Friday, March 27, 2020

Should we be spending money on computer-assisted technologies in arthroplasty?

Computer-Assisted Technologies in Arthroplasty. Navigating Your Way Today

In this article about hip and knee arthroplasties, the authors point out that computer-assisted technologies that are used in arthroplasty include navigation, image-derived instrumentation (IDI), and robotics.

However they also point out that it is not clear whether the implementation of these technologies improves the clinical outcome of surgery and that high cost and time demands have prevented the global implementation of computer-assisted technologies.

They did not model the effect of CT scanning on the risk of cancer for the patient.

Especially in these times with huge strains on the nation's medical budget, we need to be thoughtful about how our health care dollars are spent.

It is of interest to see how different countries have moved to adopt CT technologies in hip and knee arthroplasty

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.



Does a preoperative CT scan improve patient outcomes?

Comparing the Use of Axillary Radiographs and Axial Computed Tomography Scans to Predict Concentric Glenoid Wear

These authors sought to compare the use of axillary radiographs and midglenoid axial CT scans to identify glenoid wear.

Five independent examiners with differing levels of experience characterized the glenoid morphology as either concentric or eccentric on preoperative axillary radiographs and mid-glenoid axial CT scans for 330 patients who underwent anatomic total shoulder arthroplasty.



Intraobserver consistency averaged 75% for radiographs and 73% for CT scans. There was significant interobserver consistency, as higher levels of training corresponded with greater consistency between imaging analyses (p < 0.001).


Comment: Especially in these times with huge strains on the nation's medical budget, we need to be thoughtful about how our health care dollars are spent.

As the authors state, "Although CT scans are associated with greater financial cost and exposure to radiation than radiographs, the literature has yet to describe the additional clinical value and/or potential cost-value benefit as a result of improved outcomes provided by the use of CT scans in patients undergoing total shoulder arthroplasty, even when integrated with virtual planning software and generation of patient specific instrumentation."

We agree that CT scans without or with 3D reconstructions can provide additional detail regarding glenohumeral pathoanatomy in comparison to plain radiographs, it remains to be seen whether this increment in information leads to significantly better clinical outcomes for the patient. Any benefit would need to be balanced against the increased costs and the 200 to 1,000 fold increase in radiation exposure of the CT scans (2.06 mSV)75 (10.83 mSV)76 in comparison to plain radiographs (0.01 mSV). In addition to the cost, physicians are increasingly concerned about the relationship between radiation dosage and the risk of the patient developing cancer.

Further research is needed to show that preoperative CT scans contribute to improved outcomes for the patient.

Meanwhile, standardized preoperative views can provide the information needed to evaluate and manage the arthritic shoulder (see article below).

Prearthroplasty glenohumeral pathoanatomy and its relationship to patient’s sex, age, diagnosis, and self-assessed shoulder comfort and function

These authors examined 544 patients within 6 weeks before shoulder joint replacement arthroplasty with the goals of characterizing the radiographic characteristics of the arthritic joint and the relationship of these pathologic changes to the patients' age, sex and diagnosis. They also studied the inter-relationships among glenoid type, glenoid version, and amount of decentering of the humeral head on the glenoid; as well as the relationships of the pathoanatomy to the patient’s self-assessed shoulder comfort and function.

Examples of the different types of glenoid pathoanatomy are shown below.






They found that male patients had a higher frequency of type B2 glenoids and a lower frequency of A2 glenoids.



The arthritic shoulders of men were more retroverted and had greater amounts of posterior decentering.




Patients with types A1 and C glenoids were younger than those with other glenoid types. 

Shoulders with osteoarthritis were more likely to be type B2 and to be retroverted. 

Types B2 and C had the greatest degree of retroversion, whereas types B1 and B2 had the greatest amounts of posterior decentering. 



Shoulders with glenoid types B1 and B2 and those with more decentering did not have worse preoperative self-assessed shoulder comfort and function.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.



Is a stemless humeral component of value?

Stemless Humeral Implants in Total Shoulder Arthroplasty

These authors propose that the benefits of a stemless humeral implant include greater bone preservation, less stress shielding, less risk of a diaphyseal stress riser, decreased surgical time, and less intraoperative blood loss. Potential downsides include the dependence on proximal bone quality for fixation, increased cost, the dependence on the strength of subscapularis fixation, and pending FDA approval for multiple implants.

It seems that many companies are coming up with their own patentable versions of a stemless component



Yet as these authors point out, "To date, no author has suggested that stemless or canal-sparing unconstrained shoulder arthroplasty outcomes are superior to those of stemmed implants from clinical and radiologic perspectives." A recent meta analysis came to the same conclusion (see this link).

They also point out the downside of increased cost as shown below, with a typical stemless implant costing more that $1,000 more than other types of humeral components. One might wonder, "where does that $1,000 go?"




While it is stated that stemless humeral components are "bone preserving", it is not clear that less bone is removed with the stemless designs in comparison to that with an impaction autografted standard humeral stem 






Especially in these times with huge strains on the nation's medical budget, we need to be thoughtful about how our health care dollars are spent. 

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Thursday, March 19, 2020

Ream and run - 9 year followup in a handball player

Nine years ago we met a doctor who had pain in his left shoulder. Even though he had 10/12 functions of his SST


He desired to proceed with a ream and run because he could not enjoy his sport of handball.
His preoperative films are shown below

His axillary "truth" view showed joint space narrowing that was not evident on the AP view.

He has returned to full action on the the handball court. His 9 year post operative films are shown here, showing a well-fixed thin impaction grafted smooth stem


 and a stable regenerated joint surface on the axillary with no evidence of glenoid bone wear.

Three years ago he had a ream and run performed on his right shoulder. The 3year followup films are shown below.


He now gives each shoulder a SST score of 12 out of 12 and continues to enjoy handball.

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To see a YouTube video on how the ream and run is done, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Physical therapists as diagnosticians for shoulder disorders

Physiotherapists’ ability to diagnose and manage shoulder disorders in an outpatient orthopedic clinic: results from a concordance study

These authors evaluated the diagnostic, surgical triage, and medical imaging agreement between advanced practice physiotherapists (APPs) and orthopedic surgeons (OSs) for the management of patients with shoulder disorders in an outpatient orthopedic clinic.

50 patients referred to an OS for shoulder complaints were recruited and independently assessed by an OS and an APP. Each provider completed a standardized form indicating diagnosis, imaging test requests, and triage of surgical candidates.

Good diagnostic agreement was observed between the OSs and APPs  (k, 0.80; 95% CI, 0.67-0.93).

Agreement for triage of surgical candidates was moderate (k, 0.46; 95% CI, 0.21-0.71) as APPs tended to refer patients more often to OSs for further evaluation. 

Imaging test request agreement was moderate as well (k, 0.42; 95% CI, 0.19-0.66). 

Patient satisfaction with care was high, with no significant differences found between providers (P . .70).

Comment: There is a strong rationale for having physical therapists evaluate patients with non-acute shoulder conditions as shown in this study. The optimal situation is to have the physical therapists seeing patients concurrently with the shoulder surgeon so that surgical consultation can be obtained, if necessary, at the same patient visit. This concurrency also allows the therapist and the surgeon to learn from each other to optimize accuracy and efficiency of evaluation and management. It is comforting for patients to know of a close partnership between PT and MD. A further advantage of this partnership is that surgical patients will often benefit from preoperative and postoperative therapy; this is facilitated if the patient and the PT know each other from the start.

There is a group, known as the American Society of Shoulder and Elbow Therapists, from around the country (http://www.asset-usa.org) that is built on the principles above.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


Reverse total shoulder - the polyethylene wears with time.

In vivo volumetric and linear wear measurement of reverse shoulder arthroplasty at minimum 5-year follow-up

The authors point out that reverse shoulder arthroplasty is quickly becoming the most frequently performed glenohumeral joint replacement, being used to treat cases that previously would have been successfully managed with a conventional anatomic total shoulder.

In 15 patients with at least an average of 8 years after surgery, they evaluated the volumetric and linear wear rates of ultrahigh-molecular-weight polyethylene humeral liners in vivo using radiostereometric analysis to image 15 patients at terminal range of motion in forward flexion, abduction, external rotation, and internal rotation and with the arm at the side. The relative position and orientation of the glenosphere and polyethylenewere identified for each arm position.

The apparent intersection of the glenosphere into the polyethylene was recorded as wear. 



The mean volumetric and linear wear rates for the 13 shoulders with  36-mm liners were 42 mm^3/yr and 0.11 mm/yr, respectively. The graph below shows the progression with time.


The mean volumetric and linear wear rates for the two shoulders with 42-mm liners were substantially greater than for the smaller liner: 114 mm^3/yr and 0.17 mm/yr, respectively. 

Comment: The polyethylene wear particles resulting from this wear can stimulate an inflammatory response (see this link). These results may help explain the reported deterioration in reverse total shoulder clinical outcomes with time. 

See this related article 

Long-term results of the Delta Xtend reverse shoulder prosthesis

These authors reviewed 126 primary Delta Xtend reverse total shoulder prostheses implanted in our center by an individual surgeon from October 2006 until December 2009. Of these, 38 patients died, 12 were lost to follow-up, and 2 needed early revision of the prosthesis.

Follow-up of at least 8 years was available for 74 patients. The mean follow-up in our population was 113.1 months. 

The mean adjusted Constant Score was 44.6% preoperatively. It increased significantly to 75.8% after surgery and to 91.1% at 5 years. At the latest follow-up, the mean aCS had declined to 79.9%. 







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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.


===

To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

The eagle is unconcerned about COVID19

Nature continues, the bald eagle continues to terrorize coots

and catches one that separates from the raft of his other coot friends

It is somehow reassuring that much of nature remains as it has for centuries and will remain for centuries to come.

We will get through this!