Thursday, May 13, 2021

Patients having total shoulder arthroplasty are at increase risk for falling

Preoperative Screening in Patients having Elective Shoulder Surgery Reveals a High Rate of Fall Risk

These authors point out that patients having shoulder surgery are at increased risk for falls for a number of reasons, including advanced age, impaired upper extremity function, the use of shoulder abduction braces, and postoperative use of opioid medications. 


Their goal was to examine preoperative fall risk in patients undergoing elective shoulder surgery. They suggest that gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cut-off scores indicating increased fall risk.The TUG score (>14 seconds considered high fall risk) and 10 Meter Walk test (<0.7 m/s considered high risk for falls) were recorded for each patient. 


They quantified gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA).


Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed <0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group Twenty-nine percent of TSA patients and 12% of RCR patients were determined to be at high fall risk based on a TUG score >14 seconds. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk.

They conclude that  fall risk screening may be important for patients undergoing TSA and RCR surgeries and that higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.


Comment: This study uses preoperative measures of fall risk. The preoperative risk is often compounded after surgery by the after effects of anesthesia, pain medications, and shoulder immobilizers. Other important factors include eyesight, railings and lighting on stairs, shoe wear, cardiac conditions, seizures, lower extremity issues, anemia, alcohol, fluid and electrolyte disorders, hearing problems, frailty, dogs, and lack of social support.

In that the consequences of falls after surgery can be major (head injury, fractures, tendon disruption, dislocation), a good overall assessment before surgery is necessary as is a careful evaluation before the patient leaves the medical center. Taking a fall and balance history before surgery and checking to be sure the patient can get out of bed and walk securely before discharge are important and simple steps. 

A fall can ruin the results of a fine surgery. All efforts at prevention are worthwhile.

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 total shoulder arthroplasty (see this link).
The ream and run technique is shown in 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).



The scapula of our ancestor, Littlefoot, a social climber

From Science News, April 30, 2021.




"Little Foot, a nearly complete hominid skeleton painstakingly excavated from rock inside a South African cave, shouldered a powerful evolutionary load.

This 3.67-million-year-old adult female sports the oldest and most complete set of shoulder blades and collarbones of any ancient hominid. Those fossils also provide the best available model for what the shoulders of the last common ancestor of humans and chimpanzees looked like, say Kristian Carlson, a paleoanthropologist at the University of Southern California in Los Angeles, and his colleagues. Their results provide new insights into how both Little Foot and a human-chimp last common ancestor climbed in trees.

Little Foot belonged to the Australopithecus genus, but her species identity is in dispute(SN: 12/12/18). The shape and orientation of her shoulder bones fall between corresponding measures for humans and present-day African apes, but most closely align with gorillas, Carlson reported April 27 at the virtual annual meeting of the American Association of Physical Anthropologists. His talk was based on a paper published online April 20 in the Journal of Human Evolution.

Little Foot lived roughly half-way between modern times and the estimated age of a human-chimp common ancestor, says paleobiologist David Green of Campbell University in Buies Creek, N.C., a member of Carlson’s team. If that ancient ancestral creature was about the size of a chimp, as many researchers suspect, shoulders resembling those of gorillas would have supported slow but competent climbing, Green says. Gorillas spend much of the time knuckle-walking on the ground. These apes climb trees with all four limbs, reaching up with powerful shoulders and arms to pull themselves along.

“The maintenance of a gorilla-like shoulder in Little Foot offers clues that climbing remained vital for early [hominids],” Green says. It’s possible, he added, that Little Foot’s shoulder design represented “evolutionary baggage” among hominids evolving bodies more suited to upright walking.

digital reconstruction of Little Foot's shoulder bones
Researchers used a digital reconstruction of Little Foot’s nearly complete right shoulder blade, shown here, to determine that this ancient hominid climbed more like gorillas than like chimps, orangutans or humans.K. CARLSON  

The new analysis makes Little Foot’s shoulders “our best candidate for hypothesizing the appearance of the human-chimp last common ancestor,” says anatomist Susan Larson of Stony Brook University School of Medicine in New York, who wasn’t involved in the research. Ancestral shoulders that supported capable tree climbing would have provided a foundation for the evolution of human shoulders aligned with a two-legged stride and chimp shoulders designed for hanging and swinging from tree branches, she suggested.

In the new study, a digital, 3-D reconstruction of Little Foot’s more complete right shoulder blade was compared with right shoulder blades of chimps, gorillas, orangutans and present-day people. Further comparisons were made with partial shoulder blades of 11 ancient hominids. Those hominids included four South African Australopithecusspecimens and East African finds from two members of Lucy’s speciesA. afarensis, that date to around 3.3 million and 3.6 million years ago (SN: 10/25/12). Little Foot’s collarbones were compared with those of humans, chimps, gorillas, orangutans and seven ancient hominids.

Carlson’s analysis provides preliminary but still uncertain evidence that Little Foot had the most gorilla-like shoulders of any ancient hominid, says paleoanthropologist Stephanie Melillo of the Max Planck Institute for Evolutionary Anthropology in Leipzig, Germany. Melillo, who did not participate in the new study, considers it most striking that Little Foot shares many shoulder similarities with the other Australopithecus fossils studied by Carlson’s team.

Some researchers consider a 4.4-million-year-old Ardipithecus ramidus skeleton, dubbed Ardi, the best hominid model for a human-chimp last common ancestor (SN: 12/31/09). Ardi could have moved slowly in trees while holding onto branches above her head, in a manner unlike any modern ape, they contend. But Ardi’s remains lack shoulder blades and collarbones."





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 total shoulder arthroplasty (see this link).
The ream and run technique is shown in 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).


60 year old athlete with severe shoulder arthritis - glenoid remodeling after a ream and run.

A 60 year old rock climber and cross country skier had pain and stiffness in the right shoulder and these x-rays showing complete loss of radiographic joint space and posterior decentering of the humeral head in the arthritic glenoid.



He elected to have a ream and run procedure to avoid the risks and limitations associated with a plastic glenoid component. This was done without preop CT or plexus block.

His x-rays at 3 months show some early remodeling of the reamed glenoid.


Three years after his procedure, he had fully returned to his activities and had the x-rays below, showing complete remodeling of his glenoid articular surface. 





The ream and run technique is shown in this link.


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 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).


Management of a B2 glenoid in a 67 year old athlete - 10 year followup

A 67 year old international level badminton athlete presented with pain and stiffness in the right shoulder.

Radiographs showed advanced glenohumeral arthritis and a type B2 glenoid with posterior subluxation of the humeral head into a posterior glenoid concavity.



After discussion of the options, including atomic and reverse total shoulders, he elected the ream and run procedure. This was done without preop CT or plexus block.

He sent this video of his gym workout at one year after surgery.




He returned 10 years later to have a ream and run on his contralateral shoulder. At 10 years after the ream and run his shoulder x-rays showed a well centered humeral head.




His should was comfortable and he had long since been able to return to competitive badminton.

His shoulder motion is shown in this video.


The ream and run technique is shown in this link.


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 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).


Tuesday, May 11, 2021

Does the position of the glenoid component shift after total shoulder arthroplasty?

 Relationship Between Glenoid Component Shift and Osteolysis After Anatomic Total Shoulder Arthroplasty Three-Dimensional Computed Tomography Analysis

These authors sought to evaluate glenoid component position and radiolucency following anatomic total shoulder arthroplasty (TSA) using sequential 3-dimensional computed tomography (3D CT) analysis in a series of 152 patients (42 Walch A1, 16 A2, 7 B1, 49 B2, 29 B3, 3 C1, 3 C2, and 3 D glenoids) undergoing anatomic TSA with a polyethylene glenoid component.


Sequential 3D CT analysis was performed preoperatively (CT1), early postoperatively (CT2), and at a minimum 2-year follow-up (CT3). 


The preoperative CT was used to characterize the "premorbid" anatomy of the shoulder, that is what it was likely to have looked like before the onset of arthritis. 



The position of the humeral head in relation to the glenoid and to the plane of the scapular body was defined. 

Central peg osteolysis was determined using the scale shown below






Glenoid component shift was defined as a change in component version or inclination of ≥ 3 degrees from CT2 to CT3. 


Glenoid component central anchor peg osteolysis (CPO) was assessed at CT3. 


Glenoid component shift occurred from CT2 to CT3 in 78 (51%) of the 152 patients. 


CPO was seen at CT3 in 19 (13%) of the 152 patients, including 15 (19%) of the 78 with component shift; increased inclination was the most common direction


Most (81%) of the patients with glenoid component shift did not develop CPO.


Walch B2 glenoids with a standard component and glenoids with higher preoperative retroversion were associated with a higher rate of shift, but not of CPO.


B3 glenoids with an augmented component and glenoids with greater preoperative joint-line medialization were associated with CPO, but not with shift. 


More glenoid component joint-line medialization from CT2 to CT3 was associated with higher rates of shift and CPO. 


A greater absolute change in glenoid component inclination from CT2 to CT3 and a combined absolute glenoid component version and inclination change from CT2 to CT3 were associated with CPO. 


Neither glenoid component shift nor CPO was associated with worse clinical outcomes.


Most of the components shifting occurred without deformation of the implant; however, a subset of 14 components demonstrated bending of the central anchor peg between CT2 and CT3 without CPO. 


CPO was associated with a higher rate of shift with larger absolute changes in glenoid component version and inclination and a greater odds of component medialization from CT2 to CT3 compared with cases without CPO, findings suggestive of early implant loosening and subsidence that raise concern about eventual implant failure.

 

Comment: This is a very thorough and interesting study. It seems that patient reported shoulder comfort and function is relatively insensitive to component shift or central peg osteolysis at a minimum of two years after arthroplasty. It also appears that in the great majority of cases using a fluted central peg, there is bone ingrowth into the central peg that persists at two years. It is interesting that the central peg can bend with component shift without loosening. Preoperative retroversion and version correction appear to be associated with an increased rate of component shifting. 


We will continue to learn from these authors which surgeon-controlled variables will optimize the long term success of shoulder arthroplasty for our patients: what is the best way to manage preoperative retroversion? what is the best way to manage preoperative joint line medialization? To answer these questions carefully controlled studies will be required to determine how much version correction is needed and, if version correction is important, how can it be best accomplished.


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).

Sunday, May 9, 2021

How stretch the posterior shoulder capsule

Effective stretching positions for the posterior shoulder capsule as determined by shear wave elastography

These authors sought to identify the stretching positions that specifically applied the greatest passive tension on the posterior shoulder capsule by evaluating the elastic characteristics of posterior capsules and muscles in various stretching positions using ultrasound shear wave elastography in 9 fresh-frozen cadaver shoulders without osteoarthritis or rotator cuff tears. 


All posterior shoulder tissues were preserved intact. Shear moduli of the middle and inferior posterior shoulder capsule and the posterior shoulder muscles were evaluated in combinations of glenohumeral

elevation planes and angles (frontal, sagittal, scapular; –30, 0, 30, 60, respectively). A 4-Nm torque for shoulder internal rotation or horizontal adduction was applied in each position. 


They found that the middle posterior capsule was most effectively stretch by internal rotation at 30 of elevation in the scapular plane and cross body adduction at 60 of elevation. The inferior posterior shoulder capsule was most effectively stretched by internal rotation at 30 of flexion.


Comment: Posterior capsular tightness is a common finding on careful evaluation of the painful shoulder, although it is often overlooked by the casual observer. It can be noted by (a) limited cross body adduction, (b) limited internal rotation with the arm abducted, and (c) by limited reach up the back. As found in cadavers by the authors, we have found that the posterior capsule can be effectively stretched by cross body adduction (see this link) and the sleeper stretch (see this link). 


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).


The value of patient reported measures of shoulder comfort and function.

Responsiveness of patient-reported outcomes in shoulder arthroplasty: what are we actually measuring?

These authors reviewed 74 article that reported preoperative and at least 2 year postoperative measures of comfort and function after primary total shoulder arthroplasty (TSA) for glenohumeral arthritis.


Anatomic TSA was evaluated in 35 studies, reverse TSA in 32 studies, and both anatomic and reverse in 7 studies. There were a total of 7624 patients, and 25 different PRO tools were used. 


The most commonly reported PRO tools were the American Shoulder and Elbow Surgeons,

Constant, the visual analog scale for pain, and the Simple Shoulder Test. 


The effect size for each PRO was calculated by dividing the difference between postoperative and preoperative mean scores by the preoperative standard deviation. Effect size is a measure of magnitude of change within the tool after surgical intervention. An effect size is considered small if it is between 0.20 and 0.49, moderate if between 0.50 and 0.79, and large if 0.80. All instruments had comparable effect sizes >2.


Comment: The primary value of a surgeon's documenting patient reported measures of comfort and function before and after each surgery to determine what procedures for which patients work best in his or her hands.


An added value of a surgeon's documenting patient reported measures of comfort and function before and after each surgery is to compare his or her results with those published for similar procedures for similar patients. Initially it may seem that this would require the use of a common measure of patient comfort and function. However, in a prior study (One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers), we showed that the commonly used patient reported measures of comfort and function showed essentially the same results for patients before and after total shoulder arthroplasty. 




One of the convenient ways to compare studies using different measures is to determine the improvement expressed as a percent of maximum possible improvement: 
(post op score - pre op score)/(perfect score - pre op score). In the study above, both the SST and the ASES scores showed a precent of maximal possible improvement of 80%. 

Important considerations in selecting a measure of patient comfort and function are 

(1) it should facilitate ongoing participation by the maximum number of patients (minimizing the percent of patients lost to followup while enabling the capture of data 5, 10 or more years after the procedure). The requirement that patients return for measurements (e.g. with the Constant score) or access to a computer (e.g. with the PROMIS system) may pose barriers to the desired followup.

(2) it should pose a minimal burden on office staff in scoring and data entry.

(3) it should provide data on specific functions that patients can easily comprehend, rather than a numerical value that may not have meaning to patients.

For these reasons we use the Simple Shoulder Test (see this link).
(1) It is accessible and low tech - completable with pencil and paper from the patient's home without needing a computer connection or office visit
(2) It is simple to score (count the "yes" responses 0 to 12).
(3) It yields information patients can understand "does your shoulder allow you to sleep at night?"

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).