Monday, August 3, 2020

Shoulder arthroplasty: patient satisfaction and outcomes

Factors That Influence Inpatient Satisfaction After Shoulder Arthroplasty.


These authors sought to distinguish satisfaction with regards to the outcome of care and satisfaction with the delivery of care. 


They investigated inpatient satisfaction according to the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys after shoulder arthroplasty. The HCAHPS and CG-CAHPS surveys have recently become the gold-standard and preferred form of reporting patient satisfaction for CMS. This trend is relevant for orthopedic surgeons because CAHPS scores are being incorporated into financial reimbursement systems


Eight HCAHPS domains were included in the analysis: (1) communication with doctors; (2) communication with nurses; (3) responsiveness of the staff; (4) pain management; (5) communication about medications; (6) discharge instructions; (7) cleanliness and quietness; and (8) overall rating of the hospital. Five CG-CAHPS domains were included: (1) getting timely appointments, care, and information; (2) how well providers communicate with patients; (3) providers use of information to coordinate patient care; (4) helpful, courteous, and respectful office staff; and (5) patient’s rating of the provider.


They determined factors that influenced them, as well as their correlation with surgical expectations, pain perception, quality of life, surgical setting, and functional outcomes in patients having shoulder arthroplasty.


They found that the The average HCAHPS and CG-CAHPS satisfaction scores for the population were 74.7 ± 20.7 and 82.1 ± 19.4. Overall, 37 (74%) and 34 (68%) patients, respectively, had CG-CAHPS and HCAHPS scores that indicated satisfaction.


Non-smokers had a mean HCAHPS score of 77.7 ± 22.0 and current smokers reported a mean of 59.6 ± 5.2 (p = 0.03). 


Patients that were discharged home had a mean HCAHPS score of 77.3 ± 21.9 where those discharged to a skilled-nursing facility (SNF) reported a mean of 59.3 ± 6.6 (p = 0.05). 


These same groups also had significantly higher odds of being satisfied with the hospital.  They found no significant differences or higher odds seen when comparing overall CG-CAHPS satisfaction between any of the patient-specific factors tested. There was no significant correlation between age, length of stay, pain (PCS), resiliency (RS-11), expectations (SSES), and function (SF-12) for both HCAHPS and CG-CAHPS  satisfaction scores. Patients with high preoperative surgical expectations, pain perception, and resiliency are not generally more satisfied with the hospital or clinician. Preoperative diagnosis, location of surgery, and length of stay does not reliably impact satisfaction with the hospital or

36 clinician. HCAHPS and CG-CAHPS inpatient satisfaction does not correlate with legacy functional outcome measures, therefore, may not be predictive of long-term functional outcomes.


No legacy patient reported outcome measures had significant or strong correlations with either HCAHPS or CG-CAHPS satisfaction scores. From this information the authors suggested that CAHPS scores are not effective in predicting long-term functional or perceived outcomes of the arthroplasty.


Comment: We had difficulty understanding the analysis of satisfaction scores with patient reported metrics, such as the Simple Shoulder Test or the ASES score. These data were not presented in the results section or the tables. Thus an apparently unanswered question is "how does satisfaction with the process of care correlate with the functional outcome of the procedure?"


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To see our new series of youtube videos on important shoulder surgeries and how they are done, 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  arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


Ream and run - imaging the shoulder before and after surgery

Standardized imaging of the shoulder before and after the ream and run is important both for preoperative planning and for evaluating the arthroplasty. We use three views, as shown below: the AP in the plane of the scapula (Grashey view) on the left; the axillary "truth" view in the center, and the AP templating view on the right.



The AP templating view gives a good view of the humeral canal to anticipate any issues with placement of the stem as shown in the three examples below 





The AP in the plane of the scapula or Grashey is used for identifying medialization relative to the lateral acromial line, bone stock, glenoid inclination, foreign bodies and the size of the osteophytes.


This view is also used to evaluate proximal deformities that may require special placement of the humeral component.


And situations in which the humeral head cannot be dislocated safely so that an in situ osteotomy may be required.


The axillary "truth" view is used for evaluating the centering of the humeral head on the glenoid


Using this view, the centering can be compared before and after surgery


The axillary "truth" view is used to evaluate the glenoid bone stock and version relative to the plane of the scapula.


It can also be used to identify the glenoid type





However, we have found that the glenoid type is not an important consideration in the ream and run procedure, because in all cases the goal of reaming is to create a single glenoid concavity with maximal preservation of glenoid bone; changing glenoid version is not a priority and does not seem necessary for achieving stability or for a good functional result











Using these views we have not found that preoperative CT scans or 3D CT planning are needed.

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To see a YouTube video on how the ream and run is done, click on this link.

===

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'


Saturday, July 25, 2020

The superior baseplate screw in reverse total shoulder arthroplasty: the least important and the most dangerous



During implantation of the glenoid baseplate, screws are inserted through the glenoid face into the scapular body to achieve adequate fixation. Placement of peripheral baseplate screws in the superior and posterior glenoid may increase the risk of injury to the suprascapular nerve (SSN). These authors used a cadaveric model to evaluate the risk of SNN injury with placement of baseplate screws in the superior and posterior direction.

A bicortical 44 mm screw was placed in both the superior and posterior glenoid baseplate screw holes. Following implantation, the SNN was dissected and visualized through a posterior shoulder approach. The distance from the tip of the screws to the SSN and the distance from the screw’s scapular exiting hole to the SSN was recorded.

The superior screw contacted the SSN in 8 of the 12 specimens (66%). For the superior screw, the average distance from the exiting point in the scapula to the SSN was 9.2 ± 6.3mm with the shortest distance being 3.9 mm. The posterior screw contacted the SSN in 6 of 12 specimens (50%). For the posterior screw, the average distance from the exiting point to the SSN was 8.9 ± 3.8 mm with the shortest distance to the nerve being 2.2 mm.

Comment: While being the screw most likely to risk the supra scapular nerve and while being the screw most likely to predispose the scapular spine to fracture, the superior baseplate may be the least important screw for baseplate stability as shown below.

Factors affecting fixation of the glenoid component of a reverse total shoulder prothesis

The baseplate of the reverse total shoulder usually fails from superiorly directed loads






Using an in vitro model these authors examined some of the factors affecting the quality of glenoid screw fixation, including the density of the material into which the screws are placed, the purchase of individual screws, and the direction of loading in relation to screw placement.

They found that 
(1) Load to failure was less when the glenoid component was fixed to material of lesser density. 
(2) While each screw contributed to the quality of fixation; the screw nearest the point of load application made the largest contribution. 
(3) Load to failure was less when the load was colinear with a line through the nonlocking holes in the base plate compared to colinear with a line through the locking holes. 
(4) For the most important direction of loading - a superiorly directed force applied to the glenosphere - the inferior screw appeared to be the most critical.

As shown in the diagram below, superiorly directed loads applied to the glenosphere by the humeral component (black arrow) subject the critical inferior screw to traction (red arrow), while the bone at the superior aspect of the glenoid (represented by the grey box) is subjected to compression (green arrow) - which results in minimal loading of the superior screw.


For these reasons we prefer to shorten the drill hole and the screw used in the superior hole of the baseplate and work to assure good bony support for the superior aspect of the baseplate.

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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

=====
To see our new series of youtube videos on important shoulder surgeries and how they are done, 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  arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Is there an advantage of stemless implants?

Eclipse Shoulder Prosthesis vs. Univers II Shoulder Prosthesis: A Multicenter, Prospective Randomized Controlled Trial


The Arthrex Eclipse shoulder prosthesis is a stemless, canal-sparing, humeral prosthesis with bone ingrowth capacity on the trunnion as well as through the fenestrated hollow screw that provides both diaphyseal and metaphyseal load sharing and fixation. 


The Arthrex Univers is a stemmed implant, that according to the company is  "designed to account for anatomical variations of the proximal humerus commonly encountered by the surgeon. Variable adjustment with respect to the inclination angle, version and head offset are features critical to reconstruction of the proximal humerus. The simplified design of the Univers II humeral component allows the surgeon to adapt the humeral stem and articular surface to the position that best represents the patient’s normal anatomy. All of the adjustments can be made intraoperatively with the implant in the humeral canal. This unique feature allows more accurate recreation of the normal anatomical relationships of the shoulder joint. With anatomic restoration of the humerus and glenoid, soft tissue balancing of the rotator cuff is more accurate, allowing for improved functional outcome."



In this multi center study patients with glenohumeral arthritis refractory to non-surgical care were randomized to Eclipse or Univers II using block randomization.
149 Eclipse and 76 Univers II patients reached 2-year follow-up.

The success rate using a "composite clinical success (CCS) score" was 95% for Eclipse vs. 90% for Univers II group. 

No patient exhibited radiographic evidence of substantial humeral radiolucency, humeral migration, or subsidence at  any point. There were 7 (3.2%) reoperations in the Eclipse and 3 (3.8%) in the Univers II group.

The authors concluded that at two-year follow-up there were no differences in outcomes between the two implants. 

Comment: While much has been made about the advantages of a stemless humeral implant, data are lacking that show its superiority over a stemmed implant.

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To see a YouTube of our technique for total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, 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  arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'





To what degree do surgeons agree on the classification of arthritic shoulders into different glenoid types?

Reliability of the Modified Walch Classification for Advanced Glenohumeral Osteoarthritis using Three-dimensional Computed Tomography Analysis: A Study of the ASES B2 Glenoid Multicenter Research Group

These 23 experienced surgeons assessed the inter and intra-observer reliability of the modified Walch classification using three-dimensional (3D) computed tomography (CT) imaging. A summary of the classification criteria used in this study is shown here:

A1 Centered humeral head, minor glenoid erosion. 
A2 Centered humeral head, major central glenoid erosion defined by a line drawn
from the anterior to posterior rims of the glenoid transecting the humeral head.         
B1 Posteriorly subluxated humeral head, with no or minor posterior glenoid erosion. 
B2 Posteriorly subluxated humeral head, posterior glenoid erosion with biconcavity and no dysplasia. 
B3 Posteriorly worn glenoid that is monoconcave with little or no biconcavity due to posterior and central glenoid erosion, without dysplasia. A threshold of > 15 degrees of retroversion has been suggested
C1 Dysplastic glenoid with high degrees of retroversion due to dysplasia rather than glenoid erosion. A threshold of at least 25° glenoid retroversion has been suggested.
C2 Dysplastic glenoid with acquired posterior glenoid erosion creating glenoid biconcavity and posterior subluxation of the humeral head. 
D Glenoid anteversion or anterior humeral head subluxation. 

De-identified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were included: Group 1 (96 cases involving all modified Walch classification categories evaluated and Group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1,C2].

Inter-observer reliability showed fair to moderate agreement.





The authors concluded that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type due to a lack of defined thresholds.


Comment: This study points out the challenge of classifying glenoid pathoanatomy, even when experienced surgeons use CT scans and sophisticated software. As the authors point out, the problem is at least in part due to the issue of creating "thresholds" for variables that are continuous, such as the  degree erosion (which can range from none to a lot) and the degree of version (which can range from ante version to retroversion). Note that

A1 is differentiated from A2 by the degree of glenoid erosion
B1 is differentiated from B2 by the degree of glenoid erosion
A2 is differentiated from B3 by the degree of version
A1 and A2 are differentiated from D by the degree of version



Examples of the different types of glenoid pathoanatomy are shown below.




In some respects it may be more useful and more consistent among observers if arthritic glenohumeral pathoanatomy is characterized in terms of simple measurements, including the quantitative measurement of the degrees of retroversion
and the quantitative measurement of the degree of decentering of the humeral head on the glenoid face
These are measurements critical to the understanding of the pathoanatomy and to planning the shoulder arthroplasty.


===
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, July 22, 2020

Ream and run for B2 glenoid in a 30 year old

Here is the anteroposterior view of the right shoulder of a former baseball pitcher in his early 30's several years after a posterior labral repair. The film shows loss of radiographic joint space and osteophytes.

His axillary "truth" view, taken with the arm in a functional position of elevation, shows the humeral head sitting in the posterior concavity of a biconcave glenoid

With a usual amount of glenoid retroversion

And substantial posterior decentering of the humeral head on the face of the glenoid

The amount of decentering can be measured in terms of the amount of posterior displacement of the center of the humeral head in reference to the perpendicular bisector of a line segment connecting the anterior and posterior edges of the glenoid.
After discussion of the options, including an anatomic total shoulder and a reverse total shoulder, he elected to proceed with a ream and run.

A 56 diameter of curvature humeral head with a 18 mm thickness and anterior eccentricity was used. A 8 mm standard stem was secured with impaction grafting. The procedure was performed under a general anesthetic without a brachial plexus block.

The postoperative x-rays are shown below



Assisted flexion was started on the evening of surgery. The patient was able to comfortably achieve 160 degrees.


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To see a YouTube video on how the ream and run is done, click on this link.

===

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'

Monday, July 20, 2020

The arthritic shoulder: version, biconcavity and humeral head decentering

A good understanding of arthritic shoulder arthroplasty can be gained from standard plain x-ray views without the need for CT scans or 3D planning software.

Here is the anteroposterior view of the right shoulder of a former baseball pitcher in his early 30's several years after a posterior labral repair. The film shows loss of radiographic joint space and osteophytes.

His axillary "truth" view, taken with the arm in a functional position of elevation, shows the humeral head sitting in the posterior concavity of a biconcave glenoid

With a usual amount of glenoid retroversion

And substantial posterior decentering of the humeral head on the face of the glenoid

The amount of decentering can be measured in terms of the amount of posterior displacement of the center of the humeral head in reference to the perpendicular bisector of a line segment connecting the anterior and posterior edges of the glenoid.
This is all the information needed to plan his reconstructive surgery which will be a ream and run.

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To see a YouTube video on how the ream and run is done, click on this link.

===

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'