Friday, December 14, 2018

Lesser tuberosity osteotomy nonunion - why not avoid this problem?

Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty
(Journal of Shoulder and Elbow Arthroplasty Volume 2: 1–8, 2018)

These authors observe that lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate.

They present 9 patients with LTO nonunion after primary anatomic shoulder arthroplasty.



LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group.

Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128 forward elevation (FE) and 33 external rotation (ER) compared to 148 FE and 62 ER. One patient with LTO nonunion required conversion to reverse replacement.

They concluded that surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.

Comment: We have not found a place for LTO in our arthroplasty practice because it is not necessary, it creates a new possible complication, it requires sacrifice of the long head biceps tendon, and it compromises the integrity of the proximal humerus.

We prefer the bone and biceps preserving subscapularis peel.





That is carefully repaired with six #2 non-absorbable sutures 

 and well-tied knots.



The repair allows immediate postoperative assisted elevation


 with external rotation to neutral






Stretching beyond neutral rotation and internal rotation strengthening are not started until 8 weeks after surgery.



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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Wednesday, December 12, 2018

Are surgeons doing too many reverse total shoulders?

Comparative Utilization of Reverse and Anatomic Total Shoulder Arthroplasty: A Comprehensive Analysis of a High-volume Center

These authors conducted  a single-center retrospective review of 1,600 primary anatomic total shoulders (TSAs) and 1,192 reverse total shoulders (RTSAs).

During the decade between 2005 and 2015, RTSA increased from 27% to 52% of the shoulder arthroplasties. The number of RTSAs performed for osteoarthritis and irreparable rotator cuff tears increased, and the proportion of RTSAs performed for rotator cuff tear arthropathy decreased.

Comment: Let's first consider the relative economics (reference Orthopaedic Network News)

From these data we see that the average selling price of a reverse is 60% of the medicare payment to the hospital, whereas the average selling price of an anatomic total shoulder is 41%.  Surgeons should review with their hospitals the effect of implant choice on the ability to cover the costs of patient care.

Let's next consider the effect of the aTSA vs RTSA decision on the patient, take for example a 72 year old active man with capsulorrhaphy arthropathy and these x-rays (no CT scan needed!).


who was treated with a standard total shoulder - two year post op films shown below




He recently wrote: "Greetings from Alaska! It's coming up on the end of two years since my shoulder surgery. I just wanted to express to you my deepest thanks for a job well done. My only regret is that I did not find you sooner! Unfortunately with my experience and disappointment with the original surgery 20 plus years ago, it put me off  and influenced my decision to wait so long! I had almost giving up on any normal active life that I had been so used to before that surgery (an instability repair)!

Since my surgery , I have traveled and I still fly my airplane! I have killed a moose to help put meat in our extended families' freezers and I have fly fished and fished salmon and halibut to my heart's content without any discomfort whatsoever. In general, I seem to have no problems with any other recreational activity or physical activity! 

Thank you for going with the traditional total replacement surgery and not going with a reverse replacement as had been suggested by three other surgeons! I am forever grateful for how it all turned out - you have given me my life back! "

The point is that three prior surgeon had tried to convince him to have a reverse, but he was unwilling to accept the limitations.

Thirdly, as the authors of this paper point out, "  few long-term outcomes studies are available, and they suggest that functional survival after RTSA at 10 years may only be 58% to 76%" While they report a trend to performing RTSA in younger patients, younger patients are reported to have higher revision rates and higher rates of unsatisfactory results.

Finally and most importantly, the trend toward increasing volumes of RTSAs does not indicate that this is best treatment for conditions such as osteoarthritis (see case example above). It would seem that these authors are in a great position to compare cost and outcome data for anatomic TSA and RTSA stratified by diagnosis, age and sex, but these data are not presented. We hope that this information will be forthcoming.

In our practice we use RTSA only when it is clearly the best option: pseudoparalysis, anterosuperior escape, and complex proximal humeral fractures. For many other diagnosis, there are safer and less costly approaches that enable higher levels of activity.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'






Monday, December 10, 2018

Do CT scans add value to the preoperative evaluation of the arthritic shoulder?

Intraobserver and interobserver reliability of the modified Walch classification using radiographs and computed tomography 

These authors sought to evaluate the intraobserver and interobserver agreement of the modified Walch classification system using both plain radiographs and computed tomography (CT). 


Three fellowship-trained shoulder surgeons blindly and independently evaluated radiographs and CT scans of 100 consecutive shoulders (98 patients) and classified all shoulders according to the modified Walch classification in 4 separate sessions, each 4 weeks apart.

They included patients who had a diagnosis of primary osteoarthritis and who then underwent shoulder arthroplasty of some type. All patients had preoperative CT scans and axillary radiographs obtained routinely prior to surgery. There were 50 men (51%) and 48 women (49%).

The first reading by the most senior observer on the basis of CT scans was used as the gold standard (distribution: A1, 18; A2, 12; B1, 20; B2, 25; B3, 22; C, 1; and D, 2). 

The average intraobserver agreement for radiographs and CT scans was 0.73 (substantial; 0.72, 0.74, and 0.72) and 0.73 (substantial; 0.77, 0.69, and 0.72), respectively. 

The average interobserver agreement was 0.55 (moderate; 0.61, 0.51, and 0.53) for radiographs and 0.52 (moderate; 0.63, 0.50, and 0.43) for CT scans.

There was a high degree of agreement between the CT scan and the axillary views for each of the three reviewers:


This study showed that the modified classification can be applied to both CT images and axillary radiographs. It found that both axillary radiographs and CT scans can be used reliably with the modified Walch classification to deliver a reproducible assessment of glenoid morphology, as well as to broadly subcategorize the presence or absence of bone loss and eccentric wear or subluxation.This is useful for surgeons who do not, or cannot, routinely obtain CT images prior to shoulder replacement.

Comment:  This study is reassuring to those surgeons (including us) who find that an axillary view provides sufficient information to characterize the pathoanatomy and plan the surgical procedure for the great majority of patients coming to shoulder arthroplasty.

We note that CT scans expose the patient to 26 times the radiation of a standard set of plain radiographs and cost approximately $1000 more. Standardization of the axillary technique can yield highly reproducible views that can be easily analyzed for glenoid type, version, and the degree of decentering as demonstrated below





The use of standardized preoperative and postoperative axillary views provides a practical method for determining the effectiveness of surgical reconstruction.


While it can be argued that CT scans with 3D reconstructions in the plane of the scapula are more precise than an axillary view, it has not been show that patients having this more complex imaging protocol obtain the better functional outcomes necessary to justify its substantial added expense and radiation exposure.
=====

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Total shoulder - is a more expensive sling of value?

The position of sling immobilization influences the outcomes of anatomic total shoulder arthroplasty: a randomized, single-blind, prospective study

These authors randomized 36 patients undergoing anatomic total shoulder arthroplasty for osteoarthritis were randomized to a neutral rotation sling



versus an internal rotation sling.






The slings were worn at all times for the first 6 weeks except during showering, hygienic care, changing clothes, and physical therapy.

The primary outcomes assessed included the Disabilities of the Arm, Shoulder and Hand score;Western Ontario Osteoarthritis of the Shoulder score; Single Assessment Numeric Evaluation score; visual analog scale (VAS) scores for pain and satisfaction; compliance ratings; and radiographic and range-of-motion measurements. Primary outcomes were assessed at baseline and postoperatively at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year.

While there were some measurable differences in postoperative external rotation and adduction, there were no significant differences in the primary outcome patient-reported comfort and function at any time point.






There was no statistically significant difference between groups for overall satisfaction

Comment: This report did not demonstrate the value of the more expensive sling in terms of increased patient self-assessed comfort and function resulting from the use of the more expensive sling.



=====

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Sunday, December 9, 2018

PROMIS unfulfilled - why complicate patient self-assessment?

Performance of PROMIS Global-10 compared with legacy instruments in patients with shoulder arthritis

The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 measures physical and mental health and provides an estimated EuroQol-5 Dimension (EQ-5D) score. These authors goal was to determine the correlation between the PROMIS Global-10 and several conventional measures to validate its overall performance and usefulness in patients with shoulder arthritis.

 Correlation between the PROMIS and EQ-5D was excellent (0.72, P < .001). However, agreement for estimated EQ-5D ranged from 0.37 below to 0.36 above actual EQ-5D scores. Correlation of the PROMIS physical score was good with the ASES score (0.57, P < .001) and poor with the SANE score (0.23, P = .0045) and WOOS score (0.11, P = .3743). Correlation of the PROMIS mental score was poor when compared with all patient-reported outcome instruments investigated (ASES score, 0.26 [P = .0012]; SANE score, 0.13 [P = .1004]; andWOOS score, 0.09 [P = .4311]). 

The authors concluded that the PROMIS Global-10 physical scores show excellent correlation with the EQ-5D. However, the PROMIS Global-10 cannot replace actual EQ-5D scores for cost-effectiveness assessment in this population because of the large variance in agreement between actual and PROMIS Global-10–estimated EQ- 5D scores. PROMIS Global-10 physical scores showed good correlation with the ASES score but poor correlation with other gold-standard patient-reported outcome instruments, suggesting that it is an inappropriate instrument for outcome measurement in populations with shoulder arthritis. 

Comment: This study points out so of the shortcomings of PROMIS, but there are others. Use of PROMIS requires the patient to have access to and be comfortable using a computer interface, such as an iPad


While patient user support and access to such an interface may be facilitated in the surgeon's office, these resources are unlikely to available at the patient's home. As a result the ability to capture outcome data after a treatment is compromised. The actual cost and patient compliance with PROMIS have not been studied

On the other hand, the use of a simple and short paper form (see below) that can be mailed in or sent via email greatly facilitates the tracking of the patient's progress and minimizes the risk of loss to followup.


Here's commentary another PROMIS study:


Correlation of PROMIS Physical Function Upper Extremity Computer Adaptive Test with American Shoulder and Elbow Surgeons shoulder assessment form and Simple Shoulder Test in patients with shoulder arthritis 

The purpose of this study was to evaluate the Patient-Reported Outcomes Measurement Informative System Physical Function Upper Extremity Computer Adaptive Test (PROMIS PFUE CAT) measurement tool against the already validated American Shoulder and Elbow Surgeons (ASES) shoulder assessment form and the Simple Shoulder Test (SST) in patients with shoulder arthritis.

Fifty-two patients with the primary diagnosis of shoulder arthritis were asked to fill out the ASES, SST, and PROMIS PFUE CAT.

The PROMIS PFUE CAT showed a strong-moderate correlation with the SST (r = 0.64; P < .001) and a moderate correlation with the ASES (r = 0.57; P < .001). The average times to complete the SST, ASES, and PROMIS PFUE CAT were determined to be 96.9 ± 25.1 seconds, 160.6 ± 51.5 seconds, and 62.6 ± 22.8 seconds, respectively.

These authors suggest that computerized adaptive technology be used to decrease the burden placed on patients by currently accepted patient-reported outcome measurement tools.

The burden of the PROMIS approach is that the patient needs to have access to and use a computer uploaded with the necessary software. The cost of implementing this system is not mentioned in this paper. In contrast, the SST can be completed anywhere and requires only a pencil or a pen.

The scatter plot from this article also brings up another issue with the PROMIS: four patients who indicated that they could perform none of the 12 functions of the SST, still had PROMIS scores in the same range as three patients what could perform eight of these functions. Thus, the PROMIS was unable to discriminate between a non-functioning shoulder and a reasonably functional one.



At this point the promise of PROMIS does not seem compelling. 


=====
We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Thursday, December 6, 2018

Single stage exchange for periprosthetic infection

Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium

These authors point out that cultures taken at the time of revision shoulder arthroplasty are often positive for Propionibacterium.  They tested the hypothesis that the functional outcomes of revising Propionibacterium culture-positive failed arthroplasties with a single-stage revision and immediate antibiotic therapy are not inferior to the clinical outcomes of revising failed shoulder arthroplasties that are not culture-positive.

Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. Specifically all components (humeral and glenoid) were removed, a thorough debridement was carried out and a new humeral hemiarthroplasty was inserted with Vancomycin impregnated allograft. The residual glenoid bone was smoothed, but not bone grafted. No glenoid components were replaced.

Preoperative antibiotics were withheld until culture specimens were taken; a minimum of 5 tissue or explant specimens were obtained from each shoulder. Specimens were cultured for 21 days on blood agar (trypticase soy agar with 5% sheep blood), chocolate agar, Brucella agar (with blood, hemin, and vitamin K), and brain-heart infusion broth. Bacteria that were isolated received a full species-level identification by means of 16S rDNA sequencing.

After all culture specimens were obtained, 15 mg/kg of vancomycin and 2 g of ceftriaxone were administered intravenously. Patients were continued on antibiotics until the results of the cultures were finalized. Two or more cultures became positive, the infectious disease service started intravenous ceftriaxone and/or vancomycin through a PICC line with oral rifampin for 6 weeks followed by oral antibiotics in the form of amoxicillin and clavulanate or doxycycline for a minimum of 6months.

The patient self-assessed functional outcomes for those shoulders with ≥2 positive cultures for Propionibacterium (the culture-positive group) were compared with shoulders with no positive cultures or only 1 positive culture (the control group).

Below is an example of what is referred to as a 'stealth' presentation in which there were no preoperative symptoms or signs of infection, yet the cultures from revision surgery were strongly positive.


The culture-positive group were 89% male with a mean age of 63.5 ± 7.2 years. The mean Simple Shoulder Test (SST) scores for the 27 culture-positive shoulders improved from 3.2 ± 2.8 points before the surgical procedure to 7.8 ± 3.3 points at a mean follow-up of 45.8 ± 11.7 months after the surgical procedure (p < 0.001), a mean improvement of 49% of the maximum possible improvement. 

The control group were 39% male with a mean age of 67.1 ± 8.1 years. The mean SST scores for the 28 control shoulders improved from 2.6 ± 1.9 points preoperatively to 6.1 ± 3.4 points postoperatively at a mean follow-up of 49.6 ± 11.8 months (p < 0.001), a mean improvement of 37% of the maximum possible improvement. 

Subsequent procedures for persistent pain or stiffness were required in 3 patients (11%) in the culture-positive group and in 3 patients (11%) in the control group; none of the revisions were culture-positive. 

The authors concluded that the clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders. Two-stage revision procedures may not be necessary in the management of these cases. 

Fourteen patients reported side effects to antibiotics, indication that patients should be educated with regard to potential antibiotic side effects.


Another article,  One-stage exchange of septic shoulder arthroplasty following a standardized treatment algorithm, reported a retrospective study of a smaller series of 14 shoulders (average age 71, half men (note the older age and greater % women than the prior study) having a single stage exchange of septic shoulder arthroplasties that had an isolated microorganism from synovial fluid aspiration or synovial biopsy with an antibiotic susceptibility profile prior to revision surgery. If no microorganism was isolated or the underlying pathogen was a difficult-to-treat microorganism (not accessible for biofilm active antibiotics, enterococci, and fungi), 2-stage exchange was performed. 

For patients in whom septic shoulder arthroplasty was suspected, a diagnostic algorithm was followed to exclude or prove infection prior to revision surgery. The presumably infected shoulder was aspirated under aseptic conditions prior to revision surgery. Two weeks prior to aspiration, antibiotic treatment was suspended and all cultures were incubated for 14 days. In 12 patients, the underlying microorganism was identified in the synovial fluid obtained by aspiration. In 2 patients showing signs of infection with elevated serum C-reactive protein levels and synovial (WBC) counts, no microorganism grew in the synovial fluid. Consequently, they had to undergo an open biopsy, wherein infection was defined as a positive culture on at least 2 of the 5 resected tissue samples. If no microorganism was isolated prior to exchange surgery or the underlying pathogen was a difficult to-treat microorganism (not accessible for biofilm-active antibiotics, enterococci, and fungi, 2-stage exchange had to be performed.

The requirement for 1-stage exchange was an isolated microorganism from synovial fluid aspiration or synovial biopsy with an antibiotic susceptibility profile. Prior to surgery, we received a prescription from our microbiologist for local and systemic antibiotic therapy based on the antibiotic susceptibility profile of the isolated microorganism. The aim of the surgical procedure was to remove the infected prosthesis, followed by extensive d├ębridement and insertion of a new prosthesis.

The mean follow-up period was 5.8 years. The most and second most commonly detected microorganisms were Cutibacterium acnes (formerly Propionibacterium acnes), and Staphylococcus epidermidis, respectively. 


At 1-stage exchange, patients received local and systemic antibiotics based on the susceptibility profile of the microorganism. 


Twelve patients with insufficient rotator cuffs received reverse shoulder arthroplasty, whereas 2 patients with intact rotator cuffs underwent anatomic total shoulder arthroplasty. The infection-free survival rate at 1 and 5 years was 100% and 93% (95% confidence interval [CI], 59%-99%), respectively, with 1 recurrence of infection 22 months after 1-stage exchange. Another patient with limited range of motion underwent revision 6 months postoperatively, leading to a revision-free survival rate of 93% (95% CI, 59%-99%) and 86% (95% CI, 54%-96%) at 1 and 5 years, respectively. The mean preoperative Constant score was 27 and the mean followup Constant score was 65 (range, 44-95); this calculates to an improvement of 52% of the maximal possible improvement.

Comment: While a two-stage revision may be indicated for the 'obvious' infections, these articles suggests that a single stage revision may be sufficient for the management of 'stealth' presentations.

It is important to distinguish between (a) the 'obvious' presentation of a shoulder infection with findings such as abnormal blood tests (WBC, ESR, C-reactive protein), erythema, fever, and/or wound drainage from (b) the 'stealth' presentation in which none of these findings are present in shoulder arthroplasties revised for pain, stiffness or component loosening combined with cultures positive for organisms such as Propionibacterium. While in the past some have referred to the second group of  cases as "unexpected positive cultures in revision shoulder arthroplasty", it is now preferable simply to report the clinical findings (i.e. is there obvious clinical evidence of infection?), the number of specimens, and the culture results. Furthermore, since it is not currently possible to distinguish "true infections", "contamination", "false-positive cultures", "non-pathogenic Propionibacterium growth", it is preferable to avoid these terms and, again, reporting the clinical findings, the number of specimens, and the culture results.

=====
We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


Delta XTEND reverse total shoulder - how to best position it.

Geometric modification of the humeral position after total reverse shoulder arthroplasty: what is the optimal lowering of the humerus?

The Delta XTEND is a Grammont - style reverse total shoulder arthroplasty. It achieves stability by non-physiologic distal and medial displacement of the humerus relative to the scapula as shown below.



These authors sought to determine the relationship between lowering and medialization of the humerus and the short-term functional results.

In 70 patients the mean humeral lowering was 25.4 mm (range, 6-38 mm), and the mean medialization was 9.2 mm (range, 0-20 mm). 

 At 1 year of follow-up, scapular notching was found in 20 shoulders (29%): type I notching was observed in 18 and type II notching in 2. At 2 years of follow-up, only 54 patients were available for a radiographic review. Scapular notching was found in 25 patients (46%): type I notching was observed in 15, type II notching in 7, and type III notching in 3. No scapular spine or acromion fractures occurred.

They divided the lowering values the cohort into terciles below 24 above 28 mm and in between.
Active anterior elevation, which was somewhat greater in the group with >28 mm of lowering in comparison to the group with less than 24 mm of lowering. Neither the Constant-Murley score nor the pain score were influenced by the humeral lowering.

The rate of scapular notching was inconsistently related to the degree of lowering. 







Comment: The high rate of scapular notching with this type of prosthesis (46%) is noted (example shown below).


Our preference is for a design that achieves stability with East - West tensioning, enabling a more anatomic reconstruction without the need for distalization, which may jeopardize the acromion and the brachial plexus. 

The point is that the positioning of the implant depends a lot on the implant design.
=====
We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'