Friday, September 14, 2018

What might be learned from this failed total shoulder?

A middle aged patient presented with pain and clicking in the shoulder after a prior total shoulder joint replacement. 
The x-ray below shows that a large sized stem incarcerated in the humeral diaphysis preventing full seating of the humeral component. As a result the humeral head rested on the superior aspect of the glenoid giving rise to rocking horse loosening of the glenoid component. The keeled glenoid component had been inserted with a lot of cement so that when the loose component was removed a large defect in the glenoid bone was left. 


Rocking horse loosening from eccentric loading is a common contributor to glenoid component failure.  A smaller stem fully inserted and fixed with impaction grafting may have avoided humeral component malpositioning. Using a pegged glenoid component inserted with minimal cement may have reduced the amount of glenoid bone loss.
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Saturday, September 8, 2018

Management of the possibly infected shoulder joint replacement - the red and yellow protocols

We've had a number of requests for an update to our approach to revision shoulder arthroplasty, recognizing that the rate of infection in these cases is high. See prior related post here and a diagram of the protocol here.


Considerations in revision arthroplasty

I. Obvious infection
Typical characteristics
Draining sinus
Classic signs (fevers, chills, erythema, elevated WBC, ESR, CRP)
Massive osteolysis
Gross purulence

Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Treat with explant of all components, vigorous debridement and irrigation, topical antibiotics, lightly fixed antibiotic spacer and IV antibiotics via PICC line X 6 weeks; initially ceftriaxone and Vancomycin. Antibiotics modified according to culture results. 6 months oral antibiotics after IV course complete. At 6 months can consider reimplantation of prosthesis               

II. High suspicion for stealth infection – red protocol
                   Typical characteristics
Honeymoon period (onset of otherwise unexplained pain and stiffness after a period of usual post op course ranging from months to years)
                                      Patient at increased risk: young active male patient with prior surgery
                                      Rest pain
                                      Loose components (especially early humeral loosening), osteolysis
                                      Synovitis, >5 wbc/hpf, cloudy joint fluid, humeral membrane

Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Treat with explant of all components, vigorous debridement and irrigation, topical antibiotics, single stage exchange to impaction allografted hemiarthroplasty and IV antibiotics via PICC line X 6 weeks; initially ceftriaxone and Vancomycin. Antibiotics modified according to culture results. 6 months oral antibiotics after IV course complete. If cultures negative at 3 weeks consider discontinuing antibiotics.

III. Lower suspicion for stealth infection – yellow protocol
                   Typical characteristics                   
Female patient
                                      No osteolysis
                                      Pain only with activity
                                      Suspect prosthesis failure is strictly mechanical

Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Prosthesis revision as indicated by surgical findings. Oral antibiotics (Doxycycline or Augmentin) for 3 weeks. Antibiotics modified according to culture results. If cultures are positive and if revision fails to produce a satisfactory clinical result, consider repeat surgery with red protocol or spacer.

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Saturday, August 25, 2018

Outcomes of rotator cuff repair - what's important? What about integrity of the repair?

Predictors of pain and functional outcomes after operative treatment for rotator cuff tears

These authors assessed the predictors of pain and functional outcomes in a longitudinal cohort of 50 patients undergoing operative treatment for rotator cuff tears from March 2011 to January 2015.  Patients completed Shoulder Pain and Disability Index (SPADI) questionnaires at 3, 6, 12, and 18 months.

They found that lower Fear-Avoidance Beliefs Questionnaire physical activity score (P = .001) predicted a lower SPADI score (better shoulder pain and function). Those consuming alcohol 1 to 2 times per week or more had lower SPADI scores than those consuming alcohol 2 to 3 times per month or less (P = .017). 

Variables that were not significant predictors of SPADI included sociodemographic characteristics, preoperative magnetic resonance imaging characteristics, such as tear size and muscle quality, shoulder strength, and variations in surgical techniques (single row, double row, transosseous equivalent, performance of biceps surgery).

Comment: The design of this study is curious. In that the goal of cuff repair is to restore the integrity of the cuff tendons to the tuberosity, it would have seemed essential to assess the integrity of the repair at followup among the "comprehensive set of potential" "predictors of pain and functional outcomes" after surgery.  

The association of greater alcohol consumption with less self-assessed pain and functional limitation does not seem to support the concept that those consuming more alcohol are better candidates for surgery (as the article seems to suggest).

A few other questions come up:
 is the SPADI in common enough use in cuff surgery to enable comparison of the results with other studies?
 is the Fear-Avoidance Beliefs Questionnaire physical activity score a common and comparable instrument for assessing physical activity (better than the SF36, for example).  

Does this article indeed help us predict the pain and functional outcomes after operative treatment for rotator cuff tears?

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Rotator cuff tears, the critical shoulder angle and a bunch of other angles - do they matter?

Shoulder surgeons have been busy measuring angles on images of patients with and without rotator cuff disease. Here are eight examples where the authors have found higher rates of cuff disease when the measured angle is above or below a certain value:



Critical shoulder angle >35 degrees (see this link)



Greater tuberosity angle >70 degrees (see this link)


Acromial angle > 25 degrees (see this link)


Lateral acromial angle < 70 degrees (see this link)



Superior glenoid inclination angle > 9 degrees (see this link)


Acromial arch angle > 120 degrees (see this link)


Acromiohumeral centre edge angle >20 (see this link)


Decreased coracoid inclination angle (see this link)


A few questions arise about these measurements (see this link):

(1) What is their clinical utility, i.e. in this era of high quality MRI and ultrasound do these measurements affect clinical decision making?
(2) Do differences in these angles between shoulders with and without cuff disease suggest that the morphology reflected by the angle caused the cuff problem or is it likely that the cuff problem caused the morphology reflected by the angle?
(3) While it can be accomplished (see this link) is there evidence that surgically modifying these angles will change either the likelihood of subsequent cuff disease or the outcome of cuff repair surgery?
(4) Do these measurements matter? Contrast "Large Critical Shoulder Angle Has Higher Risk of Tendon Retear After Arthroscopic Rotator Cuff Repair" with "Critical Shoulder Angle and Acromial Index Do Not Influence 24-Month Functional Outcome After Arthroscopic Rotator Cuff Repair"

In our practice, we do not find that these measurements are of value in the treatment of our patients. The facts remain that
(1) Older patients with atraumatic cuff tears are less likely to benefit from rotator cuff repair surgery than their younger counterparts with traumatic cuff tears.
(2) Shoulders with inadequate cuff tendon quantity and quality have less chance of being durably reparable.
(3) The literature does not provide evidence that modifying the acromion is an important aspect of the treatment of cuff disease (see this link).
(4) Irreparable cuff tears in shoulders with retained active elevation can be well treated with a smooth and move procedure (see this link).
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Friday, August 24, 2018

Return to sport after shoulder arthroplasty for post fracture deformity

Today we received this email from a woman treated three years ago for a post fracture proximal humeral deformity


The hemiarthroplasty was performed with an impaction grafted humeral body and a posteriorly eccentric humeral head to manage the posterior offset of her malunited fracture.

 Three years after surgery she reports on her participation in the Alaskan International Senior Games: "Well worth the 640 mile drive! The Diehards, plus 2 spouses, have a medal total of 20. And the good news is I'm "aging up" next year into the 70-74-years-old category, so my developing sprint running talent will do even better. I'm not a fast swimmer, but my 100-yard backstroke, the true test of well-functioning shoulders, got me a gold. And before we left, I found a bronze medal in a scrapbook my mother kept for me. It was inscribed: "AAU shotput 1965." Fifty-three years later I got a silver medal in the shotput, and I'm still improving. Thanks again, so great to be able to depend on that shoulder! Thinking of the national games next."

This is only part of the story of this highly motivated woman, who is also a pianist, flutist, and Zumba instructor.

Comment: This is yet another example of the use of a basic solution to a potentially complex problem.

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Sunday, August 12, 2018

Reverse total shoulder failure from baseplate loosening

Incidence and risk factors for aseptic baseplate loosening of reverse total shoulder arthroplasty

These authors analyzed 202 shoulders that underwent primary or revision RTSA using 1 implant system and evaluated baseplate loosening at a minimum 2-year follow-up. They found that baseplate loosening occurred in 6 shoulders (3.0%). 

Four of the cases of baseplate failure occurred in the 39 revision RTSAs (10%) while only 2 occurred in the 163 primary arthroplasties (1.2%). 

Five of the cases of baseplate failure were among the 25 patients receiving structural bone graft.

Two of the cases of baseplate failure were among the 11 patients who did not have fixation with all locking screws. 




Comment: These data suggest that in this individual surgeon, individual prosthesis design series, baseplate failure was associated with inferior quality of glenoid bone (resulting from prior failure or necessitating bone graft or non-locking screws.

In the two examples from the article shown above, it is evident that the failure results from an upwards directed force applied to the laterally offset glenosphere by the humeral component. As emphasized in this article, Factors affecting fixation of the glenoid component of a reverse total shoulder prothesis, this force is best resisted by secure screw fixation and by solid contact between the upper aspect of the baseplate and the carefully prepared native glenoid bone.

The rates of complications after an arthroplasty are related to the patient, the prosthesis, and the physician performing the surgery. Here we have an analysis of 202 of 256 shoulders treated between 2008 to 2014 by an individual surgeon using an individual reverse total shoulder design. We can anticipate that the rate of complications, such as baseplate failure, in these experienced hands would be less than in the hands of less experienced surgeons. In fact a recent article Analysis of 4063 complications of shoulder arthroplasty reported to the US Food and Drug  Administration from 2012 to 2016, found that baseplate failure was the fourth most common cause of failure among 2390 revised reverse total shoulders:

The difference is that the data in the table above represent cases from occasional as well as from frequent shoulder arthroplasty surgeons.

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Failed shoulder arthroplasty with posterior instability.

Revision anatomic shoulder arthroplasty with posterior capsular plication for correction of posterior instability {Journal of Orthopaedic Surgery 26(3) 1–9 2018}.

These authors reported the clinical and radiographic outcomes, complications, and reoperations of posterior capsular plication (PCP) performed in 16 revision anatomic shoulders performed between 1975 and 2013.

Indications for revision arthroplasty included posterior instability in 15, glenoid loosening in 3, polyethylene wear in 2, and glenoid erosion in 1 shoulder. 

At the last follow-up, nine shoulders (56%) had absence of posterior radiographic subluxation. Five (31%) cases underwent reoperation due to persistent posterior instability. Complications were observed in seven (44%) cases. Complete pain relief was achieved in four (25%) shoulders. 
Results were excellent in two (13%), satisfactory in seven (44%), and unsatisfactory in seven (44%) shoulders.

The authors concluded that PCP to correct posterior instability during revision anatomic shoulder arthroplasty had an unacceptably high failure rate. 

Comment: What is especially interesting is that in these 16 cases, glenoid retroversion was felt to contribute to the posterior instability in only one, and that shoulder had 70 degrees of humeral retroversion combined with 30 degrees of glenoid retroversion.


We agree with the authors that posterior capsular plication is often not a robust technique for managing posterior instability. We prefer instead the use of an anteriorly eccentric humeral head component and rotator interval plication.





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