Tuesday, July 16, 2019

Shoulder arthritis: types of glenoid bone destruction

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

There is great current interest in characterizing the effects of arthritis on the bone of the glenoid socket because pathologic changes in this bone influence the surgical technique and outcome of shoulder joint replacement.

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.
Comment: This study indicates that radiographic glenohumeral pathoanatomy has previously unreported relationships to the patient’s sex, age, and diagnosis. Contrary to what might have been expected, more advanced glenohumeral pathoanatomy (ie, type B glenoids, greater retroversion, greater decentering) was not associated with worse self-assessed shoulder comfort and function before surgery.

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.

Wednesday, July 10, 2019

Shoulder joint replacements - what is driving the high costs?

An analysis of costs associated with shoulder arthroplasty

These authors reviewed 361 shoulder arthroplasties performed at their facility in an attempt to identify the patient and procedure characteristics associated with costs.

19% had revision arthroplasty procedures, 32% had anatomic total shoulder arthroplasties, and 66% had reverse total shoulder arthroplasties (RTSAs).

Of the total costs, 58% were operative supply costs, including implants.

Factors associated with increased operative costs included younger age (P . .002), use of an RTSA

(P < .001), use of a bone graft (P < .001) and implant brand.

Comment: As the authors point out there are some modifiable factors that can have a profound effect on the cost of arthroplasty.

First, the actual implant costs are hidden from view. Each hospital confidentially negotiates the actual dollar amounts paid by the medical center for the total joint implants. We are aware that some medical centers will only accept implant prices that are 15% of the median price in the U.S. Thus there is an "invisible" but huge disparity among hospital payments for shoulder implants. If the prices were known and pegged at this low value, it is evident that the total U.S. costs would be dramatically reduced. 

Secondly, there is a trend toward the use of the reverse total shoulder even in cases well suited for an anatomic shoulder arthroplasty. The average selling price for a Reverse Total Shoulder is almost 50% higher than the anatomic total shoulder (See the data below from Orthopaedic Network News, Volume 30, Number 1, January 2019:

We believe that implant pricing should be public. If vendors want to provide discounts for high volume centers, that should be public as well.

We also believe that a reverse total shoulder is usually not necessary for osteoarthritic shoulders with intact rotator cuffs.

These two steps could go a long way to reducing the implant costs for shoulder arthroplasty, which comprise the major component of the overall costs of these procedures.

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.

Tuesday, July 9, 2019

Rotator cuff tear - the value of open transosseous repair for small to medium sized defects

At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears

These authors studied 103 patients with a rotator cuff tear not exceeding 3 cm who were randomly assigned to primary tendon repair or physiotherapy with optional secondary repair. Blinded follow-up was performed after 6 months and 1, 2, 5, and 10 years. Outcome measures included the Constant score and the self-report section of the American Shoulder and Surgeons Score.

Operative treatment was open or mini-open tendon repair. Following a diagnostic arthroscopy of the glenohumeral joint, the tear was exposed through a deltoid-splitting approach, and an anterior acromioplasty was performed. Tendons were mobilized and repaired by transosseous sutures. Tenodesis of the long head of the biceps was performed in patients with a partial tear of the tendon. Postoperatively, the arm was immobilized in a sling, and passive range-of-motion exercises were started and were continued for 6 weeks. Active range-of-motion exercises were started 6 weeks after the surgical procedure and were supplemented by strengthening exercises after 12 weeks.

Ninety-one of 103 patients attended the last follow-up. After 10 years, the results were better for primary tendon repair, by 9.6 points on the Constant score (p = 0.002), 15.7 points on the American Shoulder and Elbow Surgeons score (p <0.001), 1.8 cm on a 10-cm visual analog scale for pain (p < 0.001), 19.6 for pain-free abduction (p = 0.007), and 14.3 for pain-free flexion (p = 0.01). Fourteen patients had crossed over from physiotherapy to secondary surgery and had an outcome on the Constant score that was 10.0 points inferior compared with that of the primary tendon repair group (p = 0.03).

In 47 patients treated by primary repair, tendon integrity was assessed by MRI after 1 year and by sonography after 5 and 10 years. Full or partial-thickness retears were found in 10 (21%) after 1 year, 13 (28%) after 5 years, and 16 (34%) after 10 years. Five of the retears after 10 years were classified as partial-thickness only. A comparison of the Constant score after 10 years between the 16 patients with a retear at the last follow-up (76.9 points) and the 31 patients with an intact repair (82.9 points) showed a better result for intact repairs, with a between-group difference of 6.0 points (95% CI, 0.2 to 11.8 points; p = 0.04). 

Comment: It is not known if the results with arthroscopic repairs using suture anchors are equivalent to these with open transosseous repair.

It is of interest that these structural and functional outcomes for small to medium sized tears repaired with open transosseous repairs are virtually identical to those presented by the late Douglas Harryman 28 years ago using a similar surgical technique:

Repairs of the Rotator Cuff: Correlation of Functional Results with Integrity of the Cuff.

These authors evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. They correlated the functional result with the integrity of the cuff, as determined by ultrasonography.

The size of the rotator cuff defect as seen at surgery (operative type) and as seen at followup by sonography (followup type) was classified as follows:

Type 0 - intact cuff
Type lA - thinning or a partial-thickness defect of the supraspinatus tendon. 
Type lB - a full-thickness defect of the supraspinatus tendon
Type 2 - a full thickness defect involving the supraspinatus and infraspinatus tendons'
Type 3 - a full-thickness defect involving the supraspinatus ,infraspinatus ,and subscapularis tendons.

The tear size seen at surgery was related to age at the time of repair

Eighty per cent of the repairs of a tear involving only the supraspinatus tendon were intact at the time of the most recent follow-up, while more than 50 per cent of the repairs of a tear involving more than the supraspinatus tendon had a recurrent defect. 

Older patients and patients in whom a larger tear had been repaired had a greater prevalence of recurrent defects. 

At the time of the most recent follow-up, most of the patients were more comfortable and were satisfied with the result of the repair, even when they had sonographic evidence of a recurrent defect.

The shoulders in which the repaired cuff was intact at the time of follow-up had better function during activities of daily living and a better range of active flexion (129 +/- 20 degrees compared with 71 +/- 41 degrees) compared with the shoulders that had a large recurrent defect. Similar correlations were noted for the range of active external and internal rotation and for strength of flexion, abduction, and internal rotation. 

In the shoulders in which the cuff was not intact, the degree of functional loss was related to the size of the recurrent defect.

The function of the patients who had an intact cuff after repair of a large tear was as good as that of the patients who had an intact cuff after repair of a small tear.

Comment: This study is of interest because of the detailed correlations examined among patient age, tear size, repair integrity at five years and function at five years after surgery.
It is also of interest that this study was published in 1991, bringing up the question "are current methods of cuff repair yielding results that are equal to or superior to those achieved over 25 years ago?"

For further information on our management of cuff tears, see this PDF on rotator cuff surgery.

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.

Monday, July 8, 2019

Reverse total shoulder - the risk for infection

Reverse shoulder arthroplasty has a higher risk of revision due to infection than anatomical shoulder arthroplasty 17 730 PRIMARY SHOULDER ARTHROPLASTIES FROM THE NORDIC ARTHROPLASTY REGISTER ASSOCIATION

These authors used the Nordic Arthroplasty Registry database to estimate cumulative rates and relative risk of revision due to infection after shoulder arthroplasty in 17 730 primary shoulder arthroplasties and an average of three years nine months after surgery.

188 revisions were reported due to infection during a mean follow-up of three years and nine months. The ten-year cumulative rate of revision due to infection was 3.1% for all reverse shoulder arthroplasties and 8.0% for reverse shoulder arthroplasties in men.

It is of interest that many of these revisions took place years after the index procedure.

Young paitients, those with fracture related problems and those with cuff tear arthropathy had significantly higher risks of revision for infection.

Comment: In this large experience, more than one in twelve patients having a reverse total shoulder had a revision for infection.

This article does not report the way the shoulders were evaluated for infection or the organisms responsible for the infections. However, the increased rate of revision for infection in young male patients suggests that Cutibacterium may have been the causative organism in many of them.

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.

Massive rotator cuff tear and the smooth and move

As demonstrated in the prior post, our experience with the smooth and move procedure in individuals with massive cuff tears and retained active elevation has revealed that most of these individuals regain durable shoulder function.

Recently we saw a man 12 years after a smooth and move procedure for a cuff defect extending from the upper aspect of the subscapularis all the way across to the lower third of the infraspinatus.

His preoperative MRI is shown here

He dropped by the office to show us his shoulder function and gave us the opportunity to obtain and share this video.

He rated his shoulder as 10 out of 12 on the Simple Shoulder Test, his two "no" responses were (1) unable to throw 20 yards overhand with this non-dominant shoulder and (2) unable to lift 8 pounds over head.

We continue to favor this procedure instead of patch grafting, superior capsular reconstructions, or reverse total shoulder for individuals with massive cuff tears and retained active elevation.

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.

Massive rotator cuff tears - does superior capsular reconstruction have a role?

Superior Capsular Reconstruction for Massive Rotator Cuff Tears A Critical Analysis Review

The title of this article on superior capsular reconstruction (the insertion of material between the humeral head and acromion)

 states that it is a "critical analysis review".

It points out that the cost of this procedure is very high

and points out that no comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction to other methods of treating massive rotator cuff tears.

Remarkably this critical review does not identify the indications for this procedure. The review includes the results from patients that had an average of over 130 degrees of active elevation before the procedure.

As we have pointed previously, a much more cost-effective procedure for massive cuff tears with retained active elevation is the smooth and move procedure.

Significant improvement in patient self-assessed comfort and function as early as six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation

These authors point out that it has been previously  documented that the smooth and move procedure—smoothing the proximal humeral surface while maintaining the coracoacromial arch—can provide clinically significant long-term improvement in function for patients having irreparable rotator cuff tears with retained active elevation (see previous blog post that is reproduced below).

In this study they sought to demonstrate that clinically significant gains in comfort, function, and active motion can be realized as early as 6 weeks after this procedure. They conducted a prospective cohort study of the 6-week clinical outcomes for 48 patients enrolled prior to a smooth and move procedure for irreparable rotator cuff tears. Prior rotator cuff repair had been attempted in 28 (70%).

In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID).

The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus.

In 30 patients with preoperative and 6-week postoperative objective measurements of active motion, the average abduction improved from 93(± 43) to 123(± 47)° (p = 0.005) and the average flexion improved from 102(± 46) to 126(± 44)° (p = 0.023).

They concluded that in addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.

They present the case example of a 71 year old physician photographer with a failed prior cuff repair attempt. Here is the preoperative radiograph
At surgery he had no supraspinatus or infraspinatus. The debris shown below was removed from his humeroscapular motion interface

This video (used with permission of the patient) shows his function 6 weeks after surgery.

Eight weeks after surgery he was photographing north of the Arctic Circle. Here's one of his photos.

This study should be considered along with a prior study, which is discussed below.

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.

The typical pathology in these cases is shown in the figure below.

The surgical approach is through a deltoid splitting incision that preserves the deltoid origin, the acromion and the coracoacromial ligament.

The coracoacromial arch is preserved to avoid the complication of anterosuperior escape that is commonly encountered when acromioplasty is performed in the presence of a large cuff tear.

The surgery includes smoothing of the prominence of the greater tuberosity that is exposed in cuff tears along with resection of adhesions in the humeroscapular motion interface and a gentle manipulation under anesthesia to resolve the stiffness that is commonly associated with chronic cuff tears. Immediate active assisted and active motion are encouraged immediately after surgery. Because no repair or reconstruction has been performed, activities, including deltoid strengthening can be resumed as soon as they are comfortable. 

They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery. The patient data are shown below, contrasting the patients that did and did not improve by the MCID of 2 in the Simple Shoulder Test

In 77 shoulders with previously unrepaired irreparable tears, Simple Shoulder Test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. 

For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.

They provided this case example. A rancher in his mid 60s had a right rotator cuff reconstruction with freeze-dried acellular human dermal collagen tissue matrix that subsequently became infected. He presented to us with a painful stiff right shoulder. At surgery there was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. He had a smooth and move procedure at which time the abundant scar in the humeral scapular motion interface was debrided. The previous sutures and Graft Jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. A manipulation under anesthesia was performed to assure a full passive range of motion. Passive and active range of motion exercises were started immediately after surgery. Three years later he reported excellent shoulder comfort and function and sent us this photo of his return to one of his favorite activities

They concluded that smoothing of the humeroscapular interface can durably improve symptomatic shoulders with irreparable cuff tears and retained active elevation > 100 degrees. They point out that this conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

Comment: Currently surgeons are actively pursing a variety of methods for managing patients with symptomatic irreparable rotator cuff tears, including marginal convergence, patch grafts, superior capsular reconstructions, degrading subacromial 'balloons' tendon transfers and reverse shoulder arthroplasty. Each of these procedures is more complex than the smooth and move procedure described in this article and none offers the opportunity for immediate postoperative resumption of active use of the shoulder.

These results from 151 patients having the smooth and move procedure can be contrasted to those from 24 patients having a 'superior capsular reconstruction' using an 8 mm fascia lata graft harvested from the patients thigh have been reported by Mihata et al (see this link). After the superior capsular reconstruction it is recommended that an abduction pillow be used for 4 weeks after the reconstruction with active exercises not started until 8 weeks after surgery.

Of note is that standard dermal grafts that used instead of fascial lata are often <2mm depending on the company selling them.

While future clinical research will hopefully clarify the indications for the superior capsular reconstruction and other more complex procedures, the advantages of the smooth and move procedure lie in its simplicity, its avoidance of tissue autograft or commercially available decellularized dermal allograft, its lack of postoperative 'down time', its high rate of durable improvement, and the fact that it does not preclude other surgical options should it fail to yield the desired result.

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.

Sunday, July 7, 2019

Shoulder joint replacement arthroplasty - what are the complications?

Outpatient shoulder arthroplasty: outcomes, complications, and readmissions in 2 outpatient settings

These authors reported their experience with outpatient shoulder arthroplasty including 90-day complications and readmissions in 50 consecutive patients (44 anatomic total shoulder arthroplasties, 4 reverse total shoulder arthroplasties, and 2 hemiarthroplasties).  18 had had a total of 28 prior surgeries, including 4 labral repairs, 2 Latarjets, 3 capsular shifts, 4 cuff repairs, 5 debridements, and 9 others.

The average age was 56.9 6.9 years; average body mass index, 29.75 5.9; and average Charleston Comorbidity Index, 1.6 1.2. 

All patients received an interscalene block for regional anesthesia (an indwelling catheter, used at the discretion of the surgeon, remained for 48-72 hours in most cases). All arthroplasties were performed through the deltopectoral interval, with 8 patients undergoing a tenotomy and 42 undergoing a subscapularis peel. Rehabilitation protocols varied based on surgeon and type of arthroplasty. In general, all patients were kept in a sling for 6 weeks, with HA and TSA patients allowed to perform Codman exercises and supervised limited passive range of motion with physical therapy, whereas RTSA patients were limited to Codman and basic home exercises. At 6 weeks, active range of motion was initiated, with strengthening at 12 weeks. RTSA patients received physical therapy at the discretion of the attending surgeon.

The average functional scores and ranges of motion were improved. There were 6 complications (12%) (hematoma, deep venous thrombosis, axillary nerve injury, acute infection, and 2 subscapularis failures). Four of these occurred within the 90-day global period, and only 1 patient required readmission. The subscapularis failures occurred after 3 months postoperatively and required additional surgery (arthroscopic repair and revision to reverse total shoulder arthroplasty). 

Comment: These procedures were performed in the outpatient setting. These experienced surgeons carefully report the complications among 50 carefully selected patients. They observe that the key to safe and successful outpatient shoulder arthroplasty is patient selection, noting that complications, length of stay, and readmission rates increase with age, female sex, steroid use, and comorbidities (especially cardiac disease).

None of their complications appear to be related to the fact that these surgeries were performed in the outpatient setting. 

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.

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'