Tuesday, June 21, 2016

Irreparable rotator cuff tears - is 'partial repair' helpful?

Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: midterm outcomes with a minimum 5 years of follow-up.

These authors recognize that patients with massive irreparable rotator cuff tears can have retained overhead elevation, but may have complaints of pain.

They treated 34 patients with preoperative active forward elevation >120° and no evidence of glenohumeral arthritis. In each case there remained a portion of the cuff that was not mobile and able to be fully repaired to the tuberosities.

The surgical treatment included at least five elements: (1) bursectomy, (2) d├ębridement of tendon delaminations, (3) aggressive releases and slides, (4) acromioplasty, and (5)   'partial' rotator cuff repair ("a low-tension repair of as much of the rotator cuff as could be advanced to the tuberosities") and biceps tenotomy.  Patients then had a 3 month post surgical rehab starting with a sling for 6 weeks.

Patients were followed up clinically and radiographically. 28 patients had a minimum of 5 years of follow-up. Failure was defined as an American Shoulder and Elbow Surgeons score of <70, loss of active elevation >90°, or revision to reverse shoulder arthroplasty during the study period.

The patient’s radiographs were graded on the basis of the Hamada stage with a comparison between
the preoperative radiograph and the last follow-up radiograph (grade 1, the acromiohumeral interval (AHI) is >6 mm; in grade 2, the AHI is <5 mm; in grade 3, the AHI is <5 mm with acetabularization of the acromion; grade 4 represents grade 3 with the addition of degenerative changes of the glenohumeral joint.

Patients demonstrated improvements in average preoperative to postoperative American Shoulder and Elbow Surgeons scores (46.6 to 79.3 [P < .001]) and Simple Shoulder Test scores (5.7 to 9.1 [P < .001]) along with decrease in visual analog scale for pain scores (6.9 to 1.9 [P < .001]). The patients lost an average of 14 degrees of forward elevation (168° to 154° [P = .07]), external rotation (38° to 39° [P = 1.0]), or internal rotation (84% to 80% [P = 1.0]) was identified; 36% of patients had progression of the Hamada stage. The failure rate was 29%; 75% of patients were satisfied with their index procedure.

The authors point out that this was a retrospective study with no imaging to show whether or not the 'partial repair' had healed.

Comment: In this study several procedures were included in the surgical management: a biceps tenotomy, a bursectomy, a cuff debridement, soft tissue releases a subacromial decompression, and an attempt at a partial cuff repair. Without comparing MRI or sonographic imaging of the cuff before and at followup, one cannot know if the integrity of the cuff was improved, i.e. if the attempted repair had any effect on the outcome.

In our practice, we are reluctant to attempt partial cuff repair because (1) the quality and quantity of the tendon to be repaired are usually poor and (2) after a partial repair the approach to rehab is conflicted: should one move the shoulder to prevent adhesions or should one immobilize the shoulder (as was done in this study) to optimize the chances of healing. We are also reluctant to perform an acromioplasty, especially in cuff deficient shoulders, (1) because it can weaken the shoulder (as reported here) and (2) because of the risk of creating anterosuperior escape as shown below (note that three of the 2 followed up patients in this series required a subsequent reverse total shoulder).





Instead we manage massive symptomatic rotator cuff tears with preserved active elevation and no arthritis with the smooth and move procedure, which allows immediate post operative function as well as active and passive range of motion exercises - as discussed in this link, this link and this link


Monday, June 20, 2016

The University of Washington Shoulder/Elbow Fellowship - our contribution to the future of the specialty

Shoulder and elbow surgery is 75% knowledge, 75% skill and 75% art. It cannot be learned from books or labs alone; rather, like a new language, acquiring mastery requires immersion in a comprehensive experience focused on the evaluation and management of patients and a philosophy of practice. Our program is now almost 30 years old, one of the oldest shoulder and elbow fellowships in the world. We have a growing legacy outstanding alumni of the one-year experience through which we strive to provide such an opportunity for those who aspire to be the future leaders in this field. We are most grateful to the alumni of our fellowship for their research - which includes many foundational contributions to the literature, for their help in the care of our patients, and for their ongoing work to make tomorrow's patient care better than yesterday's.

You can learn more about our fellowship by visiting this link.

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Thursday, June 16, 2016

The arthritic glenohumeral joint - how to describe it?

A modification to the Walch classification of the glenoid in primary glenohumeral osteoarthritis using three-dimensional imaging.

These authors proposed several modifications to the Walch classification for arthritic glenohumeral pathoanatomy.

They define a B3 glenoid as being monoconcave and worn preferentially in its posterior aspect, leading to pathologic retroversion of at least 15° or "subluxation" of 70%, or both. 


They define a D glenoid as glenoid anteversion or anterior humeral head subluxation. 

They redefine a A2 glenoid as having a line connecting the anterior and posterior native glenoid rims that transects the humeral head. 


Comment: These authors have obviously put a lot of thought into the description of the arthritic glenohumeral joint building on the original pioneering work of Gilles Walch.

As pointed out in prior posts (see link), there many arthritic forms that lie between and among the classically described glenoid types, so that a categorical system has difficulty capturing them all.



For example in the proposed system, the difference between an 

and a

is based on whether or not the retroversion is greater or less than an arbitrarily selected level of 15 degrees.

In addition there is confusion when the term 'subluxation' - which should be used to describe the relationship of the humeral and glenoid articular surfaces - is used to describe the relationship of the humeral head to the scapular plane (see the discussion in this link). The B3
as described does not show the separation of the the humeral and glenoid joint surfaces that characterizes 'subluxation' in the usual sense of the word.

By contrast the B2, B1, and D meet the usual definition of subluxation - "incomplete or partial dislocation of a joint "




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An alternative approach 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 example "D" glenoid below would be 50% anterior biconcavity, 10 degree retroversion, and decentering of .25 (subluxation).


the example "B3" glenoid below would be 0 biconcavity, 40 degree retroversion, and centering of .5. 

the example "A2" 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.

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Periprosthetic fracture and management

A patient with primary osteoarthritis

Had a total shoulder arthroplasty 4 years ago

Recently the patient fell, landing on the outstretched arm. At an outside facility, the arm was placed in a plaster splint and x-rays taken with the elbow externally and internally rotated. 




The patient was referred to us for internal fixation.

The splint was removed and the arm was placed in a sling that aligned the fracture well as revealed by two views shown below taken while the arm was in the sling with the forearm across the abdomen.

 


We anticipate that this fracture will heal without surgery.

Comment: This case points out that the thorax is often the best splint for a midshaft humeral fracture. It also shows that x-ray views of a fractured arm with the distal humerus internally and externally rotated may not be a good idea. 

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Monday, June 13, 2016

Total shoulder - what are the activity expectations of men and women?

Gender differences in expectations and outcomes for total shoulder arthroplasty: a prospective cohort study

These authors studied 63 patients receiving a TSA with a minimum of 3 years of follow-up: 36 men and 27 women with a mean age of 60.8 years for men (range, 37-79 years) and 66.4 years (P = .01) for women (range, 52-77 years.)

Each patient was given a preoperative survey in which patients were asked to select 3 expectations they most hoped to gain from surgery.  

American Shoulder and Elbow Surgeons and 12-Item Short Form Health Survey scores, respectively, increased significantly but did not differ between genders.

Each gender achieved their expectations at similar and high rates. Men chose exercise or participation in sports (24/36) whereas women chose to maintain daily routine and chores (18/27) as their top expectation. Both, however, chose to sleep through the night similarly as the next most important expectation. 





Comment: This is an interesting study of patient expectations. As can be seen from the table above, the leading expectations of male and female patients are quite similar as is the rate at which these expectations are achieved.

Reverse total shoulder and heterotopic bone at the inferior glenoid

Heterotopic ossification of the long head of the triceps after reverse total shoulder arthroplasty.

These authors reviewed 164 patients having a reverse shoulder arthroplasty performed between 2008 and 2012. They found heterotopic ossification (HO) inferior to the glenoid in 61.6%. In 23.2% of the cases there was contact between the HO and the humerus, 3.0% appeared ankylosed.  14.6% of the cases had scapular notching.

Male and female HO rates were 74.0% and 56.1%, respectively (P = .0304). Patients with HO had less forward elevation (121°) than those without HO (133°, P = .0087).

Comment: The rate of HO in this series is somewhat higher than we might expect. The underlying cause for this increased rate of HO in reverse shoulder arthroplasty is not clear. It is possible that the surgical technique used included release of the soft tissues from the inferior glenoid with resultant stimulation of new bone formation. Erosion of the lateral glenoid neck by the humeral prosthesis ("scapular notching") with the Grammont-style implant may release bits of bone into the area that contribute to heterotopic bone formation.

The x-rays shown below demonstrate the variety of patterns of heterotopic bone formation after reverse total shoulder arthroplasty.







We suggest that the risk of HO may be reduced through the use of a more laterally offset glenosphere that avoids contact between the humeral component and the lateral scapula, by avoiding irritating the bone at the lateral scapula when performing soft tissue releases around the glenoid, and by thorough irrigation to remove any bone fragments that may have resulted from preparation for the implants.

In bilateral arthritis, how long after the first TSA should the contralateral TSA be done?

Staged bilateral total shoulder arthroplasty: improved outcomes with less than 6 months between surgeries

These authors analyzed 82 total shoulders  (41 patients, 70 ± 9 years old) comparing 4 “interval groups” based on timing between surgeries: <6 months, 6 to 12 months, 12 to 24 months, and >24 months.

Mean postoperative UCLA, Constant, and SST scores were 29, 72, and 9 points, respectively; 83% of patients reported satisfaction with both shoulders.

Patients with <6 months between surgeries (Group 1) demonstrated significantly better UCLA scores than 6- to 12-month interval patients (P = .04), greater Constant scores compared with all other groups (P < .001), and greater SST scores compared with 6- to 12-month and 12- to 24-month interval patients (P = .002), with no differences in length of follow-up between groups.

Thirty-four patients (83%) reported that they were satisfied with both shoulders and 3 patients (7%) were satisfied with 1 shoulder. Twenty-six patients (63%) reported that 1 side endured a more difficult recovery. Of these 26 patients, 17 (65%) reported that their first side was the more difficult side to recover from, whereas 13 (50%) reported their dominant side as the most difficult side to recover from.

The authors concluded that patients may be advised that having the second arthroplasty within 6 months of the first might optimize their postoperative functional outcomes and satisfaction compared with waiting a longer interval between surgeries.

Comment: The reasons that the < 6 month group seemed to have better outcomes than the longer interval groups are not clear. In that patients were not randomly assigned to different intervals between surgeries, one wonders what factors explained the different the timing selected by the patient and the surgeons.  It could be that the patients electing to have shorter intervals between surgery were more healthy or more optimistic.

In our practice we often consider the second side at about 6 months after the first so that the patient has time to regain their strength and to get far along with the rehabilitation of the first shoulder. As often is the case (as pointed out by these authors) external factors often influence the timing of the second side, for example patients may want to have both surgeries in the same calendar year so that they can avoid paying the insurance deductible for the the second side.