Thursday, June 21, 2018

What about a cortisone shot?

Use of Intra-Articular Corticosteroids in Orthopaedics

This review of the evidence-based research on the efficacy of intra-articular corticosteroid injections of the osteoarthritic knee was inconclusive.
Combining intra-articular corticosteroid injection with a higher-dose anesthetic may compound chondrotoxic effects (that is risk the deterioration of the cartilage in the joint)
Compared with corticosteroid injections for osteoarthritis, intra-articular viscosupplements (e.g. Synvisc) have not shown a substantial difference in pain relief or functional outcomes.
Although rare and usually transient, systemic effects of intra-articular corticosteroid injections may occur and can be influenced by the type, frequency, and dosage of the corticosteroid used.
Practitioners are encouraged to use corticosteroid injections judiciously to treat pain and joint inflammation from osteoarthritis and inflammatory arthritis of large joints.

Comment: In addition to the concerns expressed above, there is concern that cortisone injections may increase the risk of infection in total joints. A common recommendation is that joint replacement should be avoided within three months of such an injection.
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Rupture of the biceps tendon and rotator cuff tears


These authors evaluated 20 men and 7 women (mean age 61 years) with acute proximal biceps tendon using MRIs of the affected shoulder.  

93% of patients had evidence of rotator cuff disease, including 13 full-thickness tears. Of the full-thickness tears, 3 were small, 6 medium, 2 large, and 2 massive. Pathology of the subscapularis tendon was identified in 7 patients (26%).

The majority of patients had with full-thickness tears of the supraspinatus. 

Comment: The association between pathology of the biceps and pathology of the cuff is well recognized. At present is not know if one causes the other or if both result from an underlying vulnerability to soft tissue failure in the shoulder
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How long are narcotics needed after shoulder joint replacement?

Risk factors for postoperative opioid use after elective shoulder arthroplasty

These authors sought to determine baseline opioid use in patients undergoing shoulder arthroplasty and identify patient characteristics, comorbidities, and surgical risk factors associated with postoperative opioid use in 3996 patients from a shoulder arthroplasty registry.  They identified the number of dispensed opioid medication prescriptions in each quarter of the first postoperative year.

The factors associated with increased opioid use were age <60 years, the amount of preoperative opioid use, anxiety, opioid dependence, substance abuse, and general chronic pain.

During the 1-year preoperative period, 75% of the patients used opioids (range, 1-79 prescriptions). Postoperatively, 92.6% used opioids in the early recovery period, and 38% to 42% used opioids in the later rehabilitation period, 39% at 1 year postoperatively

Depression was the most common opioid use-related comorbidity.

Comment: Like the authors, we are very concerned about the widespread use of narcotics. Preoperatively, we try to set the expectation that patients would be off narcotics within two weeks of surgery. For patients taking narcotics and seeking, we ask that they make substantial progress in reducing their dependency before scheduling surgery, explaining that the less narcotic medication they're taking before surgery, the less problem we'll have in managing their pain after surgery. We are reluctant to perform elective surgery on patients taking substantial doses of narcotics or long-term narcotics, such as Oxycontin, or MScontin.

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Wednesday, June 20, 2018

Revision arthroplasty: risky business

Risk factors for and timing of adverse events after revision total shoulder arthroplasty 

These authors sought to identify risk factors for unplanned readmission and perioperative complications following revision total shoulder arthroplasty, risk-stratify patients based on these risk factors, and assess timing of complications in patients from the ACS-NSQIP database from 2011 to 2015.

Of 809 revision patients, 61 suffered a perioperative complication or readmission within 30 days of discharge. Multivariate analysis identified operative time, BMI>40, infection etiology, high white blood cell count, and low hematocrit as significant independent risk factors for 30-day complications or readmission after revision surgery. 

Having at least one significant risk factor was associated with 2.71 times risk of complication or readmission within 15 days compared to having no risk factors. The majority of unplanned readmission, return to the operating room, open/deep wound infection, and sepsis/septic shock occurred within two weeks of revision surgery. 

Comment: We are often tempted to "fix" a failed shoulder arthroplasty. This article reminds us that there are major risks of revision, especially in patients with the factors identified. The less healthy the patient, the greater the risk of complications and readmissions.

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Failure of attempted rotator cuff repair

Recurrent rotator cuff tear: is ultrasound imaging reliable?

These authors point out that " Recurrent rotator cuff tears after rotator cuff repair (RCR) are common and found to be a major cause of postoperative pain. Retear rates are approximated at 7% to 17% for small tears and up to 41% to 94% for large and massive tears.  Retears most commonly occur up to 6 months after the operation."

The aim of their study was to assess the reliability of ultrasonography (US) for the detection of recurrent rotator cuff tears in patients with shoulder pain after RCR. 

They retrospectively analyzed the data of 39 patients with an average age of 66 years (range, 39-81 years) with shoulder pain after arthroscopic RCR who had subsequently undergone US, followed by revision arthroscopy.

A failed cuff repair was frequently found among these 39 patients:  by US in 21 patients (54%) and by revision arthroscopy in 26 patients (67%).



Comment: This study does not present the rate of rotator cuff repair failure in the overall experience of the authors, but it is impressive that over half of the patients with shoulder pain after a cuff repair attempt had a failed repair. This study also does not present the percentage of patients with a retear that did not have shoulder pain. Both of these bits of information would be helpful in understanding the rate and clinical significance of cuff repair failure.

We are often asked to evaluate patients with pain and weakness after attempted cuff repair. We find that the diagnosis of failed repair is usually evident from the history and physical exam. We are very rarely tempted to try a "re-repair" after a prior repair attempt failure because the tissue quality and quantity are typically inadequate for a robust repair.

For many such cases the greatest value procedure is often a "smooth and move" as described here:
Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty


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Do Propionibacterium grow on hair?

Spatial and Environmental Variation of the Human Hair Microbiota
<ScientifiC Reports | (2018) 8:9017 | DOI:10.1038/s41598-018-27100-1>

These authors point out that the skin is a complex living ecosystem harboring diverse microbial communities. Its highly variable properties and influence of intrinsic and extrinsic factors creates unique microenvironments where niche-specific microbes thrive. As part of the skin, hair supports its own microbial habitat that is also intra and inter-personal variable.

They explored the hair microbiota from scalp and pubic regions in healthy adults to investigate how the hair shaft microenvironment varies microbially. Their results suggest that there are distinct differences between the microbial communities identified on hair shafts originating from different parts of the body. The taxonomic composition of the communities from different hair sources are most reminiscent of those identified from their associated cutaneous region.

Their study confirms that human hair shafts harbor unique bacterial communities, distinctive from that of the hair follicle and more reminiscent of its associated cutaneous region. Staphylococcus, a common genera found in the skin, was also found to be abundant in hair. However, Propionibacterium, a predominant bacterium that colonizes the skin and hair follicles, is noticeably absent in hair samples. The hair shaft environment may be unfavorable for growth of Propionibacterium which prefer low oxygen levels and high sebum content as that of the hair follicle.

Comment: This study suggests that hair removal may not be of major benefit in reducing the risk of Propionibacterium colonization of a surgical wound.

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Propionibacterium DNA in normal shoulders

Cutibacterium acnes and the shoulder microbiome

These authors used DNA sequencing technologies to gain insights into the likely sources of Cutibacterium acnes (formerly Propionibacterium acnes) infections within the shoulder. Basically, their question was "do normal deep tissues of the shoulder harbor low levels of Propionibacterium that could be stimulated to grow by surgery?"

They collected tissue samples were collected from the skin, subcutaneous fat, anterior supraspinatus tendon, middle glenohumeral ligament, and humeral head cartilage of 23 patients (14 male and 9 female patients) during primary arthroplasty surgery. All samples were collected in operating rooms with vertical laminar airflow and micro-particulate air filtration, a new sterile scalpel blade was used for the collection of each tissue sample, and a fresh sterile hemostat was used to grasp and transfer the tissue into a prelabeled sterile 50-mL Falcon tube containing 6 mL of nuclease-free water

Total DNA was extracted and microbial 16S ribosomal RNA sequencing was performed using an Illumina MiSeq system.

Data analysis software was used to generate operational taxonomic units for quantitative and statistical analyses.

After stringent removal of contamination, genomic DNA from various Acinetobacter species and
from the Oxalobacteraceae family was identified in 74% of rotator cuff tendon tissue samples.



C acnes (Propionibacterium) DNA was detected in the skin of 1 male patient but not in any other shoulder tissues.

Their findings indicated the presence of a low-abundance microbiome in the rotator cuff and, potentially, in other shoulder tissues. The absence of C acnes DNA in all shoulder tissues assessed other than the skin is consistent with the hypothesis that C acnes infections are derived from skin contamination during surgery and not from opportunistic expansion of a resident C acnes population residing in the shoulder joint.

Comment: While this is an interesting study, it is curious that C acnes (Propionibacterium) DNA was recovered form the skin of only one of 14 male subjects. This rate is much lower than what would be expected based on prior culture-based studies and makes one wonder about the sensitivity of the methods used in this study.

See for example
Propionibacterium persists in the skin despite standard surgical preparation

Background: Propionibacterium acnes, which normally resides in the skin, is known to play a role in surgical site infection in orthopaedic surgery. Studies have suggested a persistence of propionibacteria on the skin surface, with rates of positive cultures ranging from 7% to 29% after surgical preparation. However, as Propionibacterium organisms normally reside in the dermal layer, these studies may underestimate the true prevalence of propionibacteria after surgical skin preparation. We hypothesized that, after surgical skin preparation, viable Propionibacterium remains in the dermis at a much higher rate than previously reported. Methods: Ten healthy male volunteers underwent skin preparation of the upper back with ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol). Two 3-mm dermal punch biopsy specimens were obtained through the prepared skin and specifically cultured for P. acnes. Results: Seven volunteers had positive findings for Propionibacterium on dermal cultures after ChloraPrep skin preparation. The average time to positive cultures was 6.78 days. Conclusions: This study found that Propionibacterium persists in the dermal tissue even after surface skin preparation with ChloraPrep. The 70% rate of persistence of propionibacteria after skin preparation is substantially higher than previously reported.

https://www.medscape.com/medline/abstract/25187583
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