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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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.




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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:


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7 month progress note on a ream and run

We received this email today:

"Been meaning to email you for a while. You did my L shoulder, hemi arthroplasty with glenoid reaming, just before Thanksgiving last year. Since I live in the SF Bay Area we emailed back and forth. I felt I wasn't making much progress the first 4-5 months and the tone of my emails may have reflected that - sorry.

I was considering a manipulation, saw a few local shoulder surgeons, but decided against it. Interestingly, one of them, Dr. XX, implied I would never get full strength back. He said the glenoid reaming 'medialized' the center of rotation of the shoulder, weakening the cuff muscles by altering the muscle length tension relationship. Not surprisingly he suggested implanting a gleniod component would fix that. Of course when I mentioned a recent large study orthopedic article showing a 37% glenoid failure rate after 10 years, he glossed over and ignored that. Looks like one should only have a total shoulder if they are not going to out live their complication!

At about the 5th month (April) the shoulder started getting much better; less pain, more ROM, stronger. It's still weaker and stiffer than he other side, but functional and in some ways less painful than my other (also bad) shoulder. For the last 2 months I've been mountain biking, sailing in regattas, and weight training at my gym."


Comment: It's worth making a few comments on this informative email. First of all it is not uncommon that shoulders having a ream and run turn the corner at about 6 months as shown here. This individual hung in there and now is getting back into his desired activities. Second, the ream and run does not 'medialize' the center of rotation of the shoulder. Only enough reaming is done to create a smooth concentric concavity 2mm greater than that of the humeral head prosthesis. The muscle length tension relationships are optimized by the selection of the thickness of the humeral head prosthesis as well as by its positioning. Finally, the shoulders having ream and run shoulder arthroplasty have often been inactive for months or years prior to the surgery, so it is not a surprise that it takes time to recover strength after the procedure. Here are the preop films


and the immediate post op films on this patient's shoulder

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Sunday, July 13, 2014

Stemless reverse total shoulder

The TESS reverse shoulder arthroplasty without a stem in the treatment of cuff-deficient shoulder conditions: clinical and radiographic results

The authors of this article acknowledge that they were involved in the design of this prosthesis and receive royalties and financial related to this product as well as funding from the company for the data collection for this article.
They present the results of 91 stemless reverse total shoulders in 87 patients (61 men and 26 women), with a mean age of 73 years, at a mean follow-up of 41 months (range, 24-69 months). The indications for surgery were massive cuff tear and cuff tear arthropathy (this series did not include the higher risk diagnoses of failed arthroplasty or fracture). On average these patients had a reasonable degree of function before surgery: an average of 96 degrees of flexion and an average of 89 degrees of abduction.

Clinical scores were improved after surgery. Inferior scapular notching occurred in 17 cases (19%). The notching rate was higher when the angle between the glenoid base plate and the humeral cup increased and when there was less inferior tilt of the glenoid component. There was no radiographic evidence of component loosening at a minimum of two years.

There was a low rate of complications, which the authors suggest was related to a high degree of surgeon experience and relatively benign diagnoses; one case of instability occurred as a result of inadequate soft-tissue tensioning, which was resolved with a thicker spacer and one fracture of the spine of the scapula. There were no infections or neurologic lesions.

Comment: It is of note that, in contrast to many other publications, the patients in this series were predominantly male and did not, on average, have the commonly reported indications of pseudo paralysis or instability. It is possible that some of these patients might have been managed with a CTA prosthesis - possibly allowing them a higher level of function.

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Stemless humeral components for shoulder arthroplasty


Stemless shoulder arthroplasty: current status

This article reviews five different stemless shoulder arthroplasty systems. The author concludes that "Early results for stemless shoulder arthroplasty indicate clinical results similar to standard stemmed shoulder arthroplasty."

Comment: There have been many marketing-driven attempts to improve on the classical stemmed humeral component: these include partial surface humeral components,  full surface humeral components, short stemmed humeral components and now stemless humeral components. It is stated that these efforts are directed at combating "stem-related complications", such as intraoperative humeral fracture, loosening, stress shielding, traumatic periprosthetic humeral fracture, difficulty with stem extraction, bone loss due to proximal stress shielding, osteolysis due to polyethylene wear debris, and difficulty with cement extraction at revision.  It is important to point out, however, that many of these issues can be avoided using modern techniques for stemmed arthroplasty, including conservative broaching to avoid stem weakening, fixation with impaction grafting to avoid cement, stress shielding and fracture, and avoidance of ingrowth stems that complicate revision. 

It is also important that the use of stemless components may limit the surgeons ability to use eccentric components to manage commonly encountered issues of stability in glenohumeral arthritis and to reconstruct shoulders with proximal humeral deformity or bone loss.


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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'