revision of painful hemiarthroplasty to total shoulder - Dec 2011 - JSES

The topic of painful hemiarthoplasty is always interesting. Is the problem "glenoid arthrosis", stiffness, infection, instability or some combination of the above?

Rhee et al reported on 34 shoulders revised from hemiarthroplasty to total shoulder because of pain. While patients experienced reduction of pain. 61% of the patients felt they were 'better' or 'much better'. 38% were the same or worse.  22 shoulders had unsatisfactory results on the modified Neer scale.

Of note is that in this series the humeral head replacement surgeries were performed for complex fractures - a situation much more complex and more prone to stiffness, cuff issues, humeral component positioning difficulties and tuberosity problems than when a hemiarthroplasty is used for non-traumatic conditions. Some had had prior attempts at internal fixation of their fractures.

These revisions involved substantial surgery: in 21 cases the humeral body was removed and replaced, some required tuberosity osteotomy and / or rotator cuff surgery in addition to lysis of adhesions. Poorer outcomes were noted in those cases needing rotator cuff surgery, greater tuberosity management or capsular tension adjustment. No mention is made of results of cultures taken at the time of these revisions.

These index surgeries and the revision surgeries were performed by Bob Cofield, one of the world's experts in shoulder reconstruction. This series points to the challenges posed by the unsatisfactory humeral hemiarthroplasty performed for trauma, even in the best of hands. While the title suggests that the revisions were performed for 'painful glenoid arthrosis', these patients had truly complex pathologies involving not only the glenoid surface, but also glenohumeral subluxation,  tuberosity malunion or nonunion, cuff tears and soft tissue contractures. These revisions are not for the faint of heart!

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Infections of the shoulder - resection - JSES Dec 2011

In a previous post we reviewed a report of the use of cement spacers in the management of deep shoulder infections. This series did not have a comparison group, that is the authors did not compare their results with a spacer (removal of all components followed by insertion of a cement spacer with antibiotics) to those with a primary exchange (removing all components and reinserting new ones) or to those with a resection arthroplasty (removing all prosthetic components without reinsertion).

Verhelst et al recently published a series of cases of resection arthroplasty comparing patients in which a spacer (containing gentamycin)  was used to those with a resection alone. This was not a controlled series so it cannot be assumed that the two patient populations were comparable prior to the revision surgery.  The initial surgeries ranged from acromioplasties and rotator cuff repairs to total and reverse shoulder arthroplasties. An average of 9 months elapsed between the initial surgery and the diagnosis of infection. The culture results were: 9 Staph aureus, 12 coagulase negative Staph, 4 Propionibacterium, and 2 Corynebacterium. No differences were observed in the results of the patients treated with and without spacers.  The authors believed infection was eradicated in 19 of the 21 cases.

Importantly, five of the ten patients treated with a spacer required a second procedure to reimplant a prosthesis at an average of 7 months after the spacer placement because of pain. Severe glenoid erosion occurred in those patients who received a stemmed spacer.  None of the patients having a resection had revision surgery. No significant differences in function were noted between the two groups.

The authors point out that preservation of the tuberosities is a key prognosticator of a good functional result.

The authors provide a thorough review of the literature on resection, primary exchange and two stage exchange.

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Our management of infections depends on the clinical presentation. Patients with draining sinuses, patients with local or systemic evidence of sepsis are likely to be managed with resection arthroplasty as suggested by Verhelst et al. Patients suspected of having low grade infections with organisms such as P. acnes are likely to be managed with a primary exchange using antibiotic-soaked allograft and prolonged antibiotic management in anticipation of a better functional outcome.

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Glenoid component lucent lines and loosening, JSES December 2011

Collin et al have provided a ten year follow-up on all polyethylene glenoid components in total shoulder arthroplasty. The authors state "Glenoid component loosening remains the most common reason for failure and revision surgery."

The shoulder arthroplasties in this study were performed by surgeons with a very high level of expertise, Gilles Walch and Pascal Boileau. While the principal purpose was to compare the track record of flat-backed versus concave backed cemented components, no significant differences were found. At 10 year followup, 20% of the glenoid components had possible loosening and 35% had definite loosening. The presence of glenoid loosening was associated with lower shoulder comfort and function by the Constant score. The authors noted that when radiolucent lines were present on the immediate post-operative films, these lucencies tended to progress. Younger patients (<60 years) tended to have a greater rate of progression than older patients. Glenoid components placed in the dominant shoulder had a greater tendency to have progressive lucencies than those in non-dominant shoulders.

This report suggests that active use and surgical technique are major factors determining the longevity of glenoid components. There was no mention of the results of cultures taken at the time of revision. The cases shown in Figures 6 &  7 (reproduced below) would seem suspect for the presence of an organism such as P. acnes.

 Note loss of alignment of metal markers in the glenoid and fragmentation of cement with osteolysis

Note massive osteolysis and fragmentation of cement.

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rotator cuff tears - articles in the December 2011 Journal of Shoulder and Elbow Surgery

Baring et al conducted a study of the change in distance between the supraspinatus tendon and the greater tuberosity with time after open rotator cuff repair. With implanted metal beads and wires they used stereophotogrammetry to monitor the relative position of the tendon and bone to which it was repaired in 10 patients.

During the first month after surgery, the arm was kept in a brace and the distance between the tendon and bone markers did not change over this time interval. During the next 10 weeks passive, then active motion motion was instituted - during this time the distance increased by an average of 7 mm; more motion was noted in the shoulders where the cuff repair eventually failed (3 of the four cases with tears initially measuring > 4 cm). Interestingly there was no significant relationship between the change in the Constant score and the change in the tendon-bone distance.

This paper is important because it shows the difficulty in defining 'success' after rotator cuff surgery. Is it cuff integrity? Is maintaining the relationship between the tendon and the bone? or Is it improvement in the Constant Score or SST?  For example, two patients were felt to have partial retears by ultra sound and over 10 mm increase in tendon-to-bone distance, yet these patients improved their SST scores from 1 to 10 and from 2 to 10, respectively - the biggest improvement in the series. By contrast three patients had final SST scores of 7 or less, each of which had intact repairs by ultrasound and some of the smallest increases in tendon-to-bone distance (2.1, 5.9. and 6.3).

This paper also brings to the surface the question "when is the repair healed enough to start motion?" The authors conclude that 'cuff repairs are most vulnerable to failure in the second and third months.'

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Registries, Shoulder arthroplasty, periprosthetic infection in December JBJS

After a winter solstice steelhead, some spectacular views from a remote mountain cabin, and slogging through a heavy snowfall, it's time to get back to work and blogging.

The December 21 JBJS has some articles of interest.

Bill Maloney wrote an editorial on the role of orthopaedic device registries in improving patient outcomes. In it he points to the difficulties in keeping track of which patients have which results with which implants performed by which surgeons. He uses the recent example of the failure of metal-on-metal hips, but there are many other examples of defective implants that might have been recognized earlier had their been a central registry of implants and their clinical performance. Yet the implant is only one of the potential causes of failure of a joint replacement.  Others include poor selection of patients, poor surgical technique, complications and poor rehabilitation. We live in a world where millions of joint replacements are done every year, yet the results of over 95% these arthroplasties are not analyzed so that the knowledge that could potentially be gained from what works and what doesn't work in different circumstances is lost. Since neither industry, nor the government, nor organized medicine can make followup happen, maybe some young person will save the day by designing an "app" called "MyJoint" that will ask the patient to enter the specifics about themself and their arthroplasty and remind them to complete a self assessment each year and post it to a central database.

Javad Parvizi et al reported on the novel idea of using a simple colorimetric strip test to look for the enzyme leukocyte esterase in the joint fluid of knees with a possible joint infection. The test correlated well with the number of neutrophils and with systemic inflammatory markers. It is exciting to see how well this works for knees; however for those of us in the shoulder world most of our infections engender less of an inflammatory response so that the effectiveness of this approach remains to be evaluated.

Sunny Kim et al reported the increasing incidence of shoulder replacements in the US. They found relatively constant growth in the number of hemiarthroplasties from 12,000 in 2000 to 20,000 in 2008, many of these being performed for fracture. The number of total shoulders grew from 8,000 in 2000 to 11,000 in 2003 and then took a sudden leap to over 27,000 in 2008, perhaps in part due to the introduction of the reverse total shoulder in the US in 2003. Unfortunately, this article contains no information on functional outcomes or revision rates.

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Recognition of the work linking pain pumps to Chondrolysis by the JBJS

A bit of good news as we go into the New Year.

The Journal of Bone and Joint Surgery has placed our article pointing to the causal relationship between the use of intra articular pain pumps to glenohumeral chondrolysis among the top four articles for 2011.

In spite of this and other evidence-based peer-reviewed publications, some remain seemingly unable to recognize this cause of glenohumeral chondrolysis: "We don't know if it's because of the surgery, during the surgery, something that happens after the surgery, we just don't know without more study," said Dr. Maryam Navaie, CEO of Advance Health Solutions. The observation that other causes of chondrolysis have been reported does not detract from the well documented causational effect of local anesthetics infused after arthroscopic surgery using a pain pump on glenohumeral chondrolysis. A parallel: the observation that other causes of cancer have been reported does not detract from the well documented causational effect of cigarette smoking on lung cancer.

Hopefully, the evidence is now clear.

As the year closes, we express our gratitude to the individuals from over 70 countries who have grown this blog to 8000 page views per month. We are looking forward to an exciting 2012.

Best wishes for health and happiness in the New Year!
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Pulmonary embolism, thromboembolic prophylaxis and shoulder arthroplasty

National organizations have developed guidelines for the prevention of blood clots after hip and knee surgery The guidelines from the American Academy of Orthopaedic Surgeons can be found here.

The risk of pulmonary embolism after shoulder arthroplasty is much less than after hip and knee surgery, probably because the patient can be up and walking around immediately after the procedure.

Our practice is to screen patients for conditions that predispose them to a high risk of blood clots and for other reasons for them to take anticoagulants, such as coumadin, including past history of pulmonary emboli. In the absence of specific indications for medical thrombophrophylaxis, we use early ambulation and compressive stockings and sequential pressure devices to reduce the risk of blood clots. We avoid anticoagulants if possible to reduce the risk of bleeding at the site of our shoulder surgery.

It is a question of balancing one risk versus another for each patient.

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