Occult thoracoacromial artery injury during reverse total shoulder arthroplasty resulting in a cascade of postoperative complications: A case report

We report a case of a 78-year old female patient got the reverse total shoulder arthroplasty with a series of events. After diagnosed with anterior shoulder dislocation and coracoid process fracture at a local hospital, she received conservative care after reduction but persistent reduction loss occurred. Preoperative Magnetic Resonance Imaging confirmed underlying massive fatty infiltration and severe retraction of rotator cuff muscles. Considering underlying chronic rotator cuff arthropathy on preoperative X-ray and Computed Tomography scan with irreparable rotator cuff tears, we decided to perform reverse total shoulder arthroplasty. After unexpected vessel injury possibly due to underlying bleeding tendency or intra-operative procedure, severe complications occurred including active arterial bleeding, brachial plexus palsy and skin necrosis. Serial managements which included embolization of the artery, wound management while implant exposure status, and operative coverage of a skin defect by Latissimus Dorsi pedicled flap and Split Thickness Skin Graft were done. This series of events suggests that surgeons should be more careful than we were about possible injuries of small vessel branches that can cause unexpected complications, and keep in mind the importance of immediate cooperation with other medical professionals such as radiologists, plastic surgeons, and thoracic surgeons.