Friday, November 21, 2014

"be vigilant in rehab" : Ream and run - patient observations at four years after the procedure for the bad arthritic triad

Report received this week from a man who had a ream run four years ago for a particularly severely arthritic glenoid with biconcavity, retroversion and posterior humeral subluxation (Walch B2+!). Here's a video of his function at two years after surgery.

Preop films





Post op flims at 3 months




Four Year Anniversary
Hello !
I am writing to you again, on this my four year anniversary from “ream and run” surgery on my left shoulder.  I will not go into the detail that I have done before regarding what I can now do with my shoulder that I could not for some 10-15 years prior to the surgery but I will say that I just finished 4 games of full court basketball.  My left shoulder feels great and after all that basketball, I just wish the rest of my body was holding up as well as my shoulder.
Even though I was feeling stronger every year after surgery, I did have the nagging thought in the back of my mind about the possibility of arthritis returning to the glenoid joint after it had been reamed.  However, I do not ever feel stiffness in my left shoulder.  When I wake up in the morning, it feels great even after nights I somehow end up on my left side during sleep.
If I could give any of your perspective patients any advice as they ponder having this surgery, I would tell them that they must be vigilant in rehab.  Be persistent but also patient in working through those first 3 months after surgery when it feels like your shoulder is just not getting much better.  During the first 3 months, every time you begin your exercises it feels like you did not do them 2-3 hours before.  Such stiffness, but it gets better.  I would tell them months 3-6 are when they will start to see great improvement but they must stick to the program and although it’s difficult, do not do too much (although doing not enough is also not acceptable).  Exercising in the pool is the way to go!  I would also tell them to keep working even beyond 1 year as they will still see improvement.  But the best news I can tell them is that after 4 years, they can expect to feel great. 
Thank you again!  Any happy anniversary!

Three Year Anniversary.
Even though you advised me that my shoulder would never be completely the way it was when I was younger, I really think it’s about 90 or 95% there.  I just wish the rest of my body was doing that well!  LOL
My shoulder has continued to improve over the last year and for the most part, I have completely forgotten that it was once my “bad” shoulder.  For those of you with injuries, you will know what I mean in that even when an injury has healed, you “favor” that injured limb or joint for a long time to come.  For 15 years, I favored my left shoulder and had to do it more and more every year as the deterioration increased.  Being left-handed only made living with my arthritic shoulder worse.
Now three years after the surgery, I have no limitations and only my cool looking scar reminds me that I once could not use my left arm for much of anything.  My wife and I just returned from a vacation in Costa Rica where we rappelled, went zip-lining, white water rafting and also kayaked, played volleyball and tennis, hit the gym and swam.  I could have done none of that in 2010 before the surgery with the exception of tennis (but at that time I had learned to play right handed) and really limited gym work-outs.
Not much to add (see year one and two comments below) other than to say thank you Dr. Matsen and staff!  You have truly improved the quality of my life several fold and please let me know if I can ever talk to any of your prospective or current patients about the recovery they will face after surgery and the results I have enjoyed!

Two Year Anniversary.
If I was happy with my shoulder at one year after surgery, I am ecstatic after two years.  While I was able to have nearly fully range of motion at one year, over the last year I have added strength and with it more speed and quickness in my shoulder versus a year ago.  I could really see this in hitting a baseball or softball.  Improved bat speed in the summer of 2012 versus the summer of 2011 led to a great increase in power.  In basketball, I can now easily shoot from outside the three point line and in flag football, I can extend my left arm without thinking about it first, something I really couldn’t get myself to do naturally after one year.
The good news for prospective patients is that you can expect continued improvement after 1 year if you keep working on it.
In my one year summary (listed below), I did point out that my goal was to play volleyball which I have recently been able to do.  As timing would have it, I strained my Achilles tendon and it really plagued me all summer so I did not have a chance to force my son to enter a volleyball tournament with me.  However, in the Fall I have been able to play volleyball and can hit hard overhead serves and spike left-handed.  Rick, the good news here is that since I can’t jump well anymore, I do not spike very often so will unlikely stress my shoulder too much. 
Due to my sore Achilles, I worked on my throwing strength this summer.  That has come around pretty slowly.   Throwing a baseball or softball still does not cause any shoulder joint pain, but there is discomfort but mainly in the soft tissues of the shoulder (muscle atrophy).  This summer I decided to work on throwing a football instead since it felt a little better on my shoulder.  I have now got to the point where I can throw an NFL football 30 yards.  I think a year ago I could maybe throw it 15-20 yards at most.  To give you some perspective on this, I could throw a football 55 yards when I was in my twenties but was probably down to 25 yards by the time I was 35 and had to start throwing right handed by the age of 38.  It’s been a very long time since I could throw at all so at age 52, it is very exciting to me to see where I am today.  Can I get to 40 yards by my third anniversary?
Currently I try to get into the gym around 3-4 times a week and work out no more than about 45 minutes per workout, so I am really not spending a great deal of time on this but it is the consistency that I think is so important.  I also typically stretch a couple times a day as it has become a habit.  I do not do the lever/pulley stretch or the table stretch anymore but I will do the three basic rotator cuff stretching exercises especially before, during and after hitting the gym or playing a sport.  Also I regularly stretch my shoulder against a wall.
Again, I would greatly encourage your patients to get into the water.  Working on your range of motion and strength in the pool really helps bring about improvement.
Please call me if you have any questions and thank you again for making me left-handed again!

One Year Anniversary
One year ago, November 16, 2010, I had surgery on my shoulder and today my shoulder is doing great.  At 1 year, I am playing basketball, flag football, tennis, swimming, going to the gym, golfing, ping-pong and just about anything I want to do.  Some of that may not sound like much but please recall my left shoulder (and I am left handed) had very limited range of motion for around 10 to 15 years with the last couple of years being so bad I could not even play darts left handed.  I could not comb my hair left handed without support from my right hand.  I could not raise my hand more than 1 foot above my head.  Needless to say, I could not do any of the sports lift above.  I even found I could no longer bowl left-handed and golf had become too painful to play toward the last could of years. 
For months 0-3, I did the exercises you gave me religiously.  I would do the shoulder stretch using a table and then the rope and pulley stretches 6 times a day.  Sleeping was a little rough but not bad.  There were times where I would wake up with pain and just go do my stretches.  Please warn future patients that each time you do your stretches it feels like you have never done them before.  It can seem like your shoulder will never get better and that the painful stretches you just went through 2-3 hours earlier had no benefit.  But day by day, things slowly get better.  On the exact 3 month anniversary of my shoulder, I was able to lift my arm completely vertical over my head for the first time.

Months 3-6 were also pretty difficult but I think I was pushing too hard.  My goal was to be back to 90% by 6 months but since my range of motion had been so limited for so long, I think I should have been more patient.  As a result, I had a couple of set-backs with rotator cuff muscle strains but the joint has never had an issue.  At that point I had a couple of appointments with different physical therapist down here in So CA.  The concern I have about PT is that sometimes they want you to just keep coming back to them.  I made it clear to them that I was no stranger to the gym and was just looking for guidance.  I learned from both of them to be more patient with my progress.  The soft tissue in my shoulder had atrophied significantly over the past 15 years and even though some of the stronger muscles of the shoulder were ready to go, I really had to focus on doing the rotator cuff muscles exercises (doing the colored rubber band stuff) and rotator cuff stretches.

Even after month 6, I have continued to see improvement up through today.  At 6 months I was not quite at 60 feet for throwing the software.  I really wanted to be there for my 6 month survey but today I can throw over 90 feet.   My arm still feels pretty weak in terms of soft tissue when I throw (but there is no joint pain) so I am taking it very easy.   Eventually I want to play in a softball league but I want to be able to throw hard without issue before that happens.  At 6 months I was still playing tennis right handed but by month 10 I could tennis left handed including serving left-handed.  My most visible improvement is in basketball.  I gave that up 14 years ago because I could no longer shot left handed or rebound with two hands.  Today, I am playing without pain and can extend my left arm without pain or resistance.  Please note that my skill level is pretty bad but I can no longer blame it on my shoulder.

The interesting thing is that some of the planes of motion are completely better while others have come around much more slowly.  For instance I can do 12 pull-ups easily and am back to full strength for many exercises in the gym (curls, rows, tricep extensions, etc…) but I am still pretty weak when benching or doing flies (while lying on my back).  Don’t worry; I am not doing any military press or any exercises involving lifting weights repetitiously over-head.  One motion that I have not improved in is raising my left hand behind my back.  It just does not go but I have not really worked on that motion too much.

In closing I just wanted to thank you and your team again for giving me back my shoulder and increasing the quality of my life.  It has really allowed me to get back into many things that I had long ago given up.  I just can’t thank you enough and please let me know if you ever need me as a reference patient or if there is any way I can ever assist you.
I also would like you to re-enforce to prospective patients that they have to commit 100% to rehab.  You actually have to like it.  Interesting that many of your survey questions touch on depression since I can see going through rehab does have its ups and down.  But if you keep a long term focus, the progress you make can definitely put a bounce in your step.  Rehab can actually give one a purpose and a break for the ordinary.  I think you need to set goals (3 month, 6 month, 12 month goals) and have a final picture of how you want things to be.  For me, my goal is to still be able to play in 2 man volleyball tournaments with my son.  I still cannot swing hard left-handed to hit a volleyball and that may not be a motion that would be recommended but I want to be able to do that.

I will keep you posted as to when that finally takes place.  The other difficult part of that equation is getting my 19 year old son to agree to do it.
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Thursday, November 13, 2014

Shoulder arthritis, why not just clean it up with an arthroscope?

Arthroscopic Debridement and Capsular Release for the Treatment of Shoulder Osteoarthritis

These authors performed a retrospective review of 33 patients having arthroscopic debridement and capsular release for shoulder osteoarthritis.

Their technique included debridement of loose cartilage, frayed labrum, and other degenerative tissues as well as complete release of the rotator interval, middle, and inferior glenohumeral ligaments.

A patient-directed home exercise program was initiated immediately for stretching and range of motion therapy.

While there appeared to be an initial improvement in range of motion and pain scores, patients returned to preoperative status 4 months after debridement and capsular release. Twenty patients (61%) reported dissatisfaction with the outcome of the procedure. Over 40% of the shoulders had total shoulders at an average of 9 months.



Comment: This information is useful. We often find patient's asking, 'can't you just clean up my shoulder arthritis without a joint replacement?' It is a good question and comes to the complexity of glenohumeral degenerative joint disease, which, as the picture below suggests, may include loss of cartilage, loss of the roundness of the joint surfaces, bone spurs (osteophytes), instability, capsular tightness, and muscle imbalance - features that are difficult to manage without arthroplasty.
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Loose glenoid components, Propionibacterium, and their management

A lady in her 70s taking insulin for her diabetes with a high BMI who uses a wheelchair presented with pain in her shoulder after a prior arthroplasty. These x-rays were taken. Showing a well fixed humeral component and a loose polyethylene and metal glenoid.



She desired surgical revision with removal of her loose glenoid. She had no clinical or laboratory evidence of infection. 
At surgery cloudy joint fluid was encountered and a frozen section showed > 5 WBC/HPF. The humeral component was well fixed. The loose glenoid was easily removed and the glenoid vault curetted to remove the reactive tissue. The wound was thoroughly irrigated and a new humeral head prosthesis with a larger diameter of curvature inserted. The well fixed ingrowth stem was not changed.  She was started on Ceftriaxone and Vancomycin via a PICC line.





The gram stain and culture results were:

*Right shoulder humeral head explant
GS: Rare PMNs, no organisms seen
C: 1+ Propionibacterium

*Right shoulder glenoid explant
GS: 2+ PMNs, 3+GPCs and 2+GPRs on gram stain
C: 1+ Propionibacterium, Dermacoccus
*Right shoulder joint fluid #1 
GS: 3+ PMNs,1+ GPCs
C: 1+ Propionibacterium type 1, 1+ Propionibacterium type 2

*Right shoulder joint fluid #2
GS: 3+ PMNs, no organisms seen
C: 1+ Propionibacterium type 1, 1+ Propionibacterium type 2

* Right shoulder glenoid membrane #1
GS: 1+ PMNs, no organisms seen
C: 1+ Propionibacterium type 1, 1+ Propionibacterium type 2

*Right shoulder glenoid membrane #2
GS: 1+ PMNs, no organisms seen
C: 1+ Propionibacterium type 1, 1+ Propionibacterium type 2, Coag neg staph (2 types)
*Right shoulder collar membrane
GS: 2+ PMNs, no organisms seen
C: 1+ Propionibacterium type 1, 1+ Propionibacterium type 2, 1+ Propionibacterium type 3

*Right shoulder capsule
GS: 2+ PMNs, no organisms seen
C: 1+ Propionibacterium type 1, 1+ Propionibacterium type 2, 1+ Propionibacterium type 3

She continues on supressive Augmentin with an improved, but imperfect shoulder.

Comment: Again it surprising how heavy a bacterial load existed in this shoulder without clinical manifestations of infection. We never know. In this case - in contrast to a prior one - we retained the humeral stem (rather than splitting the humerus to remove an ingrowth prosthesis) because of the patient's compromised health and dependency on the arm for transfers and ambulation, recognizing the risk of persistence of organisms.
This is, again, an argument against ingrowth or cemented humeral components: it is much safer to revise a humeral component fixed with impaction grafting.

3735170

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Wednesday, November 12, 2014

The axillary - truth - view. It tells us what we need to know about arthritis.

Here is the AP view of a 47 year old vintner with shoulder pain. What is the diagnosis? Note on this view the normal joint space and the absence of osteophytes.



An axillary view taken the the functional position of elevation in the plane of the scapula (note the spinoglenoid notch showing it was taken properly) reveals bone on bone contact, however. No CT necessary!



How can this be?

The answer is that cartilage is often lost in the central aspect of the head so that the joint space loss shows when the arm is in a functional position of elevation in the plane of the scapula, but not with the arm adducted where the remaining cartilage is interposed between the head and the glenoid. It's a bit like Friar Tuck.



3002344

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Glenohumeral radial mismatch and shoulder stability - a computer model.


Nonconforming glenoid increases posterior glenohumeral translation after a total shoulder replacement.

These authors state that the major complication in nonconforming total shoulder replacement (TSR) is glenoid loosening attributed to posteriorly directed humeral head translations.

They used a 6-degrees-of-freedom computational model of the glenohumeral joint to estimate the muscle forces, joint contact force, and glenohumeral translation for radial mismatches  - the difference between the radius of curvature of the humeral articular surface and the radius of curvature of the glenod articular surface - ranging from 1 mm to 20 mm with the shoulder positioned from 20° to 60° of elevation in the plane of the scapula. Their model suggested that as the radial mismatch increased, the contact location of the humeral head moved posteriorly and inferiorly. 

Comment: The title of this paper suggests that this was a study of total shoulders, but rather it was a computer modeling study. It is obvious that less joint surface conformity allows more translation - we don't need a computer model to tell us that. However, in a normal shoulder the humeral head does translate on the glenoid - a completely conforming set of humeral and glenoid components will only allow translation if the prosthetic rim is loaded, risking rim wear of the polyethylene, cold flow of the polyethylene, and rocking horse loosening. 

For truly clinical information on the effect of mismatch, see this post and here.

In our practice we use a 3 mm radial mismatch - the glenoid radius of curvature is 3 mm larger than that of the humeral head. 

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Three dimensional planning and patient specific glenoid guides: a virtual study in cadevaric scapulae without arthritis


Three-dimensional planning and use of patient-specific guides improve glenoid component position: an in vitro study.

These authors evaluated the reliability and precision of three-dimensional planning and use of patient-specific guides in the simulated placement of a glenoid guide pin in 18 normal dry cadaver scapulae.

Quantitative analysis of guide pin positioning demonstrated a good correlation between preoperative planning and the achieved position of the guide pin.

Comment: This study was performed in dry normal scapulae. It focused on pin placement - glenoid reaming and actual component placement were not included.  From the photographs, it appears that complete exposure of the perimeter of the glenoid is necessary to allow for insertion of the pin guide. Thus the ability to use this system in actual shoulder arthroplasty where exposure can be difficult  - particularly in cases of glenoid retroversion - is unknown. The cost of the system and the time necessary in its implementation are not provided in this manuscript - thus the value (benefit/cost) cannot be determined. See this related post.

We do not use a guide pin in shoulder arthroplasties out of concern for pin breakage or inadvertent pin advancement into the chest. Our technique for glenoid insertion is shown here.

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Patients on Medicaid are at greater risk for complications after arthroplasty

Medicaid Payer Status Is Associated with In-Hospital Morbidity and Resource Utilization Following Primary Total Joint Arthroplasty

The Affordable Care Act has extended health care coverage through an expansion of the Medicaid program. In order to compare outcomes of Medicaid and non-Medicaid insurees, these authors used the Nationwide Inpatient Sample database to identify patients who had undergone primary hip or knee arthroplasty from 2002 through 2011.

They found 191,911 patients who underwent total joint arthroplasty with Medicaid payer status (2.8% of the entire total joint arthroplasty population). 107,335 (56%) of these Medicaid patients were matched one to one to a non-Medicaid patient according to age, sex, race, type of total joint arthroplasty, procedure year, hospital characteristics, smoking status, and twenty-nine comorbidities.

Medicaid patients had a higher prevalence of postoperative in-hospital infection, wound dehiscence, and hematoma or seroma, but a lower risk of cardiac complications. The length of the hospital stay was longer, total cost was higher, and discharge to an inpatient facility was more frequent for patients with Medicaid status.

Comment: This study indicates that even with careful matching, Medicaid insurance status is a risk factor for complications and increase cost of care. The first implication is that such individuals deserve extraordinary preoperative medical and social evaluation as well as in depth counseling to minimize the risk and prepare for the possibilities of complications. The second implication is that medical centers and providers caring for these patients should anticipate a higher level of work and less reimbursement in caring for these individuals. The third implication is that providers and medical centers caring for a individuals on Medicaid may carry the risk that scores on quality of performance scales may be lower that with individuals on other types of health coverage. If these disincentives for providing care to Medicaid patients are to be removed, government systems need to revise the payment and readmission penalty systems currently in place. These observations are especially relevant to the bundled payment initiative. For more on bundled payments, see also here.
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