Revision reverse shoulder arthroplasty

Cement-within-cement technique in revision reverse shoulder arthroplasty

These authors reviewed 38 shoulders in which a cemented humeral component was revised to a cemented reverse humeral component fixed by cementing within the existing cement mantle.

The primary indications for revision surgery were instability or subluxation (21), glenoid  disease (wear or component loosening) (16) , and humeral component loosening within the cement mantle (1). Of those revised for instability, 7 had prior anatomic arthroplasties with rotator cuff tears leading to anterior (n = 2) or posterosuperior (n = 5) instability, 5 had instability associated with a reverse arthroplasty, and 9 had failed hemiarthroplasties associated with rotator cuff tears and superior escape.

There were 7 (18%) nondisplaced intraoperative fractures involving the greater tuberosity that occurred on implant removal; all healed at last follow-up. A second revision surgery was performed in 3 (8%) patients who underwent cement-in-cement humeral component revision for glenoid loosening (n = 1), periprosthetic instability associated with glenoid loosening (n = 1), and periprosthetic humerus fracture (n = 1). There was 1 “at-risk” humeral component (grade 4 or higher humeral lucency, moderate subsidence) that did not undergo revision surgery. There were 2 other humeral components with grade 3 humeral lucency, no subsidence.

The overall implant revision-free survival at 2 and 5 years was 95% and 91%, respectively. 

Of note, 3 of the 17 cases revised for loosening had positive intraoperative cultures.

Comment: From this report one can see that (1) the primary reasons for revision to a reverse were instability and glenoid failure, (2) revision carries the risk of intraperative fracture, and (3) failed arthroplasties can be associated with positive cultures - a potential concern because of the retained cement.

Recementing in an extant cement mantle usually requires the use of a smaller stem.

  

One of the advantages of humeral stem fixation with impaction grafting is the ease of revision as shown by a recent case of a patient with arthritis after multiple failed attempts at cuff repair but who retained active elevation. 

This patient elected to have an impaction-autografted CTA prosthesis which provided good comfort and function for seven years

A recent fall rendered this shoulder pseudo paralytic and the patient elected to have a revision to a reverse. The CTA prosthesis was removed without difficulty or fracture and the reverse stem was fixed securely with impaction allografting without down-sizing the stem. This approached optimized bone preservation.

When applicable, the impaction grafting approach may help reduce the risk of periprosthetic fractures after revision reverse arthroplasty.

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Total shoulder arthroplasty - glenoid cemening

Glenoid cement mantle characterization using micro–computed tomography of three cement application techniques

These authors compared 3 cementation methods to secure a central peg in 15 cadaveric glenoids:
(1) compression of multiple applications of cement using manual pressure over gauze with an Adson clamp,

(2) compression of multiple applications of cement using a pressurizer device, and 

(3) no compression of a single application of cement. 

Each glenoid was then imaged with high-resolution micro–computed tomography and further processed by creating 3-dimensional computerized models of implant, bone, and cement geometry.

There were no significant differences detected between the 2 types of compression techniques; however, there was a significant difference between compression methods and use of no compression at all. All morphologic characteristics of a larger cement mantle were significantly correlated with greater cortical contact.

Comment: The primary concerns in stabilizing a glenoid component to glenoid bone are (1) preserving glenoid bone stock, (2) reaming the face of the glenoid only to the point where there is a good fit between the back of the component and the bony face of the glenoid, (3) assuring that the peg holes in bone are precisely aligned to match the geometry of the glenoid component, (4) avoiding cement between the bony face of the glenoid and back of the component, (5) using a 'magic peg' for primary fixation, and (6) pressurizing the peripheral fixation holes. Our technique for glenoid arthroplasty is shown in this link.

 Excessive cement can give rise to excessive heat (see this link).

This paper demonstrates that pressurization can increase the intravasation of cement into bone, but if the carpentry is done well, a minimal amount of cement "putty" is necessary

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Total shoulder arthroplasty - cementing, failure, revision

We are often referred patients with pain after a prior total shoulder. The x-rays below are of a 50 year old man who had a total shoulder elsewhere two years prior to consulting with us. His shoulder clicked when he used it. His Simple Shoulder Test score was 0 out of 12. He had been told 'everything was fine'.  His films show that at the time of his surgery, cement had been placed between the back of his glenoid component and his glenoid bone. This 'face cement' is something we avoid in performing a total shoulder arthroplasty for three reasons: (1) it should not be necessary if the glenoid bone was properly reamed to match the back of the component, (2) bone cement is not an adhesive, so that face cement does not improve the security of the component, and (3) this thin layer of cement is brittle and can loosen and crack as shown by the dark lines separating the cement an bone on the x-rays below.

The axillary view shows a substantial amount of cement posteriorly to make up for incomplete posterior reaming of the bone.

Two months ago we revised this shoulder to a ream and run procedure, removing his loose glenoiod and using an impaction grafted humeral component.  His intraoperative cultures were negative.

His two month followup films are shown below.

 At the time of his 6 week followup, he had 150 degrees of comfortable active elevation and minimal shoulder discomfort (and no clicking on movement). He was pleased with his progressive recovery.

Comment: Glenoid component failure continues to be the principal cause of revision after total shoulder arthroplasty. One approach to the failed glenoid component is conversion to a ream and run. One approach to eliminating the problem of glenoid component failure is to consider the ream and run as the primary arthroplasty in motivated young active patients such as this man.

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Do antibiotics in cement reduce the risk of total joint infection?

We remember a meeting where a famous shoulder surgeon stated from the podium "in my country it is considered malpractice not to use antibiotics in cement".

Now, that belief may be called into question. See:

The Use of Erythromycin and Colistin-Loaded Cement in Total Knee Arthroplasty Does Not Reduce the Incidence of Infection: A Prospective Randomized Study in 3000 Knees

In this article the authors conducted a prospective randomized study with 2948 cemented total knee arthroplasties, in which bone cement without antibiotic was used in 1465 knees (the control group) and a bone cement loaded with erythromycin and colistin was used in 1483 knees (the study group). All patients received the same systemic prophylactic antibiotics. The rate of deep infection (1.4% in the control group and 1.35% in the study group) and the rate of superficial infection (1.2% and 1.8%, respectively) were similar in both groups. The factors related to a higher rate of deep infection in a multivariate analysis were male sex and an operating time of >125 minutes. In this series of surgeries antibiotics in the cement did not prove to be effective in lowering the infection rate.
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In a second article

Risk Factors Associated with Deep Surgical Site Infections After Primary Total Knee Arthroplasty: An Analysis of 56,216 Knees

The authors conducted a retrospective review of 56,216 primary total knee arthroplasties recorded in a total joint replacement registry from 2001 to 2009 was conducted. Patient factors associated with deep surgical site infection included a BMI of ≥35, diabetes mellitus, male sex, an American Society of Anesthesiologists (ASA) score of ≥3, a diagnosis of osteonecrosis, and a diagnosis of posttraumatic arthritis. Surgical risk factors included quadriceps-release exposure and the use of antibiotic-laden cement. Operative time was a risk factor, with a 9% increased risk per fifteen-minute increment.

The authors concluded that the use of antibiotic irrigation should be encouraged, but antibiotic-laden cement may not be useful.

.....

While these were articles about knees, not shoulders, we can suspect that the amount and duration of antibiotic delivered by antibiotic-laden cement is relatively small. Mixing antibiotics with cement may not provide much protection against infection and may compromise the strength of the cement.


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Donald Roberts in his JBJS commentary on these articles states " In our institution, the difference between the costs of regular bone cement and tobramycin cement would pay the wages of the nursing staff caring for that patient throughout their stay in the operating room and recovery room." We need to make sure that the incremental cost creates incremental benefit for our patients - the value equation.

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Incidence of early radiolucent lines after glenoid component insertion for total shoulder arthroplasty: a radiographic study comparing pressurized and unpressurized cementing techniques.

Incidence of early radiolucent lines after glenoid component insertion for total shoulder arthroplasty: a radiographic study comparing pressurized and unpressurized cementing techniques.

Radiolucent lines are a problem in glenoid component fixation. These lines represent areas filled with fluid or debris between the bone and the cement. These zones do not have the potential to turn into either bone or cement and as such represent insecure fixation of the component that can only progress, but not regress. In the figure below, note that there are lucencies around each of the pegs. There are also lucencies beneath cement placed beneath the articular surface of the component - a practice we avoid because this thin cement layer is brittle and can crack, leaving the component unsupported.

In a prospective study of 130 shoulders, the authors of this paper found sigificantly fewer lucent lines in a group of shoulders having a 3-step pressurization as opposed to a group that underwent minimal manual pressurization. In their 3-step technique,  the cement was first pressurized by injecting the cement into each peg hole using a syringe that fit perfectly into the peg hole. The second pressurization was completed by pushing a polished metal rod into each hole. Finally, cement in its doughy state was manually pressurized into each peg hole, followed by placement of the final implant.

We have taken a simpler approach to avoiding radiolucent lines - using a carbon dioxide jet to remove all fluid and tissue from the drill hole immediately prior to cementing. This method has virtually eliminates the radiolucent lines from our post operative films as shown in this film from last week after a total shoulder we performed for a gentleman from California. Note the absence of cement between the face of the component and the bone ( 'bone backing').

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Increasing the Elution of Vancomycin from High-Dose Antibiotic-Loaded Bone Cement: A Novel Preparation Technique. JBJS

Increasing the Elution of Vancomycin from High-Dose Antibiotic-Loaded Bone Cement: A Novel Preparation Technique. JBJS

Vancomycin is commonly used in the cement used to fix total joint replacement arthroplasty components and in cement 'spacers' used to manage periprosthetic infections.

This in vitro study has some important findings: (1) the majority of the antibiotic elution was in the first 7 days (so the notion that prolonged topical treatment is achieved may be incorrect), (2) delaying the addition of Vancomycin until after 30 seconds of cement mixing resulted in greater antibiotic elution, (3) only 3 to 5% of the total added Vancomycin was eluted over 6 weeks, and (4)  irrespective of the time of addition, preparations of 5 gm of Vancomycin with 40 g of cement powder showed dramatic reduction of compressive strength of the cement at 6 weeks after elution. Here are the results for three different methods of mixing Vancomycin with cement:

The reasons for this loss of compressive strength are unclear. It would have been of great interest if the authors had included an antibiotic-free control to see if it also showed diminished strength with the same post-mixing protocol.

So, on one hand we have reports that Antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders. While on the other hand we have this report on the limited duration of antibiotic elution combined with concerns about the effect of antibiotics on cement strength. We also recognize that while the authors of the recent JBJS paper tested compressive strength of cement cylinders, the failure mode of cement may be quite different -  including fatigue, distraction, sheer, and bending with crack propagation - and may be even more sensitive to changes in material and structural properties.

For these reasons, we continue to be attracted to cementless approaches to shoulder arthroplasty component fixation combined with careful surgical technique, strong antibiotic prophylaxis, and copious irrigation with antibiotic saline.

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Shoulder arthritis articles from July issue of the JSES - cementing, loosening, venous thromboembolism, resurfacing, revision arthroplasty, hemophilia, arthritis in Korea,

The July issue of JSES has several articles of interest.
The first is a study in cadavers: Bone cement penetration pattern and primary stability testing in keeled and pegged glenoid components points out that the more osteoporotic the bone of the glenoid, the more cement can be pressurized into it. While this result is intuitive (porous bone accepts more cement), it has some important implications. As we've show previously, more cement generates more heat as it sets up and more heat can kill bone and dead bone can contribute to loosening of the component. From the figures in this article, it appears that the authors vigorously reamed the bone of the glenoid, perhaps removing much of the firmer cortical bone that lies at the joint surface. We strive to preserve as much of this bone as possible in all cases, but especially in those with soft bone.

A second issue is that these authors state that they tested "primary" stability of the component. But rather than studying the common failure mode: the 'rocking horse', they used direct pull-out, which is a mechanism that is not possible in the living shoulder.

Further, in these 'stability' tests, they found that the components were pulled out of the cement mantle. As the examples below of the many loose glenoids I've retrieved show, this is not the mode of failure in living patients. Instead, glenoid components fail in the clinical situation at the cement-bone interface because the bone around the cement gives way.

Finally, there is a lot to be said about cement technique. The authors state that they used "3rd generation" cementing technique.  Cementing in a cadaver without bleeding is quite different than cementing in a living, bleeding bone. Cement pressurization is easier in cylindrical holes for a pegged component rather than an irregular keel hole. Placing cement on the surface of the bone beneath the prosthesis may offer greater 'initial' stability in cadavers, but this thin layer of cement is subject to fatigue cracking in the living patient.

The bottom line is that even though this is a well-done cadaver study, the clinical application of such cadaver studies must be made cautiously.

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Next an article entitled, The prevalence of shoulder osteoarthritis in the elderly Korean population: association with risk factors and function, showed that in Korea the risk of OA increased with age and with the co-existence of knee arthritis.

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Our UK colleagues found that Venous thromboembolic events are rare after shoulder surgery: analysis of a national database. Specifically after total shoulder replacement, the rates of deep venous thrombosis, pulmonary embolism, and death within 90 days were, respectively, 0%, 0.2%, and 0.22%. These rates were not changed by the implementation of thromboembolic prophylaxis. As a result the authors suggest that such prophylaxis may not be necessary.

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Long-term results and patient satisfaction after shoulder resurfacing provided a minimum of 20 year or until death followup on 61 patients having either hemi resurfacing or total resurfacing procedures.  The satisfaction rate was reported to be high; 7 patients were lost to followup. Twelve of the 41 total resurfacing prostheses showed radiolucent lines but only three had revision surgery for glenoid component loosening.

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Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems pointed out that it is often possible to revise a painful modular humeral hemiarthroplasty to a total shoulder by removing the humeral head aspect of the humeral component, inserting a glenoid component, and then replacing the humeral head component.

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Finally, Shoulder arthroplasty in hemophilic arthropathy demonstrated that satisfactory results could be obtained with this complex condition, but that the support of a hematologist was recommended.

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Failed, Unsatisfactory Shoulder Joint Arthroplasty - glenoid component loosening

As we saw in the June 27 post 59% of patients coming to us for consultation because they were dissatisfied with their total shoulder joint replacement arthroplasty had loose or worn glenoid components.

The concern about glenoid component failure comes from careful followup of patients having shoulder replacements in the past using a variety of older component designs and older techniques. 

Our shoulder fellow Lazarus published a nice paper pointing to the challenges of achieving a perfect glenoid component insertion and the effect of surgeon experience.

Ideal contouring of the bone beneath the glenoid component (as shown below) is essential as pointed out by shoulder fellow Collins.

When the bone is not properly prepared, there is a tendency to pack in a bit of cement to fill in the defect ('putty carpentry'). This is commonly seen in the posterior (back) half of the glenoid as shown below left. However, this wedge of cement is brittle and not fixed to either the component or bone so it can slip out leaving the component unsupported and at risk for loosening (below right).

The earliest sign of loosening is a dark line (radiolucency) seen on the x-ray as shown below at the "L".

From a very well done study of 333 total shoulders, here is a graph showing a 50% radiographic survivorship of glenoid components put in 10 years ago.

Loosening seems to be particularly common when the glenoid design consists of a keel that is fixed into the bone of the shoulder blade using a wad of cement as shown below left and in the color photograph of a retrieved glenoid component

Cement cures with an exothermic reaction - this heats the bone to an amount determined by the amount of cement used. Excessive cement can result in thermal death of the bone with loss of fixation as shown by the thermal camera images below.

Removing a loose glenoid component leaves a big hole in the glenoid bone, making subsequent reconstruction difficult.

We have vigorously investigated the causes of failure and ways in which the security of the component can be optimized. We continue to use a modern glenoid component in the majority of our shoulder joint replacements, because it provides predictable recovery of shoulder comfort and function

Time will tell whether the newer design and our modern techniques will improve the long term durability of the glenoid component.

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Shoulder arthritis at the 2011 ASES meeting - glenoid loosening

Three papers presented at the most recent open meeting of the American Shoulder and Elbow Surgeons (February 19, 2011, San Diego) relate to the issue of glenoid component failure, even with modern components and techniques in expert surgical hands.


Out of 518 total shoulders from 10 European surgical centers using a third generation anatomic prosthesis, radiographic loosening was found in 32% at an average of 8.6 years after surgery (Walch G, Young AA, Boileau P, et al.: Patterns of loosening of a cemented polyethylene keeled glenoid component in primary osteoarthritis - Results of a multicenter study).


The Mayo Clinic group reported essentially identical results with a different prosthesis:  in 157 total shoulder arthroplasties using a cemented Cofield II keeled all-polyethylene glenoid component, 32% of the glenoids showed radiographic failure at 10 years ( Fox TJ, Foruria A, Klika B, et al.: Radiographic survival in total shoulder arthroplasty).


A multicenter French report using a modern uncemented metal-back glenoid component found that at 12-year follow-up, approximately half of the glenoid prostheses had been revised for wear or loosening (Moineau G, Morin-Salvo N, Walch G, et al.: Long-term results of anatomical total shoulder arthroplasty with metal-backed glenoid components implanted for primary glenohumeral joint osteoarthritis).


These studies indicate the need for long term followup to determine the survivorship of the glenoid component in total shoulder arthroplasty.

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Shoulder arthritis articles from June JSES - fixation of humeral component, shoulder arthroplasty complications

There are a number of articles of interest in the June issue of the Journal of Shoulder and Elbow Surgery, but without a doubt is the note on the passing of the Father of Modern Shoulder Surgery, Dr. Neer, a friend, a teacher, a scientist, a surgeon, and an advocate for the best in care for patients with shoulder problems. We will all miss his leadership.

Another article, Cemented versus uncemented fixation of humeral components in total shoulder arthroplasty for osteoarthritis of the shoulder: a prospective, randomized, double-blind clinical trial comes to the conclusion that 'cemented fixation of the humeral component provides better quality of life, strength, and range of motion than uncemented fixation'.  However, the component used in this study, the Bigliani/Flatow Total Shoulder Solution/Zimmer,  (shown below)

has a cylindrical stem that does not have an opportunity for a good press fit in the humeral canal in contrast to the prosthesis shown in our April 6 post. Furthermore, the authors did not use impaction grafting when inserting the prosthesis without cement. Thus the article's title might have been better phrased as "Cemented Fixation vs Simple Press Fitting of a Humeral Component with a Cylindrical Stem For Osteoarthritis of the Shoulder." Given that caveat, the data do indicate that the Bigliani/Flatow Total Shoulder Solution/Zimmer yields better results when cemented. The results of our preferred method are well documented.

A third article, Factors Predicting Complication Rates After Primary Shoulder Arthroplasty,  documents that when shoulder arthroplasty is done for fracture, there are more complications than when the procedure is performed for arthritis. This article also shows that older patients and patients with rheumatoid arthritis had a lower risk of revision surgery, presumably because of lower activity levels. Implant survival rates were not found to be different between total shoulder and hemiarthroplasty procedures.

A fourth article, Ream and Run for Shoulder Arthritis - patients under 55 years, is the topic of the other post from today.

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Total shoulder replacement: avoiding heat damage

One of the concerns about fixation of the glenoid component in total shoulder replacement is the observation that 'radiolucent lines (RLL's)' may develop between the bone on one hand and the component and cement on the other. These RLL's suggest that the connection of the component to bone is not as strong as it should be. Of greater concern is that these RLLs are often progressive, that is, the fixation of the component becomes less secure with time. This is well shown in the article by Walch et al in the SUNDAY, MAY 1, 2011 post. 

There has been little study of the factors that may contribute to the development and progression of RLL's, especially in cases where no lucent lines are seen immediately after surgery.

One factor that we have studied is the possibility of heat damage to the bone of the glenoid causing local death and resorption of the bone over time with progressive mechanical loosening.  In a study with shoulder fellows Churchill, Boorman and Fehringer, Glenoid cementing may generate sufficient heat to endanger the surrounding bone, we found that the amount of heat generated was related to the volume of cement used in fixing the glenoid component. This is because cement cures with an exothermic, or heat generating reaction. With larger amounts of cement, the temperature of bone can rise to a level that can kill the bone.

This observation led us to explore methods of glenoid fixation that used only minimal amounts of cement: precise 'carpentry' with the removal of a minimal amount of bone.

In second study by shoulder fellows Clinton and Lynch along with resident Olson, we found that reaming of the bone could cause thermal damage: Thermal effects of glenoid reaming during shoulder arthroplasty in vivo. The figure below was taken during surgery using a thermal camera. 

We found that irrigating the wound with cool saline solution at the time of reaming kept the temperature of the bone within safe limits.

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