Friday, October 31, 2014

Subscapularis failure after a shoulder arthroplasty - what can be done about it?

Because shoulder arthroplasty is performed through a transection of the subscapularis attachment to the humerus - either a tenotomy, an incision at the bone tendon junction or a lesser tuberosity osteotomy. Regardless of the method of detachment, careful repair and postoperative protection of the repair are necessary to prevent failure of the reattachment  (see this link). If the reattachment fails, something more than a simple reattachment is often necessary.

Here's an illustrative case: a 77 year old male had a total shoulder arthroplasty in 2012.  He did well initially after his surgery and was quite diligent about following his rehab protocol.  Unfortunately at 3 months post operatively he was reaching for an object he felt a twinge in his shoulder and afterwards it did not feel quite right. On exam he had 80 degrees of passive external rotation with weakness in internal rotation concerning for a subscapularis tear.  His only complaint was the tendency of his shoulder to slip anteriorly with external rotation and extension. Otherwise his shoulder was comfortable and functional. An axillary x-ray suggested  anterior subluxation of the humeral head on the glenoid.



Of note he did have a history of previous rotator cuff tears in the contralateral right shoulder with two attempted repairs several years prior to his arthroplasty procedure. He was also taking chronic steroids for adrenal insufficiency.

Our approach to the evaluation of management of subscapularis deficiency has been described (see this link).

In this case surgery had to be delayed due to pressing medical issues for over a year. 

At the time of surgery his subscapularis tendon was torn with the bulk of the tendon retracted and scarred underneath the conjoined tendon. Great care was taken to release these adhesions and mobilize the subscapularis due to the close proximity of neurovascular structures and altered surgical field with scar tissue. 

After the subscpularis was mobilized, a burr was used to create a transosseus tunnel in the bicipital groove separated by a 2cm bone bridge. The allograft was passed through this tunnel and then each end was woven through the native subscapularis tendon medially.  After securing the native subscapularis to the lesser tuberosity with sutures, the allograft was looped over itself in a figure of 8 and secured laterally with suture. The quality of the repair afterwards was excellent with 0 degrees of external rotation and a firm endpoint.




His postoperative film shows centering of the humeral head on the glenoid.


He will be protected in internal rotation for 6 weeks.

This post prepared with the collaboration of Robert Lucas, M.D.

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Friday, October 24, 2014

Ream and Run for Capsulorrhaphy Arthropathy - two recent cases

Capsulorrhaphy arthropathy - arthritis after a prior repair for shoulder dislocation - (see this link) is a common indication for shoulder arthroplasty in younger active individuals. For this reason, these individuals often come for consultation for a ream and run procedure (see this link).

Here are two cases from this week's OR.

The first patient is a 56 year old very active and muscular individual who had dislocated his shoulder as a youth playing football. He had 2 open stabilization surgeries in the early 1970s which did help with his instability but resulted in significant stiffness.  Preoperatively he had very limited range of motion with only 30 degrees of forward flexion and minus 30 of external rotation with only a toggle of glenohumeral motion.  The preoperative x-rays show the staples from his prior surgeries that are loose from the bone.  The axillary ('truth') view shows the humeral head to be posteriorly subuxated on a biconcave glenoid. The screw was used in a prior coracoid osteotomy. Note the thickness of his humeral cortex.


At surgery we carefully removed the staples from near the axillary nerve and artery. The coracoid screw was left in place. His ream and run was otherwise uneventful. His head was stable and at discharge on the second postoperative day he had 140 degrees of assisted elevation.




The second patient was a 49 year old active individual who had a previous Bristow procedure in 1985 who then developed progressive shoulder pain and stiffness. He again had severely limited range of motion, especially external rotation. His preoperative films showed a retained screw from his Bristow and posterior humeral subluxation of his humeral head on the glenoid. 


At the ream and run procedure the shoulder demonstrated some excessive posterior translation so an anteriorly eccentric head and a rotator interval plication were used. His postoperative films showed his humeral head centered on the glenoid. In cases of posterior instability, it is important to make sure the prosthesis is fully seated in that if the head is high, it will increase the tendency for posterior subluxation when the arm is flexed forward.



On the second postoperative day he had 140 degrees of assisted elevation.

These cases are always difficult because of the tightness of the shoulder, the distorted anatomy and the muscularity of the patient, but the results in carefully selected patients can be terrific (see this post for example).

This post was prepared with the assistance of Robert Lucas, M.D.
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Get Shorty? Are short stemmed humeral components an advantage?

There has been recent interest in shorter stemmed humeral components - sometimes called 'mini' or even 'micro' stems. While the suggested advantages are (1) preservation of more humeral bone and (2) easier fit in the humeral canal, what is sacrificed is the ability of the longer stem to assure proper orientation of the humeral head with respect to the humerus. This problem is shown on the x-rays below of a case recently presenting to us. While the prosthesis appears properly oriented


The axillary view shows the stem in substantial anterior inclination, with lack of coverage of the posterior proximal humerus and a tendency for anterior subluxation. A revision was required.


The goals of bone conservation and ease of fit can be obtained without the risk of malposition with the use of a traditional length stem selected after minimal canal reaming with impaction grafting as shown in this link.

Here are the x-rays of a man we saw back this week who is one year out from a ream and run procedure with our standard approach to humeral component selection and fixation - no cement, no ingrowth, no loss of endosteal bone through reaming, no valgus, no varus, no angulation, no loosening, no plastic glenoid and 12/12 on the Simple Shoulder Test.



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Sunday, October 19, 2014

Rotator cuff disease - what evidence supports what treatment?

Cochrane in CORR: Surgery for Rotator Cuff Disease (Review)

While rotator cuff conditions are the most common shoulder condition to bring a patient to medical attention, and while cuff problems have a negative impact on the quality of life, and while there are many non-operative and surgical treatments available there is a lack of solid evidence to guide treatment. Theses authors present the results of a Cochrane review of all randomized and quasirandomized trials of nonoperative and operative treatments for rotator cuff disease. They found that 11 of 14 trials failed to perform or report intention-to-treat analyses (in which the results are analyzed according to the treatment group to which they were randomized, regardless of whether the assigned intervention was actually carried out), and one of the trials reported that a significant number of crossovers were not analyzed in their original group.

When intention-to-treat analysis is not used, the benefits of treatment may be inflated. These authors concluded that in the studies reviewed, the benefits of surgery and other invasive treatments have been overestimated because the authors did not rigorously apply an intention-to-treat approach.

The authors also present the issue of surgical expertise, which can be a feature of surgical randomized trials. As an example, a surgeon who is expert in arthroscopic repairs may perform a study comparing arthroscopic repairs to open repairs (in which the surgeon is not an expert). The results of open repair are inferior - is that because open repair is worse or because the surgeon is less apt at performing it? As we are fond of saying, 'the surgeon is the method!'

They found that six of the included trials did not assess described surgeon expertise. Published studies tended to lump younger and older patients together, in spite of the different mechanisms of injury, different types of pathology, and different priorities in outcome (i.e. pain relief vs improved function).

The Cochrane review found no difference in either functional outcome scores or pain relief between surgical and active nonoperative treatment for cuff disorders. Firm conclusions could not be made regarding the effectiveness of open versus arthroscopic surgical approaches and conservative management for rotator cuff disease. 

Comment: This article should be considered along with that covered in a recent post. The bottom line is that in view of the prevalence of cuff disease and the frequency and cost of surgery for cuff disorders, and the failure of one-quarter of cuff repair repairs to achieve anatomic integrity, better studies are needed to define the appropriate treatment for acute and chronic rotator cuff tears in different age groups. In our practice we continue to see failed 'heroic' attempts to repair substantial chronic cuff defects in individuals over the age of 60. We have been impressed with the success of the 'smooth and move' approach for managing irreparable cuff tears or failed attempts at cuff repair. 

Our approach to rotator cuff disease can be seen on this post.

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

Conversion of an anatomic to a reverse total shoulder, when is a 'platform' prosthesis of benefit? Reprise

Due to the great interest in this subject, we're repeating this post with some additional thoughts.

An anatomic arthroplasty can fail for many reasons, including malposition, instability, delayed cuff failure and pseudo paralysis. In these situations consideration can be given to conversion of the anatomic prosthesis to a reverse total shoulder as shown here. As demonstrated in that post out preferred method for managing a failed anatomic arthroplasty is to completely remove the existing implant, obtain cultures, and then implant the reverse prosthesis. This approach allows full access to the glenoid and optimal positioning of the humeral component of the reverse. Removal of the anatomic implant is almost always possible and is particularly straightforward if it was inserted using impaction grafting.

In certain cases, such as that shown here, a well fixed stem can be retained and the proximal end converted to a reverse total shoulder with insertion of a glenosphere. Here's another post regarding conversion with retention of the anatomic stem.

Recently, there has been the advent of 'platform' prostheses, in which a humeral stem is fixed in the humeral canal that can be attached to either an anatomic or a reverse proximal humeral prosthesis. For examples, see hereherehere, and here.

It is important to recognize that in a reverse, (1) the glenosphere is placed inferiorly on the glenoid face, (2) the proximal humeral part of the reverse is bigger than that of an anatomic humeral arthroplasty and (3) the soft tissue tensioning considerations of a reverse are different from those of an anatomic arthroplasty. Therefore, the proximal-distal positioning of the humeral component needs to be fine tuned to achieve the ideal reverse arthroplasty. While some systems provide various adaptors to adjust the height, inclination and version of the proximal humeral prosthesis, the flexibility in positioning is limited by the use of the 'platform' fixed in the humeral canal.

Fortunately, we now have a clearer understanding of the indications for a reverse total shoulder, so that the needs for convertible prostheses is diminishing. For example, it is becoming evident that proximal humeral fractures in elderly individuals are often best managed by a primary reverse total shoulder - the idea of 'trying' an anatomic arthroplasty that is convertible to a reverse later is not so appealing. Similarly, individuals with arthritis, cuff deficiency, and instability are also best managed by a primary reverse.

See related post here.

One of the aspects lacking in articles about platform and other types of new shoulder prostheses is the incremental cost of the implant. This information is necessary to determine the value (benefit/cost) of the device. The question becomes, for 100 anatomic arthroplasties, how many successful conversions to reverses would be necessary to justify the incremental cost of (1) the implant and (2) the learning curve?

In our practice, revision of an anatomic to a reverse prosthesis is required almost exclusively in cases where the index procedure is done elsewhere. Often there are problems with stem fixation or positioning that require stem removal, even if 'in theory' the platform stem is convertible to a reverse.

One of the advantages of fixation of a humeral stem with impaction grafting is that - should conversion to a reverse prosthesis be required - the stem can be easily removed and the reverse stem inserted at the desired height and version.

Finally, infection with Propionibacterium is now recognized as a not unusual complication of shoulder arthroplasty. A well fixed stem for a platform prosthesis makes prosthesis exchange complicated
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How durable is a ream and run for a B2 glenoid?

Here are the preop films of a 57 year old man showing a Walch B2 glenoid

Note the posterior displacement of the humeral head on the glenoid in the axillary view taken in the 'position of function' with the arm in 90 degrees of elevation in the plane of the scapula. At this time his Simple Shoulder Test showed 7/12 yes responses.

Here are his films one month after his ream and run, showing centering of the humeral head in the glenoid on both views. At this time his Simple Shoulder Test showed 12/12 yes responses.


Now five years later, the patient kindly sent me a few videos of his shoulder function.




Again, this is an extraordinary result in a person that put an extraordinary effort into his recovery.


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Thursday, October 16, 2014

Ream and run, variations in glenohumeral anatomy as revealed by plain films (no CT needed)

A 50 year old male who is otherwise healthy and leads an active lifestyle had the insidious onset of right shoulder pain, stiffness and crepitus. Because of his young age and high activity level, he desired a ream and run procedure.

His preoperative AP and axillary xrays revealed a downsloping and retroverted glenoid with a posterior contact position of the humeral head on the glenoid.


At surgery no attempt was made to change his glenoid version or inclination; reaming was limited to that sufficient to provide a smooth, congruent glenoid surface. His postoperative films demonstrated centering of the humeral head on the reamed glenoid socket.



This case also demonstrates that the humeral canal is not a cylinder, but in fact is oval shaped. From the AP xrays the stem appears to have extra room within the canal, while on the axillary lateral xray it has a tight intramedullary fit. Determining the prosthetic stem diameter from the AP x-ray view may lead to selection of a too large prosthesis that will not fit safely in the canal. As demonstrated in this case impaction grafting can manage this anatomy and provide a snug fit.

Case submitted by Robert Lucas

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