Sunday, January 16, 2022

Can patients accurately remember their pre-arthroplasty shoulder pain - impact on MCID calculation?

 Patients recall worse preoperative pain after shoulder arthroplasty than originally reported: a study of recall accuracy using the American Shoulder and Elbow Surgeons score

The benefit of shoulder arthroplasty is measured by the preoperative to postoperative change in shoulder comfort and function as perceived by the patient. When preoperative scores are not obtained, it is tempting to try to "retrieve" the preoperative state of the shoulder from the patient's memory. 


These authors investigated the accuracy of patient recall in determining the preoperative American Shoulder and Elbow Surgeons (ASES) score for patients having total shoulder arthroplasty (TSA). They compared actual ASES scores determined prior to surgery with ASES scores based on patient recall at  at 6 weeks, 3 months, 6 months, and 12 months after surgery.


They divided the ASES score into two subcomponents: functional ability and visual analog scale (VAS) for pain.


While recalled ASES function scores were comparable to corresponding preoperative scores across

all time points (analysis of variance, P = .21), recalled VAS pain was significantly higher at all time

points beyond 6 weeks after surgery.


As a result, the recalled preoperative total ASES score was worse than the measured preoperative score.





This indicates that the benefit of shoulder arthroplasty (preoperative to postoperative change) based on recall of the preoperative condition of the shoulder is likely to be exaggerated. Therefore, measurement of the benefit of shoulder arthroplasty needs to be based on the actual, rather than the recalled preoperative comfort and function of the shoulder.



Comment: The results of this study also create uncertainty about the commonly used "anchor method" for determining the minimal clinically important difference (MCID).  The "anchor"is often a questionnaire that asks patients to rate retrospectively the improvement in their shoulder after shoulder arthroplasty. For example, a 4-point anchor might ask patients to rate the change in pain after surgery as “worse,” “no different,” “improved,” or “much improved.” The MCID for the ASES score would be the difference in the average ASES scores of patients answering “worse” or “no change” and the average ASES scores of  patients who answered “improved.” Because this study found that patients inaccurately recalled their preoperative pain, their ability to rate the amount of change in pain may also be inaccurate. Specifically, if patients recall more pain than they actually had, some patients may rate their shoulder as "improved" whereas the actual change in pain was "unimproved". 



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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).

Saturday, January 15, 2022

Reverse total shoulder: better outcomes by selecting healthy patients with uncomplicated osteoarthritis

 Predictors of poor and excellent outcomes after reverse total shoulder arthroplasty

These authors reviewed 338 patients with a mean age of 71.5 year having revere total shoulder arthroplasty by an individual surgeonThe average preoperative ASES score was 35.3 which improved to 82.4 postoperatively.


Worse outcomes were associated with 

diagnoses other than primary osteoarthritis, 

insurance other than private coverage, 

lower preoperative ASES scores, 

workers’ compensation status, 

depression

a preoperative diagnosis of rotator cuff tear arthropathy

preoperative opioid use

a higher number of allergies, and 

prior ipsilateral shoulder surgery.


Comment: This study demonstrates what one might expect: patients who can afford private insurance, those with good preoperative shoulder function, those who have primary arthritis, those who are mentally healthy, those without prior surgery on the shoulder, and those not taking narcotics have the best outcomes after reverse total shoulder..


It would seem that this same group of patients would also do well with an anatomic shoulder arthroplasty. See the articles below:



"TSA and RSA demonstrated similar outcomes and value when used to manage glenohumeral osteoarthritis with an intact rotator cuff."


"There was no significant difference in complication rate or revision surgery rate between patients undergoing TSA and RSA. There were no differences in patient-reported outcome measures between the two groups."


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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).

Friday, January 14, 2022

Are arthroplasty outcomes improving and, if so, why might that be?

 Outcomes of shoulder arthroplasty by year of index procedure: are we getting better?

These authors performed a retrospective analysis of 1899 patient-reported outcomes from their institution’s registry between 2008 and 2018 for anatomic (aTSA) and reverse (RTSA) shoulder arthroplasty. Of 2952 patients entered into the registry, 2 and/or 5 year followup data were available in 1899 (64%); over one-third of the patients did not have followup data.


The average preoperative to postoperative improvement in ASES score for patients reporting two-year followup did not change over time for either aTSA or RTSA


The average preoperative to postoperative improvement in ASES score for patients reporting five-year followup was higher for more recently performed surgeries.





Note in both of the graphs above that the improvement in ASES scores was consistently greater for aTSA than for the more expensive RTSA. Thus the value (benefit/cost) was greater for aTSA.


ASES scores were associated with patient sex, American Society of Anesthesiologists classification, rotator cuff status, primary diagnosis, Walch classification, and revision procedures. Specifically included patients from more recent surgeries were more likely to have a diagnosis of primary osteoarthritis. This was particularly the case for patients having rTSA.


Over the duration of this study there were decreases in the rates of aTSA patients having rheumatoid arthritis, avascular necrosis, cuff tear arthropathy, torn rotator cuff or‘‘other’’ diagnoses relative to OA over time. 


There were decreases in the rates of RTSA patients with acute fracture, old trauma, cuff tear arthropathy, instability, infection, and ‘‘other’’ diagnoses.


Therefore for both procedures, the percentage of the straightforward diagnosis increased while that of the more complex diagnoses decreased.


Comment: Interestingly the 50 point improvement in ASES scores for the most recently performed anatomic shoulder arthroplasties in this study was similar to the improvement reported in a recent publication Assessing the Value to the Patient of New Technologies in Anatomic Total Shoulder Arthroplasty across 20 years:



In that publication, the reported amount improvement in ASES scores after aTSA did not change over two decades (see chart above). 



The results of Outcomes of shoulder arthroplasty by year of index procedure: are we getting better?suggest that the improved results these surgeons observed for more recently performed surgeries may be attributed in large part to a shift in indications for shoulder arthroplasty away from more complex diagnoses in favor of the more straightforward diagnosis of osteoarthritis.


This paper did not assess the value of new implants or technologies, such as preoperative 3D CT planning, in improving the outcome of shoulder arthroplasty. In their discussion they point out that patients receiving newer implant designs do not always achieve better clinical outcomes (see Is there evidence that the outcomes of primary anatomic and reverse shoulder arthroplasty are getting better?) In "Does an increase in modularity improve the outcomes of total shoulder replacement? Comparison across design generations." the authors examined three different generations of implants for total shoulder arthroplasty, determining that second and third generations of glenoid components were at a higher risk of failure when compared with first generation implants.


Since the date of surgery is usually not a modifiable predictor of the result of shoulder arthroplasty, we need to continue to evaluate the importance of procedure selection and surgical technique in optimizing arthroplasty outcomes for patients with different diagnoses and personal characteristics. 


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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).


Tuesday, January 11, 2022

Sex and shoulder arthroplasty

 Gender Influences on Shoulder Arthroplasty

These authors reviewed the recent literature regarding the influence of "gender" on shoulder arthroplasty. They found that while both female and male patients generally benefit from shoulder arthroplasty, several differences may existbin preoperative factors, acute perioperative complications, and postoperative outcomes. 


Female patients were found to 

undergo shoulder arthroplasty at an older age,

have greater levels of preoperative disability and 

have different preoperative expectations. 


Perioperatively, female patients may be at increased risk of 

extended length of stay, 

postoperative thromboembolic events, and 

blood transfusion. 


Postoperatively, female patients may achieve 

lower postoperative functional scores and 

decreased range of motion. 


Finally, female patients may be at greater risk for 

periprosthetic fracture and 

aseptic loosening 

while having a lower risk for 

periprosthetic infection and 

revision surgery.


Comment: In considering these findings, it is important to distinguish sex and gender (the term used by the authors of this article). According to  Sex and gender: What is the difference?“Sex” refers to the physical differences between people who are male, female, or intersex. A person typically has their sex assigned at birth based on physiological characteristics, including their genitalia and chromosome composition. This assigned sex is called a person’s “natal sex.” Gender, on the other hand, involves how a person identifies. Unlike natal sex, gender is not made up of binary forms: instead there is a broad spectrum of genders (a glossary of terms relating to gender may be found in this link).


Most orthopaedic studies comparing male and female patients, such as that presented above, are studies of the effect of sex, rather than gender.


Consider, for example, the chart below from "The “tipping point” for 931 elective shoulder arthroplasties  (see this link)." This graph shows a clear difference between the tipping point for elective arthroplasty between patients of male and female sex. Female patients coming to shoulder arthroplasty had worse preoperative self-assessed shoulder comfort and function. 


Consider also the effect of patient sex on arthritic glenohumeral anatomy as investigated in Prearthroplasty glenohumeral pathoanatomy and its relationship to patient’s sex, age, diagnosis, and self-assessed shoulder comfort and function

Patient sex had a strong effect on the distribution of glenoid types.



and on glenoid version
and on the degree of decentering


The chart below is from Factors Affecting Length of Stay, Readmission, and Revision after Shoulder Arthroplasty, showing the effect of patient sex on length of stay.




In, Correlates with comfort and function after total shoulder arthroplasty for degenerative joint disease, the strongest correlates with postoperative shoulder function included male sex (P<0001), and preoperative physical function (P <0001), social function (P <0001), mental health (P <0001) and shoulder function (P <0001).

Gender identification was not assessed in the studies above.


Rather than focusing on patient sex alone, medical systems are now paying deserved attention to patient gender and documenting some of the important information in the medical record.








As the importance of gender identification is being recognized and documented in medical records, future studies of patients having shoulder arthroplasty are likely to identify differences - not only between the sexes, but also among genders - in preoperative characteristics (height, weight, age, disability, expectations), tipping point for surgery, type of surgery elected, complications and outcomes.


Finally as emphasized in Equity360: Gender, Race, and Ethnicity—Title IX Turns 50:

Women Athletes Are Still Fighting Against Gender Disparities in Sports, transgender individuals may augment or suppress their sex hormone levels which, in turn, may affect bone density and periprosthetic fracture risk as well as the risk of infection after shoulder arthroplasty. See 

Association Between Serum Testosterone Levels and Cutibacterium Skin Load in Patients Undergoing Elective Shoulder Arthroplasty: A Cohort Study and Factors predictive of Cutibacterium periprosthetic shoulder infections: a retrospective study of 342 prosthetic revisions.


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).

Monday, January 10, 2022

Does benzoyl peroxide harm the skin?

The influence of benzoyl peroxide on skin microbiota and the epidermal barrier for acne vulgaris

Benzoyl peroxide (BPO) has been advocated as a means for lowering the Cutibacterium load on the skin of patients having shoulder arthroplasty.


These authors sought to determine the effect of BPO treatment on the skin microbiome and on the epidermal barrier in 33 patients with acne vulgaris and 19 healthy controls.


All subjects received topical treatment with BPO 5% gel for 12 weeks. 


After receiving treatment with BPO, subjects had significant improvement in their Global Acne Grading System (GAGS) score, porphyrin, and red areas.


However, the epidermal barrier indices of stratum corneum hydration (SCH), and transepidermal water loss (TEWL) worsened.


When compared with baseline, microbial diversity was significantly reduced after treatment. The prevalence of the Cutibacterium was significantly reduced after treatment while the prevalence of Staphylococcus tended to increase. 


The authors concluded that BPO treatment may reduce microbial diversity and damage the epidermal barrier.


They suggested that the decline of sebum level by BPO treatment may damage the stratum corneum,

which is known to be covered with a sebum membrane and primarily composed of keratinocytes and lipids to act in the homeostatic control of water. Consequently, increased  transepidermal water loss and decreased stratum corneum hydration were observed and skin irritability and dryness occurred. 


The impaired skin barrier function could promote altered microbial colonization. Their study found that the relative abundance of Staphylococcus increased after treatment alongside a decline in SCH, deterioration of TEWL, and loss of microbial diversity. 


Comment: While BPO treatment can lessen the average load of Cutibacterium on the skin, it can also have adverse effects such as skin irritability, dryness, and cause disturbance of the microbiome (dysbiosis see Cutibacterium - friend or foe?).


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).

Thursday, January 6, 2022

The negative impact of alcohol use disorder on total shoulder outcomes

 The Association of Alcohol Use Disorder on Perioperative Outcomes Following Primary Total Shoulder Arthroplasty for Glenohumeral Osteoarthritis: A Retrospective Matched-Cohort Study

Alcohol use disorder (AUD) refers to a pattern of alcohol use leading to clinically significant impairment or distress, for example continued consumption despite knowledge of physical or psychological problems due to alcohol, consumption of alcohol in excess of initial intention, persistent desire or failure to reduce consumption, cravings, failure to fulfill major roles due to alcohol use, continued use despite recurrent social problems, development of tolerance, or withdrawal with a time interval of 12 months. Approximately 14.4 million individuals over the age of 18 met these criteria for diagnosis with AUD in 2018. The national rate of AUD is rising.


These authors sought to determine whether patients who have alcohol use disorder (AUD) have higher in hospital lengths of stay (LOS), medical complications, and healthcare expenditures after total shoulder arthroplasty (TSA).


They queried the Medicare Claims Database identifying 5,479 patients who underwent primary TSA for glenohumeral OA and had AUD. These patients were 1:5 ratio to a comparison cohort of 27,367 patients matched by age, sex, and various comorbid conditions. 


Patients with AUD had significantly longer in-hospital length of stay (4- vs. 2-days), addition to higher rates  of 90-day complications (30.44% vs. 7.94%) such as surgical site infections (1.15 vs. 0.24%), cerebrovascular accidents (5.06 vs. 1.23%), respiratory failures (5.79 vs. 1.52%), myocardial infarctions (1.53 vs. 0.43%), acute kidney injuries (6.55 vs. 1.34%), and other complications.


Patients with AUD incurred significantly higher day of surgery ($12,160.60 vs. $11,308.48) and 90-day episode of care costs ($14,493.13 vs. $13,087).



Comment: Total shoulder arthroplasty in patients with alcohol use disorder is more risky and more costly. 


A number of mechanisms may contribute to the adverse effects of AUD:

(1) AUD may simply increase the amount of patient care which is required for these patients, prolonging their in-hospital course prior to discharge.

(2) Patients who have AUD may have other psychiatric comorbidities, and the synergestic effects of AUD coupled with these mental health conditions could increase in-hospital LOS.

(3) Alcohol may impair dermal fibroblast function by decreasing the threshold for dermal wound-breaking strength for immature wounds increasing the risk of infection and failure of wound healing.

(4) Chronic alcohol use is thought to disrupt the function of alveolar macrophages with a decrease in phagocytic activity when they are exposed to bacteria.

(5) Alcohol-related inhibition of fibrinolysis and induction of an inflammatory state may predispose to cerebrovascular accidents.

(6) AUD may be associated with poor nutrition, less preventative health care, inferior social support, and lower self-esteem.

(7) AUD is likely to increase the risk of falling after a TSA, injuring the shoulder.


This brings up some important, yet currently unanswered questions: 

(1) How treatable is alcohol use disorder? 

(2) Can the negative effects of AUD be prevented by prospective management? 

(3) How should the presence of AUD change the tipping point (see this link) for elective shoulder arthroplasty? 

(4) Are alcohol use biomarkers (see this link) useful in managing the patient with AUD.


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).




Wednesday, January 5, 2022

Arthroplasty for a B2 glenoid in an 80 year old active man.

Eleven years ago we met an 80 year old active man with painful stiff shoulder and the x-rays below,  showing  posterior decentering of the humeral head on a biconcave, retroverted B2 glenoid with posterior bone loss.


In many practices this situation would "automatically" lead to a reverse total shoulder. After discussion of the alternatives, this patient chose an anatomic total shoulder arthroplasty. Under general anesthesia, a standard glenoid component was inserted without attempting to change glenoid version. As expected, the central peg perforated the anterior glenoid wall. The standard humeral stem was fixed with impaction grafting. An anteriorly eccentric humeral head was used to control posterior translation.

At the age of 91, eleven years after his right anatomic total shoulder arthroplasty, he returned for evaluation of his contralateral shoulder. He reported unlimited painless function of his right shoulder, answered "yes" to all 12 questions of the Simple Shoulder Test, and had the x-rays shown below. The humeral and glenoid components are secure without evidence of radiolucent lines or stress shielding.




Comment: A decade after his arthroplasty this man has realized substantial value from his anatomic shoulder arthroplasty inserted without brachial plexus block, preoperative CT scans or three dimensional planning.

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).