Thursday, July 18, 2024

A 61 year old women with an irreparable cuff tear



A recent post, Innovation, balloons and irreparable cuff tears, reminded us that (1) rotator cuff integrity was not necessary for satisfactory shoulder function and (2) many treatments for irreparable cuff tears (superior capsular reconstructions, bioinductive grafts, subacromial balloons, tendon transfers, reverse total shoulder arthroplasty) can be more costly, have a longer recovery periods, and have higher complication rates without yielding superior outcomes than simple debridement in appropriately selected cases.

In patients having symptomatic irreparable cuff tears but with retained active elevation above the horizontal, we consider a smooth and move procedure: removing hypertrophic bursa and degenerated cuff remnants, smoothing any tuberosity prominence, manipulation to eliminate any capsular tightness, and preserving the coracoacromial arch and all functional cuff elements (including the long head tendon of the biceps unless it is frayed or unstable). No partial repair is attempted. (see Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation and Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

Here is an example from earlier this month. A 61 year old woman had chronic activity-limitng pain in her right shoulder. She answered "no" to all 12 of the Simple Shoulder Test questions

    

Her shoulder examination is shown below. Her supraspinatus was too painful to test. 

Her MRI showed a severely degenerated supraspinatus tendon with an irreparable tear.

Her symptoms did not respond to a course of physical therapy.

After discussion of the non-operative and surgical options, she elected to proceed with a smooth and move procedure. 

At surgery, the degenerated supraspinatus tendon was irreparable. It was debrided. The subscapularis and infraspinatus were intact. The intact biceps tendon was preserved.  The undersurface of the coracoacromial arch was smooth; it was preserved. The uncovered tuberosity prominence was smoothed.  The shoulder was manipulated for a full range of motion. No implants were used.

The patient began active assisted flexion immediately following the procedure without surgeon-imposed restrictions. She returned to the office three weeks after surgery with comfortable active elevation >150 degrees. 

Her three week Simple Shoulder Test responses and her active elevation are shown below.







While the smooth and move is not a perfect solution for irreparable cuff tears and while it is not applicable in all such cases, it does have the advantages of effectiveness, low cost, low complication rate, simple rapid rehabilitation, and leaving the door open for additional surgeries in the uncommon event that they become indicated.

Comments welcome at shoulderarthritis@uw.edu


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


Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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, July 14, 2024

Acromial and spine stress fractures after reverse total shoulder.



As is the case for most stress fractures, acromial and spine stress fractures (ASF) after reverse total shoulder (RSA) result from changes in the magnitude, direction and frequency of loads applied to the bone. The observation that ASF are more common in shoulders with cuff deficiency suggests that an intact cuff may reduce the changes in loads on the acromion and scapular spine by assuming a portion of the humeroscapular forces.

Changes in acromial and scapular spine loading result from surgeon-controlled factors, including implant design and implant placement. Glenoid-sided lateralization can increase shoulder range of motion by reducing abutment between the humerus and the scapula as well as reducing the risk of scapular notching. What are the down-sides of glenoid-sided lateralization?


In communication with the corresponding author, it was verified that glenoid-sided lateralization in the system used in this study reflects the combination of baseplate offset (0, 2 or 4mm) and glenosphere offset (0 to 8 mm). See red arrow in the figure below.



In this series, glenoid sided lateralization ranged from 0 to 8 mm. The amount of glenoid sided lateralization was not associated with ASF risk: the incidence of fracture did not increase with greater glenoid-sided lateralization (0-2 mm, 7.4%; 4 mm, 5.6%; 6 mm, 4.4%; 8 mm, 6.0).  



However, humeral distalization did increase the risk of ASFs. The pre- to postoperative change in acromiohumeral distance (AHD, measured as shown above) was higher in the stress fracture group (2.0 ± 0.7 cm vs. 1.7 ± 0.7 cm). For every centimeter increase in the change in AHD, there was a 121% increased risk for fracture. 

It can be concluded that for this implant system (a 135 degree inlay humeral component) the change in humeral position relative to the acromion  (whether from inferior tilt of the glenosphere, increased inferior overhang of the glenosphere, as well as from the type and positioning of the humeral implant) can change the magnitude and direction of the forces experienced by the acromion, creating a risk for stress fracture.

Minimizing the surgeon-controlled risk factors - such as avoiding over-lenthening - seems particularly important in shoulders that are intrinsically at increase risk for ASF, such as those with superior displacement of the humeral head relative to the scapula, a thin acromion, osteopenia, inflammatory arthropathy, advanced age and rotator cuff deficiency (see figure below).



Comment to shoulderarthritis@uw.edu

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

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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). 


Friday, July 12, 2024

Shoulder motion, function and satisfaction after arthroplasty


A recent article, Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty, pointed out that satisfaction after shoulder arthroplasty - can be associated with scores on patient-reported outcome measures (PROMs). (See Patient satisfaction after shoulder arthroplasty - anticipation and informing). In turn, PROMs are dependent upon restoring lost shoulder range of motion (ROM). The authors questioned whether there was a threshold in postoperative active ROM beyond which additional improvement in motion was not associated with additional improvement in the PROMs that primarily measured function (Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES] score, and the Shoulder Pain and Disability Index [SPADI]). (
Of note, other outcome measures, such as the Shoulder Arthroplasty Smart Score, primarily measure motion (70% of the total score) attributing only 10% of the points to function).

They included 4,459 TSAs (1,802 aTSAs, 2,657 rTSAs) with minimum 2-year follow-up. Indeed they found thresholds in postoperative ROM that were associated with no further improvement in the standard PROMs.

The "S" shapes of these curves are interesting. See for example the figures below plotting the patient's Simple Shoulder Test (SST) responses against active flexion and active external rotation. 




At the left side of these curves, improvement in motion has little effect on the number of SST functions the shoulder could perform. In the middle, there is a steep improvement in function with increasing range. At the right hand of the "S", the curve flattens out so that further improvements in range are not strongly associated with increased function. For the SST the inflection points (thresholds) were 153 degrees for active flexion, 50 degrees of active external rotation, and active internal rotation to L2. Similar thresholds were found for other function-based outcome measures, including the ASES score and the SPADI.

Subjective satisfaction was assessed by asking patients to rate their shoulder as being  “worse”, “unchanged”, “better”, or “much better” compared to before surgery. Among shoulders that achieved all ROM thresholds, 93% of patients rated their shoulder as “much better” compared to before surgery.

It is interesting to view these results in the light of data presented in Practical Evaluation and Management of the Shoulder. The authors of that book characterized elevation in terms of the angle of elevation


and the plane of elevation.




They learned that - rather than being confined to "abduction" and "flexion" - different functions were performed in different planes and with different angles of elevation.


It can be seen that the average maximum angle of elevation for eight normal subjects was 148 degrees, and that this range was not necessary for most of the activities of daily living.

Of course the ability to perform functions does not only depend on elevation angle and plane, but also on the rotation of the arm as shown below.


Thresholds For Diminishing Returns In Postoperative Range Of Motion After Total Shoulder Arthroplasty is an important article in that it can help guide motion goals for arthroplasty surgery and postoperative rehabilitation. It suggests that a shoulder that has active elevation to 180, external rotation to 90 and internal rotation to T7 may not be more functional or satisfactory than one has 153 degrees of active flexion, 50 degrees of active external rotation, and active internal rotation to L2. 


Comment to shoulderarthritis@uw.edu

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

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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, July 9, 2024

Innovation, balloons and irreparable cuff tears


I hope you enjoy the Hidden Brain as much as I do. 

A recent post Do less. points out that the human drive to invent new things has led to pathbreaking achievements in medicine, science and society. But our desire for innovation can keep us from seeing one of the most powerful paths to progress: subtraction. Sometimes the best way forward involves removing, streamlining and simplifying things.

One of the examples given is that while training wheels on a kid's bike seem like a good innovation, it enabled the child to ride without learning to balance.



It turns out that a better way to teach a kid to ride is to subtract the pedals and training wheels and - voila - the balance bike.

I'm also a big fan of the ASES podcast. A recent program,  Balloon vs. Tuberoplasty, reviewed options for managing irreparable rotator cuff tears, including superior capsular reconstruction, subacromial balloons, partial repairs, tendon transfers, and "biologic" tuberoplasty. The panel concluded that while there were "non-inferiority" studies and case reports, no surgical procedure was the clear favorite. As an example, a recent case series, Arthroscopic Subacromial Balloon Spacer for Massive Rotator Cuff Tears Demonstrates Improved Shoulder Functionality and High Revision-Free Survival Rates at Minimum 5-Year Follow-up, combined debridement with the placement of a subacromial balloon in 61 patients. 10 were lost to follow-up over 3 years. Of the remaining 51, 9 were lost at the latest follow-up.  17% required revisions within two years. Constant-Murley total scores increased significantly (27 to 69). 10% were highly satisfied, 48% were satisfied, and 43% were dissatisfied.

The podcast concluded with Justin Griffin saying, "There may be a future where we figure out a way to retrain the deltoid in the setting of a massive cuff tear that does not require any procedures." - an example of innovation by subtraction.

Many shoulders with chronic irreparable cuff tears (including my own) are comfortable and functional.  For patients with chronic irreparable cuff tears and problematic weakness, there is the opportunity to use a simple exercise to retrain the deltoid, which is the primary source of shoulder power no matter what other treatments are considered.



Patients with irreparable cuff tears can have painful subacromial crepitus, which can be identified by placing the examiner's finger just anterior to the acromion while the shoulder is moved in rotation and elevation. As mentioned in the ASES podcast, many surgical procedures have been advocated for such a patient, yet there are very few studies that compare these methods with each other. 

The authors of Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age network meta-analysis to analyze comparative studies of surgical treatment options for massive irreparable cuff tears - without glenohumeral arthritis or pseudoparalysis -  in patients <70 years of age. The treatments included debridement; arthroscopic bridging graft; arthroscopic partial repair; superior capsular reconstruction; long head of biceps augmented superior capsular reconstruction; InSpace balloon placement; tendon transfer; and reverse shoulder arthroplasty.

A total of 23 studies met the inclusion criteria, with 1178 patients included in the analysis. The mean weighted age was 62.8 years; 48.2% were men, mean follow-up was 28.9 months. There were no significant differences between groups in regard to sex or age. 

The treatments were ranked using the the P-score - an estimate of the likelihood that the investigated treatment is the ideal method for an optimal result for each of the different outcome measures, where 0 is least effective and 1 is most effective.

Unfortunately most studies did not evaluate treatment with simple debridement in comparison to more complex procedures. However for studies that did, debridement had the highest P-score, as shown below.



Forrest plot for Constant Score:



Forrest plot for range of active forward flexion:

This network meta-analysis found that simple debridement was the most effective procedure in significantly improving Constant score and active flexion for individuals with massive irreparable cuff tears when it was compared to other more complex surgical modalities. 

Comment: Debridement is a component of most procedures performed for irreparable cuff tears. Debridement alone subtracts away the other possible surgical elements (balloons, grafts, partial repair). It has the important advantages of not requiring any post-surgical down time and of not burning bridges for other procedures should it not yield the desired result. Furthermore it is the least costly in comparison to grafts, balloons, and partial repairs and avoids the possible complications of these procedures. 

We refer to our approach to debridement as the "smooth and move procedure" emphasizing the goals of smoothing the articulation between the coracoacromial arch and the proximal humerus and initiating passive and active motion following the procedure. We have found this procedure to be effective not only as a primary procedure for patients with irreparable cuff tears, but also as a revision procedure for patients with failed prior attempts at surgical reconstruction.

Elements of this technique include (1) preserving the integrity of the deltoid and coracoacromial arch, (2) preserving the long head of the biceps unless it is frayed or dislocated, (3) removing hypertrophic bursal tissue, (4) trimming the rough edges of the reaming cuff, (5) resecting the prominent portions of the greater tuberosity, (6) manipulating the shoulder to eliminate any capsular tightness, and (7) starting motion exercises immediately after surgery.

The surgical technique and the outcomes of two patients having the smooth and move after failed cuff reconstruction attempts is shown in this link.

Two publications present the outcomes for this procedure:

Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

Comment to shoulderarthritis@uw.edu

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

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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, July 8, 2024

B0 glenoid in a 37 year old, what is the treatment?

A 35 year old man presented with left shoulder pain for 6 months. He has been doing martial arts and took several falls onto shoulder. Has tried PT for shoulder pain, also NSAIDs - without long term relief. He had bilateral clavicle fractures treated with ORIF. His exam shoulder full motion, with no weakness. Tender over biceps groove, positive O'Brien's and Mayo shear. 

His axillary "truth" view obtained with the arm in a position of functional elevation shows posterior decentering without obvious arthritic change.



His MRI obtained with his arm at the side shows no posterior decentering, but a linear tear of the posterior labrum at the chondral labral junction (red arrow) along with a posterior glenoid articular cartilage defect (yellow arrow).




Comment: The question is whether there is any treatment that will keep the arthritis from progressing.


Contact: shoulderarthritis@uw.edu

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

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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, July 6, 2024

Is this shoulder infected?

 A 61 year old lady with systemic lupus erythematosus controlled on hydroxychloroquine on peritoneal dialysis for chronic renal failure and allergic (rash) to Keflex, Penicillins, and Doxcyline presents with a painful and stiff right shoulder hemiarthroplasty. 

Her preoperative CBC was normal. There was no clinical suggestion of infection.



After discussion of the alternatives, she elected to have a reverse total shoulder arthroplasty. 

At surgery, aspiration of her joint revealed cloudy fluid with 4+ neutrophils. A biopsy of her collar membrane was reported as below 



Her single stage revision was carried out with concern about the possibility of infection. Betadine lavage and topical antibiotics were used.


Our Infectious Disease consult recommended cefpodoxime PO, which she has tolerated well. Six deep cultures were obtained, only one of which had bacterial growth (one colony of Bacillus species, not anthracis from 1 of 5 media).

The reader may wish to decide if the MSIS criteria for periprosthetic infection are helpful in the management of this case.


In any event the plan is to continue oral antibiotics for 6 months, being thankful that she has had no adverse reactions.

Comment: A practical approach is to (1) consider treating obvious infections (e.g. erythema, swelling, drainage, elevated serum markers, positive aspirate for virulent organisms, failed single stage) with a two stage revision unless the patient's condition prohibits and (2) treating all other revisions as if they might be infected (taking five deep cultures, thorough debridement, thorough lavage, single stage revision and oral antibiotics at least until the culture results are finalized at three weeks).


Contact: shoulderarthritis@uw.edu

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

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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). 







Thursday, July 4, 2024

Managing the B2 glenoid in an active young man


A 46 yo man presented with a history of progressive left shoulder pain and stiffness. He grew up with an active lifestyle and played football and lacrosse. He injured his shoulder playing football but did not have prior shoulder surgery. He is reliant on his upper extremity function for his work that requires routinely lifting more than 25 lbs overhead. He had complaints of worsening shoulder pain and stiffness despite receiving 3 corticosteroid injections and 1 synvisc injection. He was told by his local orthopaedist that he was too young for a conventional total shoulder replacement.

His physical examination revealed very limited range of motion
His preoperative images are shown below.


Note the functional posterior decentering on his axillary "truth" view
In contrast to the relationship between the humeral head and the glenoid shown on the CT scan.




Because he had exhausted non-surgical treatment and his symptoms continued to impact his quality of life, surgical treatment was discussed, including ream-and-run arthroplasty and anatomic total shoulder arthroplasty. Because of his active lifestyle and activity demands at work, he decided to proceed with a ream-and-run arthroplasty. The long head of the biceps was tenodesed to the upper border of the pectoralis major and a lesser tuberosity osteotomy was performed to gain access to the shoulder joint. Correction of glenoid version was not attempted, and an anteriorly eccentric humeral head was used to improve centering of the articulation between the humeral head and glenoid. A short humeral stem was used to allow the use of an anteriorly eccentric humeral head. In this cases, impaction grafting was not needed to achieve adequate stability of the stem. 

His postoperative images are shown below.


Note the humeral head is nicely centered in a mono-concave glenoid.





At 6-months, he is doing great and is back at work without any activity limitations. He has done a terrific job of maintaining his motion and the focus is now on continuing to strengthen his rotator cuff, deltoid and periscapular musculature. 



This case was submitted by the patient's surgeon, Corey Schiffman.

Comment: Alternative management might have included continued non-operative management, an anatomic total shoulder without corrective reaming and a standard glenoid component, an anatomic total shoulder with an augmented glenoid component, or a reverse total shoulder. In this case a ream and run was selected - a procedure that preserved the maximum amount of glenoid and humeral bone stock, while avoiding the risks and limitations associated with anatomic or reverse total shoulder arthroplasty.

Contact: shoulderarthritis@uw.edu

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

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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).