Monday, December 17, 2018

What is the best way to image an arthritic shoulder?

Recently we met an active 70 year old man with shoulder arthritis. His Grashey view is shown here


and his axillary "truth" view (below) clearly shows posterior decentering of the humeral head on a retroverted biconcave glenoid.
Previously he had had an MRI
and a CT scan
neither of which showed the posterior decentering that was revealed by the simple "truth" view taken with the arm in a position of function, in contrast to the "advanced" imaging (MRI / CT) obtained with the arm at the side which did not reveal the functional decentering.
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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'

Gingerbread shoulders

Today, our wonderful research associate presented us with some well crafted gingerbread shoulders. 

We are so thankful for the shoulder team!


                     

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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'

Managing the B2 glenoid

A seventy year old active man presented with a painful arthritic left shoulder, a Simple Shoulder Test Score of 5 out of 12 and these x-rays, showing a retroverted biconcave (B2) glenoid.

 His axillary "truth" view clearly demonstrates retroversion, biconcavity and posterior decentering of the humeral head on the eroded glenoid.

One year ago he received a total shoulder arthroplasty using a standard (non-augmented) glenoid inserted without particular attempt to modify his glenoid version. Recently he returned to the office with excellent shoulder motion, an SST score of 8 out of 12, and these x-rays.

His axillary "truth" view is directly comparable to his preoperative view and shows centering of the humeral head prosthesis on a standard all-polyethylene glenoid component inserted without attempt to change glenoid version. Note the glenoid component is well supported on bone that has been minimally reamed.

Comment: There are many approaches to a shoulder with a B2 glenoid: posterior bone grafting, posteriorly augmented glenoid component, reverse total shoulder. This case provides an example of our approach to the B2 glenoid, which is further detailed below:


Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?


While glenoid retroversion and posterior humeral head decentering are common preoperative features of severely arthritic glenohumeral joints, the relationship of postoperative glenoid component retroversion to the clinical results of total shoulder arthroplasty (TSA) is unclear. Studies have indicated concern for inferior outcomes when glenoid components are inserted in 15° or more retroversion.

In a population of patients undergoing TSA in whom no specific efforts were made to change the version of the glenoid, these authors asked whether at 2 years after surgery patients having glenoid components implanted in 15° or greater retroversion had (1) less improvement in the Simple Shoulder Test (SST) score and lower SST scores; (2) higher percentages of central peg lucency, higher Lazarus radiolucency grades, higher mean percentages of posterior decentering, and more frequent central peg perforation; or (3) a greater percentage having revision for glenoid component failure compared with patients with glenoid components implanted in less than 15° retroversion. They examined the records of  201 TSAs performed using a standard all-polyethylene pegged glenoid component

inserted after conservative glenoid reaming without specific attempt to modify preoperative glenoid version.




Of these, 171 (85%) patients had SST scores preoperatively and between 18 and 36 months after surgery. Ninety-three of these patients had preoperative radiographs in the database and immediate postoperative radiographs and postoperative radiographs taken in a range of 18 to 30 months after surgery. Twenty-two patients had radiographs that were inadequate for measurement at the preoperative, immediate postoperative, or latest followup time so that they could not be included. In comparison to those included in the analysis, the excluded patients did not have substantially different mean age, sex distribution, time of followup, distribution of diagnoses, American Society of Anesthesiologists class, alcohol use, smoking history, BMI,  history of prior surgery or preoperative glenoid version. They analyzed the two year outcomes in the remaining 71 TSAs, comparing the 21 in the retroverted group (the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°)) with the 50 in the non-retroverted group ( the glenoid component was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°)). 

The mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%).  The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, - 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. The radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4-6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). The percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids (three of 50; [6%]; p = 0.251).

The authors concluded that in this series of TSAs, postoperative glenoid retroversion was not associated with inferior clinical results at 2 years after surgery. 

Glenoid retroversion is a relatively common finding in arthritic glenohumeral joints coming to shoulder arthroplasty. Shoulders with preoperative glenoid retroversion tend to have poorer preoperative shoulder comfort and function, posterior decentering, and glenoid biconcavity, all indicating a more severe form of the disease. There is currently great interest in methods for altering this glenoid retroversion that is commonly found in osteoarthritic glenohumeral joints. Methods used include posterior glenoid bone grafts, reaming the anterior aspect of the glenoid, and posteriorly augmented glenoid components. This study reports the two year results of a more conservative approach in which minimal glenoid bone is removed by reaming and specific attempts to alter glenoid version are not used.

Here is the two year radiographic followup on a 55 year old patient from our practice. Preoperative films show a type B2 genoid with retroversion, biconcavity and posterior humeral subluxation.



Here are the 2 year films of this shoulder after conservative shoulder arthroplasty using a standard glenoid component without attempts to modify glenoid version. The humeral head is centered in the prosthetic glenoid. At two years after surgery the patient was able to perform all 12 functions of the Simple Shoulder Test.




Note that sufficient bone stock remains to perform a revision total or a reverse total shoulder arthroplasty shoulder these procedures become necessary in the future of this young person.

Long term followup of well-characterized patients treated with the different methods for managing glenoid retroversion will be required to define the relative risks, benefits, effectiveness and durability of each of them.

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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'


Friday, December 14, 2018

Lesser tuberosity osteotomy nonunion - why not avoid this problem?

Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty
(Journal of Shoulder and Elbow Arthroplasty Volume 2: 1–8, 2018)

These authors observe that lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate.

They present 9 patients with LTO nonunion after primary anatomic shoulder arthroplasty.



LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group.

Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128 forward elevation (FE) and 33 external rotation (ER) compared to 148 FE and 62 ER. One patient with LTO nonunion required conversion to reverse replacement.

They concluded that surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.

Comment: We have not found a place for LTO in our arthroplasty practice because it is not necessary, it creates a new possible complication, it requires sacrifice of the long head biceps tendon, and it compromises the integrity of the proximal humerus.

We prefer the bone and biceps preserving subscapularis peel.





That is carefully repaired with six #2 non-absorbable sutures 

 and well-tied knots.



The repair allows immediate postoperative assisted elevation


 with external rotation to neutral






Stretching beyond neutral rotation and internal rotation strengthening are not started until 8 weeks after surgery.



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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, December 12, 2018

Are surgeons doing too many reverse total shoulders?

Comparative Utilization of Reverse and Anatomic Total Shoulder Arthroplasty: A Comprehensive Analysis of a High-volume Center

These authors conducted  a single-center retrospective review of 1,600 primary anatomic total shoulders (TSAs) and 1,192 reverse total shoulders (RTSAs).

During the decade between 2005 and 2015, RTSA increased from 27% to 52% of the shoulder arthroplasties. The number of RTSAs performed for osteoarthritis and irreparable rotator cuff tears increased, and the proportion of RTSAs performed for rotator cuff tear arthropathy decreased.

Comment: Let's first consider the relative economics (reference Orthopaedic Network News)

From these data we see that the average selling price of a reverse is 60% of the medicare payment to the hospital, whereas the average selling price of an anatomic total shoulder is 41%.  Surgeons should review with their hospitals the effect of implant choice on the ability to cover the costs of patient care.

Let's next consider the effect of the aTSA vs RTSA decision on the patient, take for example a 72 year old active man with capsulorrhaphy arthropathy and these x-rays (no CT scan needed!).


who was treated with a standard total shoulder - two year post op films shown below




He recently wrote: "Greetings from Alaska! It's coming up on the end of two years since my shoulder surgery. I just wanted to express to you my deepest thanks for a job well done. My only regret is that I did not find you sooner! Unfortunately with my experience and disappointment with the original surgery 20 plus years ago, it put me off  and influenced my decision to wait so long! I had almost giving up on any normal active life that I had been so used to before that surgery (an instability repair)!

Since my surgery , I have traveled and I still fly my airplane! I have killed a moose to help put meat in our extended families' freezers and I have fly fished and fished salmon and halibut to my heart's content without any discomfort whatsoever. In general, I seem to have no problems with any other recreational activity or physical activity! 

Thank you for going with the traditional total replacement surgery and not going with a reverse replacement as had been suggested by three other surgeons! I am forever grateful for how it all turned out - you have given me my life back! "

The point is that three prior surgeon had tried to convince him to have a reverse, but he was unwilling to accept the limitations.

Thirdly, as the authors of this paper point out, "  few long-term outcomes studies are available, and they suggest that functional survival after RTSA at 10 years may only be 58% to 76%" While they report a trend to performing RTSA in younger patients, younger patients are reported to have higher revision rates and higher rates of unsatisfactory results.

Finally and most importantly, the trend toward increasing volumes of RTSAs does not indicate that this is best treatment for conditions such as osteoarthritis (see case example above). It would seem that these authors are in a great position to compare cost and outcome data for anatomic TSA and RTSA stratified by diagnosis, age and sex, but these data are not presented. We hope that this information will be forthcoming.

In our practice we use RTSA only when it is clearly the best option: pseudoparalysis, anterosuperior escape, and complex proximal humeral fractures. For many other diagnosis, there are safer and less costly approaches that enable higher levels of activity.

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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, December 10, 2018

Do CT scans add value to the preoperative evaluation of the arthritic shoulder?

Intraobserver and interobserver reliability of the modified Walch classification using radiographs and computed tomography 

These authors sought to evaluate the intraobserver and interobserver agreement of the modified Walch classification system using both plain radiographs and computed tomography (CT). 


Three fellowship-trained shoulder surgeons blindly and independently evaluated radiographs and CT scans of 100 consecutive shoulders (98 patients) and classified all shoulders according to the modified Walch classification in 4 separate sessions, each 4 weeks apart.

They included patients who had a diagnosis of primary osteoarthritis and who then underwent shoulder arthroplasty of some type. All patients had preoperative CT scans and axillary radiographs obtained routinely prior to surgery. There were 50 men (51%) and 48 women (49%).

The first reading by the most senior observer on the basis of CT scans was used as the gold standard (distribution: A1, 18; A2, 12; B1, 20; B2, 25; B3, 22; C, 1; and D, 2). 

The average intraobserver agreement for radiographs and CT scans was 0.73 (substantial; 0.72, 0.74, and 0.72) and 0.73 (substantial; 0.77, 0.69, and 0.72), respectively. 

The average interobserver agreement was 0.55 (moderate; 0.61, 0.51, and 0.53) for radiographs and 0.52 (moderate; 0.63, 0.50, and 0.43) for CT scans.

There was a high degree of agreement between the CT scan and the axillary views for each of the three reviewers:


This study showed that the modified classification can be applied to both CT images and axillary radiographs. It found that both axillary radiographs and CT scans can be used reliably with the modified Walch classification to deliver a reproducible assessment of glenoid morphology, as well as to broadly subcategorize the presence or absence of bone loss and eccentric wear or subluxation.This is useful for surgeons who do not, or cannot, routinely obtain CT images prior to shoulder replacement.

Comment:  This study is reassuring to those surgeons (including us) who find that an axillary view provides sufficient information to characterize the pathoanatomy and plan the surgical procedure for the great majority of patients coming to shoulder arthroplasty.

We note that CT scans expose the patient to 26 times the radiation of a standard set of plain radiographs and cost approximately $1000 more. Standardization of the axillary technique can yield highly reproducible views that can be easily analyzed for glenoid type, version, and the degree of decentering as demonstrated below





The use of standardized preoperative and postoperative axillary views provides a practical method for determining the effectiveness of surgical reconstruction.


While it can be argued that CT scans with 3D reconstructions in the plane of the scapula are more precise than an axillary view, it has not been show that patients having this more complex imaging protocol obtain the better functional outcomes necessary to justify its substantial added expense and radiation exposure.
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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'

Total shoulder - is a more expensive sling of value?

The position of sling immobilization influences the outcomes of anatomic total shoulder arthroplasty: a randomized, single-blind, prospective study

These authors randomized 36 patients undergoing anatomic total shoulder arthroplasty for osteoarthritis were randomized to a neutral rotation sling



versus an internal rotation sling.






The slings were worn at all times for the first 6 weeks except during showering, hygienic care, changing clothes, and physical therapy.

The primary outcomes assessed included the Disabilities of the Arm, Shoulder and Hand score;Western Ontario Osteoarthritis of the Shoulder score; Single Assessment Numeric Evaluation score; visual analog scale (VAS) scores for pain and satisfaction; compliance ratings; and radiographic and range-of-motion measurements. Primary outcomes were assessed at baseline and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year.

While there were some measurable differences in postoperative external rotation and adduction, there were no significant differences in the primary outcome patient-reported comfort and function at any time point.






There was no statistically significant difference between groups for overall satisfaction

Comment: This report did not demonstrate the value of the more expensive sling in terms of increased patient self-assessed comfort and function resulting from the use of the more expensive sling.



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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'