Saturday, October 14, 2017

Ream and run for chondrolysis in a young woman - two year outcome

An athletic young woman in her mid 20s was diagnosed with multidirectional instability of her right shoulder. She was treated by surgeons in another state with an arthroscopic anterior and posterior capsulorrhaphy. Three years later she had a repeat surgery after which a pain pump was used to infuse local anesthetics. Eight years later she had a subacromial decompression and biceps tenodesis. At that time glenohumeral chondromalacia was identified. The shoulder was debrided and the repair sutures removed. Five months later another subacromial decompression was performed along with a distal clavicle excision. She had persistent stiffness and pain. At the time of her presentation to us - twelve years after her first surgery - she had flexion limited to 90 degrees, pain ranging from 7-10 on a scale of 10, and reported the inability to perform any of the twelve functions of the Simple Shoulder Test

Her x-rays  show the characteristic appearance of chondrolysis (see this link).




After a thorough discussion of the alternatives, she elected to proceed with a ream and run procedure. Here are her postoperative films.




Although her motion was improved at 6 weeks after surgery, she and her local orthopaedic surgeon decided to proceed with a manipulation under anesthesia in that she had lost some of her early range of motion.

She demonstrated the highest level of dedication to her rehabilitation program, taking it to trackside. 

She has generously allowed us to post some of her photos here.

Here are the photos she sent in at 4 months after surgery, stating that she can now perform 8 of the 12 functions of the Shoulder Test in contrast to 0/12 before surgery.



She is now two years out from the procedure and fully functional as shown by these images she recently sent to us along with this message "Today is my two year anniversary of my ream and run surgery! We did it! I am so happy and proud to say that my shoulder feels better and stronger than it has in 15 years, since before my very first surgery in 2003! Thank you both from the bottom of my heart for giving me the chance at a much greater quality of life! Aloha, "

She adds "I can now perform all 12 functions of the Simple Shoulder test :) (the 8lb one is challenging but I can do it!)" 





It reminds of the important principle: "it is the patient and not the shoulder that we're treating".  In this case the patient was incredibly motivated and worked to earn her result.

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Wednesday, October 11, 2017

Ream and run for severe capsulorrhaphy arthropathy with retroversion

A man in his mid sixties presented with painful stiffness of the right shoulder after a stabilization procedure performed many years ago. He could perform only 1 of 12 of the functions of the Simple Shoulder Test. Here are his preoperative films showing severe arthritis and a retroverted glenoid.



He elected to have a ream and run procedure. At two and a half years after the procedure he can perform all of the SST functions. X-rays at that followup are shown below.



His shoulder motion is shown here.

video

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Ream and run for arthritis with severe posterior decentering

A 50 year old active man presented with pain, stiffness and posterior instability of his right shoulder. He could perform only 5 of the 12 functions of the Simple Shoulder Test.
His AP x-ray showed 'ordinary' arthritis.
 However his axillary 'truth' view showed essentially 100% posterior decentering of the the humeral head on a posteriorly eroded glenoid. This is another of those glenoids that doesn't fall neatly into a 'type' - the native glenoid was not retroverted, the head was decentered and there was a posterior pathologic concavity.
He elected to have ream and run. An anteriorly eccentric humeral head and a rotator interval plication were used to manage the severe posterior instability.  His postoperative films are shown below.


The morning after surgery he was off all narcotic medications and busy with his stretching exercises, having no feelings of posterior instability.





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Patient specific instrumentation - does it add value to total shoulder arthroplasty?

Patient-specific instrumentation for total shoulder arthroplasty: not as accurate as it would seem

These authors sought to assess the effectiveness of total shoulder arthroplasty patient-specific instrumentation in improving positioning of the glenoid component.

Eleven consecutive TSAs (7 TSAs and 4 reverse TSAs) were performed using custom-made patient-specific positioning guides for the glenoid component using the Biomet Comprehensive TSR/PSI Glenoid. Preoperatively, each patient had a CT scan of the affected shoulder with the pre-established protocol using the Zimmer Biomet PSI Shoulder Planner software (Biomet). This protocol comprised coronal and sagittal localizers and high-resolution axial scans performed using an Aquilion PRIME 160-slice CT scanner. These data were then used to create a patient-specific positioning guide for the glenoid  component of the TSA. The guides were produced to allow 0° of glenoid inclination and version in anatomic TSAs and 10° of inferior inclination for reverse TSAs.



Preoperative glenoid types and versions are shown here




At one year after surgery for the conventional TSA group, the mean version was measured at 8° ± 10° retroversion and 1° ± 4° inclination. For reverse TSAs, mean version was 10° ± 10° retroversion and –1° ± 5° inclination. There were 5 cases classified as outliers in terms of version (>10° anteversion or retroversion). They observed a mean correction of version of 22° ± 9° and 17° ± 9° in inclination compared with preoperative measurements.

In their discussion, the authors provide a candid assessment of some of the issues regarding patient specific instrumentation in this group of shoulders with higher degrees of preoperative retroversion. Despite large corrections toward template neutral (or –10° inclination for reverse TSA), they were unable to fully correct the existing glenoid slope. They questioned the benefit of aiming for a neutral version in an anatomically retroverted glenoid. They found that this patient specific guidance system did not allow controlled reaming, and so the depth of central guidewire placement was variable. Shallow guidewire placement could result in toggle and thus less accurate reaming and implantation. Finally, despite the use of guides that were custom designed to fit each patient, they did not know whether the obliquity of bone loss at the glenoid articular surface allowed slight loss of positioning during reaming and thus malpositioning. 

We are left with the question of the value of patient specific instrumentation. What is the incremental cost of its use? What is its effect on operating time? For which surgeons and for which patients might it be of benefit? What is the learning curve for use of this approach? And most importantly, what is its benefit in terms of improved clinical outcomes for the patient?


We've included below a reprise of a prior post demonstrating that routine "correction" of glenoid version, preoperative CT scans, and patient specific instrumentation may not be necessary in total shoulder arthroplasty.

A 76 year old man presented to us with severe right shoulder pain, stiffness and the x-rays shown below. While his AP view suggested straightforward osteoarthritis

his axillary, 'truth' view showed what is known as the 'severe arthritic triad': glenoid retroversion, glenoid biconcavity, and posterior decentering of the humeral head on the glenoid. No CT needed to define the pathoanatomy!



He elected to proceed with a total shoulder using a standard glenoid component. At surgery we reamed the glenoid to a single concavity without trying to change glenoid version. We used an anteriorly eccentric humeral component and a rotator interval plication to optimize posterior stability. Immediately after surgery he was started on the standard total shoulder rehabilitation program with continuous passive motion and assisted flexion. At six weeks he started the supine press and active flexion.

At four months he has a comfortable shoulder, no problems with instability, active flexion over 120 degrees, and is continuing his rehab.

His four month films are shown below.






While this is very short term followup, it does demonstrate that immediate postoperative glenohumeral stability can be achieved with this approach. To date we've not had problems with posterior instability using a standard glenoid component inserted in retroversion.

See also:
Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?
That study analyzed the two year outcomes in 71 TSAs, comparing the 21 in a "retroverted" group (the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°)) with the 50 in the "non-retroverted group" (the glenoid component was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°)). The results in the retroverted group were not inferior to those for the non-retroverted group. The mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%).  The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, - 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. The radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4-6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). The percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids (three of 50; [6%]; p = 0.251).

In conclusion, glenoid retroversion is a relatively common finding in arthritic glenohumeral joints coming to shoulder arthroplasty. Shoulders with preoperative glenoid retroversion tend to have poorer preoperative shoulder comfort and function, posterior decentering, and glenoid biconcavity, all indicating a more severe form of the disease. There is currently great interest in methods for managing this glenoid retroversion commonly found in osteoarthritic glenohumeral joints using posterior glenoid bone grafts, reaming the anterior aspect of the glenoid, and posteriorly augmented glenoid components. The first study reviewed above reports the result of shoulders managed by altering the glenoid version with a posterior humeral head autograft. The second study reviewed above reports the two year results of a more conservative approach in which minimal glenoid bone is removed by reaming and specific attempts to alter glenoid version are not used.

Here is the two year radiographic followup on a 55 year old patient from our practice. Preoperative films show a type B2 genoid with retroversion, biconcavity and posterior humeral subluxation.



Here are the 2 year films of this shoulder after conservative shoulder arthroplasty using a standard glenoid component without attempts to modify glenoid version. The humeral head is centered in the prosthetic glenoid. At two years after surgery the patient was able to perform all 12 functions of the Simple Shoulder Test.




Note that sufficient bone stock remains to perform a revision total or a reverse total shoulder arthroplasty shoulder these procedures become necessary in the future of this young person.

Long term followup of well-characterized patients treated with the different methods for managing glenoid retroversion will be required to define the relative risks, benefits, effectiveness and durability of each of them.


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Monday, October 9, 2017

Two stage revision shoulder arthroplasty – how often do we get to stage 2?

A paper entitled "STAGE 1 SHOULDER ARTHROPLASTY: RISK FACTORS FOR REPEAT STAGE 1, SPACER RETENTION AND MORTALITY" was presented at the 2017 open meeting of the American Shoulder and Elbow Surgeons (see this link).

These authors sought to provide the perspective from a national Medicare database on the the outcomes at one year following stage 1 shoulder arthroplasty revision for patients who underwent removal of an infected shoulder prosthesis and placement of an antibiotic spacer.

975 patients who underwent shoulder arthroplasty prosthesis removal and cement spacer placement for infection met all inclusion and exclusion criteria. Within 1 year postoperatively, 21 patients died (2.2%), 70 patients had a repeat stage I procedure (7.2%), 55 patients had a girdlestone-type procedure (5.6%), 349 patients retained their spacers (35.8%) and the remaining 480 patients had a shoulder arthroplasty re-implanted (49.2%)



Independent risk factors for death within 1 year following stage 1 revision included older age, alcohol use, coronary artery disease (CAD) and hemodialysis

Independent risk factors for repeat Stage 1 revision include younger age, morbid obesity, diabetes mellitus and coronary artery disease. 

Independent risk factors for no re-implantation within one year include female gender, older age, tobacco use, alcohol use and inflammatory arthritis.

Only half of patients underwent re-implantation. 

One third of patients retained their spacer and just less than 10% repeated a stage 1 procedure.

Comment: We surely look forward to the publication of the full paper that would include the details of the type of infection and the condition of the shoulder. However, this abstract does indicate that a two stage revision is not always completed, leaving the patient with either a spacer or a resection arthroplasty.


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