Tuesday, December 6, 2022

The Future of American Shoulder and Elbow Surgery - the University of Washington Fellowship

This week, 24 of the brightest and best applicants for shoulder and elbow fellowship were invited and accepted the opportunity to interview for the University of Washington's advanced clinical experience in our specialty.

This group of women and men is truly outstanding - one of the best we seen since starting our fellowship in 1988. Two of these candidates will join our 57 fellowship alumni who are now practicing shoulder and elbow surgery across the country - from Seattle to Miami, from SanDiego to Portsmouth, New Hampshire. Almost all of our graduates are members of the American Shoulder and Elbow Surgeons (ASES). One-quarter of our graduates have been recruited to university faculty positions.

Our goal is to enable our fellows to master advanced skills in diagnosis and surgical management of both common and rare conditions that prevent patients from enjoying their lives. In addition, we will provide opportunities for them to engage in cutting edge research investigating some of the major questions faced by our specialty, such as
(1) when is rotator cuff repair not in the best interest of a patient with a cuff tear?
(2) what evidence should guide treatment for irreparable rotator cuff tears?
(3) what can be offered to a patient with arthritis who wishes to pursue activities beyond what is recommended for a conventional total shoulder?
(4) how important is it to "correct" glenoid retroversion in performing shoulder arthroplasty?
(5) is there a practical alternative to the reverse total should for patients with cuff tear arthropathy and retained active elevation?
(5) how can surgeons monitor the quality of their practice outcomes to identify what is working and what is not?
(6) how can we avoid unnecessary expenses of imaging - a cost that consumes much of the resource spent on shoulder and elbow care?
(7) how can we evaluate the many new orthopaedic implants and products brought to market each year to determine if their increased cost results in increased benefit to our patients?
(8) how can we make shoulder and elbow surgery safer from the risk of infection?

We are excited to be tackling these and other 'big questions'. We are excited to have the partnership of our fellows, who help us and who end out teaching us as well. For sure, the future is brighter because of them.


Here are the publications of our core faculty:
Jason Hsu
Frederick Matsen
Winston Warme
Albert Gee
Jonah Hebert-Davies

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).


Here are some links about our fellowship and our area:

The University of Washington Shoulder and Elbow Fellowship
Life in Seattle
Beautiful Seattle
How to find the best hikes around Seattle
The Pacific Northwest




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Friday, November 25, 2022

Does the evidence support the use of the InSpace balloon in the treatment of irreparable rotator cuff tears?

Rotator cuff tears are one of the most common conditions of the shoulder. While many patients can accommodate the progressive age-related deterioration of the cuff with no or minimal symptoms, others have disabling symptoms and loss of function. Surgical management of symptomatic rotator cuff tears is commonly performed. For those tears that are not durably reparable, surgical options include (1) subacromial smoothing with debridement of hypertrophic bursa and the non-functioning margins of the tendon, possible biceps surgery, and manipulation as necessary to address glenohumeral stiffness, (2) partial repair, (3) superior capsular reconstruction, (4) reverse total shoulder and (5) the recently introduced Stryker InSpace subacromial balloon spacer. The InSpace device is a saline-filled biodegradable balloon that is inserted surgically in the space between the humerus and the acromion. In theory this device helps maintain the gap between the acromion and the humerus, and reduces friction.
The balloon received Food and Drug Administration (FDA) clearance in the USA in July, 2021, with approximately 29,000 devices having been implanted outside the USA before this.



The question is, in patients with symptomatic, irreparable rotator cuff tears, does adding a subacromial balloon spacer to debridement alone improve shoulder pain and function above what is achieved with debridement alone?

While small published case series have suggested encouraging clinical results, others have reported poor results or cases of inflammation and pain. For this reason, the authors of Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS): a group-sequential, double-blind, multicentre randomised controlled trial conducted a novel, efficient, adaptive clinical trial to assess the clinical effectiveness of a subacromial spacer balloon for people with symptomatic irreparable tears of the rotator cuff. This article was summarized in In Symptomatic Irreparable Rotator Cuff Tears, Adding a Subacromial Balloon Spacer to Debridement Resulted in Worse Shoulder Pain and Function at 12 Months.

The study was conducted by surgeons in 24 hospitals in the United Kingdom and included 117 patients (mean age, 67 years; 57% men) who had irreparable rotator cuff tears with disabling symptoms (pain and loss of function) and unsuccessful nonoperative management, and in whom surgery was warranted. Patients with reparable cuff tears, arthritis, pseudoparalysis, and subscapularis deficiency were excluded.

Eligibility was confirmed intraoperatively before randomly assigning (1:1) participants to a treatment group using a remote computer system. Using concealed allocation, patients were randomized to balloon spacer plus debridement (n = 56) or debridement alone (n = 61). Patients in the balloon spacer group received the Stryker InSpace balloon inserted by subspecialty-trained shoulder surgeons after arthroscopic debridement of the subacromial space and biceps tenotomy. Participants and assessors were masked to group assignment. Masking was achieved by using identical 1.5-cm lateral portal incisions for both procedures, blinding the operation note, and a consistent rehabilitation program offered regardless of group allocation.

The study was designed to have 90% power providing a robust answer to the clinical question.

The primary outcome was shoulder-related pain and function as measured by the Oxford Shoulder Score at 12 months. Secondary outcomes included the Western Ontario Rotator Cuff Index, EuroQol-5 Dimensions-5 Levels (EQ-5D-5L), and adverse events at 12 months. 97% of patients completed follow-up for the primary outcome. The primary outcome was the Oxford Shoulder Score at 12 months.

Pre-trial simulations using data from early and late timepoints informed stopping boundaries for two interim analyses. The study was designed to be terminated either for convincing evidence of a lack of benefit (futility) or for strong clinical benefit (efficacy). This exposes fewer people to risk of harm in the trial itself, as well as preventing harm or high costs for people having the treatment in the wider community. Having both futility and efficacy stopping rules allow a study to report early if an intervention is ineffective. Recruitment to this study was stopped when the predefined boundary for futility was crossed.

As seen in the figure and table below, in patients with symptomatic irreparable rotator cuff tears, adding the InSpace balloon to debridement only resulted in worse shoulder pain and function. The mean Oxford Shoulder Score at 12 months was 34·3 (SD 11·1) in the debridement only group and 30·3 (10·9) in the debridement with device group (mean difference adjusted for adaptive design –4·2 [95% CI –8·2 to –0·26];p=0·037) favoring debridement alone.












The adverse events for the two groups are shown below.




The authors concluded that for patients with symptomatic irreparable rotator cuff tears, adding a subacromial balloon spacer to debridement resulted in worse shoulder pain and function at 12 months.

Another recent study, InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears A Multicenter, Single-Blinded, Randomized Controlled Trial concluded that the outcomes of the InSpace implant were not inferior to those of partial repair for the treatment of patients with irreparable, posterosuperior, massive rotator cuff tears and an intact subscapularis.








The authors of this second study described its limitations, including the fact that the evaluators of the physical examination were not blinded with respect to treatment groups.

Comment: These studies do not provide evidence of increased effectiveness of the InSpace balloon in comparison to debridement or partial cuff repair.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.
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Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Tuesday, November 22, 2022

Should surgeons doubt the value of cultures in shoulder surgery?

It is well recognized that bacterial infections are important causes of failed shoulder arthroplasy, failed cuff repairs and failed fracture fixation. The organisms most commonly responsible for these infections (Cutibacterium and coagulase negative staphylococcus (CNS)) are also found on and in healthy skin of healthy individuals as well as in the environment.

Of note, these organisms can be isolated from sterile swabs and sponges that are exposed to the air in the operating room, suggesting that specimens can be contaminated by air-borne organisms, specimen handling or microbiology laboratory processing. Knowing the results of control environmental non-clinical cultures for a surgeon's operating room is important to the interpretation of the results of clinical cultures isolated from deep tissue specimens and explants obtained at the time of revision surgery.

Between-hospital variability in the results of sterile cultures is demonstrated by the reported rates of control samples that are positive for Cutibacterium which range from 4% to 9% to 15% to 20%:

In Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery  4% (2 of 50) of sterile control specimens were positive for P. acnes (Cutibacterium)

In The Incidence of Propionibacterium acnes in Open Shoulder Surgery: A Controlled Diagnostic Study seven (13.0%) of fifty-four sterile control specimens returned positive for culture growth. Five of these (9%) grew P. acnes (Cutibacterium), while two (4%) grew coagulase-negative S. aureus.

In Cutibacterium acnes is Isolated from Air Swabs: Time to Doubt the Value of Traditional Cultures in Shoulder Surgery? Cutibacterium was identified by culture of sterile control swabs in 6 of 40 cases (15%) swabs and coagulase negative staphylococcus (CNS) was identified in 3 of 40 (7.5%). 

In Preoperative doxycycline does not decolonize Propionibacterium acnes from the skin of the shoulder: a randomized controlled trial 20 sterile control specimens were submitted for culture, four of which (20%) grew P. acnes (Cutibacterium).

This five fold difference among hospitals in the rate of positive cultures for sterile control specimens suggests different risks of specimen contamination in the operating room, during specimen handling and/or in the microbiological laboratory.

The magnitude of contamination from these environmental sources would be expected to be small in comparison to the load of bacteria in an infected shoulder. The authors of Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty pointed to the value of assessing the amount of bacteria in a sample using a semi-quantitative report rather than simply referring to a culture result as "positive" or "negative". In 137 Cutibacterium culture-positive revision shoulder arthroplasties the culture results were characterized by a specimen Cutibacterium value (SpCV): 0 = no growth, 0.1 = broth only or one colony only, 1 = growth on one plate quadrant, 2 = growth on two plate quadrants, 3 = growth on three plate quadrants and 4 = growth on all 4 of the plate quadrants after standard microbiological plate streaking.




The authors of Preoperative Skin-Surface Cultures Can Help to Predict the Presence of Propionibacterium in Shoulder Arthroplasty Wounds used this semi-quantitative approach to report the results of cultures for sterile control swabs submitted from the operating room in 50 cases. While 2 of the control samples had positive cultures for Cutibacterium (4%), neither (0%) of the positive control samples had a SpCV of 1 or more, indicating a very low level of contamination.

Some authors have proposed that Next Generation Squencing (NGS) may be superior to cultures in detecting bacteria doing harm in shoulders. See for example, Revision shoulder arthroplasty - what is the role of next-generation sequencing?. NGS is very sensitive to the presence of bacterial RNA and DNA. In the referenced study, NGS found evidence of no fewer than 71 different organisms in specimens from cases of revision arthroplasty. including A calcoaceticus, A excentricus, A ferrireducens, A junii, A radioresistens, A rhizogenes, A tetradius, B aggregatus, B casei, B cepacia, B dorei, B fragilis, B fungorum, B mycoides, B nordii, B thermosphacta, B thetaiotaomicron, B virosa, C tuberculostearicum, C circulans, C acidisoli, C aurimucosum, C chromoreductans, C diptheriae, C hominis, C hveragerdense, C kroppenstedtii, C paradoxus, C quinii, C striatum, C testosteroni, C tuberculostearicum, C vibrioides, C xerosis, C. acnes, E coli, E hormaechei, G ruanii, K rosea, K oxytoca, K palustris, K pneumoniae L agilis, L albida L crispatus, L manihotivorans, M catarrhalis, M granosa, M luteus, P aeruginosa P agglomerans, P saccharophilia, R gnavus, R insidiosa, R picettii, S agalactiae, S aureus (MRSA) S aureus, S cohnii S condimenti, S epidermidis S hominis, S maltophilia, S melonis, S mitis, S parasanguinis, S pettenkoferi, S piscifermentans, and S sanguinis. It is not known if these results actually reflect living bacteria in the shoulder and what implications these NGS results have for treatment.

The authors of Cutibacterium acnes is Isolated from Air Swabs: Time to Doubt the Value of Traditional Cultures in Shoulder Surgery? suggest that NGS is capable of identifying pathogens and the relative percent abundance in which they appear within a sample. They state, "due to budgetary limitations and the cost of NGS, our sample size was admittedly small and only included one sample for culture and NGS from each case".

For 40 consecutive cases they opened and exposed sterile swabs to the air in the operating room for 5 seconds.  One swab was sent to their microbiology laboratory for aerobic and anaerobic culture and held for 13 days. The other sample was sent for NGS, where samples were amplified for pyrosequencing using a forward and reverse fusion primer and matched against a DNA library for species identification.

Cutibacterium was identified by culture in 6/40 (15%) swabs and coagulase negative staphylococcus (CNS) was identified in 3/40 (7.5%). When considering the semi-quantitative assessment of bacterial growth, all six samples with isolated Cutibacterium were rated as very light growth, a finding consistent with the very low SpCVs in the two positive control cultures in Preoperative Skin-Surface Cultures Can Help to Predict the Presence of Propionibacterium in Shoulder Arthroplasty Wounds . 

2/40 cases (5%) had positive NGS sequencing with polymicrobial results in the distributions shown below.

Case #6: 
P. aeruginosa (26%), P. melaninogenica (19%),  C. tuscaniense (12%),  S. mitis (9%), B. japonicum (8%), A. wolffii (7%), C. appendicis (4%), B. antiquum (4%), A. schindleri (2%)

Case #20: S. hominis (31%), S. epidermidis (24%), M. subterranean (11%), C. kroppenstedtii (8%), E. biforme (8%), P. submarinus (4%), N. oleivorans (3%), Cutibacterium (3%)

Comment: From the foregoing, it can be concluded that
(1) contamination of sterile swabs can occur between the time of opening of the swab and the final analysis of bacterial cultures by the microbiology lab. The resulting positive cultures are not "false positives" but rather positive cultures resulting from contamination
(2) the rate of contamination from the operating room environment, specimen transport and laboratory procedures varies widely among medical centers
(3) the bacterial load - as reflected by the specimen Cutibacterium value  (SpCV) -  in contaminated sterile swabs is small in comparison to the SpCV typically seen in cultures of deep tissues and explants retrieved from shoulders with periprosthetic infections; thus reporting the culture results using a  semiquantitative system to reflect bacterial load helps identify clinically important positive cultures.
(4) Next Generation Sequencing is an expensive test that reveals RNA and DNA associated with a wide range of bacterial species, the preponderance of which have not been demonstrated to be pathogenetic. Thus the value of NGS in guiding therapy in shoulders with suspected infection remains to be demonstrated.
(5) In the absence of a better alternative, surgeons should continue to use bacterial cultures (assessed for bacterial load) to help guide the management of failed shoulder surgeries potentially caused by infection.


You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.
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Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Monday, November 21, 2022

Platelet rich plasma (PRP) and the rotator cuff - what patients should know

While arthroscopic rotator cuff repair is one of the commonest of all shoulder procedures, the postoperative re-tear rate ranges between 9% and 94% despite intensive exploration of surgical techniques and adjunctive therapies. Investigators have explored the use of growth factors - in particular, platelet-rich plasma (PRP) - with the hope of inducing a faster and better healing of the repaired tendon tissue.

The authors of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: Clinical and Radiological Results of a Prospective Randomized Controlled Trial Study at 10-Year Follow-Up sought to compare, at 10-year follow-up, the clinical and radiological outcomes of arthroscopic rotator cuff repair with or without the addition of platelet-rich plasma (PRP) over the tendon-bone interface at the end of
the surgical procedure.

Patients were randomly divided into 2 groups: 26 received PRP and 27 served as controls. 38 (71%) patients (median age 71 years) were re-evaluated at least 10 years after the index procedure performed by an individual highly experienced surgeon. The patients in the two groups were similar.





The clinical outcomes were not better for the shoulders receiving PRP



While the mean ASES score was higher for the PRP group (100) than for the non-PRP group (93), the difference did not approach clinical significance (see Establishing clinically significant outcome after arthroscopic rotator cuff repair).

On average, 37% of the operated patients had a re-rupture on ultrasound examination, regardless of whether PRP was used or not (PRP group: 35%; control group: 38%; P . 1.0000).

Interestingly, the clinical outcomes were essentially the same whether the repair remained intact or not.


While the average Constant score was higher for patients with intact cuffs in comparison to those with re-tears, the difference failed to reach clinical significance (see Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery).

The authors concluded that in comparison to patients not receiving PRP, patients treated with PRP did not have better clinical outcomes and did not have lower re-tear rates of the repaired tendons. These finding are similar to those reported by the authors of The clinical efficacy of leukocyte-poor platelet-rich plasma in arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials in which the clinical effects of PRP failed to reach clinical significance.

Comment: PRP can be an expensive adjunct to rotator cuff repair and the expense may not be covered by the patient's insurance. Further evidence is needed to support the value (benefit/cost) of PRP as an adjunct to rotator cuff repair. 

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

To add this blog to your reading list in Google Chrome, click on the reading list icon




Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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, November 20, 2022

Active arm elevation after reverse total shoulder arthroplasty

Active humerothoracic (HT) elevation (elevation of the arm in relation to the thorax) is accomplished by a combination of glenohumeral (GH) and scapulothoracic (ST) movement.

To gain an understanding of how patients having had reverse total shoulder arthroplasty (rTSA) accomplish HT elevation, the authors of Reverse Total Shoulder Arthroplasty Alters Humerothoracic, Scapulothoracic, and Glenohumeral Motion During Weighted Scaption studied ST and GH motion during elevation of the unweighted and weighted arm in the plane of the scapula (scaption).

The subjects included 10 patients >1 year after rTSA (six males, four females; age 73 ± 8 years) who could perform pain-free scaption of the unweighted arm. 
All rTSA patients received Grammont-style implants inserted by the same highly experienced surgeon.
These patients were compared to 10 participants with non-pathologic shoulders (five males, five females; age 58 ± 7 years).

Participants in both groups performed scaption without and with a 2.2-kg handheld weight while being imaged with biplane fluoroscopy. Maximum humerothoracic elevation and 3D scapulothoracic and glenohumeral kinematics across their achievable ROM were collected via dynamic imaging.

When compared with unweighted scaption, maximum humerothoracic elevation decreased during weighted scaption for patients who underwent rTSA (-25° ± 30°; p = 0.03) but not for the control group (-2° ± 5°; p = 0.35). 

For the rTSA group the addition of 2.2 kg to the arm during scaption resulted in severe decreases in maximum HT elevation (> 35°) for 4 patients, moderate decreases (10° to 20°) for 3 patients, and negligible decreases (< 10°) in 3 patients.

Information on the positioning and orientation of the glenosphere and humeral components for these different groups is not provided.
 
The control participants showed no loss of active elevation with the addition of the weight.

The figure below compares the maximum active scaption for unweighted (left) and weighted arms for patients having rTSA (in red) and controls (in black).




For the 4 rTSA patients having good active elevation of the unweighted arm but weighted scaption of less than 90°, humerothoracic elevation was accomplished using almost exclusively scapulothoracic motion, with little glenohumeral contribution as shown in the diagram below ("A" unweighted, "B" weighted).




Weighted scaption demonstrated a strong correlation with the Simple Shoulder Test score (r = 0.76; p = 0.01). 

Comment: These results suggest that - in some patients having rTSA - the deltoid is unable to generate sufficient force to elevate the modestly loaded arm resulting in reduced comfort and function as reflected by lower Simple Test Scores.  It is not clear to what degree the inability to actively elevate the loaded arm is the result of poor conditioning of the deltoid muscle or to differences in muscle tensioning and moment arms related to implant size and position.  

We are left with at least two questions:
(1) can rehabilitative exercises directed at the deltoid muscle improve active elevation of the weighted arm after rTSA?
(2) what rTSA implant selection and positioning variables correlate with the ability to actively elevate the weighted arm?

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

To add this blog to your reading list in Google Chrome, click on the reading list icon




Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Saturday, November 19, 2022

Managing posterior glenoid wear with shoulder arthroplasty


As shown below in diagrams by Steve Lippitt, there are at least six arthroplasty methods for shoulders with posterior bone loss (A):
Anatomic total shoulder
B. Incomplete glenoid reaming along a normalized glenoid axis leaving the posterior aspect of the glenoid component unsupported
C. Complete glenoid reaming along a normalized glenoid axis removing sufficient anterior bone to normalize version (ATSA+HSR)
D. Conservative glenoid reaming removing a small amount of glenoid bone accepting glenoid retroversion
E. Incomplete glenoid reaming along a normalized glenoid axis supporting the posterior aspect of the glenoid component with a bone graft
F, Incomplete glenoid reaming along a normalized glenoid axis using an augmented glenoid component to accommodate the gap between the reamer and the bone

G Reverse total shoulder (RSA)
 1. With glenoid reaming along a normalized glenoid axis alone
 2. With glenoid reaming along a normalized glenoid axis with posterior bone graft or a metal augmented base plate 
 3. With reaming along a modified glenoid axis




The authors of Anatomic Shoulder Arthroplasty With High Side Reaming Versus Reverse Shoulder Arthroplasty For Eccentric Glenoid Wear Patterns With An Intact Rotator Cuff: Comparing Early Versus Mid-Term Outcomes With Minimum 7 Years Of Follow Up did an interesting study comparing the two year and 7 year outcomes from anatomic arthroplasty with method "C" to a reverse total shoulder with method "G1".

A single highly experienced shoulder arthroplasty surgeon performed each of these cases making the intraoperative decision to proceed with either an ATSA+HSR or an RSA according to a defined protocol not involving preoperative planning software: 

After exposure of the glenoid, the anterior high side of the glenoid was preferentially reamed with the glenoid reamer to lower the high side and change glenoid version to zero degrees while minimizing the removal of the subchondral plate. In some cases up to 10 degrees of retroversion was accepted. A glenoid trial sizer was used to estimate how much of the component would be supported by bone, and what percentage was not supported posteriorly. 

If 90% or more of the glenoid component would be supported with host bone, then an ATSA was performed with a pegged, cemented all polyethylene glenoid component. 

If this degree of bony support was not achieved, the surgeon proceeded with a RSA (flat, center screw, non-augmented baseplate with peripheral locking screws, a lateralized glenosphere, and a 135 degree neck shaft angle humeral component). Structural bone graft was used beneath the baseplate in five cases. 

101 ATSA+HSR and 93 RSA had both two-year and final follow-up with a minimum of 7 years after surgery (average 8.3 years for ATSA+HSR and 7.8 years for RSA).

The ATSA+HSR group had 95% B2 and 5% B3 glenoids with an average retroversion of 17 degrees
The RSA group had 74% B2, 22% B3, and 4% C glenoids with an average retroversion of 23 degrees

The postoperative glenoid version for these cases is not reported.

At the two-year follow-up point the ATSA+HSR group had better average SST and ASES scores, while at final followup, the RSA group had better scores. However, while these differences were statistically different, the differences were not clinically different (MCID for SST 2.4, MCID for ASES 20.9 - see this link).







 

At two-year follow-up 95% of the ATSA+HSR cohort were satisfied compared to 93% in the RSA cohort. 
Patient satisfaction at final follow up had decreased in the ATSA+HSR group to 82%, compared to 95% satisfied in the RSA group. 

Of the initial ATSA+HSR cohort 8% of patients had undergone revision compared to 2% in the RSA cohort.



Comment: This study clearly points out the importance of followup longer than the traditional two years. The average time to revision for glenoid loosening and cuff failure after ATSA was over seven years. 

One of the problems with high side reaming is the removal of the dense bone that has been articulating with the arthritic humeral head. Removal of this bone and "correction" of glenoid retroversion  (A) leaves less bone and bone of poorer quality to support an anatomic glenoid component (B). By contrast, conservative glenoid reaming with acceptance of glenoid retroversion (C) preserves the amount of dense bone and provides bony support for a larger glenoid component (D).

As pointed out previously, a large industry has formed around the assessment of, planing for, special components to address, and surgical "correction" of glenoid retroversion to 15 degrees or less in performing an anatomic total shoulder arthroplasty.

        

In Do glenoid retroversion and humeral subluxation affect outcomes following total shoulder arthroplasty? the authors studied 113 patients at an average of 4 years after arthroplasty.  Retroversion and humeral head subluxation before and after surgery were measured on axillary radiographs. 


Left figure above. Assessment of preoperative glenoid retroversion. Line A-C represents the glenoid plane, which is drawn connecting the anterior (A) and posterior (C) rims of the glenoid. Line B-Y represents the scapular plane. Line B-X is the perpendicular bisector of line A-C. The retroversion of glenoid is defined as the angle between lines B-X and B-Y. 

Right figure above. Assessment of preoperative subluxation. The same lines A-C and B-X are drawn. The humeral head circle is drawn with point Z at the center. Line segment D-F marks the humeral diameter, parallel to line A-C. Point E is the intersection between lines D-F and B-X. Subluxation is defined as the percentage of the humeral head posterior to line B-X, and is calculated as (E-F)/(D-F) X 100%.

At surgery, reaming of the anterior glenoid was carried out until satisfactory implant support (>80% of bony contact with the component) was achieved. There was no specific targeted amount of retroversion that was deemed acceptable.

In contrast to many other studies in which CT scans were used to measure the preoperative anatomical relationships and axillary views to make the postoperative measurements, these authors measured postoperative retroversion and subluxation in a manner identical to the preoperative measurements. As shown below.

 

At a mean followup of 4.2 years, the authors found no significant correlation between preoperative glenoid version or humeral head subluxation and the postoperative ASES scores. 




The authors found no significant correlation between postoperative glenoid version or humeral head subluxation and the postoperative ASES scores. 



For patients with preoperative retroversion of >15 degrees, there was no difference in outcome scores based on postoperative retroversion. 



There were no significant differences in preoperative or postoperative version for patients with or without glenoid lucencies.

The overall complication rate was 11.3%, including 5 periprosthetic joint infections, 3 with glenoid loosening, 2 rotator cuff failures, 2 periprosthetic fractures, 1 patient with stiffness treated with lysis of adhesions, and 1 patient with recurrent posterior instability after treatment with shoulder replacement after a locked posterior dislocation. Eleven of these patients underwent component revision. There was no observed difference between patients with or without revision surgery for either preoperative retroversion (15.2 ± 5.5 deg for failures vs. 15.3 ± 7.7 deg for non failures); or postoperative retroversion (7.1± 5.2 deg  vs. 10.0 ± 6.8). 

For the patients with eventual glenoid loosening, the preoperative retroversion was 15 and 17 deg in 2 of the 3 patients (third patient did not have available preoperative imaging) and the postoperative retroversion was 6, 8, and 19 deg. The preoperative subluxation was 64% and 60%, whereas postoperative subluxation was 58%, 49%, and 48%. 

This study does not support the need to "correct" glenoid version to < 15 degrees in performing an anatomic total shoulder. These findings are consistent with the findings in Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?

In a population of patients undergoing TSA in whom no specific efforts were made to change the version of the glenoid, these authors asked whether at 2 years after surgery patients having glenoid components implanted in 15° or greater retroversion had (1) less improvement in the Simple Shoulder Test (SST) score and lower SST scores; (2) higher percentages of central peg lucency, higher Lazarus radiolucency grades, higher mean percentages of posterior decentering, and more frequent central peg perforation; or (3) a greater percentage having revision for glenoid component failure compared with patients with glenoid components implanted in less than 15° retroversion. They examined the records of  TSAs performed using a standard all-polyethylene pegged glenoid component

inserted after conservative glenoid reaming without specific attempt to modify preoperative glenoid version.




They analyzed the two year outcomes in  71 TSAs, comparing the 21 in the retroverted group (the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°)) with the 50 in the non-retroverted group ( the glenoid component was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°)). 

The mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%).  The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, - 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. 


The radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4-6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). The percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids having revision (three of 50; [6%]; p = 0.251).



The authors concluded that in this series of TSAs, postoperative glenoid retroversion was not associated with inferior clinical results at 2 years after surgery. 


This study evaluated the ability of shoulder arthroplasty using a standard glenoid component to improve patient self-assessed comfort and function and to correct preoperative humeral-head decentering on the face of the glenoid in patients with primary glenohumeral arthritis and type-B2 or B3 glenoids. 


The authors identified 66 shoulders with type-B2 glenoids (n = 40) or type-B3 glenoids (n = 26) undergoing total shoulder arthroplasties with a non-augmented glenoid component inserted without attempting to normalize glenoid version and with clinical and radiographic follow-up that was a minimum of 2 years. The Simple Shoulder Test (SST) score (and standard deviation) improved from 3.2 ± 2.1 points preoperatively to 9.9 ± 2.4 points postoperatively (p < 0.001) at a mean time of 2.8 ± 1.2 years for type-B2 glenoids and from 3.0 ± 2.5 points preoperatively to 9.4 ± 2.1 points postoperatively (p < 0.001) at a mean time of 2.9 ± 1.5 years for type-B3 glenoids; these results were not inferior to those for shoulders with other glenoid types. 




Postoperative glenoid version was not significantly different (p > 0.05) from preoperative glenoid version. The mean humeral-head decentering on the glenoid face was reduced for type-B2 glenoids from -14% ± 7% preoperatively to -1% ± 2% postoperatively (p < 0.001) and for type-B3 glenoids from -4% ± 6% preoperatively to -1% ± 3% postoperatively (p = 0.027). The rates of bone integration into the central peg for type-B2 glenoids (83%) and type-B3 glenoids (81%) were not inferior to those for other glenoid types.





The authors concluded that shoulder arthroplasty with a standard glenoid inserted without changing version can significantly improve patient comfort and function and consistently center the humeral head on the glenoid face in shoulders with type-B2 and B3 glenoids, achieving >80% osseous integration into the central peg. These clinical and radiographic outcomes for type- B2 and B3 glenoids were not inferior to those outcomes for other glenoid types


Long term followup of well-characterized patients treated with the different methods for managing glenoid retroversion will be required to define the relative risks, benefits, effectiveness and durability of each of them.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

To add this blog to your reading list in Google Chrome, click on the reading list icon




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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).


Friday, November 18, 2022

Ream and run - outstanding rehabilitation using swimming

The ream and run procedure is considered for strongly motivated resilient patients who wish to avoid the risks and limitations associated with a plastic glenoid component (see The Ream and Run Procedure - A Shoulder Joint Replacement for Active Individuals.) The technique for this procedure is shown in this link.

Maintaining flexibility is the key to success after a ream and run procedure. In addition to the basic rehabilitation program, swimming has been a valuable complement to the recovery for many patients. 

Here are the preoperative and post operative x-rays of a patient who had her bilateral ream and run procedures 6 months apart, the last being almost a year ago.










From the start, she dedicated to the ream and run rehabilitation program  (see this link), 



By six months after her second side ream and run, she was back swimming in the lake




As the lake has lately gotten a bit chilly for swimming, she's developed some "dry land" swimming simulations, which she has kindly permitted us to show here




Comment: The value of swimming is that it is a gentle, repetitive exercise that (like the pull down and rowing) requiring pulling with the shoulder, Pulling provides distraction of the joint surfaces, which is valuable especially in the early phases of recovery (in contrast to pushing exercises, such as bench press, military press and pushups which compress the healing joint surfaces against each other).

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

To add this blog to your reading list in Google Chrome, click on the reading list icon




Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).