Wednesday, November 22, 2017

Russia connection

With all the political news about the relationships of Russia and the U.S., it is important to recall that the people in Russia have the same sort of shoulder issues as the citizens of any other country and that the physicians caring for these patients are, like us, eager to learn.

In this spirit, it is of interest to note that among residents of countries visiting the Shoulder Blog, those from Russia are fourth in number - see below.

To our Russian colleagues we say "Счастливое плечо", Happy Shouldering!

The reader may also be interested in these posts:

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

Information about shoulder exercises can be found at 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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

Ream and run - the importance of patient-surgeon communication

A man in his early forties had a great result from his left ream and run performed 2 years ago

Two weeks ago he returned for a ream and run on his right side

As for all our patients, he is encouraged to provide frequent feedback on his progress. Yesterday we received this email "Dear Doctor: I am still doing great. Here I am at 15 days after surgery. Thanks again."

He enclosed this photo of him doing the forward lean in his office.

This type of patient-surgeon communication is essential for assuring the best result from the ream and run, especially for patients living a ways away (this man lives 2151 miles from our center). 

Acromioplasty S.A.D: R.I.P.

The acromion is innocent.

From NPR: "Popular Surgery To Ease Chronic Shoulder Pain Called Into Question" (see this link).

In 1934, Codman pointed out that the proximal humerus normally articulates with the coracoacromial arch, providing stability of the shoulder against superiorly directed loads. He stated that the coracoacromial arch “has an important duty and should not be thoughtlessly divided at any operation”. 

There is a tendency to confuse the association of cuff pathology and acromial changes with causation of the cuff changes by the acromion. Today, many hold the belief that ‘impingement” causes cuff lesions. By contrast, in 1972, Neer reported shoulders with a “characteristic ridge of proliferative spurs and excrescences on the undersurface of the anterior process (of the acromion) apparently caused by repeated impingement of the rotator cuff and the humeral head, with traction of the coracoacromial ligament”, in other words the changes in the acromion were a result of the cuff disease.

Over a decade ago, it was recognized that acromioplasty was not necessary for achieving a good result from rotator cuff repair (see this link).

Authors of a recent article (see Published Evidence Relevant to the Diagnosis of Impingement Syndrome) were unable to find good evidence to support any of these statements:  (1) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch, (2) spurs on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and (3) successful treatment of the “impingement syndrome” requires surgical alteration of the acromion and/or coracoacromial arch. 

In spite of the lack of evidence in support of its use, the rate of acromioplasty has been on the increase

Acromioplasty is not benign. Many of the cases coming for reverse total shoulder arthroplasty have anterosuperior escape resulting from the violation of Codman's admonition to preserve the coracoacromial arch.

Recently, it has been pointed out that the benefits previously ascribed to acromioplasty can be achieved without acromioplasty (see Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty at this link).

This week, the Journal Lancet published "Arthroscopic subacromial decompression for subacromial shoulder pain: a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial" (see this link). 

These authors did a multicenter, randomised, pragmatic, parallel group, placebo-controlled, three-group trial at 32 hospitals in the UK with 51 surgeons. Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were eligible for arthroscopic surgery, and had previously completed a non-operative management program that included exercise therapy and at least one steroid injection.
They randomly assigned 303 participants to receive (a) arthroscopic subacromial decompression, (b) investigational arthroscopy without acromioplasty, or (c) no treatment.

In the surgical intervention groups, patients were not told which type of surgery they were receiving (to ensure masking). 

At 6 months, data for the Oxford Shoulder Score were available for 90 patients assigned to decompression, 94 to arthroscopy, and 90 to no treatment. There was no difference between the average  Oxford Shoulder Scores of those patients receiving acromioplasty and those receiving arthroscopy without acromioplasty. Both surgical groups showed a small benefit over no treatment, but these differences were not clinically important. This difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. 

Based on these findings, the authors question the value of acromioplasty.

Another recent article, (Declining incidence of acromioplasty in Finland, see this link) gives insight into factors affecting the incidence of acromioplasty: "The incidence of acromioplasty increased by 117% from 75 to 163 per 105 person years between 1998 and 2007. The highest incidence was observed in 2007, after which the incidence rate decreased by 20% to 131 per 105 person years in 2011. The incidence declined even more at non-profit public hospitals from 2007 to 2011. In contrast, it continued to rise at profit-based private orthopedic clinics."

Thursday, November 16, 2017

Ream and run for arthritis in a 41 year old with a B2 glenoid - remodeling at one year

A 41 year old man from New York presented to us with severe pain and loss of function of the left shoulder years after a prior surgical procedure for anterior instability. He could perform only 5 of the 12 functions of the Simple Shoulder Test. His preoperative films show capsulorrhaphy arthropathy with severe decentering on the the axillary 'truth' view.

Because of his active lifestyle, he elected a ream and run procedure. At that time an anteriorly eccentric humeral head and a rotator interval plication were added to re-center his humeral prosthesis on the glenoid. No cement, polyethylene or CT scans were used.

At one year after surgery, his humeral head was well centered on the remodeled glenoid. His impaction grafted thin smooth stem is well fixed.

His SST score had improved to 8/12.

Comment: This highly motivated man has regained excellent passive motion and is continuing to work on his strength. It is a work in progress.

The reader may also be interested in these posts:

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

Information about shoulder exercises can be found at 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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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

Ream and run for arthritis in a 37 year old - 5 month progress report

A very active 37 year old male presented to us with a long standing history of right shoulder pain. He had history of a right shoulder dislocation at the age of 16 for which he underwent an arthroscopic bankart repair. He did well until approximately 2003, when he was involved in a motor cycle accident in which he sustained a shoulder fracture. He subsequently underwent a debridement and did well up until 2011 when he had a bicycle accident and sustained a second shoulder fracture (unsure of anatomic location). He then developed progressive stiffness and pain that did not respond to steroid injections. At the office visit he could perform only 3/12 of the Simple Shoulder Test functions. His radiographs are shown below

Because of his active lifestyle, he elected to have a ream and run procedure.

He recently sent this email from his home in South Africa:

"I wanted to touch base with you since now I am five months out of having the Ream and Run. Its been a bit up and down, as I'm sure you are aware of, but overall I know in the long run my shoulder is going to be much better off than it was prior to the procedure. I wanted to ask you about certain exercises to focus on and avoid. I've been sticking to the rowing, lat pulldowns, light yoga, and strengthen my back. The physiotherapist I am working here has added some external rotation exercises and I am finding them very problematic. I remember reading to avoid them for at least three months after surgery, which I did, but at five months one set of external rotation exercises will cause pain and stiffness in the front part of the shoulder for several days. I wanted to see if that was normal and what your thoughts were on the type of rehab exercises I should focus on?

On a side note, South Africa is a gorgeous country. After living in big Asian cities the last seven years it's nice to get back to a place, much like the Northwest, that I can enjoy an outdoor lifestyle. I'm not back to cycling yet, but once back on the bike I know I will enjoy it even more here. Appreciate your time and feedback."

He also sent these videos of his shoulder motion, which he generously gave us permission to show here

Comment: This five month progress report points out that the recovery of motion and function after a ream and run requires dedication and time. It also points to the importance of avoiding external rotator stretching until it can be performed comfortably

Sunday, November 12, 2017

Cuff tear arthropathy: is a reverse necessary? The CTA arthoplasty

What Factors are Associated With Clinically Important Improvement After Shoulder Hemiarthroplasty for Cuff Tear Arthropathy?

These authors sought to determine the factors associated with achieving the minimum clinically important improvement in the Simple Shoulder Test (SST) in 42 patients (24 males/18 females) at a mean of 48 months (range, 24–132 months) after hemiarthroplasty for cuff tear arthropathy performed between 1991 and 2007.

The authors' indication for hemiarthroplasty was superior translation on plain radiographs of the humeral head with respect to the glenoid, loss of articular surface of the humeral head, bone loss of the superior glenoid, and erosion of the greater tuberosity and undersurface of the acromion. They excluded shoulders with instability of the shoulder with attempted forward elevation (anterosuperior escape), active infection, and inflammatory arthritis.

21 shoulders received a conventional humeral head replacement and 21 received a cuff tear arthropathy arthroplasty prosthesis. At surgery, soft tissue balancing
was thought to be ideal when the following criteria were achieved: (1) posterior drawer testing with 40% to 60% translation of the center of the prosthetic head relative to the center of the glenoid, (2) 60 internal rotation was present with the arm positioned in 90 abduction, (3) the hand on the involved side could be placed on the superior aspect of the contralateral shoulder without protraction of the scapula, and (4) there was 45 external rotation with the subscapularis approximated to the proximal humeral osteotomy site. Assisted motion was started immediately after surgery with progressive activities as comfort allowed.

At latest followup, 33 of 42 patients (79%) achieved a clinically important percentage of maximum possible improvement (%MPI), defined as an improvement of 30% of the total possible improvement on the 12-point SST scale. They reported no complications and no revision procedures.

Intraoperative findings of a rotator cuff tear limited to the supraspinatus and infraspinatus and limited preoperative external rotation were associated with achieving the defined minimum functional improvement (30% of MPI) on multivariate analysis. Preoperative active elevation and use of a CTA-specific implant were not significantly associated with achievement of 30% of MPI.

The results of the univariate analysis are shown here

and the results of their multivariate analysis are shown here

Comment: As appears to be the case in the practice of these authors, many of our patients with classical cuff tear arthropathy want to lead active lives. They wish to avoid a reverse total shoulder because of concerns about activity limitations, dislocation, screw breakage or humeral shaft fracture should they fall. If these individuals have active elevation > 90 degrees and have no evidence of anterior superior instability, we discuss the option of a CTA prosthesis.

Here's the example of a lady in her mid sixties with a failed cuff repair. Two years after that surgery she presented to us with a weak and painful shoulder. She was taking prednisone, methotrexate and Humira for her rheumatoid arthritis. She had active elevation to 110 and passive elevation to 160 degrees. Her x-rays at this time are shown below.

She elected a CTA arthroplasty. At surgery she had an irreparable cuff defect involving her supraspinatus and infraspinatus.

She dropped by to see us nine years after surgery. Her films at that time are shown below.

Her shoulder was painless. Her active elevation is shown below.

As another example we recently we saw an active physician-rancher who had had bilateral CTA prostheses performed after failed cuff repairs. Because he recognized that his ranching was demanding on his shoulders and carried the risk of falls, he preferred the CTA over the reverse total shoulder.

Before his left shoulder surgery his films were as shown below and he reported the ability to perform only 5 of the 12 Simple Shoulder Test functions. He was able to elevate his arm to over 90 degrees and had no anterosuperior instability.

At the time of surgery he had no supraspinatus, no infraspinatus and a detached subscapularis.
We were able to reattach his subscapularis.

At four years after surgery, he could perform 8 of the 12 SST functions and had the radiographs shown below. Note the impaction grafted humeral stem and the articulation of the prosthesis with the undersurface of the coracoacromial arch.


Two years ago he presented with a similar situation in his right shoulder. His SST score was 3/12. He had active elevation of 100 degrees without anterosuperior escape. His preoperative x-rays shown below.

Two years after his right shoulder arthroplasty he could perform 8/12 SST functions and was back at work on his ranch. His 2 year films are shown below.


Here's a video of his function at his last clinic visit.

Here is a video of an active women two years after her CTA arthroplasty for cuff tear arthropathy.

Here are the x-rays and the shoulder function of a man one year out from his CTA arthroplasty

Comment:  From our standpoint, the CTA arthroplasty is a most attractive option for consideration by active individuals with cuff tear arthropathy and the ability to actively elevate the arm above 90 degrees without manifesting anterosuperior instability.

It has a very low complication and revision rate, avoids issues of modular components and activity restrictions.

Inserting the prosthesis with impaction grafting makes for an easy conversion to a reverse should that be necessary, fortunately this is rarely the case. The cuff tear arthropathy prosthesis is considered for individuals with active elevation of 90 or more degrees without anterosuperior escape – especially those who desire higher levels of physical activity or those who are at increased risk of falls. It is important to realize that this prosthesis has an extended lateral joint surface for articulation with the undersurface of the coracoacromial arch, thus it is distinct from the usual hemiarthroplasty prosthesis. The implant system should allow selection of the appropriate diameter of curvature and should enable fixation by impaction grafting.


The surgical keys to a successful CTA arthroplasty are (1) optimizing stability and (2) matching the prosthetic diameter of curvature to that of the resected humeral head. The patient positioning, anesthetic, prophylactic antibiotics, skin preparation, and skin incision are identical to that for an anatomic arthroplasty. 


In exposing the humeral head, we retain as much as possible of the clavipectoral fascia attached to the coracoacromial ligament (the “CA+”) as an additional barrier to anterosuperior instability. 

The subscapularis is carefully incised from the lesser tuberosity taking care to keep the subjacent capsule attached to its deep side. The humerus is exposed by gentle external rotation allowing for debridement of cuff tendon remnants and osteophytes as well as sectioning of the long head tendon of the biceps if it remains intact. The humeral head height and diameter of curvature are measured, ideally before the head is resected.

The medullary canal is entered and progressively larger reamers inserted as sizers until the diaphyseal endosteal cortex is encountered at a depth corresponding to the length of the prosthetic stem (‘love at first bite’); this reamer defines the orthopaedic axis. The humeral head is resected at an angle of 45 degrees with the orthopaedic axis; the proximal humerus is prepared as for a standard humeral arthroplasty. The lateral tuberosity is resected. The humeral head diameter of curvature is chosen to match that of the resected head. Trial reduction is carried out. The height of the prosthesis is selected so that the deltoid is under mild-moderate tension when the arm is adducted. Impaction grafting is carried out using bone from the resected humeral head. If the biceps tendon is available, an in-and-out biceps tenodesis is performed. Drill holes are placed for reattachment of the subscapularis. The is prosthesis assembled and inserted and the subscapularis is securely repaired.


Additional relevant posts can be found here and here and here

We first described our approach over two decades ago in a publication, Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint, which reported on twenty-one shoulders in nineteen patients, fifty-four to eighty-four years old, who had disabling pain attributable to a massive tear of the rotator cuff, accompanied by loss of the surface of the glenohumeral joint. These patients were not candidates for total shoulder replacement because of the massive deficiency in the cuff and the fixed upward displacement of the humeral head. At that time reverse total shoulder was not an option. A prerequisite for hemiarthroplasty was a functionally intact coracoacromial arch to provide superior secondary stability for the prosthesis. One important aspect of the operative technique was the selection of a sufficiently small prosthesis so that excessive tightness of the posterior aspect of the capsule could be avoided. Eighteen shoulders in sixteen patients were available for follow-up, which ranged from twenty-five to 122 months. Pain decreased from marked or disabling in fourteen shoulders preoperatively to none or slight in ten and to pain only after unusual activity in four. Active forward elevation improved from an average of 66 degrees preoperatively to an average of 109 degrees postoperatively. One patient, who had had an excellent result, fell and sustained an acromial fracture, so the functional result changed to poor. Three patients had persistent, substantial pain in the shoulder that led to a revision. Neither infection nor prosthetic loosening nor instability developed in any shoulder.

The reader may also be interested in these posts:

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

Information about shoulder exercises can be found at 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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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