Sunday, August 24, 2014

Reverse shoulder arthroplasty - concentric vs eccentric glenospheres - how big a deal is notching?

A Comparison of Concentric and Eccentric Glenospheres in Reverse Shoulder ArthroplastyA Randomized Controlled Trial

The clinical significance of unwanted contact between the medial aspect of the humeral component of a reverse total shoulder and the bone of the scapula lies in the increased risk of instability, inferior scapular notching, limited adduction range of motion, poorer functional scores, and lower patient satisfaction. These authors conducted randomized, controlled, double-blinded trial of 50 patients with rotator cuff tear arthropathy in an attempt to determine if the use of an eccentric glenosphere diminished these problems.

The mean follow-up period for the groups was forty-three and forty-seven months. Four patients in the concentric group had developed inferior scapular notching ranging in size from 1.1 to 7.4 mm, compared with one patient in the eccentric group (p = 0.36). No notching occurred in any patient with glenoid overhang of >3.5 mm. No significant difference between the groups was seen with respect to functional outcome scores, patient satisfaction, or shoulder motion.

Three of these patients had complications. One having a concentric prosthesis developed instability after a fall and two (one in each group) developed acromial stress fractures. These fractures healed without surgery, but the functional results were poor.

Comment: There are two basic strategies for avoiding unwanted humero-scapular contact in reverse total shoulder. One is the 'South' approach: moving the humeral component distally using some combination of inferior placement of the glenosphere baseplate, use of an inferiorly eccentric glenosphere, or tilting the glenoid component inferiorly. These strategies may increase the risk of over lengthening the humerus with resulting acromial fractures (as shown in this report) and neurologic complications from plexus traction. The other is the 'East-West' approach: moving the humeral component laterally using a glenosphere that offsets the center of rotation from the glenoid bone. This strategy requires very secure fixation of the glenoid component to the glenoid bone.

We use a combination of the 'South' and the 'East-West' approaches to avoid unwanted contact in reverse total shoulder as shown here and here.

While some surgeons are inclined to pass off 'notching' as having no clinical importance, this cannot be the case as explained here.

===
Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

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'



To see other similar posts, click on the label of interest below.


Failed glenoid component, lessons and questions

Our readers are aware that the glenoid component is the 
 in total shoulder arthroplasty.

Recently we were consulted on a patient from elsewhere whose post operative x-ray taken two years ago had this appearance
Here's a closer view of his glenoid fixation showing lucency's around the pegs of the glenoid component
The dark areas between the pegs and the bone in postoperative films are filled with fluid and/or soft tissue so that the component is not well fixed in the bone. As shown in an earlier post, we use a CO2 jet to remove fluid and soft tissue from the bone/cement interface. This enables pressurized cement to completely fill the space between the pegs and the bone, optimizing component fixation. This practice has essentially eliminated the issue of postoperative periprosthetic lucent lines.

Two years later, we met this shoulder for the first time. At the time of presentation to us for consultation the patient had been experiencing increasing pain in the shoulder since his original total shoulder arthroplasty. The x-rays taken at our first visit are shown below. Note the osteolysis around the glenoid component pegs on the AP view
 and the 'watermelon seed' of cement between the glenoid component and the bone posteriorly on the axillary view. The problem with this 'watermelon seed' is shown in this prior post.
 After discussion of the alternatives and considering the possibility of Propionibacterium infection, the patient desired to have a revision with complete prosthesis removal, harvest of specimens for culture, thorough debridement, insertion of a new prosthesis with Vancomycin allograft fixation, and the red antibiotic protocol.

At surgery, the joint fluid was turbid and the glenoid component was completely loose; the 'watermelon seed' was floating free in the joint space. Removal of the trabecular metal stem was very difficult because of bone ingrowth; multiple osteotomies around the component were required. A modified bodice repair was needed to close the humeral osteotomies made for component removal. A glenoid component was not used in the reconstruction.

Note that bone ingrowth is not necessary for humeral component fixation and greatly complicates revision.

The postoperative films are shown below.


Immediate assisted range of motion exercises were started after surgery. IV antibiotics will be continued for 6 weeks and transitioned to oral antibiotics if the cultures (which are now pending) become positive. 

The patient reports that the shoulder is already more comfortable than in the prior two years. We are hopeful.

===
Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

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'



To see other similar posts, click on the label of interest below.

Wednesday, August 20, 2014

Customizing a prosthesis: shoulder arthroplasty after a total elbow


Not infrequently the performance of a shoulder arthroplasty is complicated by a prior procedure on the humerus below. Here is the shoulder film of a patient with severe rheumatoid arthritis and several years of progressively worsening shoulder pain.On preoperative examination he had very little range of motion due to his central medial erosion into the glenoid.
 



He had prior bilateral hip, knee, elbow and right shoulder arthroplasties. The ipsilateral elbow arthroplasty and two intramedullary cement restrictors are shown in the film below. We recognized that a standard humeral prosthesis would not fit in his canal, so a preoperative plan was made to customize his implant.




A deltopectoral approach was used and the subscapularis was dissected from the lesser tuberosity medial to the biceps tendon. Due to the limited range of motion and severely osteopenic bone we performed an in-situ humeral head cut. Once accomplished, we were able to safely access his medullary canal and to visualize this thin but intact attachment of the supraspinatus. Given the intact cuff we decided to proceed with a  standard hemiarthroplasty rather than a CTA arthroplasty.
The cement restrictors were retrieved with pituitary rongeurs and the canal was reamed conservatively to protect his fragile bone. The distance within the canal to the previously placed cement from the total elbow was measured. A Midas Rex burr was used to remove 3 cm from the stem and to round off the distal end of the prosthesis.

The prominent bone at the inferior margin of the glenoid was removed with a burr and rongeur due to concerns for contact with the medial proximal humerus. Care was taken to protect the axillary nerve.

The humeral component was then cemented into position and the subscapularis repaired. The postoperative film is shown below.
co-authored by Robert Lucas
===



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'




To see other similar posts, click on the label of interest below.

Tuesday, August 19, 2014

The Axillary view = the 'truth' view

It is always nice to hear from our colleagues from across the pond. Recently, Angus Wallace, surgeon to Nottingham, posted on ResearchGate: "I agree with Rick Matsen and Bob Neviaser, you should train your radiographer to provide high quality AP and Axillary or Axial radiographs. I carry out 110 shoulder Arthroplasties per year and only order CT scans about twice per year, even for difficult cases." As Mr Wallace says, it is essential that the techs take the films properly as shown here.

We refer to the axillary view as the 'truth' view because it often lets us know what's really going on. Here's an example from our clinic yesterday. An active person in the mid 60s is having difficulty kayaking. The range of motion was restricted by about 20% in all planes. The AP view in the plane of the scapula looked unremarkable except for a small inferior osteophyte.



However, the axillary view showed posterior displacement of the humeral head on the glenoid and bone on bone contact between the center of the humeral head and the posterior glenoid - indicating complete loss of cartilage in these areas. 



===



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'




To see other similar posts, click on the label of interest below.

Monday, August 11, 2014

Is lesser tuberosity osteotomy a benign approach to shoulder arthroplasty?

Failure of the lesser tuberosity osteotomy after total shoulder arthroplasty

These authors  report a case series of 5 patients who sustained failure of lesser tuberosity osteotomy (LTO) repair after primary total shoulder arthroplasty (TSA). The typical patient was a 52 year old male.  The mean time from initial TSA to diagnosis of LTO failure was 9 weeks. Two patients reported no trauma, 2 had minor trauma (using a pulley, rolling over in bed), and 1 sustained a fall.

All patients required revision surgery. Only 1 patient required no additional procedures beyond the revision LTO repair. Another patient required a second revision LTO repair. The remaining 3 patients either underwent or were recommended to undergo reverse arthroplasty.

The authors conclude that lesser tuberosity osteotomy failure may be an under-reported complication  associated with poor clinical outcomes and limited options for revision surgery. In patients with a high risk of LTO failure, considerations should be made to augment the LTO repair during the index TSA procedure.

Comment: While advocates of LTO claim that this approach offers better glenoid exposure and improved healing of the subscapularis takedown, this article demonstrates the substantial problems that can occur when the repair fails. The loss of the lesser tuberosity makes salvage of a failed repair very difficult. One can only recall the 'old days' of greater trochanteric osteotomy as the recommended approach to total hip arthroplasty - a practice now rarely employed because of complications. We continue to expose the shoulder by incision of the subscapularis from the lesser tuberosity, leaving the lesser tuberosity intact for support of the humeral component and for reattachment of the subscapularis as shown here and here. It is possible that prior reports of failure of tendon to lesser tuberosity repair (i.e. without lesser tuberosity osteotomy) may be related to (a) failure to use at least six strong sutures, (b) failure to achieve secure suture fixation in bone, (c ) failure to achieve secure fixation in the tendon, (d) failure to preserve the capsule on the deep side of the tendon to optimize the quality of the tissue for repair, and (e) failure to avoid subscapularis stretching and strength use for six weeks after surgery. 

Of course yet another issue is that lesser tuberosity osteotomy obligates the surgeon to perform a biceps tenotomy or tenodesis - something we avoid unless the biceps is frayed or unstable.

===

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'


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.

===

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'