Monday, April 14, 2014

Humeral resurfacing arthroplasty problems

Today in the office we're seeing two patients with unsatisfactory results after a hemicap resurfacing arthroplasty. Each had an Simple Shoulder Test score of only 1/12 positive responses.
A review of the cases show the difficulty in the placement of the prosthesis as well as the unresolved glenoid pathoanatomy.

Case 1 - clinical exam suggests failure of the subscapularis as well as stiffness. Note the varus position of the component.



Case 2 - Note the large amount of residual humeral neck resulting in 'overstuffing' of the joint.




The purpose of this post is not to state that humeral resurfacing is a bad operation; any surgery can have problems. The point is that (1) a humeral resurfacing is a technically challenging procedure, (2) that reconstructing the anatomy is not trivial, and (3) humeral resurfacing does not manage the glenoid side of glenohumeral arthritis. In such cases, it may not be a 'conservative' approach.

Both of these cases require surgical revision because of pain and stiffness that has not responded to non-operative management.


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Is the anatomy of the glenoid vault abnormal in shoulders with arthritis?

Is premorbid glenoid anatomy altered in patients with glenohumeral osteoarthritis?

These authors sought to determine whether the glenoid vault had different anatomical orientation in arthritic than in normal shoulders.

They obtained bilateral CT scans in in 27 patients with unilateral glenohumeral osteoarthritis. Thirty normal cadaver control shoulders also underwent CT scans. 

Arthritic shoulders had an average of 16 ± 11 degrees of retroversion as compared to 7 ± 5 on the contralateral side and 7 ± 4 for control cadavers. However, the glenoid vault anatomy for pathologic shoulders was similar to that for non-arthritic shoulders.

Comment: While these observations are interesting, surgeons are required to manage the great range of glenoid anatomy encountered in surgical reconstruction, which is demonstrated here. The surgical technique is about managing the glenoid surface anatomy.

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Sunday, April 13, 2014

Reverse total shoulder for failed hemiarthroplasty for fracture.

The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture.

While humeral hemiarthroplasty is often used to treat fractures of the proximal part of the humerus, this procedure has a high failure rate because of the development of glenoid arthritis and rotator cuff deficiency due to tuberosity failure.

These authors treated 29 such patients (twenty-five women and four men) with a mean age of sixty-nine years (range, forty-two to eighty years) with removal of a hemiarthroplasty prosthesis and revision with a reverse total shoulder alone or in combination with a proximal humeral allograft.

The average total American Shoulder and Elbow Surgeons score improved from 22.3 preoperatively to 52.1.
The average American Shoulder and Elbow Surgeons pain score improved from 12.2 to 34.4 (p < 0.001), 
The average American Shoulder and Elbow Surgeons function score improved from 10.1 to 17.7 (p = 0.058). 
The average Simple Shoulder Test score improved from 0.9 to 2.6 (p = 0.004). 
The overall complication rate was 28% (eight of twenty-nine). 
Complications occurred in three of the eight patients who had been managed with an allograft-reverse total shoulder combination. One patient fell and sustained a periprosthetic humeral fracture distal to the humeral stem along with a fractured polyethylene socket at twenty months and later sustained a dislocation at twenty-five months requiring surgical revision. The second patient developed a postoperative infection that required surgical revision.  The third patient had a postoperative dislocation treated non operatively. 
Complications occurred in five of the twenty-one patients treated with a reverse total shoulder alone. One patient had failure of the baseplate with broken screws requiring surgical revision. A second patient had dislocation of the prosthesis at eight months requiring surgical revision.  A third patient had  humeral stem loosening at twenty-two months requiring surgical revision. A fourth patient underwent revision complicated by penetration of the cortex and a radial nerve palsy. The fifth patient had two dislocations and was successfully managed with closed reduction.

Comment: These results indicate the risk and complexity of revision reverse total shoulders, even in the hands of very experienced surgeons.

The treatment of substantial proximal humeral bone loss is a challenge in reverse total shoulder arthroplatsy. 
Furthermore, a malunited greater tuberosity and scarring of the posterior rotator cuff may block reduction and increase the risk of instability. The authors advise releasing the posterior rotator cuff from the proximal part of the humerus to enhance stability and soft-tissue balance.

In the presence of proximal humeral bone deficiency, the authors recommend consideration of a proximal humeral allograft  to add rotational and structural stability.

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Blood transfusion - the risk of infection - a game changer

Health Care–Associated Infection After Red Blood Cell TransfusionA Systematic Review and Meta-analysis

Confession: We used to insist on a 'good solid hemoglobin' before our patients were discharged because of fear of syncope and increased risk of infection and poor wound healing.

These authors challenged that practice by studying the association between red blood cell transfusion strategies and health care–associated infection.

They performed a meta-analysis of 21 randomized trials comparing restrictive vs liberal transfusion strategies (8735 patients). Most trials define a restrictive transfusion strategy as the administration of red
blood cells once hemoglobin falls below either 7 or 8 g/dL, and most trials define a liberal strategy as transfusion once hemoglobin level falls below 10 g/dL.

They found that the pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity.

With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight.

They concluded that among hospitalized patients, a restrictive transfusion strategy was associated with a reduced risk of health care–associated infection compared with a liberal transfusion strategy. 

Comment: This article has changed our practice to a restrictive transfusion strategy unless there are overriding reasons to be more liberal.

A very nice discussion of this paper can be found here. In this discussion the point is made that the ideal  threshold for transfusion has yet to be determined.

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Scapular fracture in reverse total shoulder arthroplasty

What is the effect of postoperative scapular fracture on outcomes of reverse shoulder arthroplasty?

These authors reviewed 25 nonoperatively treated postoperative scapular fractures after reverse total shoulder with a minimum 2-year follow-up from surgery and 1-year follow-up from fracture.

These cases were matched 1:4 to a control group for age, sex, follow-up time, surgery indication, and primary operation vs revision.

The rate of scapular fracture  in this series was 3.1%. Fractures occurred from 1 to 94 months postoperatively. Fracture patients had inferior clinical outcomes. In this study the outcomes were not significantly different for acromial and scapular spine fractures. The revision rate was higher in the fracture group (8% vs 2%). Only 10 of 18 fractures (55%) with greater than 1 year of radiographic follow-up showed osseous union of the fracture. The union rate was 57% (8 of 14) for acromial fractures and 50% (2 of 4) for scapular spine fractures.

This study showed that scapular fractures can occur at any point in the postoperative period, from as early as 4 weeks to nearly 8 years. The surgeon must maintain a high index of suspicion for this complication whenever a patient presents with scapular pain after reverse total shoulder arthroplasty. The diagnosis is made by careful physical exam and plain radiographs.

It has been noted previously that scapular spine fractures may occur at the site of the fixation screws.

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Shoulder arthroplasty infection

Diagnosis of Periprosthetic Infection After Shoulder ArthroplastyA Critical Analysis Review

These authors review some of the important concepts regarding infections around shoulder arthroplasty components. Even though the recognized incidence of this complication is relatively low there is evidence that many infections are overlooked because (1) their manifestations may be subtle, presenting only as pain, stiffness or component loosening without the classical signs of inflammation and (2) some infections, such as those with Propionibacterium, require special approaches of specimen harvest and culture methods to establish the diagnosis. In this regard periprosthetic shoulder infections often differ from those of hip and knee arthroplasty - thus the guidelines for  diagnosis and treatment of periprosthetic joint infections of the hip and knee are often not applicable to the shoulder (i.e. CBC, Sedimentation rate, C-reactive protein, joint aspiration for culture, and intraoperative frozen sections are often insensitive to the presence of Propionibacterium. 


An evidence-based approach to culturing these organisms is shown here.

Because the diagnosis of periprosthetic infection may not become evident until cultures become positive weeks after the surgical revision, antibiotic therapy for suspected infection after operative intervention should be considered to avoid delay in treatment and re-colonization of the revised arthroplasty.

Risk factors have been identified: male gender, humeral osteolysis, humeral component loosening, glenoid wear, cloudy joint fluid and the formation of a membrane between the humeral component and the humeral bone each significantly increased the chances of a positive culture for Propionibacterium

Our current management of possibly infected shoulders is described here.

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Saturday, April 12, 2014

Failed shoulder arthroplasty


The evaluation of the failed shoulder arthroplasty.

The authors begin this article by stating "A recent study reported a 22.6% overall complication rate for anatomic total shoulder arthroplasty, with 11.2% of cases requiring revision."  This is an eye catching statistic for a procedure viewed by many as the 'gold-standard' treatment for shoulder arthritis.

They review the presentation and wide range of factors that may contribute to the failure of this procedure to meet the expectations of the patient and the surgeon.

Comment: We have learned a lot recently about factors related to arthroplasty failure, including
( ) Failure of the glenoid component
( ) Low grade infection with Propionibacterium
( ) The overall health of the patient
( ) The experience of the surgeon
( ) The glenohumeral pathoanatomy

Our approach to the failed arthroplasty is described here.

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