Sunday, January 17, 2021

Which cuff repairs fail and does failure affect the clinical outcome?

 Combination of risk factors affecting retear after arthroscopic rotator cuff repair: a decision tree analysis

These authors investigated factors associated with retear of rotator cuff repairs in 286 patients having magnetic resonance (MR) imaging at 6 months after arthroscopic cuff repair. 254 of the repairs were intact at 6 months and 32 (11%) had failed.


The mean patient age was 65 years, and the mean symptom duration was 10 months. The tear was of small/medium size in 177 patients and large/massive in 109 patients. The technique for surgical repair was single row in 42 patients, double row in 60 patients, and suture bridging in 216 patients. 


On univariate analysis there were significant differences between the patients with healed and failed repairs in the anteroposterior (AP) tear size, mediolateral tear size, hyperlipidemia, global fatty degeneration index, supraspinatus fatty degeneration stage, and critical shoulder angle (CSA).

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Comment: These data confirm that repairs of bigger tears in tendons with poorer muscle quality have a higher risk of failing. While the difference in average CSA between the healed and failed repairs was statistically significant, this average difference was only of two degrees while the standard deviations of the averages where almost twice as large. Thus it is difficult to attach clinical significance to this difference in the average CSA.


It is of interest that the clinical scores were not significantly different between the healed and failed groups. How important is integrity of the repair to the clinical outcome? Does it benefit the patient to repair large tears of higher Goutalier grade?



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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 arthroplasty - failure of the glenoid component used with a stemless humeral component

 Glenoid Component Loosening in Anatomic Total Shoulder Arthroplasty: Association between Radiological Predictors and Clinical Parameters—An Observational Study

These authors studied 147 patients with primary osteoarthritis who underwent aTSA with a stemless humeral implant and a pegged glenoid between January 2011 and December 2016.




Anteroposterior radiographs were evaluated at six, 12, 24 months, and five years post-TSA for lateral humeral offset (LHO), joint gap (JG), acromiohumeral distance (AHD), andradiolucency (modified Franklin score); patients were included. 



36% of patients had "severe systemic disease".

Over half of the glenoids were type A


All pegs were cemented. Over half of the glenoid components were the small size

The five x-rays below show progressive loss of joint gap and osteolysis around the humeral and glenoid component. 



The average changers in the radiographic parameters is shown below.

The changes in clinical scores over time are shown below with a drop off at 5 years. Both constant score (CS) and subjective shoulder value (SSV) markedly decreased at five years follow-up compared to one year (p < 0.001 for both). 


AHD, LHO, and JG all showed a consistent and statistically significant decline over time, with the joint gap decreasing by half.  Consistently, smaller joint gap and acromiohumeral distance were correlated with lower subjective shoulder values (p = 0.03 and p = 0.07, respectively).The relationship between the AHD, offset and joint gap to the degree of glenoid loosening and clinical scores are shown below. Massive loosening was associated with a 14.5 points lower SSV (p < 0.01). Narrowing of the joint gap was significantly correlated with increased radiolucency (p < 0.001) and tended toward worse SSV (p = 0.06).





The authors concluded that radiographic parameters displaying medialization and cranialization after aTSA with a cemented pegged glenoid are useful predictors of impaired shoulder function.


Comment: In this study there are many factors that could have influenced the radiographic and clinical outcomes, including serve systemic disease in over one third, the status of the rotator cuff, the degree of cross linking of the polyethylene, the glenohumeral pathoanatomy, the degree of glenoid reaming, the use of a small glenoid component, the cement technique and the placement of the humeral component. Note that in the example given in the article, the humeral component was placed superiorly in relation to the "perfect circle". Superior positioning of the humeral component could lead to eccentric wear of the superior glenoid component (A recent article, Radiographic humeral head restoration after total shoulder arthroplasty: does the stem make a difference? reported, "Restoration of humeral anatomic parameters occurred significantly less with stemless implants than with short- and standard-stem implants. The stem of a shoulder arthroplasty implant aids surgeons in accurately restoring patient-specific anatomy.")




Thus it would be of interest to know which pf these eight factors were related to loss of the joint gap and to superior migration of the humeral head. It would also be of interest to know what percentage of the 211 shoulders were surgically revised.


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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, January 16, 2021

Surgical revision of a failed shoulder - over 20% get revised again within 8 years

 The rate of 2nd revision for shoulder arthroplasty as analyzed by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)

These authors compared the rate of (2nd) revision following aseptic 1st revision shoulder arthroplasty. They found an increased risk of 2nd revision in the 1st month only for the rTSA group (n = 700) compared with the non-rTSA group (n = 991); hazard ratio (HR) = 4.8 (95% CI 2.2–9). The cumulative percentage of 2nd revisions (CPR) was 24% in the rTSA group and 20% in the non-rTSA group at 8 years. 




Collectively, the diagnoses of instability/dislocation, loosening, and infection accounted for 85% of 2nd revision procedures in the rTSA group, and 68% in the non-rTSA group.



Comment: It is indeed revealing that the re-revision rate is so high. As a result the cost to the patient and to society of revision arthroplasty is substantially higher that what would be estimated from the first revision. Surely some patients require re-re-revisions. Each repeat procedure risks further compromise of  the bone and soft tissues and increases the risk of infection. There is a premium for getting it right the first time!


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How you can support research in shoulder surgery Click on this link.

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'

Thursday, January 14, 2021

Doing an arthroplasty on the opposite (second) side - don't rush it!

The relationship of bilateral shoulder arthroplasty timing and postoperative complications

These authors investigated the effect of time between bilateral shoulder arthroplasties on the complication rate using two insurance databases.

 From 2005-2016, a total of 1764 patients (6.3%) underwent bilateral shoulder arthroplasty out of 27,962 shoulder arthroplasties


Of the bilateral patients, 49.1% waited more than 1 year before their second shoulder arthroplasty.

Patients waiting less than 3 months between surgeries comprised 4.9% of the total number of staged bilateral surgeries. 


Overall, implant complications were higher in patients with surgeries less than 3 months apart compared to controls, including revision arthroplasty, loosening/lysis, and periprosthetic fractureThere were no significant increases in any implant-related complications when surgeries were staged by 3 months or more compared to controls. 


Venous thromboembolism and blood transfusion occurred at a significantly higher rate in patients with less than 3 months between surgeries compared with controls. There were no differences in any medical complications when surgeries were staged by 3 months or more compared with controls.





Comment: Shoulder arthritis is often a bilateral condition. For a variety of reasons, patients and physicians may wish to have the second side arthroplasty done soon after the first. One of these reasons is to have the surgeries in the same calendar year so that a second deductible payment is not needed.  


This study indicates that if the second arthroplasty is performed within 3 months, the complication rate essentially doubles: 

revision arthroplasty -11.6% vs. 5.4%, 

loosening/lysis - 8.1% vs. 3.5%

periprosthetic fracture -  4.7% vs. 1.2%

venous thromboembolism - 8.1% vs. 2.2%

blood transfusion - 9.3% vs. 1.7%


To see our approach to total shoulder arthroplasty, see this link.
To support our research to improve outcomes for patients with shoulder problems, click here.
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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 problems of reverse total shoulder in patients with rheumatoid arthritis

Comparison of outcomes after reverse shoulder arthroplasty in patients with rheumatoid arthritis and cuff tear arthropathy

These authors compared the outcomes of reverse total shoulder (RSA) for 24 patients with rheumatoid arthritis (RA) with those of 35 patients with cuff tear arthropathy (CTA) after and average  follow-up period of 31 months (range, 24-64 months). 


The Aequalis Reverse prosthesis (standard stem) was used in 27 cases and the Aequalis

Ascend Flex prosthesis (short stem) in 34 cases.


There was no statistically significant difference between the RA group and the CTA group in the clinical outcomes.


However glenoid component superior tilt was more likely in the RA group (12 of 24) than in the CTA group (4 of 35).


Complications occurred in 7 of 26 patients (27%) with RA and 3 of 35 patients (9%) with CTA. 

Within the RA group, complications included greater tuberosity fractures in 4, lesser tuberosity in 1, glenoid fracture in 1, and transient musculocutaneous nerve palsy in 1. 

Within the CTA group, complications included lesser tuberosity fracture in 1, acromial fracture in 1, and periprosthetic humeral fracture in 1. 


Comment: The relatively high rate of fracture in both groups is noteworthy. The paper does not reveal whether these fractures occurred with the standard stem system

or the short stem system, which relies on a tight metaphyseal fit. A press fit in soft rheumatoid bone may carry the risk of fracture

To see a YouTube of our technique for a reverse total shoulder arthroplasty with humeral component fixation using impaction grafting, click on this link.


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How you can support research in shoulder surgery Click on this link.

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'


Progression of arthritic glenoid bone loss as shown by the axillary "truth" view.

Natural history of glenoid bone loss in primary glenohumeral osteoarthritis: how does bone loss progress over a decade?

These authors sought to determine how glenohumeral subluxation and glenoid bone loss changed over time in 48 shoulders that underwent arthroplasty and had been evaluated with standardized high-quality axillary radiographs 



at 1 or more time points over the 5-15 years before arthroplasty. The mean interval time between the oldest and most recent radiographs was 8.9 years (range 5-15 years). 

Below is an example of how glenoid morphology progressed over roughly an 8-year period of time from an A1 glenoid to a B3 glenoid. Note the standardization of the axillary "truth" views that enabled comparisons of the glenohumeral pathoanatomy over time. The patient was a 43-year-old male (body mass index 26.6) at initial presentation for symptomatic right shoulder osteoarthritis and went onto an anatomic total shoulder arthroplasty. From presentation to year 5, the glenoid morphology remained A1 with 3 intervening radiographs documented. At year 6, the patient was noted to have a B1 glenoid (top right), a B2 glenoid at year 7 (bottom left), and a B3 glenoid at year 8 before proceeding with surgery (bottom right).




On each axillary view, the glenoid type



and the degree of posterior humeral decentering on the face of the glenoid


were documented.


Glenoid morphology on the earliest radiograph was classified as A1 in 22, A2 in 13, B1 in 1, B2 in 9, B3 in 1, and D in 2 shoulders. 


Walch A patterns identified on early radiographs most commonly maintained an A pattern over time, but 20% developed eccentric wear with 5 of 35 becoming B type and 2 of 35 becoming a D type before arthroplasty. 








All B-type glenoids remained B type. 




Classic progression of bone loss along the same concentric or eccentric ‘‘track’’ occurred 41% of the time, with , the only B1 glenoid becoming a B2 glenoid, and 56% (5/9) of B2 glenoids becoming B3 glenoids before arthroplasty. 


Only 15% (2/13) of A2 glenoids developed eccentric wear compared with 32% (7/22) of A1 glenoids.


Comment: This study demonstrates that glenohumeral pathoanatomy can be well characterized using the axillary "truth" view without the additional expense and radiation dosage of a CT scan.


This study also demonstrates that the description of glenoid pathoanatomy cannot be constrained to discrete static types, but rather the amount of bone loss, change in version, and humeral decentering each exist on a continuum from "none" to "a lot" with progressive transitions from one type to another.


Finally, in considering the case example provided, it seems that a standard approach to anatomic arthroplasty would have served the patient in each of the 4 different stages of his disease.


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Our approach to total shoulder arthroplasty can be viewed by clicking here.


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How you can support research in shoulder surgery Click on this link.

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, January 13, 2021

Reverse total shoulder in the bone-deficient glenoid - the alternative center line

Mid-term outcomes of reverse shoulder arthroplasty using the alternative center line for glenoid baseplate fixation: a case-controlled study

These authors point out that secure glenoid baseplate fixation is essential for a successful reverse total shoulder (RSA). In cases of glenoid bone loss, use of the anatomic glenoid center line may not provide sufficient bone support for fixation. Anteversion of the baseplate and central screw fixation along the alternative center line is a described method for achieving baseplate fixation in such cases. 


The authors comparde the outcomes of RSA using the anatomic or alternative center line using a retrospective case-controlled study. 66 patients treated with the anatomic center-line technique

for baseplate fixation were matched 3:1 based on sex, indication for surgery, and age with 22 patients treated with the alternative center-line technique. The mean age was 74.2 years (range, 58-89 years) and mean follow-up period of 53 months (range, 24-130 months). 


monoblock central-screw glenoid baseplate was used in all cases. One of the features of this design is that the preponderance of the fixation is provided by a large central compression screw.



 

 In cases in which the anatomic center line was used, the baseplate was inserted along the standard glenoid center line. Alternative center-line placement of the baseplate was used to achieve primary baseplate

fixation in cases in which it was determined preoperatively or intraoperatively that there was inadequate bone to support fixation of the center screw.



If <80% coverage of the baseplate could be obtained on host bone, structural grafting with either humeral head autograft or femoral head allograft was used to augment baseplate support as shown in the case below.



Attempts were made to achieve secondary fixation by resting the peripheral rim of the glenosphere on the host glenoid bone or bone graft to distribute the load observed through the baseplate fixation.

Often, a glenosphere with a lip extension was used to achieve this goal (glenosphere sizes of 36 mm – 4, 40 mm neutral, and 40 mm – 4). 


Postoperatively, all patients were managed with the same rehabilitation protocol consisting of wearing a shoulder immobilizer with a self-directed therapy protocol focused on only pendulum exercises for the first 6 weeks, followed by an activeassisted stretching program. Strengthening and lifting were delayed for 3 months.


At the final follow-up, they found no significant differences in patient reported measures, including the Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, visual analog scale pain score, and Single Assessment Numeric Evaluation score


The overall improvements in these measures and all active motions and functional tasks of internal rotation were not different.


No radiographic evidence of glenoid loosening was found in either group. 


Two patients in each cohort (3% of the anatomic group and 9% of the alternative group) experienced an acromial fracture.


Low-grade scapular notching developed in 15.2% of the anatomic group and 18.2% of the alternative center line group.


Comment: This report demonstrates that - in experienced hands - placing the central screw in the thickest part of the glenoid neck can provide good fixation if coupled with bone grafting when adequate support by native bone cannot be achieved. 


We have found it useful to use a small diameter drill to confirm the orientation that will provide the maximum (ideally 3 cm) of screw fixation.


While the surgeon attempted to achieve secondary fixation by resting the peripheral rim of the glenosphere on the host glenoid bone, it is important that this contact not interfere with complete seating of the glenopshere on the baseplate.


As the authors point out, these results may not be generalizable to practitioners who have less experience or those who use other reverse shoulder devices, such as those without a central compression screw (see an example of such an implant below).






To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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To support our research to improve outcomes for patients with shoulder problems, click here.
To subscribe to this blog, enter your email in the box to your right that looks like the below



===
How you can support research in shoulder surgery Click on this link.

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'