Monday, February 18, 2019

Cuff tear arthropathy - is there a safe and effective alternative to the reverse total shoulder?

Clinical effectiveness and safety of the extended humeral head arthroplasty for selected patients with rotator cuff tear arthropathy

Cuff tear arthropathy is a type of shoulder arthritis in which both rotator cuff and the cartilage normally covering the joint are both deficient.






When the patient is unable to elevate the arm above the horizontal, cuff tear arthropathy is often treated using a reverse total shoulder. 


However, when active elevation of the arm is present,  a humeral hemiarthroplasty with an extended humeral head (the CTA arthroplasty) can provide a safe, effective and less invasive alternative.  In this procedure the resurfaced humeral head articulates with the undersurface of the intact coracoacromial arch.




This surgical procedure requires matching of the diameter of curvature of the native humeral head


And preserving the stabilizing tissue covering the anterior aspect of the humeral head.

Appropriate sizing of the humeral head prosthesis can re-tension the deltoid.

This procedure cannot be used when the shoulder has been destabilized by a prior acromioplasty



More about this technique can be seen in this youtube (link).

Here is an example of a shoulder with cuff tear arthropathy before surgery. In spite of the destruction of the joint surface, the patient was able to actively elevate her arm.


She elected to have a CTA arthroplasty. At surgery she had complete and irreparable failure of her supraspinatus or infraspinatus.

Here is her shoulder shoulder nine years after the CTA arthroplasty, showing remodeling of her coracoacromial arch.


She generously granted permission for us to show her function nine years after surgery.



This paper analyzed the preoperative characteristics, surgical findings, and clinical outcomes for 42 patients selected for extended head hemiarthroplasty - the CTA arthroplasty.

At an average of 2-years after surgery, there were no complications or revisions. Specifically the complications that have been associated with a reverse total shoulder were avoided: no component dissociations, no baseplate failures, and no dislocations.

The Simple Shoulder Test score improved from a median of 3.0 to 8.0 (P < .001). The median percentage of maximal possible improvement was 50% (P < .001). The percentage of patients able to perform each of the functions of the Simple Shoulder Test was significantly improved; for example, the ability to sleep comfortably increased from 19% to 71%, and the ability to place a coin on the shelf at shoulder level increased from 38% to 86% (P < .001).



Comment:
There are circumstances in which reverse total shoulder is clearly the preferred procedure for cuff tear arthropathy, including pseudoparalysis, anterosuperior escape, and glenohumeral instability; however, in shoulders with preserved active motion and stability of the humeral head provided by an intact coracoacromial arch, the extended head humeral arthroplasty can enable selected patients to realize improved comfort and function without the potential risks of RTSA.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

Monday, February 11, 2019

How long after surgery does a reverse total shoulder function?

Long-term results of the Delta Xtend reverse shoulder prosthesis

These authors reviewed 126 primary Delta Xtend reverse total shoulder prostheses implanted in our center by an individual surgeon from October 2006 until December 2009. Of these, 38 patients died, 12 were lost to follow-up, and 2 needed early revision of the prosthesis. 

Follow-up of at least 8 years was available for 74 patients. The mean follow-up in our population was 113.1 months. 

The mean adjusted Constant Score was 44.6% preoperatively. It increased significantly to 75.8% after surgery and to 91.1% at 5 years. At the latest follow-up, the mean aCS had declined to 79.9%. 






An overall survival rate of more than 97% was seen at 8 years of follow-up. The rate of revision surgery was 2.6% due to major complications such as dislocation and infection.

Comment: This is an impressive study, both in terms of the high rate of followup and the clinical outcomes. It is of note that these results were achieved by an individual surgeon highly experienced in reverse total shoulder. 


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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

Thursday, February 7, 2019

How long does it take to recover from a rotator cuff repair?

When Do Patients Return to Previous Daily Activity After Arthroscopic Rotator Cuff Repair?

These authors sought to characterize the functional recovery after arthroscopic rotator cuff repair in 135 patients (mean age 60 years) (45 small-sized, 45 in medium-sized, and 45 in large-to massive-sized tears). The mean age was 60 years.

Twenty-seven shoulders (20%) had failure of the repair on MRI taken 9 months after surgery. 

Patients experienced the average recovery of 

low-level front-of-the-body activities at 2 months
high-level ROM front-of-the-body activities at 3 months
high-level ROM behind-the-back activities at 9 months
simple strength-related activities at10 months
and sports/leisure activities at 14 months

Patients with large-to-massive tears were delayed from some activities compared with patients with small tears (10 ± 0 versus 7 ± 1 for washing back, p = 0.010; 11 ± 0 versus 10 ± 0 for lifting 5 kg, p = 0.020; 15 ± 0 versus 13 ± 0 for sports/leisure).

Patients with retears, compared with intact healing, had a longer time to return to washing hair (3 ± 2 versus 3 ± 1, p = 0.007), combing (4 ± 3 versus 2 ± 1, p = 0.002), washing the back (10 ± 3 versus 8 ± 3, p = 0.034), and sports/leisure (15 ± 3 versus 14 ± 3, p = 0.010). 



The authors concluded that it took patients an average of 14 months to recover their daily motion after surgery. Tear size and retear affected only the recovery period of high-level motion activities and sports/leisure.

===
We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.


Tuesday, February 5, 2019

Workers' compensation insurance is a comorbidity for shoulder arthroplasty

Inferior outcomes and higher complication rates after shoulder arthroplasty in workers’ compensation patients

These authors compared the complication rates and clinical outcomes after shoulder arthroplasty (total shoulder arthroplasty, reverse total shoulder arthroplasty, or hemiarthroplasty)  in workers' compensation patients and control non-WC patients. 

They matched 45 WC and 45 non-WC patients by age and sex, with the WC group having a higher rate of prior surgery (82% vs 38%, P < .001). 

The WC group had inferior 2-year outcomes for all PROs and forward elevation (P ≤ .001 for all), as well as a higher reoperation rate (16% vs 2%, P = .030) and higher rate of persistent pain at final follow-up (33% vs 11%, P = .021). 

On multivariate regression controlling for other variables including number of prior surgical procedures, WC status remained associated with lower improvements in the Simple Shoulder Test (P < .001) scores, as well as a higher reoperation rate (P = .015) and higher rate of persistent pain (P = .027).

Comment: Many reasons have been proposed for the well-documented poorer outcomes in WC patients, including young age, patient sex, higher exceptions, lower motivation, secondary gain, and associated co-morbidities, such as smoking.

This study controls for some of these variables and finds that prior surgery is more frequent in WC patients. 


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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

Can injection infect the shoulder with Propionibacterium?

The colonisation of the glenohumeral joint by Propionibacterium acnes is not associated with frozen shoulder but is more likely to occur after an injection into the joint

These authors investigated the prevalence of Propionibacterium (P.) acnes in the subcutaneous fat and capsule of 46 patients undergoing shoulder surgery for frozen shoulder or instability. Patients were asked if they have ever had an injection into the shoulder to be operated on, including an injection of contrast for MR arthrogram.

25 patients (53%) had P. acnes in one or more tissue samples and 35 (74%) had other bacterial species. The same microbe was found in the subcutaneous fat and the capsule in 13 patients (28%). 

Male gender was significantly associated with an increased capsular colonisation of P. acnes (odds ratio (OR) 12.38, 95% confidence interval (CI) 1.43 to 106.77, p = 0.02). 

A pre-operative glenohumeral intra-articular injection - either as treatment for a frozen shoulder or for the injection of contrast in patients with instability - was significantly associated with capsular P. acnes colonisation (OR 5.63, 95% CI 1.07 to 29.61, p = 0.04. 

Positive fat colonisation with P. acnes was significantly associated with capsular P. acnes (OR 363, 95% CI 20.90 to 6304.19, p < 0.01). 

Patients who had a pre-operative glenohumeral injection who were found intra-operatively to have fat colonisation with P. acnes had a statistically significant association with colonisation of their capsule with P. acnes (OR 165, 95% CI 13.51 to 2015.24, p < 0.01).

These authors concluded that there was a statistically significant association between subcutaneous skin P. acnes culture and P. acnes capsular culture, especially when the patient has undergone a previous injection. 

Comment: This paper provides additional evidence that any invasion of the joint, even an injection, may introduce Propionibacterium into the shoulder. This paper does not provide data on how long prior to the surgery the injections were performed. There is a common believe that shoulder arthroplasty shoulder not be performed within three months of an injection. However, there is no evidence that Propionibacterium introduced by an infection would have been eliminated by host defenses in that period of time. Thus we must ask, does the risk of shoulder colonization after injection decrease with time after injection, or is it long standing?

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

Monday, February 4, 2019

Outcomes of arthroscopic rotator cuff repairs

Establishing clinically significant outcome after arthroscopic rotator cuff repair

These authors assessed the minimal clinical important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for 288 patients having cuff repairs using the  American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (Constant) scores preoperatively and 1 year postoperatively

The MCID, SCB, and PASS were, respectively, 11.1, 17.5, and 86.7 for ASES, 4.6, 5.5, and 23.3 for the Constant score, and 16.9, 29.8, and 82.5 for the SANE score. 

Factors such as current smoking, type of repair, Workers’ compensation, and preoperative were inconsistently associated with these outcomes.

Comment: This study did not include two important determinants of the outcome from cuff repair surgery: the size of the cuff tear and the integrity of the cuff at followup.

While there are many approaches to outcome measurement, one that is easy for surgeons to use and patients to understand is the percent of maximum possible improvement (%MPI) as explained here:

Determining the minimal clinically important difference for the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog scale measuring pain after shoulder arthroplasty.

Primary anatomic total shoulder arthroplasty (TSA), primary reverse TSA, or hemiarthroplasty was performed in 326 patients. The SST score, ASES score, and VAS pain score were collected preoperatively and at a minimum of 2 years postoperatively (mean, 3.5 years).

The minimal clinically important differences (MCIDs) were calculated for the ASES score, SST score, and VAS pain score using a 4-item anchor question evaluating improvement after treatment. Patients were asked the following: “Since your shoulder replacement surgery, please rate your response to treatment: A, none—no good at all, ineffective treatment; B, poor—some effect but unsatisfactory; C, good—satisfactory effect with occasional episodes of pain or stiffness; D, excellent—ideal response, virtually pain free.” Patients were classified by the anchor question as having “no change” (A group [none] and B group [poor] combined) or “change” (C group [good]). The D group (excellent) was not included in the analysis because this was considered beyond minimal change.

The MCIDs for the ASES score, SST score, and VAS pain score were 20.9 (P < .001), 2.4 (P < .0001), and 1.4 (P = .0158), respectively. 

Duration of follow-up and type of arthroplasty (anatomic TSA vs reverse TSA) did not have a significant effect on the MCIDs (P > .1) except shorter follow-up correlated with a larger MCID for the ASES score (P = .0081). 

Younger age correlated with larger MCIDs for all scores (P < .024). Female sex correlated with larger MCIDs for the VAS pain score (P = .123) and ASES score (P = .05).

Patients treated with a shoulder arthroplasty require a 1.4-point improvement in the VAS pain score, a 2.4-point improvement in the SST score, and a 21-point improvement in the ASES score to achieve a minimal clinical importance difference from the procedure.


Comment: MCID is one way of looking at the amount of improvement, but it has a problem. Consider two patient having a shoulder arthroplasty, each with an improvement of 3 in the SST score (both exceeding the 2.4 MCID improvement).




Their outcomes are not the same. For that reason we use both the preoperative to postoperative change in the SST as well as the percent of maximal possible improvement to characterize the result:


Here we can see that Smith only improved by 27% of the maximal possible improvement, whereas Jones improved by 75% of the maximal possible improvement (even though the improvement in both cases exceeded the MCID).

Predicting outstanding results after anatomic total shoulder arthroplasty using percentage of maximal outcome improvement

These authors sought to determine the percentage of maximal improvement in the Simple Shoulder Test (SST) or American Shoulder and Elbow Surgeons (ASES) score associated with “excellent” patient satisfaction after total shoulder arthroplasty (TSA).

For 301 and 319 patients with at least 2 years’ follow-up for the SST score and ASES score, respectively, they used receiver operating curve analysis to determine that 72.1% of maximal improvement in the SST score and 75.6% of maximal improvement were the thresholds for excellent satisfaction.

Comment: This article is most reassuring. First of all it supports the concept that use of the percent maximal possible improvement renders similar results for different outcome scoring systems. In their study improvement of 70-76% of the maximal possible improvement was associated with an "excellent" clinical outcome whether the Simple Shoulder Test or the ASES score was used. 

Second, The SST scores improved from 27% to 77% of the maximum score of 12; similarly,  the ASES improved from 31% to 81% of the maximum score of 100.

Third, the distribution of preoperative SST scores for total shoulder patients in this paper 



was virtually identical to that for total shoulders (shown in green below) in a recent paper from a different group of surgeons writing on the "Tipping Point" for surgery (see this link).




The average SST score before total shoulder arthroplasty for patients in both centers was 3.

Thus there is reassuring consistency in the results for different patient reported outcome scales and in the results between different centers.

Here's another related post showing the consistency among outcome scales:

Establishing maximal medical improvement after anatomic total shoulder arthroplasty 

These authors conducted a systematic review  of 13 studies reporting sequential followup of 984 patients at several time points, up to a minimum of 2 years after total shoulder. Assessment for clinically significant improvements between time intervals was made by using the minimal clinically important difference specific to each patient-reported outcome measure.

Clinically significant improvements in patient-reported outcome scores were noted up to 1 year following TSA, but no further clinical significance was seen from 1 year to 2 years.

For both the subjective and objective outcomes, the majority of improvements occurred in the first 3 months after the procedure.

These authors found similar results for reverse total shoulders as shown in this link.

Comment: It is of interest and importance that the Simple Shoulder Test results of our recent, currently unpublished 11 international center study including 1270 patients receiving anatomic total shoulders with a standard (non-augmented) all polyethylene glenoid component (shown below):  





are virtually identical to the Simple Shoulder Test results from this systematic review (shown below):


It also of interest that in this systematic review, the normalized outcomes are essentially independent of the patient reported outcome scale used:






Thus measuring the outcomes of shoulder arthroplasty can be simplified: (1) any of the validated patient reported scoring systems can be used and (2) the one year results are as good as the two year year results (the "standard" requirement for 2 year followup may not be necessary for TSAs). In order for new total shoulder systems to demonstrate that they offer increased value over current approaches, their one year outcomes need to exceed those shown here.

We can conclude that most of the common outcome scores yield similar results and that the percent of maximal possible improvement provides an easy way for patients and surgeons to understand the results.

===
We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

Reverse shoulder arthroplasty–allograft for revision of failed arthroplasty associated with proximal humeral bone deficiency

Clinical outcomes following reverse shoulder arthroplasty–allograft composite for revision of failed arthroplasty associated with proximal humeral bone deficiency: 2- to 15-year follow-up


These authors report the results of 73 patients were treated with a reverse shoulder allograft composite for failed prior arthroplasty. A typical preoperative defect is shown below


Press-fit stems were removed using a combination of burrs and osteotomes to separate the bone-implant interface, followed by impaction devices and mallets to remove the stem.  For cemented stems, if the previous cement mantle was stable and there was no concern for infection, the cement was left intact and a cement-within-cement technique was performed.

If the degree of bone loss compromised the stability of the revision prosthetic stem, a fresh-frozen allograft was shaped using an oscillating saw and a step-cut technique.
 
The prepared allograft was then cabled to the host bone using multiple 1.7-mm cables, and the definitive humeral component was cemented into the final construct. 




Patients were significantly improved and were usually satisfied, but the self-assessed function remained limited: the Simple Shoulder Test score improved from 1.3 to 3.5.  Range of flexion improved from 49° to 75°.  Revision was required in 14 patients (19%) for periprosthetic fracture (n = 6), instability (n = 2), glenosphere dissociation (n = 2), humeral loosening (n = 2), and infection (n = 2) at a mean of 38 months postoperatively. 

The reoperation-free survival rate of all reconstructions was 88% (30 of 34) at 5 years, 78% (21 of 27) at 10 years, and 67% (8 of 12) beyond 10 years. 

Ten patients had radiographic evidence of humeral loosening at final follow-up.

Comment: Failed reverse total shoulders often have associated loss of proximal bone with poor remaining bone quality - factors that complicate surgical revision.
The authors of this paper have extensive experience with these revisions. As they point out, infection, host bone quality that is insufficient for circlage, and massive amounts of bone loss present additional challenges. Finding an appropriately sized proximal humeral allograft of the desired side can also be a major problem. Hand crafting the humerus using struts and a long stem prosthesis may be necessary.


===
We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.