Tuesday, July 29, 2014

What has been accomplished by our shoulder research team over the past year

Each year we're asked to provide a summary of our activities conducted with the support of the Harryman/DePuy endowed Chair for Shoulder Research.

We thought the summary might be of interest to our readers and have posted it here.



Thanks to your support, the Harryman/DePuy Chair continues to yield high quality, clinically important contributions to the foundation of knowledge on which modern shoulder surgery is based. Simply stated, without your support, this research would not have taken place.  This past year our work has focused in several critical areas and I’ve tried to summarize them here.

(1) Propionibacterium infections after shoulder joint replacement
We have noted that infections with Propionibacterium – a normal inhabitant of our skin – can cause problems of joint pain and stiffness after shoulder joint replacement without obvious evidence of infection, such as fever, chills, tenderness or redness. [1] These organisms live in rather than on the skin so that skin surface preparation is not effective in eliminating the bacteria from the surgical field[2]. In fact, we did a study that showed that we could recover Propionibacterium from punch biopsies of the skin in spite of standard surgical skin preparation[3] The subtle evidence of infection can appear long after the surgery[4] so that a high index of suspicion is necessary to pursue the appropriate cultures at the time of all revision surgery and a comprehensive plan of surgical and antibiotic management is necessary to resolve the infection.

(2) The Axillary View
Contrary to the opinion of many, it is not necessary to get an expensive CT scan to identify the pathoanatomy of the shoulder before and the results after a ream and run procedure. Instead of a computerized tomographic scan, which costs more money and which subjects the patient to additional radiation, we use a plain axillary view to make the necessary determination of the anatomy of the arthritic shoulder and the effectiveness of the ream and run procedure in restoring the desired shoulder anatomy.[5]

(3) Failure of the glenoid component in total shoulder
The weak link in total shoulder replacement is the glenoid component[6]. While many surgeons are working to develop metal backed glenoid components, our research suggests that these metal backed glenoids have a much higher failure rate than all polyethylene components.[7] We continue to use an all-polyethylene component and are meticulously careful to craft the bone to fit this prosthesis so that the risk of loosening is minimized.

(4) Factors associated with failure of rotator cuff repair.
In a comprehensive review of the published literature, we discovered that – while the number of articles published about rotator cuff repair has increased dramatically over the last three decades – the clinical and anatomic results have not improved with time. In other words the ‘technological advances’ have not yielded better results for the patients. The weighted mean retear rate was 26.6% at a mean of 23.7 months after surgery. Retears were associated with more fatty infiltration, larger tear size, and advanced age. Interestingly, patient-reported outcomes were generally improved whether or not the repair restored the integrity of the rotator cuff. [8]

(5) Learning about improving patient safety by studying malpractice claims.
We reviewed 108 closed upper extremity liability claims from a large United States-wide insurer for events that occurred between 1996 and 2009. We found that liability claims were primarily for the care of common problems, such as fractures or degenerative conditions, rather than complex challenging conditions or disorders, such as deficiencies treated with replantation or tissue transfers. The most common adverse outcomes in these claims were nonunion or malunion of fractures, nerve injury, and infection. Most claims involved a permanent injury. The surgeon's operative skills were more commonly an issue in paid claims than in claims without payment. Claims for mismanagement of fractures were more likely to result in payment than nonfracture claims. We concluded that that the incidence of upper extremity claims made and claims paid may be reduced if surgeons acquire and maintain the knowledge and skills necessary for the care of the common conditions they encounter, including fractures.[9]


(6) The Blog.
Our blog on shoulder arthritis and rotator cuff tears has become immensely popular not only in the US but also in over 100 countries around the world.[10] [11] It now has almost 1000 posts reviewing concepts, recent articles and our cases of interest. There have been almost 500,000 page views as well as a major interest from Twitter and Facebook. The most popular posts include “the shoulder: arthritic or frozen”, “shoulder exercises”, “x-rays for shoulder arthritis”, “shoulder arthritis – what you should know about it” and “rotator cuff and rotator cuff tears – what you should know about them”.

As you can see, in addition to our active practice in helping individuals needing surgical reconstruction of their shoulders, things are busy in the research and teaching domains. All of our activities are supported by your contributions to the Harryman/DePuy Endowed Chair. For your interest and your support, we are most grateful.
If you have any questions about our work or how you might continue to support it, please feel free to drop me an email anytime at matsen@uw.edu. Lot’s more coming up – stay tuned!


J Bone Joint Surg Am. 2012 Nov 21;94(22):2075-83.
[2] Matsen FA 3rd, Butler-Wu S, Carofino BC, Jette JL, Bertelsen A, Bumgarner R. Origin of Propionibacterium in surgical wounds and evidence-based approach for culturing Propionibacterium from surgical sites. J Bone Joint Surg Am. 2013 Dec 4;95(23):e1811-7.
[3] Lee MJ, Matsen FA 3rd, Pottinger P, Bumgarner R, Butler-Wu S, Russ S. Propionibacterium Persists In The Skin In Spite Of Standard Surgical Preparation. The Journal of Bone and Joint Surgery. Accepted for Publication.
[4] McGoldrick E, McElvany MD, Butler-Wu S, Pottinger PS, Matsen FA 3rd.
[5] Matsen FA 3rd, Gupta A. Axillary View: Arthritic Glenohumeral Anatomy and Changes After Ream and Run. Clin Orthop Relat Res. 2014 Mar;472(3):894-902.
[6] Papadonikolakis A, Neradilek MB, Matsen FA 3rd. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013 Dec 18;95(24):2205-12.
[7] Matsen FA 3rd, Papdonikolakis A. Metal-Backed Glenoid Components Have A Higher Rate Of Failure And Fail By Different of Bone and Joint Surgery. 2014 Jun 18;96(12):1041-1047.
[8] McElvany MD, McGoldrick E, Gee AO, Neradilek MB, Matsen FA 3rd. Rotator Cuff Repair: Published Evidence on Factors Associated With Repair Integrity and Clinical Outcome. Am J Sports Med. 2014 Apr 21.
[9] Matsen FA 3rd, Stephens L, Jette JL, Warme WJ, Huang JI, Posner KL.
J Hand Surg Am. 2014 Jan;39(1):91-9
[10] http://shoulderarthritis.blogspot.com/
[11] Albania, Algeria, Argentina, Armenia, Australia, Austria, Bahrain, Bangladesh, Barbados, Belarus, Belgium, Belize, Bosnia, Brazil, Bulgaria, Canada, Chile, China, Columbia, Costa Rica, Croatia, Cyprus, Czech Republic, Denmark, Dominican Republic, El Salvador, Egypt, Eritrea, Estonia, Finland, France, Georgia, Germany, Greece, Herzegovina, Hong Kong, Hungary, India, Indonesia, Iraq, Ireland, Isle of Man, Israel, Italy, Japan, Jordan, Kenya, Kuwait, Laos, Latvia, Lebanon, Libya, Lithuania, Malaysia, Malta, Mauritius, Mexico, Moldova, Mongolia, Morocco, Nambia, Nepal, Netherlands, New Zealand, Norway, Oman, Pakistan, Panama, Peru, Philippines, Poland, Portugal, Puerto Rico, RĂ©union, Romania, Russia, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, South Africa, South Korea, Spain, Sri Lanka, Sweden, Switzerland, Syria, Taiwan, Thailand, Trinidad and Tobago, Turkey, Ukraine, United Arab Emirates, United Kingdom, United States of America, Venezuela, Vietnam, and Yemen.

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Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


Monday, July 28, 2014

Propionibacterium in a primary arthroplasty after a Latarjet procdure, seeing what you look for

A man is his early twenties presented with pain and stiffness in the shoulder after two prior instability procedures, the last being a Latarjet in 2012.



He had a primary hemiarthroplasty with removal of the screw, the head of which was rubbing on his humeral head. Because of the global loss of cartilage seen on his preoperative films, we obtained cultures before administering antibiotics.

At surgery there was no obvious evidence of infection. The humeral head showed global loss of cartilage as shown here.
His postoperative films are shown here.


After surgery he was started on the 'yellow' antibiotic protocol. Range of motion exercises were started on day one and he had 150 degrees of motion on discharge two days later.

Five days after surgery, the cultures grew out coagulase negative staph in one specimen and Propionibacterium in three (capsule, humeral head #1 and humeral head #2). At that time a PICC line was plaeced and he was converted to the 'red' antibiotic protocol.

Comment: It would have been easy to miss this infection. Our index of suspicion was heightened by the generalized destruction of the joint surface in contrast to the local destruction that would be expected from contact of the humeral head with the screw.

===

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


Ream and run for B2 glenoid - beach smashball at 13 weeks

A man in his late 40s had a ream and run for the bad arthritic triad (BAT) which developed after a previous repair for anterior instability ( = capsulorrhaphy arthropathy). His preoperative films showed complete loss of the joint space and the arthritic triad: a biconcave glenoid, glenoid retroversion and posterior subluxation of the humeral head on the face of the glenoid.


Thirteen weeks ago, he had a ream and run with a 56 21 anteriorly eccentric head and a rotator interval plication.

His postoperative films show centering of the humeral head on the glenoid.


He recently send a video of his playing smashball on the beach 13 weeks after surgery - possibly a new way to rehabilitate a shoulder.


video


===

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'



Saturday, July 19, 2014

Propionibacterium in shoulder surgery - the skin micro biome

Propionibacterium acnes Infections in Shoulder Surgery

The abstract to this paper reads, "Perioperative shoulder infections involving Propionibacterium acnes can be difficult to identify in a patient who presents with little more than pain and stiffness in the postoperative period. Although indolent in its growth and presentation, infection of the shoulder with P acnes can have devastating effects, including failure of the surgical intervention."

The authors point out, as we've previously emphasized, that Propionibacterium are commonly found in failed shoulder surgeries, including arthroplasty, cuff repair and fracture fixation. These failures may present as pain, stiffness or mechanical loosening - only rarely with redness, swelling, tenderness, wound drainage, fever, elevated white blood cell counts, elevated C reactive protein, or elevated sedimentation rate. Our approach to the finding Propionibacterium in surgical wounds is explained here. In contrast to the statement of these authors, the date indicate that cultures for Propionibacterium should be on three different media and held for 17 days.

The authors suggest that Propionibacterium contamination from the skin of the patient can be prevented by "proper preparation of the surgical field" but as they point out this is difficult. Recent evidence has shown that the organisms lie in not on  the skin, so that they are not susceptible to normal skin preparation. A great article on the ecology of skin bacteria is shown here. These two figures come from that article. Note that Propionibacterium are common in the oily areas (face, chest, back) and not the moist areas (axilla and groin). From the second figure one can see that Propionibacterium were NOT present in the axilla, contrary to popular belief.






They point out that presurgical preparation of the skin is ineffective in eliminating Propionibacterium from the hair follicles and sebaceous glands. The authors advocate changing to a new clean knife blade after the skin incision - a practice we have adopted as well. The bottom line is that there is no effective method of preventing Propionibacterium contamination of the surgical field.

We suggest that the risk of infection may also be reduced by copious irrigation with antibiotic-containing fluid and avoiding contact between the implants being inserted and the skin edge at the time of insertion.

The authors refer to our prior study demonstrating that patients having revision shoulder arthroplasty had a high risk of positive Propionibacterium cultures if they were male with osteolysis and humeral and/or glenoid component loosening. This study suggests that the effect of Propionibacterium is to create bone resorption rather than acute inflammation.



Friday, July 18, 2014

The 4Ps and Modification of Patient factors prior to surgery

The Ethics of Patient Risk Modification Prior to Elective Joint Replacement Surgery.

We emphasized in prior posts that the outcome of surgery depends in large part on the 4 Ps: the problem being treated, the patient with the problem, the procedure used to treat the problem and the physician providing the treatment.

This article discusses the importance of patient factors and strategies for optimizing them. Their list of potentially modifiable risk factors includes bacterial colonization, diabetes control, body mass index(BMI), smoking status, fall risk, narcotic and/or alcohol dependence, physical conditioning, neurocognitive disorders, nutritional status, cardiovascular status, nongenetic thromboembolic risk, and anemia. This is an important list and gives both patients and their surgeons a lot to think about. How can we best minimize these risk factors in elective surgery?

Here are some of the data they present:
Patients with a BMI > 45 have an 8 times greater risk of complications than average weight patients.
Smokers have a 24% higher risk of postoperative complications, including surgical site infections, pneumonia, stroke and death.
Uncontrolled diabetes (perioperative hyperglycemia) increases the risk of infection.
Staph aureus colonization increase the risk of infection.

Complications, longer lengths of hospital stay, and readmissions increase the risk of penalties or non-payment under current and planned federal programs. Thus on one had there is an incentive for providers to operate on individuals with increased risk to build case volume on one hand and there are incentives for delaying surgery and modifying these risk factors or avoiding elective surgery on individuals at increased risk on the other.

This article provides an interesting discussion of these issues from the standpoint of the surgeon as well as from the standpoint of the patient and 'patient autonomy'. How much of the decision to delay surgery while risk is minimized should be up to the doctor and how much to the patient? How to balance nonmaleficence and beneficence. How to balance the benefit of delay for risk modification with the harm of delay from progression of disease?

This article does not discuss the problems in applying the systems encouraging the reduction of modifiable risk to the situation with unmodifiable risk, such as past medical history, genetics, Medicaid status, race and age. Policies that discourage surgery on high risk patients require complex stratification to distinguish modifiable and unmodifiable risk. Otherwise, Medicaid patients with a history of malignancy and certain ethnicities may be unable to find providers willing to perform the surgeries they need.


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Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


One year followup: Ream and run for B2 glenoid (the Bad Arthritic Triad)

Email received today from a Californian in his mid forties:

"I can only explain how my shoulder is doing now by comparing it to the start of my journey.   Before we met and before the ream and run surgery; I could be simply walking and with a swing of the arm be brought down almost to my knees by shooting pain resonating from my shoulder.  This pain was never consistent and I never knew when or where it would strike.  I could not lift my arm above horizontal and would receive immense amount of pain when attempting to push past this point.  For years I dealt with this issue and considered my life being immobilized and in fear of the next random occurrence.

 I am very pleased to say that I have been pain free of normal activities since roughly the six month mark.  I returned to playing softball and at first was hesitant to swing the bat hard and continue with a full follow through.  It's been a full year almost to the day and I can say that my home run hitting power is back!  I have no worries and swing as hard as I possibly can with nary a thought to my repaired shoulder.  I am still working on the flexibility and have yet to obtain 100% mobility but I attempt to get closer with my daily stretches and exercises.  I've lost roughly 45 pounds and I am in much better shape than before.  I expect to learn kite boarding within the month and that would not have even crossed my mind last year.  I am thankful I went through with the the surgery and I am especially thankful that you were available.

Here are the preoperative films showing the B2 glenoid with posterior humeral subluxation and glenoid retroversion:


And the immediate postoperative films showing humeral head centering in the glenoid without change in glenoid version. Note this surgery included the use of an eccentric humeral head and a rotator interval plication.




===

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'



Wednesday, July 16, 2014

Eight year progress note on bilateral ream and runs.

Email received today:
"I read the post on the 7 month update. Just want to say THANKS! 8 years later and both my shoulders are doing great! Cant say the same for the Idaho salmon. although, they taste great. I Just want to let you know that in my case. My shoulders continue to get better and stronger long after the 2 years that we thought would be full recovery. My left might get a little sore after a long day of HARD USE OR GREAT FUN. No more than the guys trying to keep up with original equipment. IT Seems to recover quick with a mobic. I might take 4 or 5 a month."

Preop x-rays right side:



7 year followup x-rays right side:

Preop x-rays left side:

7 year followup x-rays left side:


===

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Consultation for those who live a distance away from Seattle.

To see the topics covered in this Blog, click here

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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'