Monday, September 1, 2014

Extraordinary rehabilitation effort after a bilateral ream and run procedure

The owner of a CrossFit gym had bilateral ream and run procedures, the left in 2010 and the right in 2012.
Here are his left preoperative films, 


the axillary view showing anterior joint space loss and anterior subluxation of the humeral head on the glenoid.


Here are the two year post operative films

the axillary view shows the use of a posteriorly offset eccentric humeral prosthesis to center the head on the reamed glenoid.

Here are the preoperative films on the right

And the immediate postoperative films on the right. We've yet to obtain the two year post operative films on that side.


Last week he kindly posted this video on Facebook. Be sure to turn the volume up!

A super result from a super effort on his part!


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Propionibacterium acnes in primary shoulder surgery - a surprising result

Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?

These authors assessed Propionibacterium in intraoperative samples of different tissue layers in 118 consecutive patients (mean age, 59.2 years; 75 men, 43 women) undergoing first-time shoulder surgery.
Patients in this study had either an anterolateral approach for open rotator cuff reconstruction/open subacromial decompression or a deltopectoral approach for shoulder arthroplasty or open anterior shoulder stabilization. Patients were excluded if they had tumors or systemic inflammatory diseases or if they had received systemic or topical antibiotics or anti-inflammatory medications within 6 months before surgery. Patients with subacromial injection before the surgery were identified.

Preoperative antibiotics were withheld until the final intraoperative sample was collected. Intraoperative samples were correlated to preoperative subacromial injection, the type of surgical approach, and gender. One skin, one superficial, one deep tissue, and one test sample were cultured for each patient.

Samples were cultured on Columbia agar, chocolate agar,Schaedler agar, and Schaedler kanamycin-vancomycin agar plates and inoculated in thioglycollate broth. Cultures were observed for 14 days.

The cultures were positive for P. acnes in 36.4% of cases. 35 of the 75 men were Propionibacterium–positive , while  8 of the 43 female patients were Propionibacterium–positive.

Subacromial injection was not associated with bacterial growth of Propionibacterium other bacteria. 

Skin samples were positive for Propionibacterium in 8.5%, superficial samples were positive in 7.6%, deep samples were positive in 13.6%, and both samples (superficial and deep) were positive in 15.3% of cases (P < .0001). 

Propionibacterium was detected in the anterolateral approach in 27.1% of cases and in the deltopectoral approach in 9.3% of cases.

Two patients in this study had a postoperative infection requiring revision surgery. During the revision, intraoperative samples confirmed the presence of Propionibacterium in both cases. The patients were both male and were positive for P. acnes in all tissue layers (skin, superficial, and deep) at the index operation.

One segment of the Discussion was of particular interest: " Our data demonstrate that P. acnes colonization of intraoperative samples is predominantly a male problem, confirming reports from shoulder revision surgery and topical skin testing. Men have more sebaceofollicular glands with a greater volume, resulting in a greater P. acnes load. A strong positive correlation has been reported between male sex, pore size, and sebum excretion.White men reportedly have a sebum average of 3 mg/cm2 of skin surface (with large interindividual variability), whereas white women have only 0.7 mg/cm." 


Comment: This is a very well done and important study. The authors were very careful with their methodology, even using test samples to check for contamination (none of the 118 were positive for Propionibacterium). 

Their results strongly suggest that primary surgical wounds are routinely contaminated with Propionibacterium,  most likely from the patient's own skin and that this contamination is not prevented by careful surgical preparation and draping. In view of the fact that Propionibacterium is adept at forming biofilms on implants and is known to be associated with delayed implant failure, three actions seem in order: (1) patients having shoulder surgery, especially males, need to be informed of the risk of Propionibacterium colonization,  (2) thorough irrigation and careful handling of implants should be exercised to reduce the effects of the contamination, and (3) infection with Propionibacterium should be suspected when  shoulder procedures are followed by unexpected pain, stiffness or component loosening, even if the onset of symptoms is delayed substantially beyond the index procedure.

Sunday, August 31, 2014

Risk factors for hospital readmission after shoulder arthroplasty - consequences

Hospital readmissions after primary shoulder arthroplasty.

These authors used State Inpatient Databases from 7 different states  to identify 26,218 patients who underwent hemiarthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty from 2005 through 2010.

These patients had an overall 90-day readmission rate of 7.3%. RTSA had the highest rate (11.2%), followed by hemiarthroplasty (8.2%) and TSA (6.0%; P < .001). Medical complications contributed to 82% of readmissions, and surgical complications contributed to 18%. Osteoarthritis was the most common medical diagnosis (11%), followed by deep venous thrombosis or pulmonary embolism (4.4%) and pneumonia (3.9%). Infection was the most common surgical cause of readmission (4.8%), followed by dislocation (4.6%). There was a stepwise increase in risk of readmission with increasing age as well as for patients with comorbidities. Patients with Medicaid insurance had more than a 50% greater risk of readmission than patients with Medicare. Procedures performed at medium-volume and high-volume hospitals showed lower risk of readmission than low-volume centers.
Comment: The importance of developing strategies for minimizing readmissions has recently be amplified by the Centers for Medicare and Medicaid Services' Readmission Reduction Program that requires CMS to reduce payments to hospitals with excess readmissions, a program that became effective for discharges beginning on October 1, 2012. It is of note that such a program can create an unintended consequence:  a disincentive to offer shoulder arthroplasty to older individuals on Medicaid insurance who have comorbidities. If such patients are to receive surgical care for shoulder arthritis, steps will be needed to modulate the risk to medical centers.

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Biologic resurfacing of the glenoid with humeral head resurfacing - poor results

Biologic resurfacing of the glenoid with humeral head resurfacing for glenohumeral arthritis in the young patient.

These authors reviewed the results of 16 patients having humeral head arthroplasty with soft tissue interposition grafting of the glenoid with a minimum follow-up time of 2 years, unless revision surgery was required.

There were 12 male and 4 female patients with a mean age of 36.1 years (range, 14-45 years). Preoperative indications for surgery included glenohumeral arthritis in 11, glenohumeral
chondrolysis in 3, instability arthropathy in 1 and capsulorrhaphy arthropathy after a Bristow procedure in 1.

The humeral head was replaced with a standard Tornier hemiarthroplasty prosthesis or an Arthrosurface humeral head resurfacing implant. Seven glenoids were resurfaced using a GraftJacket acellular, allograft human dermal matrix–based scaffold and 9 with an Achilles tendon allograft.

At a mean follow-up of 60 months, the patients showed improvement in the visual analog scale score for pain from 8.1 to 5.8 and the American Shoulder and Elbow Surgeons score improved from 23.2 to 57.7 (P < .05). However, conversion to a total shoulder arthroplasty was performed in 7 patients (44%) at a mean of 36 months. The authors concluded that because of the limited improvement in patient outcomes and the high revision rate, biologic resurfacing of the glenoid with humeral head resurfacing should be used with caution.

Comment: Young patients with shoulder arthritis present a tough challenge, first of all because they have more complex pathologies, second because they have high expectations and third because the requirement for durability is so much greater. There is no perfect procedure for these folks. In our practice, we considering discussing the possibility of a ream and run procedure with well-motivated, non-smoking, non-depressed young patients who are not on substantial narcotics.

Another point worth making is that we find that a well positioned AP in the plane of the scapula and a true axillary view as shown in a prior post are more useful than x-rays such as those shown below in assessing shoulder pathology before surgery and the glenohumeral anatomy after surgery.



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Sunday, August 24, 2014

Reverse shoulder arthroplasty - concentric vs eccentric glenospheres - how big a deal is notching?

A Comparison of Concentric and Eccentric Glenospheres in Reverse Shoulder ArthroplastyA Randomized Controlled Trial

The clinical significance of unwanted contact between the medial aspect of the humeral component of a reverse total shoulder and the bone of the scapula lies in the increased risk of instability, inferior scapular notching, limited adduction range of motion, poorer functional scores, and lower patient satisfaction. These authors conducted randomized, controlled, double-blinded trial of 50 patients with rotator cuff tear arthropathy in an attempt to determine if the use of an eccentric glenosphere diminished these problems.

The mean follow-up period for the groups was forty-three and forty-seven months. Four patients in the concentric group had developed inferior scapular notching ranging in size from 1.1 to 7.4 mm, compared with one patient in the eccentric group (p = 0.36). No notching occurred in any patient with glenoid overhang of >3.5 mm. No significant difference between the groups was seen with respect to functional outcome scores, patient satisfaction, or shoulder motion.

Three of these patients had complications. One having a concentric prosthesis developed instability after a fall and two (one in each group) developed acromial stress fractures. These fractures healed without surgery, but the functional results were poor.

Comment: There are two basic strategies for avoiding unwanted humero-scapular contact in reverse total shoulder. One is the 'South' approach: moving the humeral component distally using some combination of inferior placement of the glenosphere baseplate, use of an inferiorly eccentric glenosphere, or tilting the glenoid component inferiorly. These strategies may increase the risk of over lengthening the humerus with resulting acromial fractures (as shown in this report) and neurologic complications from plexus traction. The other is the 'East-West' approach: moving the humeral component laterally using a glenosphere that offsets the center of rotation from the glenoid bone. This strategy requires very secure fixation of the glenoid component to the glenoid bone.

We use a combination of the 'South' and the 'East-West' approaches to avoid unwanted contact in reverse total shoulder as shown here and here.

While some surgeons are inclined to pass off 'notching' as having no clinical importance, this cannot be the case as explained here.



Failed glenoid component, lessons and questions

Our readers are aware that the glenoid component is the 
 in total shoulder arthroplasty.

Recently we were consulted on a patient from elsewhere whose post operative x-ray taken two years ago had this appearance
Here's a closer view of his glenoid fixation showing lucency's around the pegs of the glenoid component
The dark areas between the pegs and the bone in postoperative films are filled with fluid and/or soft tissue so that the component is not well fixed in the bone. As shown in an earlier post, we use a CO2 jet to remove fluid and soft tissue from the bone/cement interface. This enables pressurized cement to completely fill the space between the pegs and the bone, optimizing component fixation. This practice has essentially eliminated the issue of postoperative periprosthetic lucent lines.

Two years later, we met this shoulder for the first time. At the time of presentation to us for consultation the patient had been experiencing increasing pain in the shoulder since his original total shoulder arthroplasty. The x-rays taken at our first visit are shown below. Note the osteolysis around the glenoid component pegs on the AP view
 and the 'watermelon seed' of cement between the glenoid component and the bone posteriorly on the axillary view. The problem with this 'watermelon seed' is shown in this prior post.
 After discussion of the alternatives and considering the possibility of Propionibacterium infection, the patient desired to have a revision with complete prosthesis removal, harvest of specimens for culture, thorough debridement, insertion of a new prosthesis with Vancomycin allograft fixation, and the red antibiotic protocol.

At surgery, the joint fluid was turbid and the glenoid component was completely loose; the 'watermelon seed' was floating free in the joint space. Removal of the trabecular metal stem was very difficult because of bone ingrowth; multiple osteotomies around the component were required. A modified bodice repair was needed to close the humeral osteotomies made for component removal. A glenoid component was not used in the reconstruction.

Note that bone ingrowth is not necessary for humeral component fixation and greatly complicates revision.

The postoperative films are shown below.


Immediate assisted range of motion exercises were started after surgery. IV antibiotics will be continued for 6 weeks and transitioned to oral antibiotics if the cultures (which are now pending) become positive. 

The patient reports that the shoulder is already more comfortable than in the prior two years. We are hopeful.

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Wednesday, August 20, 2014

Customizing a prosthesis: shoulder arthroplasty after a total elbow


Not infrequently the performance of a shoulder arthroplasty is complicated by a prior procedure on the humerus below. Here is the shoulder film of a patient with severe rheumatoid arthritis and several years of progressively worsening shoulder pain.On preoperative examination he had very little range of motion due to his central medial erosion into the glenoid.
 



He had prior bilateral hip, knee, elbow and right shoulder arthroplasties. The ipsilateral elbow arthroplasty and two intramedullary cement restrictors are shown in the film below. We recognized that a standard humeral prosthesis would not fit in his canal, so a preoperative plan was made to customize his implant.




A deltopectoral approach was used and the subscapularis was dissected from the lesser tuberosity medial to the biceps tendon. Due to the limited range of motion and severely osteopenic bone we performed an in-situ humeral head cut. Once accomplished, we were able to safely access his medullary canal and to visualize this thin but intact attachment of the supraspinatus. Given the intact cuff we decided to proceed with a  standard hemiarthroplasty rather than a CTA arthroplasty.
The cement restrictors were retrieved with pituitary rongeurs and the canal was reamed conservatively to protect his fragile bone. The distance within the canal to the previously placed cement from the total elbow was measured. A Midas Rex burr was used to remove 3 cm from the stem and to round off the distal end of the prosthesis.

The prominent bone at the inferior margin of the glenoid was removed with a burr and rongeur due to concerns for contact with the medial proximal humerus. Care was taken to protect the axillary nerve.

The humeral component was then cemented into position and the subscapularis repaired. The postoperative film is shown below.
co-authored by Robert Lucas
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