Monday, June 29, 2015

Reverse total shoulder - what outcome score to use?


Assessment of the optimal shoulder outcome score for reverse shoulder arthroplasty

These authors used a database of 148 patients having reverse total shoulders to compare preoperative and postoperative Constant-Murley Scores, American Shoulder and Elbow Surgeons Scores, and Subjective Shoulder Values.

They found no significant differences in the mean improvement between the scores.  Multivariate regression analysis the 3 outcome measures was able to predict 38.9% of the variation in improvement in forward elevation.

The authors concluded that the 3 shoulder outcome scores, regardless of whether they were patient reported or physician based, appear to appropriately reflect improvements after RSA with equal validity.

Comment:  This study demonstrates that various outcome instruments can show the benefit of reverse total shoulder arthroplasty. So what is there to choose among them?

It seems to us that the goals of outcome scores are (1) to enable each surgeon to track his/her results so that those patients failing to improve can be identified and the reasons for those failures investigations and (2) to enable different surgeons to compare and contrast results with different surgical approaches for different pathologies.

Keeping in mind that there is a cost with administering and analyzing each score in each patient, we have sought to optimize the benefit / cost ratio for outcome assessment. This consistently leads to the Simple Shoulder Test, a test that is patient-derived, sensitive, validated, short (12 questions), easy to administer and covers the range of complaints of individuals with shoulder disorders. For fun, compare the effort needed to administer the Constant Score or the ASES score and decide if there is enough incremental value (if any) of these instruments to justify the increased cost of administration and analysis.

The use of the Simple Shoulder Test in evaluating reverse total shoulders is illustrated in the articles below:

What is a Successful Outcome Following Reverse Total Shoulder Arthroplasty?

Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years.

The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture





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Subacromial 'impingement' - it's the way the shoulder normally works!


Which shoulder motions cause subacromial impingement? Evaluating the vertical displacement and peak strain of the coracoacromial ligament by ultrasound speckle tracking imaging

These authors studied 16 normal male shoulders (average age 28.6 years). They measured the vertical displacement and peak strain of the coracoacromial ligament by a motion tracing program during these active motions: (1) forward flexion in the scapular plane, (2) horizontal abduction in the axial plane, (3) external rotation with the arm at 0° abduction (ER0), (4) internal rotation with the arm at 0° abduction (IR0), (5) internal rotation with the arm at 90° abduction (IR90), and (6) internal rotation at the back (IRB).

An experienced sonographer examined the shoulders using 2-dimensional speckle tracking echocardiography (2D STE). Dynamic ultrasonography with the motion tracking program was used to evaluate the vertical displacement and peak strain of the coracoacromial ligament during the active motions. The coracoacromial ligament was identified with the ultrasonographic transducer placed perpendicular to the skin between the coracoid process and the acromial tip. The coracoacromial ligament was traced throughout each shoulder motion. The vertical displacement of the coracoacromial ligament with various degrees of superior bulging away from the surface of the rotator cuff could be seen, and degree of vertical displacement was measured from the vertex of the coracoacromial ligament convexity to a line connecting the acromion and coracoid process. The longitudinal peak strain of the coracoacromial ligament was calculated by the horizontal fractional change. 

The mean vertical displacement of the coracoacromial ligament during forward flexion (2.2 mm), horizontal abduction (2.2 mm), and IR90 (2.4 mm) was significantly greater than that during the other motions (ER0, −0.7 mm; IR0, 0.5 mm; IRB, 1.0 mm; P < .003). The mean peak strain was significantly higher in forward flexion (6.88%), horizontal abduction (6.58%), and IR90 (4.88%) than with the other motions (ER0, 1.42%; IR0, 1.78%; IRB, 2.61%; P < .003).

The authors concluded that normal shoulders without any pathologic change could result in physiologic contact beneath the coracoacromial ligament. The coracoacromial ligament was vertically displaced during some shoulder motions in all subjects. These findings indicate that there is physiologic contact between the coracoacromial ligament and the rotator cuff in normal shoulders.

Comment: This is a very interesting and important study. It demonstrates that loading of the coracoacromial ligament by the subjacent rotator cuff occurs in normal movements of the normal shoulder. Nature's design is marvelous in that rather than having a rigid unyielding bony bridge between the coracoid and the acromion, the coracoacromial ligament provides a conforming 'spring' ligament between these two structures that can accommodate loading by the cuff and minor variations in the shape of the proximal humeral convexity.

 In previous studies, we have demonstrated the loading of the coracoacromial arch by the rotator cuff in vivo and in vitro. Superiorly directed forces are applied to the coracoacromial arch by the subjacent rotator cuff (for example when pushing down on the arms of a chair to stand).

Loss of the coracoacromial ligament by surgery to 'decompress' the rotator cuff can result in anteriorsuperior escape.

Contact between the cuff and the ligament, "impingement", is normal!

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Rotator cuff tears - how do they heal: the role of vascularity at the footprint


Does microvascularization of the footprint play a role in rotator cuff healing of the shoulder?


These authors sought to evaluate the relationship between bone microvascularization of the footprint and tendon integrity after a single-row repair of chronic cuff tears in 48 patients (mean age, 59 years; ±7.9). Microvascularization was assessed using immunohistochemistry on core samples obtained from the footprint area of the tuberosity during the procedure. Clinical evaluation was performed at a minimum of 12-months; rotator cuff integrity was assessed with ultrasound.

Ultrasound identified 18 patients with Sugaya type I healing, 27 patients with type II healing, and 3 patients with retears (Sugaya type IV). The rate of microvascularization of the footprint was 15.6%, 13.9%, and 4.2% for type I, II, and IV tendon integrity, respectively (I vs. II, P = .22; II vs. IV, P = .02; I vs. IV, P = .0022). Patients with a history of corticosteroid injection had a lower rate of microvascularization than the others (10.3% vs. 16.2%; P = .03).

They concluded that a lower rate of microvessels decreases the tendon integrity and healing potential after repair.

Comment: This paper emphasizes the important role that vascularity of the bone at the insertion site plays in healing of a rotator cuff repair. Because of the relatively poor vascularity at the edge of a torn rotator cuff tendon, it appears likely that the healing response - notably the ingrowth of micro vessels as well as stem cells and growth factors - comes from the bone at the insertion site. This response would seem to be enhanced by burring the bone, micro fracture or creating a trough at the insertion site. One might also expect that the use of cautery to clean the insertion site may result in poorer healing.

The adverse effect of subacromial corticosteroid injections on the microvascularization at the footprint is worthy of note. This is consistent with the known effects of steroids on tissue quality.

The number of retears in this study was small and did not offer the opportunity to statistically correlate patient age, tear duration, tear size, sex and other factors with footprint vascularity.



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Sunday, June 28, 2015

Ream and run shoulder arthroplasty - what it takes to get a super result

Our experience is that super results after the ream and run come from super effort by the patient in the rehab program. The high achievers routinely report that, "I have not missed even one of my five daily exercise sessions in the 6 weeks since my surgery."

Here's an example of a person 6 weeks out from a ream and run. At the time of the visit the patient was eager to show off his range of motion and photo documentation of his rehabilitation program. He followed up his visit with this email, 

"Thank you for the great six week appointment. I am so excited about my progress over the six week period, it has been a true journey though. I have attached some photos of my wall chart, accountability chart, floor video and how I use my IPad to watch my progress during my stretching. These items have played a large success in my stretching and my ability to stay accountable every day.
You have my permission to use these photos and video as you wish. Have a great weekend."


Wall Chart (note pulley at left)


Wall Chart #2


Floor Chart


Workout Schedule


IPad


Video - the results at six weeks speak for themselves!




Basically, the key is getting 150 degrees or more of forward elevation. 


One of our friends suggested an easy way to illustrate the angles.

Take a piece of paper 



and fold the upper right corner down to the bottom edge so that it looks like this, making a 135 degree angle between the upper edge and the horizontal



Fold the upper edge down on the lower edge, making a 157 degree angle as shown below.





This is essentially the same angle as that between the arm and the floor shown in the photo below, which was sent in by a patient 6 weeks after a ream and run procedure.





Note that it is important that the back not be arched, but rather remains flat on the floor. We encourage our patients to send photos taken from this perspective so that we can be assure that the desired motion is taking place.


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Reverse total shoulder - failure by glenosphere dissociation from base plate

A colleague sent us this instructive case:

A patient had a reverse total shoulder as shown below:



At six weeks the shoulder was functioning well and had this x-ray appearance:



Eight months after surgery, while doing some upper extremity exercises, the patient noted pain over the lateral shoulder and clicking on motion. x-rays at that time demonstrated dissociation of the glenosphere from the baseplate:


A CT scan was also obtained:


Comment: The key x-ray view is the one taken at 6 weeks, showing that glenoid bone above the base plate prevented complete seating of the glenosphere allowing it to dissociate as the subsequent films demonstrate.




We have previously discussed the issue of glenosphere dissociation as shown in this link, emphasizing that bone and soft tissue can prevent compete seating of the glenosphere.

Our current reverse total shoulder technique is shown in this link.

Seems as though glenosphere dissociation is being describe more commonly:

Glenosphere disengagement in a reverse total shoulder arthroplasty with a non-Morse taper design.


Sunday, June 21, 2015

Some orthopaedic surgeons have attitudes that have been characterized as being 'hazardous".

How prevalent are hazardous attitudes among orthopaedic surgeons?

The Federal Aviation Administration and the Canadian Air Transport Administration have defined "hazardous attitudes" (macho, impulsive, antiauthority, resignation, invulnerable, and confident). These attitudes have been associated with road traffic incidents among college-aged drivers and aviation accidents. These authors surveyed a cohort of orthopaedic surgeons to determine the following: (1) What is the prevalence of these attitudes in a cohort of surgeons? (2) Do practice setting and/or demographics influence  these attitudes in this cohort of surgeons? (3) Do surgeons feel they work in a climate that promotes patient safety?

They asked 364 members of practicing orthopaedic and trauma surgeons from around the world to complete (1) a questionnaire validated in college-aged drivers measuring six attitudes associated with a greater likelihood of collision and used by pilots to assess and teach aviation safety and (2) a questionnaire assessing the absence of a safety climate that is based on the patient safety cultures in healthcare organizations instrument. 

137 of the 364 surgeons had at least one score that would have been considered dangerously high in pilots, including 102 with dangerous levels of macho (28%) and 41 with dangerous levels of self-confidence (11%). The variables most closely associated with a macho attitude were supervision of surgical trainees in the operating room; location of practice in Canada, Europe, and the United States; and being an orthopaedic trauma surgeon (when compared with general orthopaedic surgeons). However these factors accounted for only 5% of the variance. On average, 19% of surgeon responses implied absence of a safety climate.

Comment: It is not known if these attitudes are associated with adverse surgical outcomes. Certainly, one of the attitudes, 'confidence' and 'supervision of surgical trainees in the operating room' must be common among the best and safest surgeons and may not by themselves lead to increased rates of adverse outcomes.

Because of the importance of patient safety and the multiple factors that contribute to it, we suggest that each organization needs to implement a system that seeks to identify the relationship of adverse outcomes to variations in surgeon attitude, experience and skill.
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Shoulder joint replacement arthroplasty - do short stems offer an advantage?


These authors reviewed the radiographs of 44 shoulder arthroplasties using a short uncemented humeral stem of which 6 shoulders (14 %) showed features of stress shielding at the medial cortex.



Comment: While it is suggested that this prosthesis is bone conserving, cementless and facilitating of revision, it may carry the risks of creating a stress riser at the tip of the stem and of producing bone resorption of the unloaded bone proximal to the tip.

We have previously posted on the potential problems of "shorty" prostheses here.

Our preference is to minimize the risk of stress shielding and periprosthetic fracture by using impaction grafting to secure the humeral prosthesis without contacting the cortex. As shown in the two year postoperative films below, this approach preserves bone and enables easy prosthesis removal should that ever become necessary.




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