Thursday, May 5, 2016

The ream and run and its relation to the most cited orthopedic article (by Bill Harris)

A few years ago, CORR published the 100 most cited orthopedic articles (see this link). At the top of the list was

 This is a case series of mold arthroplasties performed between 1945 and 1965 by three orthopaedic icons: M.N. Smith-Peterson, Otto E. Aufranc, and Morton Smith-Peterson. In this procedure the acetabulum was reamed and the reamed femoral head was covered with a metallic cup. Some of the preoperative and followup radiographs are shown below.






All of the procedures is-crc standard arthroplasties with
decortication arid reaming of both the head and acetabulum except for tis’o in ‘which
the cup was placed on the mid-portion of the femoral head ansd tivo in is-hich the cup
‘was seated against the periphery of the acetabulum in preference to inserting it
more deeply insto an e;;kxploded socket
 The clinical results as summarized by the authors are shown below.
kxploded socket
While there are few histological studies of the effect of this early hip procedure the one below suggests the presence of fibrocartilage over the reamed acetabular surface.






It was actually this figure that inspired our exploration of the ream and run procedure (see this link). Histology from an animal model shown below immediately after reaming (left) and six months after showing growth of fibrocartilage over the reamed surface (right).


In case you're curious, American English has no "mould", and British English has no "mold". In other words, the word referring to (1) the various funguses that grow on organic matter or (2) a frame for shaping something is spelled the same in both uses, and the spelling depends on the variety of English.


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Monday, May 2, 2016

Reverse total shoulder - progressive scapular notching

While some authors have stated that scapular notching (the erosion of the lateral scapula from contact with the humeral component of a reverse total shoulder) is not of clinical importance, there are patients where it is of obvious clinical consequence.

Here is the x-ray of a lady with a failed prosthesis for fracture. Note the superior displacement of the humeral head, the long cemented stem and the poor quality of the glenoid bone.

Her surgeon converted her to a reverse total shoulder with bone graft around the humeral component and a Grammont-style prosthesis



At two years after surgery, she had increasing shoulder pain and these films showing bone loss at the inferior aspect of her glenoid along with some evidence of contact between the lower screw and the humeral component.

Her most recent films show progressive loss of the bone supporting the glenoid component.

While this patient has yet to undergo a revision, we suspect that her humeral component may look like this.

This is a good time to review the article:


Anytime we have unintended contact between high density polyethylene and bone, it is a problem. Scapular notching is a radiographic finding, but the real concerns are about (1) the damage to the poly of the humeral cup, (2) loss of the bone of the scapula that supports the glenoid component, and (3) the potential for instability resulting from leverage of one against the other. See this previous post which discusses this phenomenon in some detail.



In the Grammont-type reverse total shoulder, contact of the adducted humeral component against the scapula is not uncommon as shown in these figures from a manufacturer's website (arrow inserted by us to show point of contact when the arm is brought to the side).




These authors retrospectively reviewed 448 patients who underwent a Grammont-type reverse total shoulder  (461 shoulders) performed for rotator cuff tear arthropathy or osteoarthritis with cuff deficiency with a mean followup of 51 months (range, 24-206 months). They found notching of the scapula in 68% of the cases; it was present in 48% at one year after surgery. 

Notching was more common in active patients, in patients with cuff tear arthropathy, and in patients with greater degrees of superior displacement of the humeral head before surgery. Strength and range of motion were compromised in patients with notching.

Importantly, 36% of shoulders with notching had humeral radiolucent lines (in contrast to 17% in those without notching), suggesting the possibility that polyethylene particles from the humeral cup causing bone resorption. Similarly glenoid loosening was three times more common in the presence of notching.

The authors point out that standardized plain x-rays are necessary for the evaluation of notching, noting that sometimes notching is better seen on the axillary view.

Comment: Scapular notching is important and can be expected to adversely affect the long term durability and function of the reverse. It is best avoided by (1) use of a glenoid component design that offsets the center of rotation from the scapula, (2) proper positioning of the glenoid component at the inferior aspect of the glenoid, (3) avoiding superior tilt of the glenoid component, and carefully checking for contact between the humeral component and scapula at surgery when the arm is adducted and rotated (see below).



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Arthritis from a prominent suture anchor - anchor arthropathy

Here are the films of a man in his mid twenties who had a shoulder repair for recurrent instability 8 years ago. He now can perform only 5 of the 12 functions of the simple shoulder test. His x-rays suggest that one of the suture anchors used in his instability repair has become prominent.




Comment: The challenge with suture anchors placed on the glenoid surface is that they may appear to be buried beneath the surface of the cartilage at the time surgery, but with a small amount of cartilage wear or a slight shift in the position of the anchor, part of it becomes prominent so that it can rub on the humeral surface leading to secondary arthritis. 

This is a particularly serious issue in a very young patient and demonstrates that shoulder arthritis in young individuals is usually a different condition that what is commonly seen in individuals over the age of 50.

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Rotator cuff repair reinforcement with extracellular matrix graft - does integrity matter?

A prospective, multicenter study to evaluate clinical and radiographic outcomes in primary rotator cuff repair reinforced with a xenograft dermal matrix.

These authors studied  61 shoulders with large repairable rotator cuff tears (3 to 5 cm). The rotator cuff tears were surgically repaired and reinforced with a extracellular matrix (ECM) xenograft. The average patient age was 56 years (range, 40-69 years). The average tear size was 3.8 cm.  Double row cuff repair was performed by minimally invasive open technique.  The graft was cut to overlap the completed repair of the rotator cuff covering the entire repair and was attached medially using a modified Mason-Allen technique.

Functional outcome scores, isometric muscle strength, and active range of motion were significantly improved compared with baseline. 
Magnetic resonance imaging at 12 months showed retorn rotator cuff repairs in 33.9% of shoulders, using the criteria of a tear of at least 1 cm, and tears in 14.5% of the shoulders using the criteria of retear >80% of the original tear size. Three patients underwent surgical revision. Complications included 1 deep infection.

Comment: While the absence of a comparison group treated without ECM does not allow determination of the value (benefit/cost) of the ECM in comparison to double row repairs performed without graft, the results are interesting in two particular regards. First the retear rates did not increase between 6 and 12 months. 


Second, the clinical outcomes showed the same amount of improvement whether or not the cuff repairs remained intact or retore as shown below.




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Sunday, May 1, 2016

Rotator cuff tears after total shoulder arthroplasty in primary osteoarthritis

Rotator cuff tears after total shoulder arthroplasty in primary osteoarthritis: A systematic review

These authors conducted a systematic review of multiple databases for levels I-IV evidence clinical studies of patients with primary osteoarthritis with a minimum 2-year follow-up.

They found 15 studies with 1259 patients (1338 shoulders) were selected. 

Radiographic humeral head migration was the most commonly reported indication of rotator cuff failure. After 6.6 ± 3.1 years, 29.9 ± 20.7% of shoulders demonstrated superior humeral head migration and 17.9 ± 14.3% migrated a distance more than 25% of the head. This was associated with an 11.3 ± 7.9% incidence of postoperative superior cuff tears. 

The incidence of radiographic anterior humeral head migration was 11.9 ± 15.9%, corresponding to a 3.0 ± 13.6% rate of subscapularis tears. 

They found an overall 1.2 ± 4.5% rate of reoperation for cuff injury.


Comment:  Shoulder arthroplasty abruptly re-activates a rotator cuff that has been relatively inactive because of the reduced shoulder use imposed by the pre surgical arthritis. As a result, the cuff experiences loads to which it has not been recently exposed and becomes at risk for failure. The results of this study indicate that cuff dysfunction (as suggested by superior humeral head migration) is not uncommon six years after shoulder arthroplasty. it appears that this cuff dysfunction does not routinely lead to repeat surgery.

Being mindful of the risk of delayed cuff and subscapularis failure, we caution patients about their cuff-related activities after arthroplasty as shown in this link. It is of note that the average age of individuals having shoulder arthroplasty for arthritis is very similar to the average age of individuals with rotator cuff tears.
If the cuff deficiency leads to major functional loss, such as pseudo paralysis or anterosuperior escape as shown below


a reverse total shoulder can be considered (see this link). The reverse total shoulder does not depend on the rotator cuff for stability; instead its geometry enables the deltoid to function independent of the cuff.







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Shoulder arthroplasty - a minimal set of data to assess outcomes - a big step forward

Is it feasible to merge data from national shoulder registries? A new collaboration within the Nordic Arthroplasty Register Association.


A group of surgeons from Denmark, Norway, and Sweden have explored the feasibility of merging data from their national shoulder registries by defining a common minimal data set. They  agreed on a data set containing patient-related data (age, gender, and diagnosis), operative data (date, arthroplasty type and brand), and data in case of revision (date, reason for revision, and new arthroplasty brand).

From 2004 to 2013, there were 19,857 primary arthroplasties reported. The most common indications were osteoarthritis (35%) and acute fracture (34%). The number of arthroplasties and especially the number of arthroplasties for osteoarthritis have increased in the study period. The most common arthroplasty type was total shoulder arthroplasty (34%) for osteoarthritis and stemmed hemiarthroplasty (90%) for acute fractures.

The minimal set of data and key definitions are shown below.



 Comment: By creating a set of data that are common to all three registries, the surgeons can carry out analyses on trends in implant type (such as the growth in reverses and the diminution in resurfacing shown below)

and the revision rate by prosthesis type) shown below.



What is important is that the minimal set of data are collected for each patient, and that the data for all patients are made available for analysis. This is in marked contrast to the usual type of Level IV study in which summary statistics are presented for an individual case series. Congratulations to these Nordic surgeons for showing an example that all countries should follow.



In a prior post we pointed to an article that proposed a minimal data set for cuff surgery:

"The authors suggest that future clinical studies of cuff repairs need to include the following minimal dataset on each patient in an accessible appendix so that the data can be used in further systematic reviews and meta analyses:

•Patient (age, gender, smoking)
•Shoulder (tear size, fatty infiltration, preoperative clinical scores)
•Procedure (treatment method, rehabilitation protocol)
•Results (repair integrity, postoperative clinical scores, duration of followup)"

Total shoulder outcomes - B2 glenoids.


Predictors for satisfaction after anatomic total shoulder arthroplasty for idiopathic glenohumeral osteoarthritis

These authors reviewed 80 of 95 shoulders having total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis at a mean of 3 years (range 2–9). These cases were performed by an individual surgeon working in Vail, Colorado who performed 132 TSAs between December 2005 and January 2013. The patients were overall healthy and active as reflected by their ASA and SF 36 PCS data



In patients with a B2 glenoid, the glenoid was eccentrically reamed to achieve a flat plane and essentially convert the B2 situation to a B1 situation (subluxation without biconcave glenoid). Bone grafting was not used in any case. Here is the example provided for a B2 glenoid

and here are their outcome data by glenoid type (we think they meant to include the B1s only in the right hand group). 







Three complications (3 %) and 2 failures (2 %) occurred.
They concluded that outcomes after TSA for type B glenoid morphology with posterior subluxation were similar to outcomes after TSA for centered type A morphology. Overall patient satisfaction was high and was not influenced by the demographic, anatomic, and surgical variables investigated.

Comment: This study presents the results of total shoulder arthroplasty performed by a high volume surgeon for primary osteoarthritis in generally healthy patients. In this specialized circumstance, the authors did not identify any predictors for satisfaction after anatomic total shoulder arthroplasty for idiopathic glenohumeral osteoarthritis. It is of particular interest that the glenoid type did not appear to influence the outcome and that the authors did not use special glenoid components to manage type B2 pathoanatomy.


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