Thursday, January 23, 2020

Severe B2 glenoid in a young man => ream and run

An active man in his 40s presented with severe pain and loss of motion in his left shoulder.
His x-rays on presentation are shown below.


His axillary "truth" view shows a severe B2 glenoid with retroversion, biconcavity and posterior decentering.
 He elected to have a ream and run operation. His films at two years are shown below.
 His postoperative view shows an anteriorly eccentric humeral head centered on a mono concave, retroverted glenoid.


At two years after surgery, his motion was excellent and painless.


Comment: This case shows a bone-preserving approach to the B2 glenoid in comparison to the bone removal associated with some posteriorly augmented glenoid components

or with "corrective" anterior reaming.


As well it avoids the risks and limitations associated with a prosthetic glenoid component.


To see a YouTube video on how the ream and run is done, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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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'

Saturday, January 18, 2020

Shoulder arthroplasty in the younger patient, risk of revision

Defining the younger patient: age as a predictive factor for outcomes in shoulder arthroplasty

The purpose of this study was to define an age cutoff at which clinical outcomes and revision rates differ for patients undergoing primary anatomic total shoulder arthroplasty (TSA) and patients undergoing primary reverse shoulder arthroplasty (RSA).

This retrospective cohort study included 1250 primary shoulder arthroplasties (1131 patients) with minimum 2-year clinical follow-up (mean, 50 months). TSA (n . 518; mean age, 68.1 years) was performed for osteoarthritis in most cases (99%), whereas the primary diagnoses for RSA (n . 732; mean age, 70.8 years) included rotator cuff arthropathy (35%), massive cuff tear without osteoarthritis (29.8%), and osteoarthritis (20.5%). 

In patients younger than 65 years, TSA was associated with a 3.4-fold increased risk of revision.
RSA performed in patients younger than 60 years was associated with a 4.8-fold increased risk of revision.


TSA patients aged 65 years or older and RSA patients aged 60 years or older had better total ASES scores (82 vs. 77 and 72 vs. 62, respectively).

Comment: For appropriate, motivated young patients with osteoarthritis or capsulorrhaphy arthropathy, we consider the ream and run arthroplasty (click on this link). Here is the abstract of a relevant paper: 

Ream and run and total shoulder: patient and shoulder characteristics in five hundred forty-four concurrent cases.

Total shoulder (TSA) is commonly used to treat arthritic shoulders with intact rotator cuffs; however, some patients choose a ream and run (RnR) to avoid the potential risks and limitations of a prosthetic glenoid component. Little is known about how patients selecting each of these two procedures compare and contrast.

We analyzed the patient characteristics, shoulder characteristics, and two year clinical outcomes of 544 patients having RnR or TSA at the same institution during the same six year period.

Patients selecting the RnR were more likely to be male (92.0% vs. 47.0%), younger (58 ± 9 vs. 67 ± 10 years), married (83.2% vs. 66.8%), from outside of our state (51.7% vs. 21.7%), commercially insured (59.1% vs. 25.2%), and to have type B2 glenoids (46.0% vs. 27.8%) as well as greater glenoid retroversion (19 ± 11 vs. 15 ± 11 degrees) (p < .001). The average two year SST score for the RnRs was 10.0 ± 2.6 vs. 9.5 ± 2.7 for the TSAs. The percent of maximum possible improvement (%MPI) for the RnRs averaged 72 ± 39% vs. 73 ± 29% for the TSAs. Patients with work-related shoulder problems had lower two year SSTs and lower %MPIs. Younger patients having TSAs did less well than older patients. Female patients having RnRs did less well than those having TSAs (p < 0.001).

The poster below summarizes these findings. Note the differences in age, sex, glenoid retroversion and prevalence of B2 glenoids. Note also that the results with TSA are worse for younger patients, but not for those having the ream and run.










To see a YouTube of our technique for total shoulder arthroplasty, click on this link.
To see a YouTube video on how the ream and run is done, click on this link.

=====
To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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'

What good is a preoperative chlorhexidine shower?

While home chlorhexidine washes prior to shoulder surgery lower skin loads of most bacteria, they are not effective against Cutibacterium (Propionibacterium)

Chlorhexidine showers prior to shoulder arthroplasty are commonly used by surgeons in hopes of reducing the risk of periprosthetic infection; however, the effectiveness of these washes in eliminating bacteria from the skin of the shoulder has not been thoroughly evaluated. The objective of this study was to determine the degree to which pre-operative chlorhexidine washes effectively eliminate bacteria from the epidermal skin surface and from the dermis freshly incised during shoulder arthroplasty.

Sixty-six patients undergoing primary shoulder arthroplasty were instructed to shower with chlorhexidine before surgery. Each patient had three skin swabs: (1) the epidermis at a pre-operative clinic appointment, (2) the epidermis at surgery after home chlorhexidine showers but prior to skin preparation, and (3) the dermis after incision of the prepared skin. The bacterial loads of Cutibacterium and other bacterial types from each swab were compared to determine whether the showers were effective in altering the bacterial loads.

Chlorhexidine washes were effective in reducing the skin load of other bacterial species (p < 0.005), but they did not decrease the skin load of Cutibacterium (p = 0.585).
Bacterial loads on the epidermal skin surface of patients having elective shoulder
arthroplasty before (dark columns) and after (light columns) prescribed
chlorhexidine showers. Results are shown for coagulase negative Staphylococcus

(left), Cutibacterium (center) and other bacteria (right).

The authors concluded that pre-operative skin showers with chlorhexidine were not effective in reducing the load of Cutibacterium on the skin of patients having shoulder arthroplasty. Since Cutibacterium is responsible for the highest percentage of shoulder periprosthetic infections, research is needed to identify more effective means of preventing these bacteria from entering the surgical field.

Comment: While Chlorhexidine showers may be effective in removing other bacteria from the skin surface, they do not appear to be effective in reducing the amount of Cutibacterium, the most common organism causing shoulder periprosthetic infections.

Friday, January 17, 2020

Stemless humeral prosthesis - do they achieve better results?

The short- to midterm effectiveness of stemless prostheses compared to stemmed prostheses for patients who underwent total shoulder arthroplasty: a meta-analysis

These authors systematically compared the short- to midterm effectiveness of stemless prostheses to that of stemmed prostheses for patients who underwent total shoulder arthroplasty (TSA). They found two randomized controlled trials and six case-controlled studies with a total of 347 shoulders for inclusion in this meta-analysis.

They found no significant differences between the stemless and stemmed prostheses in terms of the Constant score, pain score, strength, activities of daily living, postoperative range of motion (ROM), and postoperative maximum active ROM.

 Comment: These authors did not find evidence for increased benefit of stemless components.  If value = benefit/cost, stemless implants would have to have superior outcomes to attain the same value as standard stemmed implants because of their increased cost.

The 2019 Orthopaedic Network News, provides a cost comparison (ASP = average selling price).




The rationale behind stemless implants, according to these authors, include "bone preserving", "less stress shielding distally", "no diaphysial stress riser", and "less lateralization".

We observe that an impaction grafted standard stem is also bone preserving, without distal stress shielding, without a diaphysial stress riser, and with the desired amount of lateralization.


We continue to use an impaction grafted standard humeral component, finding that it is safe, efficient, cost effective, and adaptable to almost all situations.


A standard stem also enables us to use an anteriorly eccentric humeral head if necessary to manage excessive posterior translation if this is encountered at surgery.


Finally, we note that every new prosthesis requires a new learning curve for each surgeon




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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

=====
To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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'

Shoulder arthroplasty - selecting the right patient - the 4 Ps

Psychosocial factors affecting outcomes after shoulder arthroplasty: a systematic review

These authors conducted a review of sixteen article located using keywords ‘‘shoulder arthroplasty outcomes,’’ ‘‘psychosocial factors shoulder,’’ ‘‘shoulder replacement outcomes,’’ ‘‘depression shoulder arthroplasty,’’ ‘‘satisfaction shoulder arthroplasty,’’ ‘‘factors shoulder replacement,’’ ‘‘expectations shoulder arthroplasty,’’ and ‘‘predictors shoulder arthroplasty.’’

Six reviewed mental health disorders as predictors of postoperative outcome after shoulder arthroplasty. Of these, 4 found that disorders such a depression and anxiety were associated with increased risk of perioperative complications and lower final functional outcome scores. Two studies evaluated workers’ compensation status as a possible predictor of outcomes and found that patients with claims had lower satisfaction and outcome scores at final follow-up compared with those without claims. Two studies showed that preoperative opioid use was associated with lower outcome scores and overall satisfaction rate after shoulder arthroplasty. 





Three studies showed that higher patient confidence and preoperative expectations were correlated with better outcomes.

Comment: We like to point out that the outcome of shoulder arthroplasty, or any treatment for that matter, depends on for independent factors, the 4 Ps: the problem being treated, the procedure used to treat the problem, the physician rendering the treatment, and the patient reiving the treatment. This study calls our attention to the importance of the last P, the patient. Best results can be obtained by optimizing all four!

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

=====
To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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'



Thursday, January 16, 2020

Rotator cuff tears - the benefits of non-repair surgery

Arthroscopic debridement of irreparable rotator cuff tears: predictors of failure and success

These authors reviewed 26 patients who underwent arthroscopic debridement for an irreparable rotator cuff tear with a median follow-up of 98 months (range, 58-115 months). The rotator cuff was deemed irreparable intraoperatively by the treating surgeon based on inability to mobilize the tendon to the medial footprint without excessive tension, or poor-quality tissue that could not be secured with suture and anchor fixation. All patients underwent a subacromial bursectomy. A tuberoplasty or acromioplasty was performed at the surgeon’s discretion. Management of the biceps was dependent on the operating surgeon’s assessment of biceps disease.

The average age at the time of surgery was 60±11 years. Six patients (23%) had a reoperation at a median 11 months (range, 1-91 months), with 5 of those being revised to reverse shoulder arthroplasty. Median ASES and visual analog scale pain scores improved significantly from preoperatively to postoperatively (P <.01). Lower preoperative forward elevation was associated with worse postoperative ASES scores (P <.004) and revision to reverse shoulder arthroplasty. The authors found no associations between preoperative radiographic variables and reoperation or lower outcome scores.

Median ASES scores improved significantly from preoperatively to postoperatively from 38 (IQR, 29-49; range, 17-73) to 74 (IQR, 54-87; range, 25-95) (P <.007). Patients with <90 degrees of preoperative active forward elevation (FE) had worse median postoperative ASES scores (54, IQR, 39-73; range, 25-77) compared with those who had >90 degrees of preoperative FE (82, IQR, 63-88; range, 43-95). Also, 5 of 11 (45%) patients with <90 degrees of preoperative FE had a revision to RSA compared with 0 of 15 (0%) (P <.007) with >90 of preoperative FE. Patients with prior surgery had lower median ASES scores as well (48, IQR, 34-74; range, 25-87 vs. 81, IQR, 63-88; range, 43-95), but this only trended to significance (P =.06).

Comment: This study is important because it shows that patients with preserved active elevation above 90 degrees can benefit from surgical smoothing of the humeroscapular motion interface, irrespective of the preoperative MRI findings. Cost-effectiveness of more expensive procedures such as superior capsular reconstruction, subacromial balloon spacers or reverse total shoulder should be considered in the context of these successful results.

This study should be considered along with a paper reporting a larger series:Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty, the abstract of which is posted below.

PURPOSE:
These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation 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.

METHODS:
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.

RESULTS:
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.

CONCLUSION:
Smoothing of the humeroscapular interface can improve symptomatic shoulders with irreparable cuff tears and retained active elevation. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

The technique of the smooth and move procedure is shown in this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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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'




Rotator cuff tear - which patients should get surgery?

Surgical Versus Nonsurgical Management of Rotator Cuff Tears A Matched-Pair Analysis

These authors retrospectively evaluated a cohort of patients over 18 years of age who had a full-thickness rotator cuff tear seen on magnetic resonance imaging . After clinical evaluation, each patient elected to undergo either rotator cuff repair or nonsurgical treatment. Treatment allocation was determined by agreement between the patient and surgeon after clinical evaluation and thorough discussion of the risks and benefits of surgical and nonsurgical treatment options for full-thickness rotator cuff tears.

Demographic information was collected at enrollment, and self-reported outcome measures (the Normalized Western Ontario Rotator Cuff Index [WORCnorm], American Shoulder and Elbow Surgeons score [ASES], Single Assessment Numerical Evaluation [SANE], and pain score on a visual analog scale [VAS]) were collected at baseline and at 6, 12, and >24 months. The Functional Comorbidity Index (FCI) was used to assess health status at enrollment. The size and degree of atrophy of the rotator cuff tear were classified on MRI. Propensity score analysis was used to create rotator cuff repair and nonsurgical groups matched by age, sex, symptom duration, FCI, tear size, injury mechanism, and atrophy.

One hundred and seven patients in each group were available for analysis after propensity score matching. There were no differences between the groups with regard to demographics or rotator cuff tear characteristics.






 For all outcome measures at the time of final follow-up, the rotator cuff repair group had significantly better outcomes than the nonsurgical treatment group (p < 0.001). At the time of final follow-up, the mean outcome scores (and 95% confidence interval) for the surgical repair and nonsurgical treatment groups were, respectively, 81.4 (76.9, 85.9) and 68.8 (63.7, 74.0) for the WORCnorm, 86.1 (82.4, 90.3) and 76.2 (72.4, 80.9) for the ASES, 77.5 (70.6, 82.5) and 66.9 (61.0, 72.2) for the SANE, and 14.4 (10.2, 20.2) and 27.8 (22.5, 33.5) for the pain VAS.

J

In the longitudinal regression analysis, better outcomes were independently associated with younger age, shorter symptom duration, and rotator cuff repair.

They concluded that patients with a full-thickness rotator cuff tear reported improvement in pain and functional outcome scores with nonoperative treatment or surgical repair. However, patients who were offered and chose rotator cuff repair reported greater improvement in outcome scores and reduced pain compared with those who chose nonoperative treatment.

Comment: In that patients make decisions based on the expectations set by their surgeons, this study shows essentially that these surgeons were able to select patients who would benefit from cuff repair. In a sense it is a study of the effectiveness of selection bias in choosing surgical candidates. While they attempted to match patients by age, sex, symptom duration, FCI, tear size, injury mechanism, and atrophy, surgeons base their recommendations on many other factors that affect outcome, such as the presence or absence of depression, smoking, workers' compensation status, nutrition, narcotic use and socioeconomic factors (see this link). Thus, even though the authors "used propensity score analysis to approximate a randomized controlled trial to minimize the effects of confounding bias while maintaining a realistic method of treatment allocation", this study does not "approximate a RCT" because of the many important variables that could not be accounted for in the matching process.

So we are not left with much generalizable guidance on patient selection except to say that experienced surgeons appear to be able to select good candidates for surgery. That is a good thing!

=====
To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

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'