Sunday, October 24, 2021

Total shoulder arthroplasty complicated by rocking horse glenoid component loosening

 A 70 year old patient presented to his surgeon with rheumatoid arthritis, loss of comfort and function in the right shoulder and these radiographs. 




A total shoulder arthroplasty was performed using a stemless humeral component and a posteriorly augmented glenoid component. Early postoperative films are shown below.

After a year or two the patient was seen by a close colleague of ours who documented a history of progressive shoulder pain and stiffness, but no systemic signs and no history of injury. On examination the cuff muscles appeared strong and there was no evidence of instability, crepetance, or swelling.

Plain films showed evidence of glenoid component loosening and loss of bone from the medial humeral cortex.


The shoulder was evaluated arthroscopically with the findings of 11,000 WBC, 2500 RBC (87%PMN), negative cultures and a loose glenoid component. 

CT scan confirmed glenoid loosening with severe osteolysis and evidence of component rocking in the superior and posterior direction. 

The rocking horse mechanism for glenoid component loosening is described in this link.






It is uncertain whether an augmented glenoid component results in an increased loosening arm when the humeral component applies posteriorly directed loads to its rim.


At the time of revision, abundant synovitis and a massive glenoid defect were discovered. The loose glenoid component was removed.


Specimens were sent for culture and single stage revision to a stemmed hemiarthroplasty was performed. The glenoid was allografted. There was insufficient bone for fixation of another anatomic glenoid component or baseplate.






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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link)
Shoulder arthritis - x-ray appearance (see this link)
The smooth and move for irreparable cuff tears (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).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          
Note that author has no financial relationships with any orthopaedic companies.


Saturday, October 23, 2021

Superior capsular reconstruction with autograft: the importance of the subscapularis

Clinical outcomes and temporal changes in the range of motion following superior capsular reconstruction for irreparable rotator cuff tears: comparison based on the Hamada classification, presence or absence of shoulder pseudoparalysis, and status of the subscapularis tendon

These authors report their outcomes for 54 consecutive patients with irreparable rotator cuff tears or pseudoparalysis (PPS) who underwent superior capsular reconstruction (SCR) using autologous tensor fascia lata with an average graft thickness of 8.3 mm.


The inclusion criterion for SCR was an irreparable rotator cuff tear or PPS with failed conservative treatment, supervised by physiotherapists, for >6 months. In all patients, the Hamada classification was grade 2 in 11 patients and grade 3 in 43 patients.


Included shoulders had a Goutallier grade 3 or higher fatty infiltration of the tendon with the tendon retracted to the glenoid level as evaluated on magnetic resonance imaging and torn tendons that could not reach the original footprint after the release of soft tissues at the time of surgery.


Pseudoparalysis (PPS) was defined as

(1) moderate PPS (n=16), no shoulder stiffness, active shoulder elevation (both flexion and abduction) ≤ 90 degrees , and the ability of the patient to maintain  ≥ 90 degrees  of elevation once the shoulder was passively elevated; 

(2) severe PPS (n=16), comprising no shoulder stiffness, active shoulder elevation  ≤ 90 degrees, and the inability of the patient to maintain  ≥  90 degrees of elevation once the shoulder was elevated passively; and 

(3) non-PPS (n=22), comprising no shoulder stiffness and active shoulder elevation 90 degrees. 


Lidocaine was routinely injected into the subacromial space preoperatively; patients whose ROM improved were considered to have a painful loss of elevation and were not considered as patients with PPS. 


Patients who could not elevate their shoulders even in the supine position were considered to have deltoid insufficiency and were excluded from this study.


The 32 PPS patients were divided into 3 groups: intact subscapularis (SSC) (11 patients), repairable SSC (16 patients), and irreparable SSC (5 patients). 


They found no significant differences in postoperative ASES scores and shoulder range of motion between the Hamada grade 2 and grade 3 groups or between the non-PPS, moderate PPS, and severe PPS groups.  PPS patients required a longer duration to achieve shoulder elevation 130 degrees; nevertheless, the authors found no significant differences in final outcomes between the non-PPS and PPS groups. 



However, significant differences in postoperative ASES scores were observed between the intact SSC (final ASES =  91) and irreparable SSC groups (final ASES = 56) and between the repairable SSC (final ASES = 92) and irreparable SSC groups (final ASES = 56). There were significant differences in postoperative shoulder elevation (see graph below). The repairable SSC tear group tended to take longer to achieve improvement in shoulder elevation than the intact SSC group, although the final outcomes between the 2 groups did not show a significant difference. 



The patients noted to have anatomic failure of the SCR had excellent shoulder function and no or minimal pain as did patients with partial failure of the subscapularis repair.

The authors concluded that the status of the subscapularis, rather than the Hamada grade or the presence or absence of PPS, influenced the clinical outcomes in this series of SCRs.

Comment: This study demonstrates the importance of the subscapularis integrity in the functional outcomes of reconstruction for irreparable rotator cuff tears. It also demonstrates the potential for reversing pseudoparalysis using superior capsular reconstruction with autologous tensor fascia and the timeframe for recovery.

The application of superior capsular reconstruction, rather than reverse total shoulder, is interesting and requires further clinical investigation of indications, technique and outcomes.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/


How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link)
Shoulder arthritis - x-ray appearance (see this link)
The smooth and move for irreparable cuff tears (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).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          
Note that author has no financial relationships with any orthopaedic companies.


Failed arthroscopic rotator cuff repairs - the importance of patient selection.

It is estimated that at least 25% of individuals over 60 years of age and almost 50% of individuals over the age of 70 have problems with rotator cuff function and integrity. Hundreds of thousands of rotator cuff surgeries are performed each year at costs estimated at over $7 billion. The reported percentage of rotator cuff repairs that fail after arthroscopic rotator cuff repair (ARCR) because of postoperative re-tear ranges from 10 to 94%. 

For these reasons it is important to understand which patients are likely to have a failed repair. A recent article attempted to address this question.

Risk factors affecting rotator cuff retear after arthroscopic repair: a meta-analysis and systematic review

These authors assessed 14 studies from 6 countries with a total of 5693 patients. 


Their meta-analysis revealed that the risk factors for re-tear after rotator cuff repair were age, body mass index, diabetes, subscapularis and infraspinatus fatty infiltration, symptom duration, bone mineral density, tear length, tear width, tear size area, amount of retraction, critical shoulder angle, acromiohumeral interval, distance from the musculotendinous junction to the glenoid, operative duration, biceps procedure, and postoperative University of California Los Angeles shoulder score.


Comment: While the authors suggest that this study may lead to "targeted prevention and treatment strategies for modifiable risk factors, which are of great significance for reducing the occurrence of rotator cuff retear after ARCR", it is not clear that any of the identified risk factors are actually modifiable. The value of this analysis may lie primarily in its guidance in the selection of patients for ARCR who do not have the risk factors and, thus, are more likely to have a successful repair.


A discussion of the evaluation and management of patients with cuff tears can be found in the Rotator Cuff Tear Book (see this link).


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/


How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link)
Shoulder arthritis - x-ray appearance (see this link)
The smooth and move for irreparable cuff tears (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).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          
Note that author has no financial relationships with any orthopaedic companies.


Friday, October 22, 2021

The value of outpatient shoulder arthroplasty and selection bias

 Safety and Cost Effectiveness of Outpatient Total Shoulder Arthroplasty: A Systematic Review

These authors conducted a systematic review of patient selection, perioperative protocols, complications, costs, patient satisfaction, and clinical outcomes of outpatient total shoulder TSA and compared these with inpatient total shoulder TSA.

Their review identified 25,808 and 231,408 patients undergoing outpatient and inpatient TSA, respectively. 


Patient selection for outpatient TSA was based on patient age, medical comorbidities, social support, living proximity to location of surgery where emergency care is available.


Common criteria for outpatient arthroplasty included

    age younger than 70 years

    no evidence of preoperative anemia or previous venous thromboembolism

    no chronic obstructive pulmonary disease; no uncontrolled sleep apnea

    no cardiac comorbidities (no heart failure, no anticoagulation use and two or fewer cardiac stents).

    no pacemaker or defibrillator

    no opioid dependence 

    no hypertension or diabetes

    no bleeding disorder, dialysis, cancer

    no peripheral vascular disease

    no depression

    no chronic anemia

    approval for outpatient surgery by  anesthesia staff

    adequate social support

    close proximity of residence to the hospital or ASC

    ASA Physical Status scores of 3 or less


Readmission rates were similar between inpatients and outpatients, with one study finding more readmissions after inpatient TSA. 


Five studies found that patients having outpatient TSA were at a lower risk of overall complications,and

shoulder-related complications (eg, dislocation, manipulation under anesthesia, surgical site infection, capsulitis, and hematoma).


Three articles discussed reasons for outpatient readmissions; medical complications (n = 57, 67.0%), implant-related complications (n = 17, 20.0%), and uncontrolled pain (n = 11, 13.0%) were the most common. 


Five studies found no statistical difference in ED visits between outpatient and inpatient TSA. 


Ten studies, with 446 outpatient TSAs found that only six patients (1.3%) having outpatient arthroplasty required an unplanned overnight stay.


Reasons for failed outpatient surgery were surgery delays,  patient convenience, hypoxia and not meeting postanesthesia care unit (PACU) discharge criteria.


Outpatient TSA demonstrated a charge reduction of $25,509 to $53,202 per patient. One study found  that a bundled payment program in an ambulatory surgery center reduced total charges of care, mainly through reduced implant charges ($42,410 versus $44,530, P = 0.024).


Patient satisfaction after outpatient TSA was “good to excellent” in more than 95% of patients.


Comment: It is apparent that the successful implementation of an outpatient arthroplasty program requires dedication to a carefully delineated patient selection program, a well organized approach to preoperative education, anesthesia, postoperative pain management, and infrastructure to support patients that may have postoperative difficulties. It also requires thoughtful scheduling, in that a patient having early morning surgery is more likely to be ready for same day discharge than a person having arthroplasty in the late afternoon.


Performance of arthroplasty in an ambulatory surgery center may enable cost-saving negotiations, such as implant cost - the principal driver of arthroplasty expense.


Finally, there may be other selection bias effects of outpatient vs inpatient arthroplasty. It seems possible that patients having outpatient surgery would be more likely to have commercial insurance, to have higher household incomes, to have better family support, and to be better educated - each of which is likely to be associated with better outcomes. While these patient characteristics were not investigated in this study, it seems important that they be included in future studies.


If outpatient surgery enables lower implant costs and selects for socially advantaged patients who are likely to have better outcomes, the value (benefit/cost) will be appear to be greater for ambulatory surgery. These effects should be controlled for in comparative studies.


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/


How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link)
Shoulder arthritis - x-ray appearance (see this link)
The smooth and move for irreparable cuff tears (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).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          
Note that author has no financial relationships with any orthopaedic companies.

Thursday, October 21, 2021

Subscapularis and shoulder arthroplasty: repair, failure and reconstruction

Failure of the subscapularis after shoulder arthroplasty is a clinically important complication that can substantially compromise the comfort and function of the shoulder. 

Take down and repair

Like most complications, subscapularis failure is better prevented than treated. Our approach includes takedown using a careful subscapularis peel, keeping the subjacent capsule intact to the tendon.

After the arthroplasty, the subscapularis tendon and subjacent capsule are repaired to the humerus using at least 6 sutures passed through secure drill holes at the margin of the humeral head cut.





The superior band of the subscapularis, also known as the upper rolled border, is the major strength of the subscapularis. The suture laced through it at the time of repair carries a disproportionately high percent of the total tendon load when the arm is externally rotated (see this link). We refer to this most important suture as the Mother Stitch.



This repair can be reinforced with a rotator interval plication.

                         

During the first two months after shoulder arthroplasty, we are careful to have the patient stretch in flexion



but NOT in external rotation to avoid stressing the repair.






Diagnosing failure

Because post operative MRIs and sonograms after shoulder arthroplasty can be difficult to interpret, the diagnosis of subscapularis failure is often best made from 

(1) history - force on the repaired tendon within the first two months after surgery resulting from

    a fall on the arm, 

    a sudden or unexpected stretch in external rotation beyond the handshake position 

    a forceful internal rotation (e.g. while restraining a dog chasing a squirrel)

(2) physical exam

    increased external rotation from what was recorded in the operating room at the close of the case


    weakness of belly press with the arm out to the side


(3) radiographs
    
    anterior subluxation of the humeral head on the glenoid seen on the axillary "truth" view of the left shoulder


Reconstruction

    When diagnosed early after injury, the subscapularis can often be reconstructed with a hamstring allograft passed through drill holes in the lesser tuberosity laterally.


and through the residual tendon medially



Securing the graft back to the tuberosity reinforces the subscapularis attachment to the humerus






and restores stability to the joint.

Here's a variation of the method used in a case last week, this time on the right shoulder.  The graft was first passed through the lower hole in the tuberosity, then up through the subscapularis tendon, then back down through the subscapularis tendon and then out the upper hole in the lesser tuberosity. In this case the graft was used to back up a standard repair of the subscapularis tendon to the humeral neck cut.


The two limbs of the graft passed through the lesser tuberosity were then tied to each other and secured with locking sutures.




An article on subscapularis failure was recently published:

Failure rates and outcomes after anatomic total shoulder arthroplasty are equivalent irrespective of subscapularis repair technique

They conducted a retrospective study of patients who underwent primary anatomic TSA with subscapularis tenotomy using either transosseous repair (TOR #=192) or direct primary tendon repair (PTR #=114) of a subscapularis tenotomy. 


The "primary outcome studied was clinical subscapularis failure, defined as anterior subluxation of the glenohumeral joint as seen on axillary lateral radiographs with accompanying clinical decompensation, including pain and loss of active forward elevation and internal rotation.""Patients were not routinely screened by ultrasound or MRI to evaluate subscapularis integrity. Additionally, internal rotation strength testing was based on manual muscle testing. Clinical assessment of internal rotation strength is fairly subjective and limited because nearly all of the patients had 4/5 or 5/5 internal rotation strength." Substantial emphasis was placed on the patient's response to a question from the ASES score which asks about the ability to perform functional internal rotation activities such as putting on a bra or washing the back. Of note only 41.4% of the TOR group and 33.3% of the PTR group responded with “not difficult.”


Subscapularis failure was recognized in 13 patients (4.2% among the TOR group and 4.4% among the PTR group). Reoperation was performed in 18 patients. Subscapularis failures, complications not requiring surgery, and reoperations were not significantly different between the two groups. 


Comment: In this retrospective study of an institutional database it appears that the patients in this series may not have been routinely and systematically examined for subscapularis failure, but rather the diagnosis was inferred from radiographs and from ASES scores. It is therefore possible that the rate of subscapularis failure was underestimated.


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/


How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link)
Shoulder arthritis - x-ray appearance (see this link)
The smooth and move for irreparable cuff tears (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).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          
Note that author has no financial relationships with any orthopaedic companies.


Anatomic or reverse total shoulder for capsulorrhaphy arthropathy?

Capsulorrhaphy arthropathy is a condition in which arthritis follows a prior procedure for recurrent shoulder instability.





Some of these patients have arthritis related to prominent suture anchors (see this link and this link).



A recent article reported on the results of two approaches to the management of capsulorrhapy arthropathy.

Anatomic and Reverse Total Shoulder Arthroplasty for Dislocation Arthropathy Yield Comparable Functional Outcomes to Matched Cohort

These authors sought to compare outcomes of anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA) for arthritis following prior shoulder stabilization (capsulorrhapy arthropathy) versus matched cohorts without previous stabilization surgery. 


They conducted a retrospective cohort study that compared 36 aTSA and 32 rTSA patients with prior shoulder stabilization with 3-to-1 matched cohorts with no prior shoulder instability or surgery. 


The functional outcomes were comparable for the two implant types.




The postoperative adverse events (AE) rate was 8.3% and 4.6% in the aTSA group and matched cohort, respectively.


The postoperative AE rate was 6.3% and 4.2% among the rTSA group and matched cohort, respectively.


The overall adverse event rate was not different between aTSA and rTSA.




 

Comment: This study does not demonstrate increased value to the patient from the use of the more expensive reverse total shoulder arthroplasty in the management of patients with capsulorrhaphy arthropathy.


For active individuals, we've found that the ream and run procedure (see this link) can be effective in the management of capsulorrhapy arthropathy while avoiding some of the types of adverse events seen in aTSA and rTSA (see this link and this link).


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/


How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link)
Shoulder arthritis - x-ray appearance (see this link)
The smooth and move for irreparable cuff tears (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).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          
Note that author has no financial relationships with any orthopaedic companies.