UW Shoulder and Elbow Academy

Wednesday, May 15, 2024

How should we treat massive irreparable cuff tears?

Even though massive irreparable rotator cuff tears are common, the relative effectiveness of the different treatment approaches remains unknown.

The authors of Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age used a powerful tool, network meta-analysis, to analyze comparative studies of surgical treatment options for massive irreparable cuff tears - without glenohumeral arthritis or pseudoparalysis - in patients <70 years of age. The treatments included debridement; arthroscopic bridging graft; arthroscopic partial repair; superior capsular reconstruction; long head of biceps augmented superior capsular reconstruction; InSpace balloon placement; tendon transfer; and reverse shoulder arthroplasty.

A total of 23 studies met the inclusion criteria, with 1178 patients included in the analysis. The mean weighted age was 62.8 years; 48.2% were men, mean follow-up was 28.9 months. There were no significant differences between groups in regard to sex or age.

The treatments were ranked using the the P-score - an estimate of the likelihood that the investigated treatment is the ideal method for an optimal result for each of the different outcome measures, where 0 is least effective and 1 is most effective.

Unfortunately most studies did not evaluate treatment with simple debridement in comparison to more complex procedures. However for studies that did, debridement had the highest P-score, as shown below.

Forrest plot for Constant Score:

Forrest plot for range of active forward flexion:

Comment: This network meta-analysis found that simple debridement was the most effective in significantly improving Constant score and active flexion for individuals with massive irreparable cuff tears when it was compared to other more complex surgical modalities.

While not reported in this study, the cost and complication rates for debridement are lower than for the other procedures; thus, one may conclude that debridement is the most cost effective treatment for these patients based on the currently available evidence.

Our technique for debridement is shown in this link and summarized below.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Conclusion: For patients \70 years with MIRCT without significant arthritis or pseudoparalysis, it appears that graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and bal- loon arthroplasty provide superiority in various outcome domains, while RSA provides the least benefit in forward flexion.

Keywords: massive irreparable rotator cuff tear; network meta-analysis; superior capsular reconstruction; latissimus dorsi; lower trapezial tendon transfer; reverse total shoulder arthroplasty

Sunday, May 12, 2024

Managing an acute acromial fracture in an active man with cuff tear arthropathy.

An 80 yo active man was 8 years after an anatomic right total shoulder and had returned to full function (including swimming) in spite of some early evidence of cuff tear arthropathy of the left shoulder as seen on the x-rays below taken 10 years prior to his recent presentation. Because of his high level of function, there were no interim x-rays taken.

He presented 16 months ago with the sudden atraumatic onset of the inability to raise his left arm (that had been fully functional the day before).

Imaging revealed a fragmented acromial fracture and advanced cuff tear arthropathy.

His care was transferred to our partner Jonah Hebert-Davies who discussed staged management with the patient.

Stage one was internal fixation of the acromion. After cleaning out the fracture site, commercial allograft was placed in the fracture site. After temporary fixation with a clamp and two 0.045 K-wires, a 2.4 mm plate was placed, cutting the plate to fit the patient's anatomy, bending it and placing nonlocking screws on either side. Locking screws were placed in the distal segment with the hooks from the plate holding into the deltoid insertion. This provided good stability. Another plate was added medially with good positioning. At this point, a FiberTape was placed through the deltoid insertion anteriorly and then passed posteriorly around the posterolateral corner creating a figure-of-eight. Fluoroscopic imaging demonstrated good reduction and good position of all the components. Another another 1 mL of allograft was placed over top of the fracture and medially.

Three months later there was clinical a radiographic union of the acromial fracture.

Stage two was then performed: a reverse total shoulder arthroplasty.

Recently he wrote: "I just finished filling out the 8-year followup study for my right total shoulder. I have full use of my right shoulder without limitation. In addition, my left reverse total shoulder recovery is equally good now that I’m seven months post-op. I’m back to swimming with no symptoms of pain at all, doing freestyle, backstroke and breast stroke. With the long period of restricted activity after the original injury in December 2022, I have had a profound loss of upper extremity strength, mostly manifested by very slow swimming speeds. This certainly qualifies as first-world whining. Orthopedically both shoulders are a complete success, and I know that I will eventually regain at least some vestige of my pre injury shoulder strength."

The stepped glenoid component

In their classic article, Stepped Augmented Glenoid Component in Anatomic Total Shoulder Arthroplasty for B2 and B3 Glenoid Pathology, the authors demonstrate that a stepped augmented glenoid component can restore premorbid glenoid anatomy in patients with asymmetric biconcave glenoid bone loss (Walch B2), with short-term clinical and radiographic results equivalent to those for patients without glenoid bone loss (Walch A1) treated with a non-augmented component.

They found a greater risk of osteolysis around the central peg in patients with moderate-to-severe B3 glenoid pathology with this stepped augmented glenoid component. As demonstrated in the technique guide, use of this component involves reaming of the posterior glenoid to fit the step, which may diminish the bony support for the back of the component.

Should this component fail, the posterior bone stock available for conversion to a reverse total shoulder may be compromised.

A recent paper, Total Shoulder Arthroplasty for Glenohumeral Arthritis Associated with Posterior Glenoid Bone Loss: Midterm Results of an All-Polyethylene, Posteriorly Augmented, Stepped Glenoid Component, presented a 5 year followup of 35 shoulders receiving a stepped glenoid for the treatment of glenohumeral osteoarthritis with posterior glenoid bone loss. The average preoperative glenoid retroversion was 21.6˚. Although postoperative CT scans were obtained, the postoperative glenoid retroversion was not presented.
Two patients (6%) experienced prosthetic instability requiring revision.

The average Lazarus score (0 no radiolucency to 5 gross loosening) was 0.72. The average Yian score (0 no radiolucency to 18 radiolucent line around entire component) was 2.6. There was an increase in Lazarus score and decrease in Wirth score between 2- and 5-year follow-up. The severity of radiographic loosening correlated with patient-reported pain levels.

The authors point out that these results are not inferior to those achieved with standard glenoid components in the treatment of glenohumeral arthritis with posterior bone loss.

Comment: Since posterior reaming removes posterior bone and the stepped component adds posterior polyethylene, it would be of interest to know the net change in glenoid retroversion in these patients.

Two figures from this series seem to suggest that substantial retroversion remains after insertion of the stepped component.

As pointed out in the two posts referenced below, future research is needed to determine the clinical value and means of "correcting" glenoid retroversion.

What happens when glenoid version and inclination are "corrected"?

Glenoid version: acceptors and correctors

Monday, May 6, 2024

Anatomic or reverse total shoulder for primary glenohumeral osteoarthritis? What do 10 recent articles say?

There is a growing trend to treat primary glenohumeral osteoarthritis in older individuals with reverse total shoulder arthroplasty (RSA). However, as pointed out by the authors of Limited Preoperative Forward Flexion does not Impact Outcomes Between Anatomic or Reverse Shoulder Arthroplasty for Primary Glenohumeral Arthritis (Sears 2024), "RSA has been shown to generally result in diminished range of motion, particularly internal rotation, compared to anatomic TSA. Additionally, RSA has several unique complications not seen in TSA patients including dislocation, component dissociation, scapular spine fractures and scapular notching."

These authors compared the minimum two year outcomes between TSA and RSA in matched patients under the age of 80 years with primary glenohumeral arthritis and limited preoperative active forward flexion (≤90 degrees). The average preoperative active forward flexion was 68±20 for the TSA and 64±19 for the RSA groups. The post operative ranges of active flexion were 141±22 and 139±21.

They also examined a subset of matched patients having TSA and RSA with severely limited preoperative forward flexion (≤70 degrees). They found no significant differences in postoperative forward flexion, external rotation, strength, ASES score, VAS, Constant score, SANE score or revision rates between the the TSA and RSA groups. The limited active forward flexion TSA group achieved significantly improved internal rotation compared to the RSA group.

This article prompted a review of some of the other articles published in 2023 and 2024 that compared TSA and RSA. Eight of these articles addressed particular subsets of patients with glenohumeral arthritis/intact cuff: limited active flexion, limited external rotation range, weak external rotation, and age. The chart below allows the reader to compare the pre and final post operative range of active forward flexion for the shoulders in these eight articles.

Here is a brief review of the articles.

Comparison between Anatomic Total Shoulder Arthroplasty and Reverse Shoulder Arthroplasty for Older Adults with Osteoarthritis without Rotator Cuff Tears (Kim 2024) compared the clinical outcomes of anatomic TSA and reverse shoulder arthroplasty (RSA) in patients aged over 70 years with primary glenohumeral osteoarthritis without rotator cuff tears. Of the 67 patients included in this study, TSA was performed in 41 patients, and RSA was performed in 26 patients. The two groups had no clinical differences in the patients’ preoperative demographic and radiographic data. At final follow-up, both groups showed improved pain, ROM, and functional outcomes. The TSA group demonstrated significantly better postoperative ASES and Constant-Murley scores than the RSA group. The TSA group showed significantly better postoperative active forward flexion, external rotation and internal rotations than the RSA group.

In Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy (Nazzal 2023) TSA was compared to RSA in shoulders with preservation of the rotator cuff. While the TSA patients had more external and internal rotation, there were no significant differences in outcome scores or complication rates.

Patients 75 years or older with primary glenohumeral arthritis and an intact rotator cuff show similar clinical improvement after reverse or anatomic total shoulder arthroplasty (Ardebol 2023) studied patients 75 years of age or older who underwent TSA (n=67) or RSA (n=37) for primary GHOA with an intact rotator cuff with a minimum 2-year follow-up. The TSA cohort showed significantly greater improvement in external rotation; however both TSA and RSA provided similar clinical outcomes otherwise.

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative rotational stiffness and an intact rotator cuff: a case control study (Hao 2023) compared stiff patients(ER ≤ 0 degrees) having RSAs to matched stiff patients having TSAs. Postoperative outcome scores were similar across all matched cohort comparisons. Preoperative limitations in passive ER did not appear to be a limitation to utilizing TSA.

Clinical outcomes of anatomical versus reverse total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and limited forward elevation (Trammel 2023) compared the minimum 2 year outcomes in matched patients with glenohumeral osteoarthritis, an intact rotator cuff, and limited forward elevation (FE ≤ 105°) having TSA (n=344) or RSA (n=163). The outcome scores were significantly better in stiff RSAs compared with stiff TSAs. The complication rate did not significantly differ between stiff TSAs and stiff RSAs, but there was a significantly higher rate of revision surgery in stiff TSAs.

After accounting for confounders, the authors of Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients (Orvets 2023) observed no significant difference in all-cause revision risk for RSA vs. TSA . The most common reason for revision following RTSA was glenoid component loosening. Over half of revisions following TSA were for rotator cuff tear. No difference based on procedure type was observed in the likelihood of 90-day ED visits or 90-day readmissions.

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative external rotation weakness and an intact rotator cuff: a case-control study (Hones 2024) analyzed the two year minimum outcomes for 333 TSAs and 155 RSAs performed for primary cuff-intact osteoarthritis and having ER weakness (strength <3.3 kilograms (7.2 pounds)). When comparing weak TSA vs.weak RSA, no differences were found in postoperative outcome measures, rate of complications or rate of revision surgery.

Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty (Karimi 2024) sought to determine whether there was a difference in functional outcomes and postoperative range of motion between TSA and RSA in patients with preoperative restricted motion (≤90 degrees of active elevation). There was no difference in outcome scores between RSA (57 patients) and TSA (59 patients). Postoperative active ROM was similar between RSA and TSA cohorts in forward flexion and external rotation. However, internal rotation was less in the RSA group. There was no statistically significant difference in complication rates between cohorts.

Reverse total shoulder replacement versus anatomical total shoulder replacement for osteoarthritis: population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England (Valsamis 2024) sought to compare the risk-benefit and costs associated with reverse total shoulder replacement (RSA) and anatomical total shoulder replacement (TSR) in patients having elective primary shoulder replacement for osteoarthritis. RSA had a reduced hazard ratio of revision in the first three years with no clinically important difference in revision-free restricted mean survival time, and a reduced relative risk of reoperations at 12 months. Serious adverse events and prolonged hospital stay risks, change in Oxford Shoulder Score, and modelled mean lifetime costs were similar. Outcomes remained consistent after weighting. Despite a significant difference in the risk profiles of revision surgery over time, no statistically significant and clinically important differences between RSA and TSA were found in terms of long term revision surgery, serious adverse events, reoperations, prolonged hospital stay, or lifetime healthcare costs.

Comment: These articles show similar outcomes for anatomic and reverse total shoulder arthroplasty in treating patients with primary osteoarthritis with an intact rotator cuff, even for older patients, stiff shoulders and weak shoulders.

Saturday, May 4, 2024

Recurrent infection after two-stage revision arthroplasty

We prefer to treat suspected periprosthetic shoulder infections with a single stage revision: thorough debridement, antibiotic/Betadine irrigation, topical antibiotics, complete exchange of implants, and a course of postoperative antibiotics. Two stage revision is usually reserved for cases of draining sinus, infection with particularly virulent organisms, or failed prior single stage revision. Completion of a two stage procedure requires (a) removal of implants and insertion of a spacer at the first stage and (b) insertion of new implants at a second procedure. Not only does the two stage require two surgeries, it also subjects the patient to increased challenges of spacer fixation/removal and challenges of fixation of the final implants. A substantial percentage of patients planned for a two stage never end out having the second stage completed.

Evaluating whether a revision surgery has failed to eliminate an infection is a problem because the only sure evidence of a failed revision for infection is evidence that the organism cultured at the first stage persists in the shoulder. This evidence can come from cultures obtained at the second stage (or a joint aspirate, arthroscopic biopsy, or draining sinus) that are positive for the original causative organism.

Because the organisms that are most commonly isolated from failed shoulder arthroplasties tend to form biofilms on implants, it is preferable to remove all metal and plastic components and cement when performing a revision for suspected periprosthetic shoulder infection. However, complete removal of cement and retained fragments of broken hardware can be not only difficult, but also hazardous, risking the integrity of bone and the surrounding neurovascular structures.

Against this background, let's look at a recent article Does retained cement or hardware during 2-stage revision shoulder arthroplasty for infection increase the risk of recurrent infection? that compared the rates of repeat infection after 2-stage revision for PJI in patients who had retained cement or hardware compared to those who had complete removal. The authors retrospectively analyzed two-stage revision total shoulder arthroplasties (TSAs) performed for infection with minimum two-year follow-up. Postoperative radiographs after the first-stage were reviewed to evaluate for retained cement or hardware. Repeat infection was defined as either ≥2 positive cultures at the time of the second-stage with the same organism that was cultured during the first-stage revision or repeat surgery for infection after the two-stage revision in patients that met the ICM criteria for probable or definite infection.

Thirty-seven patients were included in the analysis. Stage one revision failed to resolve the periprosthetic infection in ten patients (27%). The authors found that the risk of recurrent infection was not associated with age, BMI, comorbidity index, patient, sex, or presence of diabetes.

Only two of the 10 (20%) of the cases of recurrent infection were culture positive for Cutibacterium at the index surgery, while 16 of the 27 (59%) of the cases without recurrent infection were culture positive for Cutibacterium at the index surgery. 70% of the recurrent infections were due to Staph Aureus or were polymicrobial.

Six patients had retained cement and one patient had two retained broken glenoid baseplate screws after first-stage revision. All retained cement identified in this study was distal to the humeral stem

Of the ten cases of recurrent infection, one case involved retained cement/hardware.

The authors point out that surgeons must balance the potential benefit of complete cement/hardware removal against the risks.

Comment: It is interesting that while 1 of 7 patients with retained cement or hardware were documented has having recurrent infection, 9 of 30 patients without retained cement or hardware had recurrent infection. Thus we must wonder why the initial surgery failed to achieve its objective of successful infection resolution in these 9 cases of complete cement and hardware removal. The pie graphs shown above suggest that a determinant of the percentage of success in resolving the infection at the first stage may be whether the infection was due to Cutibacterium (lower risk of failure) versus Staph aureus or polymicrobial (higher risk of failure). Not assessed in this study are the possible effects on infection recurrence of adjunctive measures at the first stage procedure, such as antibiotic and Betadine irrigation, topical antibiotics, and postoperative antibiotic choice, route of administration and duration.

Bodybuilding championship after ream and run

A 60 year old bodybuilder who presented with glenohumeral arthritis.

After a discussion of the risks and benefits of a standard anatomic total shoulder and the ream and run procedure, he elected the latter.

His followup x-rays 18 months after surgery are show below showing no evidence of stress shielding or glenoid wear.

He recently sent the news that he had won a local bodybuilding championship in his age division and was headed for the national championship.

Wednesday, May 1, 2024

Stemless to stemless revision for overstuffing

A 55 year old may presents with pain and stiffness in his left shoulder that came on after a stemless ream and run procedure performed almost two years prior. His pre ream and run film is shown below.

Below is his postoperative film at the time of his presentation to us showing overstuffing related in part to a conservative head cut.

On examination his active and passive flexion were limited to 30 degrees limited by extreme pain.

After discussion of the options, he decided to proceed with a revision ream and run arthroplasty after discussion of the risks and alternatives of total shoulder arthroplasty.

At surgery there was no evidence of synovitis. Specimens were sent for Cutibacterium-specific cultures; a vigorous release of the sub scapulars and capsule was preformed. The prior implant was removed, preserving as much bone a possible. A new head cut was made using the hinge point as a reference. The glenoid was re-reamed to a smooth surface. Impaction grafting was used to fix a #2 nucleus and a 50 18 humeral head. The subscapularis was securely repaired. The postoperative films are shown below, showing restoration of the desired anatomy.

His procedure was performed under general anesthesia without a plexus block. The morning after surgery he had assisted elevation to 160 degrees.