The B2 glenoid in a 76 year old active surgeon - 7 year followup after ream and run

 A 76 year old physically active surgeon presented with pain and stiffness in the left shoulder and these x-rays showing a type B2 glenoid with retroversion, biconcavity, and posterior decentering of the humeral head on the glenoid.

Because of his active lifestyle and his glenoid deformity he elected a ream and run procedure (https://www.reamandrun.com/). At the time of surgery the glenoid was conservatively reamed to a single concavity preserving glenoid bone stock without attempting to change the glenoid version. An anteriorly eccentric humeral head was used to center the humerus on the glenoid. A thin stemmed, smooth, standard length stem was fixed with impaction autografting.

He presented 7 years after surgery at the age of 87 for evaluation of his opposite shoulder. He reported and demonstrated full function of his left shoulder. His x-rays at 7 years after his ream and run are shown below. There is no evidence of stress shielding. The glenoid has remodeled to a smooth stable joint surface.

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

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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).

Reverse total shoulder or anatomic total shoulder for osteoarthritis for patients 70 years old and above?

           

As pointed out in yesterday's post (see this link), failure of the rotator cuff can be a problem after anatomic total shoulder arthroplasty (TSA). However, this did not lead to an increased revision rate in comparison to reverse total shoulders (RSA) for patients with arthritis and an intact cuff. Since the risk of cuff failure increases with age, some surgeons may be inclined to use RSA for older patients.

The authors of Similar rates of revision surgery following primary anatomic compared to reverse shoulder arthroplasty in patients ≥70 years old with glenohumeral osteoarthritis: A cohort study of 3,791 patients, sought to determine whether RSA was associated with lower rates of revision surgery in comparison to TSA for patients with arthritis and an intact cuff aged 70 and above. The mean age was 75.8 years; 43.4% were male.

TSA was more commonly performed for these patients: 685 RSA and 3,106 TSA. Completeness of follow-up was excellent: 97.1% for the overall cohort (97.7% for RSA and 97.0% for TSA).

The cumulative revision probability at 5-years follow-up was 2.4% and 3.4% for RTSA and TSA. After accounting for confounders, no significant differences in revision risk or 90-day emergency room visit or readmission rates were observed when comparing RSA to TSA.

The most common reasons for revision following RSA were glenoid component loosening, followed by dislocation and periprosthetic fracture.

Over half of those who had a revision following TSA did so for rotator cuff tear, followed by dislocation and glenoid component loosening. The relatively high dislocation rate after TSA has not been commonly observed in other series.

This study did not evaluate radiographic findings, patient reported outcome measures, or complications not requiring revision surgery, such as scapular spine fractures and closed reductions in the RSA group and subscapularis failure in the TSA group.

The authors point out that within their healthcare system, there is a higher implant cost for RSA compared to TSA and that "As value-based care continues to be a focus in healthcare, future analysis should explore the long-term cost effectiveness of either procedure".

Comment: While data from this study suggest that the cumulative revision probability for RSA levels off two years after surgery,



this may be related to the observation that the percent of patients available for longer term followup was lower RSA than for TSA.






This is important in that the authors of Total shoulder replacement stems in osteoarthritisdshort, long, or reverse? An analysis of the impact of crosslinked polyethylene found that the revision rates, especially for RSA, continue to rise with increasing time after arthroplasty as seen below





The authors of Similar rates of revision surgery following primary anatomic compared to reverse shoulder arthroplasty in patients ≥70 years old with glenohumeral osteoarthritis: A cohort study of 3,791 patients have an impressive population-based registry with >90% followup. It will be of great interest to see future publications regarding implant survivorship for TSA and RSA in patients 70 years old and above.

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: https://twitter.com/shoulderarth
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Follow on facebook: https://www.facebook.com/frederick.matsen
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Anatomic vs reverse total shoulder for elderly patients

 Shoulder Replacement in the Elderly with Anatomic versus Reverse Total Prosthesis? A Prospective 2-Year Follow-Up Study

These authors point out that in older patients with glenohumeral arthritis and an intact rotator cuff, there is uncertainty on whether an anatomic TSR (aTSR) or a reverse TSR (rTSR) is best for the patient. 

They conducted a comparison study of same-aged patients aims to assess clinical and radiological outcomes of older patients (75 years or older) who received either an aTSR or an rTSR for either advanced primary glenohumeral osteoarthritis (OA) with or without an intact rotator cuff (RC), or an irreparable rotator cuff tear with minor osteoarthritis.

Decision on prosthesis type (aTSR or rTSR) depended on the rotator cuff’s status as assessed by clinical examination and imaging.  If the patient had osteoarthritis but the cuff was intact and not degenerated, with no major muscle atrophy, the decision was made for an aTSR. If the patient had osteoarthritis and the RC was torn or degenerated, including severe fatty atrophy, the decision was made for an rTSR. If imaging demonstrated a massive irreparable RC tear with minor arthritis, an rTSR was indicated.

For the aTSR, a stemless Affinis® short humeral ceramic head component was used with a double-pegged, cemented, all-polyethylene glenoid component (below left). For rTSR, a Grammont-style humeral prosthesis was used—Aequalis Reversed II Shoulder System (below right).

 

They prospectively identified consecutive patients with a minimum age of 75 years who received an aTSR (n = 44) or rTSR (n = 51). 

In addition to the differences in indications for the two procedures (see above), there were differences in age (77 aTSR vs 82 rTSR) and sex (%male 27% aTSR vs 10% rTSR). Preoperative active elevation was 84 degrees for aTSR and 72 degrees for rTSR.

They found postoperative improvement for ROM and all clinical assessment scores for both groups. Postoperative active elevation was 147 degrees for aTSR and 125 degrees for rTSR. Patient satisfaction was 98% for aTSR and 91% for rTSR. 

There were significantly better patient reported outcome scores in the aTSR group compared with the rTSR patients. Both groups had only minor osteolysis on radiographs. No revisions were required in

either group. 

The main complications were scapular stress fractures for the rTSR (n = 11) patients and acromioclavicular joint pain for both groups (aTSR = 2; rTSR = 6). 

Comment: In contrast to yesterday's post, this is a prospective study with a low rate of patients lost to followup (albeit followup is easier to achieve at 2 years rather than 10).

Although the paper states, "both groups started from a similar basepoint for all indices", however, in fact the patient group differ with respect to diagnosis, demographics, and preoperative active range of motion - any or all of which can affect the postoperative assessment of comfort and function. This limits the ability to compare outcomes for aTSR and rTSR.

We agree with the authors that aTSR is an attractive option for most patients with osteoarthritis and an intact rotator cuff - irrespective of patient age - because of its dependable return of function and low rate of serious complications (our technique is shown in this link).

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: https://twitter.com/shoulderarth

Follow on facebook: click on this link

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

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

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Arthritis surgery for a 70 year old weight lifter/powerlifter - a ten year followup.

A 70 year old weight lifter presented with pain and stiffness of his right shoulder and these x-rays. He started lifting in 1969. He stated that his arthritis resulted "because of lifting too-heavy-too-long, including a period of Powerlifting competition"

Because he wanted to continue high level workouts in the gym, he elected a ream and run glenohumeral arthroplasty with a standard length humeral stem fixed with impaction grafting. The ream and run technique is shown in this link.

Ten year after surgery he obtained these radiographs, showing a stable arthroplasty.

He has been able to return to his weight workouts in the gym.

 

He forwarded a workout video celebrating his 80th birthday. This video shows the function of the right shoulder a decade after his ream and run (see this link).

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: https://twitter.com/shoulderarth

Follow on facebook: click on this link

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

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

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Anatomic or reverse total shoulder for cuff-intact arthritis in patients >70 years of age - which provides the best value?

 The outcomes of shoulder arthroplasty in those over 70 years with glenohumeral arthritis: A New Zealand Joint Registry Study.

These authors used data from New Zealand Joint Registry to compare the outcomes of a primary anatomic Total Shoulder Arthroplasty (aTSA) and a primary reverse (RTSA) performed for arthritic shoulders with an intact rotator cuff in patients >70 years old. They sought to determine if there is clear evidence to support a primary RSA in those >70 years of age instead of a primary TSA.

A total of 3449 primary TSA, 4681 primary RTSA and 104 revision RTSA’s were identified. 

The mean Oxford Shoulder Score (OSS) at 6 months for 

a primary aTSA was 39.5± 9.0

a primary RTSA was 35.5± 9.4

a revision RTSA was 32.5± 9.7.

Primary aTSA yielded significantly higher scores than primary RSTA (p <0.001)

The mean OSS at 5 years for 

a primary aTSA was 42.1± 7.5 

a primary RTSA was 39.8± 8.4 (p <0.001).

The revision rates for 

a primary TSA was 0.53/100 component-years

a primaryRTSA was 0.51/100 component years (p=0.193)

The authors listed the indications for the patients having a primary aTSA revised to a RTSA: rotator cuff disorder, dislocation, component loosening, instability, and infection.

They did not provide similar data for the indications for the patients having a primary RTSA having a revision for RTSA failure. 

These authors concluded that anatomic TSA remains the gold-standard for primary shoulder arthroplasty. For those individuals >70 years of age with OA as their primary diagnosis, a primary TSA was associated with a higher OSS score and similar revision rates to a primary RTSA.

Comment: The average selling price for a RTSA implant is about 50% higher than that of an aTSA (see data below from Orthopaedic Network News).

 If value is defined as benefit to the patient divided by cost, the patient-realized outcomes for a RTSA would have to be about 50% better to achieve the same value as that for an aTSA.

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

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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)

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.

Management of a B2 glenoid in a 67 year old athlete - 10 year followup

A 67 year old international level badminton athlete presented with pain and stiffness in the right shoulder.

Radiographs showed advanced glenohumeral arthritis and a type B2 glenoid with posterior subluxation of the humeral head into a posterior glenoid concavity.

After discussion of the options, including atomic and reverse total shoulders, he elected the ream and run procedure. This was done without preop CT or plexus block.

He sent this video of his gym workout at one year after surgery.

He returned 10 years later to have a ream and run on his contralateral shoulder. At 10 years after the ream and run his shoulder x-rays showed a well centered humeral head.

His should was comfortable and he had long since been able to return to competitive badminton.

His shoulder motion is shown in this video.

The ream and run technique is shown in this link.

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).

How to x-ray the shoulder (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).

Anatomic total shoulder for patients over 75 with arthritis and partial-thickness cuff tears.

Preoperative partial-thickness rotator cuff tears do not compromise anatomic total shoulder replacement outcomes: medium-term follow-up

These authors reported the 5.8 year (range, 5-9 years) outcomes for 36 patients of 79.2 years (range, 75-88 years) with  partial-thickness rotator cuff tears on magnetic resonance imaging (MRI) scans.

Significant improvements in pain and range of movement were reported in all cases. While radiolucencies were seen around 8 glenoids, there were no cases of implant loosening. 

Four patients were noted to have rotator cuff weakness but only 2 showed evidence of proximal migration. One patient remained satisfied, whereas the other patient, with moderate-grade proximal migration, underwent revision for rotator cuff failure; one further patient underwent revision surgery for infection.

Comment: It would seem that partial thickness cuff lesions would be very common among individuals at 75 years of age or older. 

While some surgeons prefer reverse total shoulder for patients in this age group, our practice is to consider anatomic shoulder arthroplasty for such patients as long as they have good bone stock, good strength, no x-ray evidence of proximal migration and no pseudoparalysis.

 

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).

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).

Reverse total shoulder in patients over 80 years of age

 Primary reverse total shoulder arthroplasty in patients older than 80 years: clinical and radiologic outcome measures

These authors identified 171 shoulders in 159 patients treated by 11 different surgeons with RTSA at a mean age of 84 years with a  minimum follow-up of 1 year.

The main indication for RTSA was cuff tear arthropathy (43%), isolated rotator cuff tear (22%), and fracture (21%). 

For pain control, an interscalene catheter with ropivacaine was installed preoperatively and withdrawn

2 days postoperatively in most patients.

136 patients (79%) had clinical followup at 41 months. Relative Constant-Murley scores improved

from 39%  to 77%. The mean pain score was reduced from 6 points preoperatively to 14 Constant-Murley score points, where 15 points are defined as no pain and 0 points as the worst imaginable pain. 

The mean active anterior elevation improved from 64 to 109 degrees.

Overall, 76% of the patients rated their outcome as good or very good. 

The overall mortality was 16% with a mean time to death of 53 months. The earliest postsurgical

death occurred at 15 months postoperatively. The deaths were unrelated to the surgery.

During the hospitalization, 3 patients required treatment for dyspnea. In 2 cases, the dyspnea was explained by the regional anesthesia that involved the diaphragm. Pulmonary embolism was ruled out in these 2 cases but confirmed in the third. 

There were 2 cases of acute decompensation of chronic heart failure, which was treated conservatively.

A total of 30 (18%) local complications occurred, requiring reoperation in 13 cases (8%). These were periprosthetic fractures of the humeral stem in 6 cases (4%), fractures of the acromion in 5 cases (3%), and the scapular spine in 3 cases (2%). All fractures occurred postoperatively, and 38% were related to a fall. 

Five of the 6 stem fractures were treated operatively; all acromion and scapular spine fractures were treated conservatively. 

There were 9 cases (5%) of glenoid loosening potentially related to a fall. Four of them with complete displacement underwent revision surgery.

There were 4 periprosthetic infections (2%), of which 2 needed multiple revisions surgeries. The other 2

were treated with antibiotics without revision surgery. 

In 2 cases, a transient neurologic lesion of the radial or axillar nerve was noted. 

There were 2 postoperative hematomas; 1 was treated surgically. Another patient underwent debridement for painful scarring.

Comment: This is an informative report of a substantial experience with RTSA in individuals over the age of 80. 

These authors used indwelling brachial plexus catheters X 2 days for pain management. Two patients experienced dyspnea from paresis of the diaphragm.

Falls were an issue in this patient population, resulting in humeral fractures, scapular fractures and glenoid component failure.

In our practice, we focus on the physiological age of the patient - some 85 year olds are better surgical candidates than some 60 year olds. Second, we strive to make sure all medical issues, such as cardiac disease, are under control before surgery. Third, we focus on social support, making sure the patient has a safe post-surgical environment. Fourth, we minimize the use of postoperative narcotics to reduce the risk of falls. Finally we consider more conservative procedures for rotator cuff tear arthropathy (see this link) and for painful irreparable rotator cuff tears (see this link).

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).

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).

Does the patient over the age of 55 benefit from attempting a repair of small atraumatic cuff tears?

OPERATIVE VS. CONSERVATIVE TREATMENT OF SMALL NON-TRAUMATIC SUPRASPINATUS TEARS IN PATIENTS OVER 55 YEARS: OVER 5-YEAR FOLLOW-UP OF A RANDOMIZED CONTROLLED TRIAL

A previous post (see this link) discussed the management of traumatic rotator cuff tears in individuals with an average age of 60 years. By contrast this study discusses the management of atraumatic rotator cuff tears in individuals with an average age of 71.

180 shoulders with symptomatic, non-traumatic supraspinatus tears were randomly assigned to one of the three treatment groups: physiotherapy (Group 1), acromioplasty and physiotherapy (Group 2) and rotator cuff repair,  acromioplasty and physiotherapy (Group 3). 

150 shoulders (mean age 71) were available for analysis after a mean follow-up of 6.2 years. 

The mean sagittal tear size of the supraspinatus tendon tear was at baseline 10 mm in all groups.

Eight shoulders in Group 1 and two shoulders in Group 2 crossed over to rotator cuff repair during the follow-up. 

There were no significant differences in the mean change of the Constant score.

There were also no statistically significant differences in the change of visual analog scale for pain and patient satisfaction. 

Preoperatively there was no or mild radiographic evidence of osteoarthritis  At follow-up moderate or severe osteoarthritis was detected in 7 (19%), 14 (40%), and 13 (35%) shoulders in Groups 1, 2, and 3 respectively (p=0.124). Despite non-significant between group differences, there was a statistically significant mean progression in the grading of osteoarthritis from baseline to follow-up in the overall study group.

From this study, the authors concluded that 

(1) operative treatment was not better than non-operative treatment of small non-traumatic single tendon supraspinatus tears in patients over 55 years of age. 

(2) operative treatment did not protect against degeneration of the glenohumeral joint or cuff tear arthropathy. 

(3) non-operative treatment is a reasonable option for the primary initial treatment for these tears.

Readers may be interested in a recent Cochrane analysis, Does repair of torn rotator cuff tendons work?, that concluded, "As compared with non-operative treatment, moderate-certainty evidence (downgraded due to risk of bias) indicates that surgery (rotator cuff repair with or without subacromial decompression) probably provides little or no benefit in pain and low-certainty evidence indicates that it may provide little or no improvement in function, participant-rated global treatment success or overall quality of life (downgraded due to bias and imprecision) in people with rotator cuff tears." The AAOS practice guidelines for the management of cuff tears can be found at this link.

Comment: Rotator cuff repair is a surgical procedure that can be associated with increased costs,  substantial postoperative discomfort and a prolonged "down time" to protect the repair during the time of anticipated healing. In this light, surgical repair should be reserved for cases in which the procedure offers a definite benefit to the patient in comparison to non-operative treatment.

An example of "right sizing" treatment is shown in the case below of a degenerative supraspinatus cuff tear.

With a simple stretching and strengthening rehabilitation program (see this link), durable full, comfortable function was achieved.

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).

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).