Saturday, November 17, 2018

Is "comprehensive arthroscopic management of glenohumeral osteoarthritis" a conservative procedure?

Survivorship and Patient-Reported Outcomes After Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis Minimum 5-Year Follow-up

These authors reported their outcomes and survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of glenohumeral osteoarthritis at a minimum of 5 years postoperatively in 46 patients (49 shoulders).

 The CAM procedure included glenohumeral chondroplasty, capsular release, synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture, and biceps tenodesis. 



Two patients were excluded for refusing to participate before study initiation. 

The mean age at surgery was 52 years (range, 27-68 years) in 15 women and 29 men. 

Twelve shoulders (26%) progressed to total shoulder arthroplasty at a mean of 2.6 years (range, 0.5-8.2 years). For 45 of 47 (96%) shoulders, survivorship was 95.6% at 1 year, 86.7% at 3 years, and 76.9% at 5 years. 

2 additional patients required secondary arthroscopic surgery; one underwent capsular release for stiffness at 5.6 months, and another underwent a revision CAM procedure at 7.9 years.

Factors associated with failure and progression to TSA were a Walch type B2 or C glenoid shape and preoperative joint space narrowing defined as less than 2 mm of joint space remaining as seen on a Grashey or true  anterior-posterior radiograph of the glenohumeral joint.

Subjective outcome data were available for 28 shoulders at a mean of 5.7 years. 



Comment: 
As indicated by Table 2 of this paper, there is wide variability in what is actually done in this procedure, making it difficult to discern what elements contribute to the outcome. For example, is there evidence that an axillary nerve release is indicated in 1/3 of shoulders with arthritis? Do patients with osteoarthritis have synovitis requiring synovectomy? 
Five year followup was available only on 53% (28/49) of the cases.
It appears that the outcomes were better if the arthritis was milder (2 mm or more of preserved joint space, less severe Walch glenoid types). 
It would be of interest to know whether the 26% of the patients who required subsequent total shoulder arthroplasty realized the same quality results as patients having primary arthroplasty.

Further comparative studies will be needed to determine the place of this procedure among the other options in the management of arthritis for patients with a mean age of 52. 
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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.


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'


Wednesday, November 14, 2018

Reverse total shoulder - failure by baseplate loosening

Incidence and risk factors for aseptic baseplate loosening of reverse total shoulder arthroplasty

These authors analyzed 202 shoulders that underwent primary or revision reverse total shoulder (RSA) with a DJO prosthesis at a minimum 2-year follow-up.

Presumed aseptic baseplate loosening (AGBL) occurred in 6 shoulders (3.0%). The incidence of AGBL after revision RTSA (10%) was significantly higher than that after primary RTSA (1.2%; P = .014). There were significant associations between AGBL and the use of bone graft and the use of nonlocking screws. 

Multiple logistic regression analysis showed that the use of all peripheral nonlocking 3.5-mm screws and the use of bone graft were independent risk factors for AGBL.

Here is an example of baseplate loosening at 13 months after RSA associated with severe scapular notching.

Here is an example of central screw failure at 20 months after RSA, possibly associated with incomplete seating of the baseplate.


Our approach is to avoid bone grafting of the baseplate except in the rare case when good bone purchase cannot be achieved with the central screw, to assure good seating of the glenoid baseplate, and to use for peripheral locking screws.
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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.


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'


Tuesday, November 13, 2018

Shoulder pain at one year after rotator cuff repair

A prospective evaluation of predictors of pain after arthroscopic rotator cuff repair: psychosocial factors have a stronger association than structural factors

These authors evaluated the correlation of preoperative factors with pain after arthroscopic rotator cuff repair in 93 patients prospectively enrolled and evenly distributed by tear size.

54% of the patients were men with a mean age of 56.4 years. There were 68% traumatic tears, 11% smokers, and 13% used narcotics preoperatively. 

Overall the Simple Shoulder Test Scores improved from an average of 4.4 before surgery to 11.2 out of 12 at 1 year after surgery. Patients with lower preoperative SST scores had significantly more pain at 2 weeks and one year after surgery.

Preoperative narcotic use, higher preoperative VAS, and lower scores on the WORC index and emotion sections correlated with increased pain scores at 1 year.

Supraspinatus atrophy and smoking status also correlated with worse outcomes at 1 year. 

The authors concluded that  the factors most predictive of persistent pain after ARCR were psychosocial characteristics, including poor performance on validated measures of emotional well-being. Demographic and tear-specific structural factors did not correlate with postoperative pain scores.

Comment: This is an interesting study suggesting that surgeons should inform patients with the identified psychosocial features that they are at risk for persistent postoperative pain. 

It would have been of interest to know the relationship of the structural integrity of the cuff repair to the patients postoperative pain.

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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.


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'

The Latarjet procedure - how safe is it?


Ninety-day complications following the Latarjet procedure

These authors sought to describe the rate and type of complications occurring within 90 days following the Latarjet procedure for anterior glenohumeral instability. They reviewed consecutive patients undergoing the Latarjet procedure by fellowship-trained surgeons from a single institution between 2007 and 2016 were included for analysis. Their indications for the Latarjet procedure included primary or recurrent anterior instability with clinically significant anterior glenoid bone loss and/or failed prior arthroscopic stabilization. Patients undergoing the Latarjet procedure after prior glenoid bone grafting were excluded.

Among 133 patients (average age, 28.5 ± 11.8 years; 75% male patients), 10 total complications occurred within 90 days of surgery, for an overall short-term complication rate of 7.5%. Of these 10 complications, 6 required subsequent surgery, with recurrent instability in 2 cases (overall rate, 1.50%), infection in 2 (overall rate, 1.50%), musculocutaneous nerve palsy in 1 (overall rate, 0.75%), and postoperative pain in 1 (overall rate, 0.75%).

Each of the 2 patients who experienced recurrent subluxation events ultimately required conversion to arthroplasty. The 2 patients with infections underwent subsequent irrigation and d├ębridement, as well as antibiotic therapy. The patient with the musculocutaneous nerve injury ultimately required further surgery in the form of a musculocutaneous nerve decompression and subsequent nerve transfer procedure. The remaining 4 complications were transient and resolved with nonoperative treatment, including wound dehiscence, hematoma, complex regional pain syndrome, and ulnar neuritis.

Comment: An increasing number of surgeons are being attracted to the Latarjet procedure for patients both without and with glenoid bone deficiencies. This article concerns the Latarjet complications in a single institution with highly trained shoulder surgeons - their report is likely to underrepresent the nature and frequency of Latarjet complications in the hands of community surgeons. 

It is to be noted that this study of 90 day complications would not capture the longer term complications of this procedure, such as screw loosening, coracoid non-union, and capsulorrhaphy arthropathy. Their article did show one case of arthritis related to contact of the fixation screw with the humeral head.
In our practice we have been referred a number of patients with hardware problems after the Latarjet procedure; some performed on shoulders without glenoid bone deficiency.

Here are some examples:




Patients and surgeons considering the Latarjet procedure should be aware of these potential complications as well as the difficulties associated with revision surgery in patients with a failed Latarjet (subscapularis scarring/deficiency, altered surgical anatomy, glenoid bone deficiency, nerve entrapment).

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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.


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'

Friday, November 9, 2018

Measuring clinical outcomes from total shoulder arthroplasty - it is simpler than what we might have thought

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.

Of course it is recognized that radiographic failure often occurs at 5 to 10 years after shoulder arthroplasty, so much longer periods of followup are required to assess loosening and revision rates.


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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.


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'

Treatment of large rotator cuff tears with a graft - the problem with long-term followup

Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up

These authors sought the long term outcomes of treatment for 13 irreparable cuff tears using synthetic interposition grafts made of Dacron to bridge the defect between the residual tendon and the tuberosity. The patients included 11 men and 2 women with a mean age of 55 years (range, 38-72 years).

After a mean of 18 years (range, 17-20 years), 1 patient had died, and 12 were available for x-ray imaging and 10 also for ultrasonography and clinical scores. Cuff tear arthropathy (Hamada grade ≥2) had developed in 9 of 12 (75%; 95% confidence interval, 43%-95%), including 3 patients operated on with arthroplasty in the follow-up period. 

The mean absolute Constant-Murley score was 46 (standard deviation, 26), and the mean Western Ontario Rotator Cuff score was 59 (standard deviation, 20). In 7 of 10 patients (70%) with available ultrasonography, the graft was interpreted as not intact. 

All patients had a contralateral full-thickness tear, and 7 of 12 patients (58 %; 95% confidence interval, 28%-85%) had contralateral cuff tear arthropathy. The number of patients with cuff tear arthropathy was not significantly different between the shoulder repaired with a Dacron graft and the contralateral shoulder (P = .667). 

Comment: Here we have a common issue in clinical research. Patients want to know the long term results of the treatment they are considering. But usually we can only give them either (1) the long term results of a method no longer in use (such as a Dacron graft)


or (2) the short term results of a new type of graft




as shown in a recent post (see this link)

or even a balloon



=====
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.


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'

Total shoulder arthroplasty for arthritis after coracoid transfer for instability

In a prior post (see this link) we reviewed the problem of arthritis after a Bristow or Latarjet procedure. Because of the increasing utilization of these coracoid transfer surgeries, there is an increasing number of shoulders requiring revision because of complications or because of capsulorrhaphy arthropathy. 

We had such a case recently, in which the dissection was difficult, the subscapularis was scarred and the screw and bone block were approximated to the axillary nerve.


 In spite of his B2 glenoid, this shoulder was managed with a standard (non-augmented) all polyethylene glenoid component. The screw and most of the bone block was removed by careful dissection. The subscapularis was securely reconstructed.
 The patient sent us this photo of his motion at his home on the second day after surgery.
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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.


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'