Monday, July 25, 2016

How can we control rising health care costs while still assuring optimal patient care?

Ethics of the Physician’s Role in Health-Care Cost Control

The United States health-care expenditure is rising precipitously. The Congressional Budget Office has estimated that, in 2025, at our current rate of increased spending, 25% of the gross domestic product will be allocated to health care. Our per-capita spending on health care also far exceeds that of any other industrialized country. Health-care costs must be addressed if our country is to remain competitive in the global marketplace and to maintain its financial solvency. If unchecked, the uncontrolled rise in health-care expenditures will not only affect our capacity to provide our patients with high-quality care but also threaten the ability of our nation to compete economically on the global stage. This is not hyperbole but fiscal reality.

As physicians, we are becoming increasingly familiar with the economics impacting health-care policy. Thus, we are in a unique position to control the cost of health care. This includes an increased reliance on creating and adhering to evidence-based guidelines. We can do this and still continue to respect the primacy of patient welfare and the right of patients to act in their own self-interest. However, as evidenced by the use of high-volume centers of excellence, each strategy adapted to control costs must be vetted and must be monitored for its unintended ethical consequences.

The solution to this complex problem must involve the input of all of the health-care stakeholders, including the patients, payers, and providers. Physicians ought to play a role in designing and executing a remedy. After all, we are the ones who best understand medicine and whose moral obligation is to the welfare of our patients.

Comment: This is such an important issue, yet many of our actions fail to address it: we continue to order tests that are not needed for the evaluation and management of the patient, we continue to develop and promote more complex and expensive technologies without evidence that they improve the outcome for the patient, and we continue to perform major surgeries in low volume settings, in spite of the evidence that this practice is associated with inferior outcomes. In our view, the issue is best addressed, not by a top-down set of directives, but rather by individual surgeons advocating decisions that are in the best interest of their patients and of the health care system of the nation.

==

Wednesday, July 20, 2016

Rotator cuff tears - non-operative and arthroscopic management

Clinical Outcomes of Conservative Treatment and Arthroscopic Repair of Rotator Cuff Tears: A Retrospective Observational Study.

These authors conducted a retrospective study of 357 symptomatic patients aged >50 years with either a high-grade partial-thickness or small-to-medium-sized (≤3 cm) full-thickness tear.

 183 patients received conservative treatment (various approaches including rest, PT, medication) and 174 patients received an arthroscopic repair. 



The pain assessment score (p<0.001) and the ROM in forward flexion (p<0.001) were significantly improved in both groups. The pain assessment score and ROM were not significantly different between the two groups. Retear was observed in 9.6% of patients who had an arthroscopic repair and tear progression was found in 6.7% of those who underwent conservative treatment. The proportion of aggravation for pain and ROM did not significantly differ between the two groups. The charts below compare the outcomes at 2-6 months (FU1) and one year (FU2).




The authors concluded that the effectiveness of conservative treatment was not inferior to arthroscopic repair for patients >50 years old with a less than medium-sized rotator cuff tear in a 1-year follow-up period. 

Comment: This was a retrospective study: patients were not randomized to the two groups. The treatment protocols were not standardized. However, the results are of importance in indicating that patients with these tears can improve with non-operative measures.

==

Tuesday, July 19, 2016

Why all these different approaches to fixation of the humeral component?

The month of July 2016 has featured many different approaches to fixation of the humeral head prosthesis to the humerus that we encountered in the last few weeks of our referral practice of revision surgery. Each of these revisions was technically challenging, but they have one thing in common: all revisions were accomplished using an impaction grafted smooth stem (making one wonder if that method of fixation might have been preferable for the primary procedure). 

The trabeculated stem shown the image below of a dislocated humeral prosthesis required humeral osteotomy for removal before insertion of an impaction grafted reverse shoulder prosthesis.

The resurfacing humeral component required removal in the revision of a failed glenoid component after which an impacting grafted smaller diameter smooth stem prosthesis was used.


 The press fit stem below wedged in the humeral diaphysis before it could be fully seated, resulting in rocking horse loosening of the glenoid component. It was revised with a smaller diameter impaction grafted stem.



 This 'canal preserving' short stem component required removal because of excessive stiffness and concern for infection.

It was revised to a standard stem length prosthesis without any additional bone removal (in fact with the addition of cancellous allograft).


Each of these revised humeral components present their own particular challenges. Our preference remains the impaction grafted stem inserted with minimal endocortical contact because of its virtually universal applicability (as shown in the two ream and run cases we did yesterday, see below) .




===

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'



Failed resurfacing with mini glenoid component

We had the opportunity to see a patient whose glenohumeral arthritis


was treated in another state with a humeral head resurfacing with a mini glenoid component.

Eight months later, the shoulder was increasingly painful; x-rays showed evidence of loosening of the glenoid component.

Two months later the glenoid was removed by the original surgeon.

The shoulder continued to be stiff and painful. The patient presented to our service. After discussion of the alternatives and the possibility of low grade infection, we performed a revision with multiple tissue and explant cultures, all of which were fortunately negative.



Three months after the revision the patient reports that the discomfort has yet to completely resolve.
The patient's therapist reported
AAROM flexion 165* (able to consistently achieve)
AAROM abduction 160* (limited at times to 90*)
AAROM Internal Rotation in Abduction 40*
AAROM External Rotation in Abduction 60*

We'll keep you posted!

===

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'




Monday, July 18, 2016

Glenoid retroversion ≠ subluxation, two year followup on a ream and run

In a prior post (see this link), we've pointed out that humeral decentering on the glenoid (i.e. subluxation) does not necessarily accompany glenoid retroversion. 

The x-ray below from a 35 year old man shows 40 degrees of preoperative glenoid retroversion, but the humeral head is centered on the face of the glenoid.


On the postoperative film two years after his ream and run procedure, the glenoid is still retroverted by 40 degrees. The prosthetic humeral head is remains centered on the glenoid on the 'truth' view.


===

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


More on the B2 glenoid

Earlier today, we posted on the assessment of glenoid pathoanatomy: see this link.

In the office today, we saw three of our patients in followup after arthroplasty for "B2" type posteriorly biconcave glenoids: two total shoulders and one ream and run. The preoperative and postoperative 'truth' views are shown below. Note that in each case the preoperative decentering was corrected even though there was no attempt to change glenoid version with anterior reaming, posterior bone graft or posteriorly augmented glenoid components.










===

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


The B2 glenoid

Management of the Biconcave (B2) Glenoid in Shoulder Arthroplasty: Technical Considerations.

These authors point out that severely biconcave arthritic glenoid pathoanatomy can create major technical challenges in shoulder arthroplasty and jeopardize the longevity of prosthetic glenoid components.  They review different strategies for managing this anatomy, ranging from eccentric reaming and total shoulder arthroplasty, to posterior glenoid bone grafting, to posteriorly augmented implants and to  reverse shoulder arthroplasty.


Comment: As we consider the management of various types of glenoid pathoanatomy it is important to recognize that there is a continuum in "B" glenoids - between those that have minimal biconcavity to those that have severe biconcavity as shown in the diagram below. In fact as our recent posts show, there are many types and many shades of glenoid pathoanatomy.


In our experience, every shoulder with posterior humeral decentering has some degree of biconcavity, so maybe there is no such thing as a pure B1.



One of the interesting things that can be observed from this paper (Figure 3) is that the position of the humeral head relative to the glenoid articular surface depends on the position of the arm when the image is obtained. Note that in the CT scan below taken with the arm at the side, the head is relatively centered in the glenoid and not resting in the posterior pathologic concavity.

 However, when the arm was abducted to obtain the axillary view, the humeral head falls in to the posterior concavity as shown below.


For that reason we make a point of taking the axillary view when the arm in the functional position of elevation in the plane of the scapula, what we refer to ask the 'truth view'. See this link.

Another interesting observation in this paper (Figure 5) is the possibility of overcorrecting posterior subluxation. The preoperative view shows posterior subluxation into a pathologic posterior concavity.
 The post operative view shows the humeral head to be anteriorly decentered on the glenoid.



An alternative approach to the description of glenohumeral pathoanatomy can be based on three parametric measurements:

(1) The percent of the glenoid surface that has a pathologic biconcavity (33% posterior in the example below).

 (2) The angle of retroversion of the glenoid face (G) in relation to the scapular body (S)

(3) The centering of the humeral head with respect to the glenoid  (the distance between the anterior glenoid lip and the center of glenohumeral contact (C) divided by the distance between the anterior and posterior glenoid lips (G)).  0.5 indicates a centered humeral head.
Using this system, 
the glenoid below would be 50% anterior biconcavity, 10 degree retroversion, and decentering of .25 (subluxation).


the example glenoid below would be 0 biconcavity, 40 degree retroversion, and centering of .5. 

the example  glenoid below would be 0 biconcavity, 15 degree retroversion, and centering of .5. 

Such a system can provide the information necessary for characterizing the pathology and for planning treatment.

===

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'