscopic surgery of any kind, and if someone doesn't recognize what it is and gives the wrong drug, it can really cause some trouble. Well going back to the patient, so we'll sort of skip this, but of course some of us use epinephrine, it really does help visualization, and it's a reasonable thing to do, especially diluted, but it is somewhat of a risk, and so we shake the bags now, or at least turn them upside down, back and forth a few times to make sure it's mixed in the fluid, but this was definitely an issue, or beta blockers, given were not the right thing to do in that situation, maybe we should have agitated the bag, now we do, and we also changed the bottles, and now epinephrine bottles in the OR have to have foil cover over top to differentiate them so no one could potentially pick it up and not know what it is in the dark or something, and so there's probably a few things to think about with your team. But how about the patient, so how did all this go? Well, so I went out to speak to the family to let them know, and they said, wow, you did that surgery really quick, it was six minutes, right? And I said, yeah, I wish I could do that, but unfortunately, I have to tell you about what happened at the time, I didn't know what it was, that it was the epinephrine, didn't really understand, it could have even, I thought, been some kind of heart issue she had, and the family was quite confused, and certainly really nervous, and so I told them what we were doing, that she was stable at the moment, and going over to the main hospital, and really spent some time with them, and told them we would be updating them and getting them over to the hospital, transporting them over to see her, and as Matt was saying, leaning in, the worst thing to do in a situation, especially nearly fatal like this, is to back away and not be there for the family, okay? So we had her see the cardiology, so she stayed in the CCU a couple days, and she ended up being really totally normal on her echo, and everything seemed completely resolved, and so they saw her back and follow up a week later, and really felt like she was okay, and it was just due to the epinephrine, and she could go ahead and have surgery, so I'm not sure the family was that keen on that at that point. So she came back to see me 10 days later, you know, I'd called the family several times, and actually visited her in the CCU a couple times a day, even to update the family and make sure everybody was okay, but the family was still quite upset and suspicious because nobody really took credit for what actually happened. Some of that was because we didn't know, and they're really apprehensive about more surgery, you know, so this is where having a good relationship and really leaning in early really helped, and so I told them, you know, it is definitely the medical team, you know, there was an epinephrine that she got an overload, and there's several sources, we're not 100% clear, and I just made it, told them, I said, it could be, you know, what we had put in the bag, it could be something with anesthesia, but it's our team's responsibility, you know, and I really, you know, spent some time early, and all, as I said, visited, but really, I think, created trust by not, like, backing away and taking responsibility, and then I think a really interesting concept is if a patient has a complication, and then they need more surgery, like she still has shoulder instability and really is interested in having surgery, but now afraid to do that, you know, I think emphasizing that you want to take care of the patient to correct the problem, and so saying, I'm committed to seeing you through, and Beth mentioned patients are afraid of being abandoned is true, and saying, I know I really want to see you through this, and want to work with you, but I think you need to acknowledge that the patient might be uncomfortable working with you because of what happened, and it really gives, it's sort of a relief to tell them, I understand that you may be apprehensive about working with me and my team after what happened, and it's okay to see somebody else, sometimes they feel relief that you brought that up, and I'll often say, let me help you see a trusted colleague, and I'm not abandoning you, if you want to see somebody else get another opinion, let me help you set that up so it's easy for you, and I think just showing willingness to have them see someone else, but also if they were, are willing to stick with you, telling them that you'd like to help them, I think those things really help. So the end of the story is that she agreed to have surgery with me amazingly, and we did not use epinephrine, and she did really well with the surgery, thank God, and ended up getting back to sports and doing well, everything, like we did monitor her every six months, the cardiology team, to make sure that everything continued to be fine with her heart, and everything ended up being normal, and what was really gratifying is that she came back eight years later to see me for her other shoulder. So obviously building a good relationship there went on to be a good thing, and I think just having a scary complication near fatal in a 26-year-old, and something that could probably happen to any of us that do arthroscopic surgery, is kind of a good story to just sort of think about how to manage that at the time it's happening, and talking about what to do when you need to do more surgery, and a patient may feel uncomfortable. So if she believes that you didn't intend to harm her, and you stay engaged, she might not go elsewhere, and frankly might not consider litigation, you know, if you're honest about it and admitting that you either know or you don't know, but that you really want to continue working, I think that all these things are really quite important. So now more of a really a clinical shoulder case, with really more of the surgical issues. So this is a 19-year-old male with a seizure disorder, it was really quite severe, he'd had multiple dislocations, I did his other side, just did more of an arthroscopic repair because he didn't have bone loss, and he did very well with that, but then this particular shoulder left side, you can see on his initial films that he's got this, you know, huge hill sacs, really can't even see his anterior labrum, big elpsa, and so ended up doing a little, so we did an arthroscopic repair anteriorly at that time, since I felt like he had good tissue and he didn't have glenoid bone loss, but he had this large hill sacs, and so did an osteochondral allograft for that, but then unfortunately dislocated again, and now he knocked off, as you can see, really knocked off a huge part of his glenoid this time. Fortunately his humeral head stayed intact there, and so we decided to do a revision with a Latter-Jay, and then really we talked with the team, with seizure patients, I'm sure most of you know, you really want to make sure they're not going to seize again and destroy your repair, so we worked with the pediatric neurologist to make sure his doses were higher, kept him overnight, and sent him home, and everything seemed fine, but 24 hours after his Latter-Jay, here is his shoulder in the ER, dislocated, locked there, broke the screws, and so total disaster, and so, you know, you can see after reduction here you can just see, you know, even the screws right in the joint, and this difficult situation, he also now has a huge hill sacs, probably from having a seizure that locked out and then kept seizing, and so now the patient, but the parents are really distraught, so despite all the planning, working with neurology here, he had a seizure and the surgery has totally failed, it actually fractured the coracoid graft, and now he's got this huge recurrent hill sacs, and so the, you know, the family has even lost a little faith, you know, thinking, we went through this huge surgery and within 24 hours it's all destroyed, I mean they understand that he had a seizure, but they thought we were supposed to be doing everything to prevent that, they thought we fixed it, and so now they're really upset with him, now what are we going to do? And so the Latter-Jay gone awry, you know, so now what do we have to do? So we had to do a pretty big surgery, and you can see on the left side the hill sacs lesion is massive there, and you can see the osteochondral allograft we did there, and then he really had knocked off, geez, almost like 50% of his glenoid, so you can see a huge distal tibial allograft, you know, there, and so I admitted him to the hospital for five days and basically then snowed him with drugs for preventing seizures for six months, he'd come in clinic and hardly keep his eyes open, he's like dragged around for six months because we wanted to keep him, his seizure threshold really low, and you know, fortunately at that point he did pretty well, and you can see some post-operative pictures here now with, you know, you can see that his glenoid there, so on the right you can really see how that's really lengthened the glenoid appropriately, and the hill sacs, you know, it looks like that's fortunately fixed a lot better than a pre-film, so three months later he's doing fine, went on and did very well, and has not had to have more surgery and it's been about eight years ago now, so you know, of course, seizure control must be maximized, and what I learned from that is I probably should have admitted him to the hospital, this is not just your average seizure patient, this is somebody who's seizing constantly and probably should have had him in the hospital on the neurology service and really worked a little harder to make sure that was optimal, and I've considered, so I like would consider avoiding a Latergé because if the patient seizes again, like now they don't have a coracoid, like you're going to lose that piece, and so distal tibial allograft, you know, that's, it's certainly, you know, always a reasonable option, and in the future I would think about that in case that happens, like if they seize again, you know, at least they still have their coracoid and biceps there I guess, and so I would tend to avoid a Latergé with a patient like that, and really the correcting bone loss, we all know about it, but in a seizure patient that's probably even more important to make sure you're doing that because soft tissue, you know, may not hold up quite as well, so another thing to think about, and being really clear with families about the potential complications and being ready to revise whatever you do, that's why doing a Latergé to revising that can be a little bit harder, even like from a nerve standpoint when you've moved that coracoid. So that's it on, you know, my presentation there, and I think we'll have the other speakers, you know, go ahead and give their talks, but I think hopefully some good lessons learned there and love to get some questions from everybody at the end will all come up and be available.

shoulder surgery cases

complications

epinephrine administration

seizure disorder

surgical considerations