Wednesday, November 23, 2016

What about heavy weight training after a bilateral ream and run?

We've had the chance to work with a wide variety of athletes with severe shoulder arthritis. One example is a highly motivated weight lifter who came to us with a painful stiff left shoulder and these x-rays.



Which he elected to have managed with a ream and run procedure in March of 2015.

In February of 2016 he returned for a right ream and run because of a similar problem 




His x-rays from July 2016 are shown here.








He has been extremely dedicated to his rehab program. This past week he generously gave us permission to show some videos of his most recent workout.


Bent over bar bell row 315 pounds for 8 reps
video

Bench press 225 pounds for 12 reps
video


Seated cable rows 285 pounds for 8 reps
video

Lat pull down 285 pounds for 8 reps
video


He is enthusiastic about his progress as are we. Stay tuned.

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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'



Friday, November 18, 2016

Shoulder arthroplasty registries - why are the US, France, Germany, Switzerland and others not on the list?


A review of national shoulder and elbow joint replacement registries.

Between 1994 and 2004, 6 shoulder registries; by the end of 2009, the shoulder registries included between 2498 and 7113 replacements. The registries were initiated by orthopedic societies and funded by the government or by levies on implant manufacturers. In some countries, data reporting and patient consent are required. Completeness is assessed by comparing data with the national health authority. All registries use implant survival as the primary outcome. Some registries use patient-reported outcomes as a secondary outcome.




Data from national registries can cause us to re-think our approach.  For example, many surgeons are convinced that total shoulder is superior to hemiarthroplasty, but the Finnish data on revision rates (see below) deserve consideration.

A recent article goes a step further, asking: Is it feasible to merge data from national shoulder registries? A new collaboration within the Nordic Arthroplasty Register Association.

Emerging data from this collaboration enable comparison of survival rates among implants









Comment: Notably NOT on the list of countries with national registries are those performing the largest number of shoulder joint replacements: the United States, France, Germany and Switzerland.  Imagine how much faster we'd learn about what was and what was not working if we followed the example of our Scandinavian and South Pacific colleagues. It is also of interest that the great preponderance of shoulder arthroplasty implants are made in the countries NOT participating in national registries. One would think that the wealth created by implant sales would easily support registries in these countries

For example, the US market for extremity implants in 2015 was $934 million compared to $890 million in 2014. Shoulder implants account for 62% of the extremity market (link). If a fraction of this was used to support a registry......

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Use the "Search" box to the right to find other topics of interest to you.

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Does failure of cuff repair allow for greater range of motion in some patients?

The Relationship Between Shoulder Stiffness and Rotator Cuff Healing A Study of 1,533 Consecutive Arthroscopic Rotator Cuff Repairs

These authors reviewed 1,533 consecutive shoulders having an arthroscopic rotator cuff repair.
Patients assessed their shoulder stiffness using a Likert scale preoperatively and at 1, 6, 12, and 24 weeks (6 months) postoperatively, and examiners evaluated passive range of motion preoperatively and at 6, 12, and 24 weeks postoperatively. Repair integrity was determined by ultrasound evaluation at 6 months.

Intraoperatively, 62% of the shoulders were noted to have a full-thickness tear and 38% had a partial-thickness tear, with amean tear-size area of 3.5 ± 1.4 cm2 (range, 0 to 64 cm2; Fig. 1). Of note is that most of these patients had partial or small full thickness tears. 


An undersurface repair technique was used in 58% of the repairs, while 19%were bursal and 23% required both approaches.

After rotator cuff repair, there was an overall significant loss of patient-ranked and examiner-assessed passive shoulder motion at 6 weeks compared with preoperative measurements (p < 0.0001), a partial recovery at 12 weeks, and a full recovery at 24 weeks. 


Shoulders that were stiff before surgery were more likely to be stiff at 6, 12, and, to a lesser extent, 24 weeks after surgery (r = 0.10 to 0.31; p < 0.0001). 

A stiffer shoulder at 6 and 12 weeks (but not 24 weeks) postoperatively correlated with better rotator cuff integrity at 6 months postoperatively (r = 0.11 to 0.18; p < 0.001). 

The retear rate of patients with ≤20° of external rotation at 6 weeks postoperatively was 7%, while the retear rate of patients with >20° of external rotation at 6 weeks was 15% (p < 0.001).

Comment: From these data one might deduce that patients with a stronger fibroblastic response to surgery are more likely to have stiffer and healed repairs in contrast with those with a weak fibroblastic response who tend on average to be less stiff and heal less well. An alternate deduction is that a cuff repair is, in effect, a capsulorrhaphy (i.e. a shoulder tightening operation) and that a re-tear releases the surgically created limitation to passive range of motion.

We are not provided data on the comfort and function of these shoulders before and after surgery, so are unable to determine the relationship of stiffness and healing to the clinical condition of the shoulder before or after surgery.

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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'




Shoulder arthroplasty - avoiding posterior instability

Management of intraoperative posterior decentering in shoulder arthroplasty using anteriorly eccentric humeral head components 

These authors report the use of anteriorly-eccentric humeral head components to manage posterior instability recognized at shoulder arthroplasty when standard trial components are in place. Radiographic centering was characterized before surgery and at follow-up on standardized axillary radiographs with the arm held in a position of functional elevation. Preoperative posterior humeral head decentering did not correlate with preoperative glenoid version.

In 33 shoulder arthroplasties with 2-year outcomes the preoperative radiographic humeral decentering was reduced from 10.4% ± 7.9% to 0.9% ± 2.3% postoperatively (P < .001). SST scores improved from 4.8 ± 2.3 to 10.0 ± 2.3 (P < .001).  Glenoid retroversion was 19.8° ± 8.9° preoperatively and 15.5° ± 7.5° postoperatively. Rotator interval plication was performed in 16 cases as an adjunctive stabilizing procedure.

Comment: Posterior instability after a shoulder arthroplasty can result in pain, functional loss and rocking horse loosening or rim wear of a glenoid component.

While posterior decentering can be identified before surgery by the 'truth' view (an axillary taken with the arm in a functional position of elevation in the plane of the scapula) as shown below


often this preoperative posterior instability will respond to soft tissue balancing and use of standard humeral components. In other cases, the posterior instability persists at surgery, being manifest by a posterior 'drop back' when the arm is elevated. 


Not infrequently a shoulder without apparent posterior instability before surgery becomes posteriorly unstable at surgery after osteophyte resection and soft tissue releases. 

In cases where posterior instability is identified at surgery when trial components are in place, centering of the humeral head can usually be established through the use of an anteriorly eccentric humeral head without or with a rotator interval plication.




resulting in a stabilized head without needing to change glenoid version. Below is the postoperative view of the case shown in the earlier x-ray in which these methods were used.


See these related posts:
Ream and Run - surgical technique

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Check out the new Shoulder Arthritis Book - 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'


Thursday, November 17, 2016

How does the fillet relate to reverse total shoulder implant failure?

Not this fillet


but this one, the degree of rounding of the interior corner of a part. A larger radius dispurses the stress at the junction.






Some implant designs have a stem that can be used either for an anatomic (below left) or a reverse (below center) total shoulder. In order to adapt the stem to a polyethylene (PE) cup, some designs use a tray with a trunion that fits into the Morse taper of the stem. The junction between the tray and the trunion is a fillet (arrow below right). 


 



There are two articles with similar findings.

In vivo fracture of a reverse total shoulder replacement humeral tray: A case report

Failure analysis was performed for two humeral tray components in the same patient that fractured in vivo after only 6 and 9 months.



Implant retrieval analysis indicated that the components failed due to fatigue failure initiating from a small radius fillet at the interface of the Ti6Al4v trunnion and tray regions. Finite element simulations revealed the small radius fillet to have resulted in a large stress concentration and confirmed the possibility for fatigue failure in 6 months. The stress concentration caused by both the small radius fillet and the insufficient tray thickness contributed to the premature fatigue failure of the humeral trays.



Fatigue failure of reverse shoulder humeral tray components of a single design.

These authors retrieved 8 humeral trays of nearly identical designs: 4 Ti-6Al-4V (Ti) and 4 CoCrMo (CoCr). The two Ti devices were revised for in vivo fracture. All Ti humeral tray retrievals fractured in vivo or were cracked at the taper fillet.




 Scanning electron microscopy showed cracking in the other 2 Ti trays and no evidence of cracking in the CoCr components. A geometric difference in the CoCr devices resulted in a 25% decreased stress under simulated activities of daily living. Accounting for the tray material properties, the fatigue failure envelope ranged from 1000 to 1 million cycles for Ti and from 30,000 to >10 million cycles for CoCr.

They concluded  that fatigue failure is possible for some reverse shoulder components and is likely exacerbated by fillet radius, tray thickness, and material choice.

Comment: Modularity and convertibility from anatomic to reverse shoulder arthroplasty are common among currently available shoulder implants.   Each of these designs carries with it features that may expose the patient to risks of prosthetic failure. Surgeons need to be thoughtful as they try newer implants with greater number of intercalated elements, each of which carries with it unique benefits and failure modes.

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See the countries from which our readers come on this post.

Rotator cuff repair, does integrity matter?

A prospective, multicenter study to evaluate clinical and radiographic outcomes in primary rotator cuff repair reinforced with a xenograft dermal matrix.

These authors point to the prevalence of retears after cuff repair: "Galatz et al reviewed 18 patients after arthroscopic repair of tears > 2 cm using a single-row technique and ultrasound evaluation after 12 months and found 17 of 18 retears. Lee et al reported retear after arthroscopic double-row repair in 30 of 62 (48.4%). In patients aged > 60 years, the retear rate was 62.5%, and medium to large tears retore in 27 of 51 (53%). Tashjian et al reported arthroscopic repair of 2-tendon tears evaluated by ultrasound imaging and found 64% retears after double-row repair. Bishop et al evaluated open and arthroscopic rotator cuff repair by MRI. Large rotator cuff tears had a retear rate of 38% in the open group and 76% in the arthroscopic group."

Against this background they conducted a study of 61 shoulders with large rotator cuff tears (3 to 5 cm) surgically repaired and reinforced with a extracellular matrix (ECM) graft.  The average tear size was 3.8 cm.

Three patients underwent surgical revision. Complications included 1 deep infection.
Functional outcome scores, isometric muscle strength, and active range of motion were significantly improved compared with baseline. Magnetic resonance imaging at 12 months showed retorn rotator cuff repairs in 33.9% of shoulders, using the criteria of a tear of at least 1 cm.

Comment: This is a carefully done followup study but does not offer the opportunity to compare outcomes of repairs with and without application of the ECM.

It is of interest that the functional outcomes were not different for shoulders with and without retears, as shown below.








Total shoulder arthroplasty in patients with HIV - when does it make sense?

Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends.

These authors identified 2528 HIV-positive patients who underwent TSA or reverse TSA (RTSA) in the 2005 to 2012. Medicare database. 1353 patients had 2-year follow-up. The percentage of TSA/RTSA done for HIV positive patients is on the increase


These patients had a higher prevalence of comorbidities. 


These patients had significantly higher rates of 7 to 30 medical complications

Particularly impressive was the 45 times higher risk of stroke CVA.

 In addition to the medical complications,  HIV-positive patients had higher overall rates surgical complications, including broken prosthetic joints (OR, 1.72; CI, 1.20-2.47), periprosthetic infection (OR, 1.36; CI, 1.01-1.82), and TSA revision or repair (OR, 2.44; CI, 1.81-3.28).





Comment: These data remind us that shoulder arthroplasty is in almost all cases and elective procedure. The 'indications' for these procedures are not 'arthritis' or 'cuff tear arthropathy' but rather a patient who has a good chance of benefitting from the surgery, considering not only the shoulder pathology but also the risk factors for complications and poor results. We need to be prepared for the situation where the shoulder 'needs' surgery, but the patient doesn't.


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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 run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'