Sunday, September 22, 2019

Rotator cuff repair - is a porcine dermal patch of value to the patient?

Prospective randomized controlled trial for patch augmentation in rotator cuff repair: 24-month outcomes

These authors used a double-blinded randomized control trial of 92 patients to evaluate the anatomic integrity of rotator cuff repair performed by medialized single row and augmented by a porcine dermal patch, in comparison with a nonaugmented group.

The patch group showed a healing by MRI of 97.6% compared with 59.5% for the standard repair group. 

However, there was no significant difference for most of the outcome measures of patient comfort and function.

Comment:
It is of note that the patient reported outcomes by Simple Shoulder Test were outstanding for both the non-patch and the patch groups: preoperative scores of 3 to postoperative scores of 10, representing an improvement of over 80% of the maximum possible improvement.

This article did not compare the MRI results with the clinical results - this would seem to be important for determining the clinical importance of the MRI outcomes.

The article did not report on the incremental operative time or cost attributable to the use of the porcine graft.

At this point, therefore the value to the patient of the porcine graft remains undetermined.

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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'

Saturday, September 21, 2019

Total shoulder arthroplasty - why not smoke?

Smoking is associated with increased surgical complications following total shoulder arthroplasty: an analysis of 14,465 patients

These authors evaluated the association between smoking and postoperative complications in 14,465 patients having total shoulder arthroplasty using the American College of Surgeons National Surgical Quality Improvement Program database from 2005 through 2016; 10.5% were active smokers. Smokers were more likely to be younger, to be female patients, and to have a lower body mass index compared with nonsmokers (P < .001). 

Univariate analysis demonstrated that smoking was not associated with postoperative medical complications (P >.05) but was associated with a three fold increased risk of overall surgical complications(<.001). 




Multivariate modeling showed that smoking  was associated with a 7 fold increased risk wound complications and a 2 fold increase in surgical-site infections.

Comment: Individuals who smoke have two important features: (1) they are less healthy than non smokers and (2) they care less about their health than non smokers. In our practice, we do not perform elective surgery on individuals who have smoked within the prior 3 months.

Smoking has often been made to seem glamorous
but it not only compromises health, but also is a marker for individuals that tend to put themselves at increased risk. 

The results of this study are consistent with some others (see below).


These authors identified 163 patients with primary anatomic total shoulders performed for glenohumeral arthritis and divided them into 3 groups: current tobacco users (28), nonusers (88), and former users (47). Former tobacco users were defined as patients who reported cessation of tobacco use longer than 3 months before their initial surgical evaluation.

Patients in the current tobacco use group had 
(1) significantly higher visual analog scale scores preoperatively and at 12 weeks postoperatively
(2) less improvement in visual analog scale scores
(3) higher cumulative oral morphine equivalent use at 12 weeks and higher average oral morphine equivalent per day

They concluded that although length of stay, complication rates, hospital readmissions, and reoperation rates were not significantly different, tobacco users reported increased postoperative pain and narcotic use in the global period after TSA. Former tobacco users were found to have a postoperative course similar to that of nonusers, suggesting that discontinuation of tobacco use can improve a patient’s episode of care performance after TSA.

Interested readers may want to review information on smoking previously posted:
Smoking Increases the Rate of Reoperation for Infection within 90 Days After Primary Total Joint Arthroplasty

These authors sought to investigate the association between smoking and readmission and/or reoperation within 90 days of total joint arthroplasty among 15,264 patients (6,749 male and 8,515 female)  who underwent 17,394 primary total joint arthroplasties between 2000 and 2014. Of these patients, 1,371 (9.0%) were current smokers, 5,195 (34.0%) were former smokers, and 8,698 (57.0%) were nonsmokers. Former smokers reported a median of 22.2 years (range, 0.2 to 60 years) of abstinence prior to the surgical procedure.

Current smokers were significantly younger (57.7± 10.3 years) than nonsmokers (63.2± 11.8 years). 

Current smokers were significantly more likely than nonsmokers to undergo reoperation for infection (odds ratio [OR], 1.82 [95% confidence interval (CI), 1.03 to 3.23]; p = 0.04). 
Former smokers were not at significantly increased risk (OR, 1.11 [95% CI, 0.73 to 1.69]; p = 0.61). 

Packs per decade were independently associated with an increased risk of 90-day nonoperative readmission regardless of smoking status (OR, 1.12 [95% CI, 1.03 to 1.20]). 


Comment: This well controlled study indicates that in this cohort, active smoking almost doubled the risk of reoperation for infection. In that total joint arthroplasty is an elective procedure and in that smoking is a voluntary activity, surgeons need to consider whether it is reasonable to perform joint replacement on active smokers. We suggest that smoking is not only directly harmful to the patient's health, but it is also an indication of a patient's voluntary disregard for their own well-being.

We've discussed this phenomenon in prior posts:


These authors reviewed 1834 shoulders in 1614 patients (814 smokers and 1020 nonsmokers) having primary TSA or RSA at the Mayo Clinic between 2002 and 2011 and had a minimum 2-year follow-up. Smoking status was assessed at the time of surgery: non-smokers, former smokers (no smoking in the month before surgery), and current smokers (smoking within a month before surgery).

Complications occurred 4% of the cases, 5.4 % in smokers and 3.0 % in non smokers.

Multivariable analyses showed that
-in comparison to non-smokers, the risk of periprosthetic infection was 7.3 times higher in current smokers and 4.6 times higher in former smokers.
-in comparison to non-smokers, the risk of postoperative fracture was 7 times higher in current smokers.

The overall complication-free survival rate for the three groups is shown below.

























Comment: It is of interest that 44% percent of the patients in this series were classified as smokers. It is also of interest that the risk of postoperative fracture was dramatically less in those that had stopped smoking a month or more prior to surgery, whereas the effect of smoking cession was less pronounced for the risk of infection.




The interested reader will also want to check out these two related posts:
Cigarette smoking affects bone, cuff repair, surgical risk and more
Pain and smoking

as well as this article:


Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair.

These authors used the PearlDiver Patient Records Database, a for-fee insurance-based database of patient records, to explore the relationship between tobacco use and the adverse outcomes of arthroscopic superior labrum anterior and posterior (SLAP) repairs. The cohort of primary SLAP repairs was then divided into tobacco use and non–tobacco use cohorts using ICD-9 code 305.1 (tobacco use disorder). It is not known how accurate this coding is and how it reflects the different uses of tobacco (inhaled, chewed, etc).

They found that the incidences of revision SLAP repair or revision to a biceps tenodesis (P = .023) and postoperative infection (P = .034) were significantly higher in patients who used tobacco versus matched controls.

They suggest that tobacco’s negative effects on poor wound healing and the development of postoperative infection may results from a combination of factors. "On a cellular level, tobacco use reduces cutaneous blood flow, impairing soft tissue oxygenation, resulting in increased anaerobic metabolism in healing tissues. Simultaneously, thrombi are generated as a result of increased platelet aggregation, which compounds an already hypoxic environment, leading to decreased healing potential. This reduced perfusion impairs the delivery of critical lymphocytes to areas undergoing healing or prone to infection. Furthermore, systemic nicotine has been shown to have a negative immunomodulatory effect on T-cell function, resulting in cells that are more susceptible to infectious pathogens. Finally, and perhaps most specific to tendon healing required for a successful SLAP repair, the synthesis of collagen has been shown to be greatly impeded in smokers, leading to impaired wound and soft-tissue healing."

Comment: The same factors that impair success in SLAP repairs must apply to the healing of rotator cuff repairs, Bankart repairs and subscapularis healing in In addition to its effect on healing (see this link), tobacco use is also associated with increased pain (another cause of 'surgical failure')  as shown here and here .

The prior post also emphasizes the risk.

There is another association of importance than may account for some of the surgical failures in smokers, and that is the observation that smokers tend to take more risks than non-smokers (see this post). Here is a compelling quote from that article.

"The fact that smoking is bad for people’s health has become common knowledge, yet a substantial amount of people still smoke. Previous studies that sought to better understand this phenomenon have found that smoking is associated with the tendency to take risk in other areas of life as well. The current paper explores factors that may underlie this tendency. An experimental analysis shows that smokers are more easily tempted by immediate high rewards compared to nonsmokers. Thus the salience of risky alternatives that produce large rewards most of the time can direct smokers to make bad choices even in an abstract situation such as the Iowa Gambling Task. These findings suggest that the risk taking behavior associated with smoking is not related to the mere pursuit of rewards but rather reflects a tendency to yield to immediate temptation."

Now here's a quiz. This paper comes from Virginia. Can you name the top five tobacco producing states in order? The answer can be found here.

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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'

Saturday, September 14, 2019

Ream and Run in comparison to total shoulder

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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, September 11, 2019

Complications of shoulder surgery - an instructive history

Here is an instructive story:

Operation 1. A woman had a cuff repair that failed. 
Operation 2. A year later another repair was attempted, but failed. 
Operation 3. A year later she had a total shoulder arthroplasty. 
Operation 4. This failed and the humeral component was revised to a CTA head. Five years later she had painful dysfunctional shoulder she had these radiographs and pseudoparalysis of her shoulder.


Operation 5. This was revised to a reverse total shoulder 


Four months later she developed pain in the back of her shoulder. Radiographs showed a fatigue fracture of her scapular spine (see arrow in the x-ray below).

A month later the fracture displaced allowing the acromion to angulate inferiorly (compare the scapular spine to the immediate postoperative radiographs.

11 months later the fracture appeared to be healing

Four months later there was increased healing
                                     

Two months later the fracture was asymptomatic but the shoulder had very limited elevation with pain and popping as the superior aspect of the humeral component abutted against the inferior aspect of the lateral acromion.
Comment: This case demonstrates (a) complications of cuff surgery, (b) complications of total shoulder, (c) complications of reverse total shoulder, and (d) consequences of a displaced scapular spine fracture. 

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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'

The Shoulder and Elbow Fellowship at the University of Washington - insuring the future of our specialty

Shoulder and elbow surgery is 75% knowledge, 75% skill and 75% art. It cannot be learned from books or labs alone; rather, like a new language, acquiring mastery requires immersion in a comprehensive experience focused on the evaluation and management of patients and a philosophy of practice. To provide this opportunity to selected candidates, we will soon be interviewing candidates for the University of Washington Shoulder and Elbow Fellowship. This is a one year advanced clinical and academic experience that enables two highly qualified orthopaedists to hone their skills as shoulder and elbow surgeons, as investigators and as educators.

Our fellowship started in 1988, making it one of the longest standing advanced clinical experiences in our field - this will be our 32nd anniversary! Our graduates now practice shoulder and elbow surgery across the country - from Seattle to Miami, from SanDiego to Portsmouth, New Hampshire. The two candidates paired with us by the American Shoulder and Elbow Surgeons fellowship matching program will become the 55th and 56th University of Washington Shoulder and Elbow Fellows.

Our goal is to enable our fellows to master advanced skills in diagnosis and surgical management of both common and rare conditions that prevent patients from enjoying their lives.  In addition, we will provide opportunities for them to help answer some of the major questions faced by our specialty, such as
(1) when is rotator cuff repair not in the best interest of a patient with a cuff tear?
(2) what can be offered to a patient with arthritis who wishes to pursue activities beyond what is recommended for a conventional total shoulder?
(3) how can surgeons monitor the quality of their practice outcomes to identify what is working and what is not?
(4) how can we avoid unnecessary expenses of imaging - a cost that consumes much of the resource spent on shoulder and elbow care?
(5) how can we evaluate the many new orthopaedic implants and products brought to market each year to determine if their increased cost results in increased benefit to our patients?
(6) how can we make shoulder and elbow surgery safer from the risk of infection?

We are excited to be tackling these and other 'big questions'. We are excited to have the partnership of our fellows, who help us and who end out teaching us as well. For sure, the future is brighter because of them.

Half of our graduates have earned admission to the prestigious American Shoulder and Elbow Surgeons society. One of our alumni, Tony Romeo, is its immediate past president. Here are a few of our older fellows, perhaps you recognize some of them.


From left to right, Steve Lippitt, John Sidles, Mark Lazarus, Kevin Smith, David Duckworth, the late Doug Harryman, Michael Pearl, Rick Matsen, Dean Ziegler, Craig Arntz, and Tony Romeo.

To learn more about our fellowship and our alumni, see this link and this link.

For information on life in Seattle, check out this link and this one and this on beautiful Seattle.


B2 glenoid - ream and run 12 years later

An active man presented with pain and stiffness of his right shoulder requesting a ream and run procedure so that he could use his shoulder for a full range of challenging activities.

His preoperative x-rays are shown below


His axillary "truth" view shows functional posterior decentering of the humeral head in a biconcave glenoid.

At three years after surgery, he reported full function of his shoulder and return to heavy use of his shoulder, including chopping wood as shown in the video he kindly shared with us.




Now 12 years after surgery he sent this report:

"I use my shoulder for anything these days. Two years ago I decided to replace the concrete driveway at a duplex I own. It was partially two ribbons that turned into an 8' wide slab - but all but broken up by a trees roots from a tree that was removed. Using a pick, mattock and sledgehammer, I smashed up 75' of concrete. While halfway through, I found a full 8' slab 4-6" below the one I was busting up. So I kept going. I had a drainage problem and eliminated flooding by building French drains under the driveway and repaving with two ribbons of brick. I only had help by a couple (daughter and son-in-law of a neighbor) on one day mostly to help me fill an 18 Cu. Yd. dumpster with the rubble. I attached two pics - rubble and a not full dumpster. No action shots this time. Just the results of a lot of work - and the picture of concrete was just the top slab! You can see part of the concrete ribbon in the lower right with the pick ax just in front of it laying on top of the next slab to be busted up."



His x-rays at 12 years show a well fixed impaction grafted stem, a well centered humeral head in a nicely remodeled glenoid.


 


=====
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'

Tuesday, September 10, 2019

Severe B2 glenoid in a 40 year old active man - how to manage?


 A young active man presented with pain, stiffness and the ability to perform only 5 of the 12 functions of the Simple Shoulder Test. His preoperative films are shown below.


His axillary "Truth" view showed essentially a complete posterior decentering of his humeral head on a biconcave glenoid. 


He elected to have a ream and run procedure.

He returned two years after his procedure to have a ream and run on the opposite side. His right was comfortable and his Simple Shoulder Test and improved to 8 out of 12. His function is continuing to improve. We obtained two year followup right shoulder films prior to his left shoulder surgery (see below).


Note the use of an anteriorly eccentric humeral head that is now centered in his reamed glenoid.

Comment: This case demonstrates the conservative reconstruction of a severe B2 glenoid with a ream and run procedure, rather than the other options of posterior bone graft, posteriorly augmented glenoid component or reverse total shoulder. 


=====
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'