Wednesday, March 29, 2017

Posterior glenoid bone loss and total shoulder arthroplasty

Two years ago a middle age patient presented with pain, stiffness and a sensation of posterior instability of the right shoulder. There was no history of seizures or prior injury to either shoulder. The exam showed stiffness, pain and posterior translation as the arm was elevated. X-rays showed posterior superior displacement of the humeral head on an eroded glenoid.



The patient wished to avoid a reverse total shoulder arthroplasty and asked to have an anatomic total shoulder. Two years after a total shoulder with a standard glenoid component,  the patient has a comfortable, stable and functional shoulder. Current x-rays show centering of the humeral head in the prosthetic glenoid without evidence of instabilty or loosening.


Interestingly the left shoulder is becoming similarly symptomatic and has the radiographic appearance shown below.



The patient desires a similar procedure on the left.

Comment: This pathology is unusual in our experience. For this active patient, we elected the most bone-conserving method of reconstruction. Should this fail down the line, there would be sufficient bone stock for a reverse total shoulder.

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A case of glenoid component failure with a simple revision

A patient present to us recently with progressive pain and feelings of instability starting 13 years after a left total shoulder arthroplasty. On examination the shoulder was painful and clunking on any movement. Radiographs shown below demonstrate glenoid loosening as well as glenoid and humeral osteolysis.



At revision 44 21 humeral head was removed. The posterior aspect of the glenoid component was seen to be worn through. Joint fluid was clear and frozen section showed foreign body reaction and particulate debris without findings of acute inflammation. The glenoid bone was severely deficient.


After thorough removal of the reactive tissue from the humerus and glenoid bone, a 52 18 humeral head was inserted on the retained humeral stem and seen to be stable in the eroded glenoid cavity.



On the morning after surgery the patient had assisted elevation of 150 degrees without clunking or sensation of instabilty. 

Comment: While the eventual clinical outcome remains to be determined, we were pleasantly surprised that a stable shoulder could be achieved with this simple conversion, especially since we were prepared to perform a reverse total shoulder had this approach not been successful.

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Rotator cuff repair. Does technique matter? Does integrity matter?

Advantages of Arthroscopic Rotator Cuff Repair With a Transosseous Suture Technique. A Prospective Randomized Controlled Trial

These authors conducted a randomized controlled trial of two rotator cuff repair techniques: (a) single-row anchor fixation and (b) transosseous hardware-free suture repair. Sixty-nine patients with rotator cuff tears were enrolled: 35 patients were operated with metal anchors and 34 with standardized transosseous repair. 

Patients operated with the transosseous technique had significantly less pain, especially from the 15th postoperative day, however no differences in functional outcome were noted between the 2 groups at the final evaluation. In the evaluation of rotator cuff repair integrity, based on Sugaya magnetic resonance imaging classification, no significant difference was found between the 2 techniques in terms of retear rate.

Comment: In this randomized study, repair technique did not have a significant effect on outcome. Furthermore, at followup the 88% of the repairs that were intact (Sugaya classes I, II, III) had similar outcomes to the 12% that were retorn ( Sugaya classes IV and V = retorn).


Reverse total shoulder complications

Revision of reversed shoulder arthroplasty

These authors report on 20 shoulders with failed reverse total shoulder arthroplasty. Nine were managed with an extra large humeral head prosthesis after removal of the glenosphere. This approach often results in anterosuperior escape of the large head as shown below.



Six were managed with a spacer placed for infection.
 

Five were managed with a resection of the arthroplasty components.



Comment: This article serves to remind us of the nature and severity of complications that can occur after a reverse total shoulder and the challenges of managing these complications.


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Sunday, March 26, 2017

Is there such a thing as injection arthropathy?

We often see patients whose physicians have tried to delay the need for arthroplasty through the use of injections (steroids, PRP, hylaluronic acid) The safety and efficacy of these injections is unclear (see this link, this link, this link, this link, this link, and this link). Laboratory investigations, such as Lidocaine Potentiates the Chondrotoxicity of Methylprednisolone (see this link), may be of relevance.
Not infrequently we'll see patients in whom the first or second injection helped, but from #3 on, there was no appreciable benefit. Occasionally we see shoulders that have had multiple injections and changes in the shoulder radiographs that are not typical of osteoarthritis. This is not intended to imply a cause/effect relationship.

Here's a recent example.

A very active young man sustained a hard fall on his shoulder. He received a series of intra articular injections as he documented for us here:


His current shoulder radiographs are shown here:


While this use of injections is common practice, we were struck by the cystic changes in the bone on both sides of the joint - changes that are not typical of post-traumatic arthritis in our experience. It is surely not possible to know if there was an association between these changes and the injections.

For comparison, the x-rays below show the more typical appearance of osteoarthritis.




Here are some quotes from the American Academy of Orthopaedic Surgeons 2013 guidelines (see this link) regarding the use of injections for arthritis of the knee:

Procedural Treatments: Recommendations 8-11
RECOMMENDATION 8
We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.

RECOMMENDATION 9
We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Strong
Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supportingevidenceishigh. Aharmsanalysisonthisrecommendationwasnotperformed.
Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.


RECOMMENDATION 10
We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role. 

Here is an interesting recent post about platelet rich plasma (see this link).

The bottom line is that we do not know (1) how injections affect the natural history of shoulder arthritis or (2) what regimen of injections is likely to maximize safety and efficacy.

The patients we most commonly see in our office have advanced arthritis with virtually complete loss of the cartilage over the glenoid and humeral head. In such cases it seems unlikely that injections will change the subsequent course of the disease.

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

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Wednesday, March 22, 2017

Patient outcomes - what's the score?

Clinical outcomes of arthroscopic rotator cuff repair: correlation between the University of California, Los Angeles and American Shoulder and Elbow Surgeons scores

These authors performed a retrospective study of 143 patients who underwent arthroscopic rotator cuff repair using the University of California, Los Angeles (UCLA) and American Shoulder and Elbow Surgeons (ASES) scores preoperatively and at 6, 12, and 24 months after surgery. They found that the UCLAand ASES scores showed a very high correlation (r = 0.91). In all the postoperative clinical evaluations, the scores obtained from the 2 scales were highly or very highly correlated (r = 0.87-0.92, P < .001). For the preoperative scores, the correlation was moderate (r = 0.67, P < .001).

Comment: Documenting the effectiveness of treatment is of great importance to shoulders surgeons and their patients.  Recently, authors have pointed to the observer dependence of scales that include measurements of strength and range of motion, such as the Constant and UCLA scores. Theses scales also have the disadvantage of requiring return of patients for an in-person examination, resulting in attrition of those available for followup. In contrast, scales such as the modified ASES, SANE and Simple Shoulder Test (SST) are purely patient reported metrics with the advantages of absence of observer dependence and the ability to complete the assessment without return to the office. The convenience of these forms puts outcome assessment within reach of all shoulder surgeons, so that they can learn the effectiveness of their treatments of their own patients.

As for the choice among the different patient reported measures, each has its own characteristics of convenience, brevity, and assessment of different aspects of shoulder comfort and function. Some, such as the SANE, boil everything down to one number, loosing the ability to assess different components of the shoulder's status. Others, such as the ASES score, require the patient to choose among "unable to do", very difficult to do", "somewhat difficult" and "not difficult" for each shoulder function. Still others, such as the Simple Shoulder Test, provide "yes" or "no" questions regarding twelve common activities of daily living.

In that surgeons from multiple countries desire to compare outcomes, having the scale validated in different languages can be helpful.

The authors of this paper are from São Paulo, Brazil; so it would be of interest to know how generally applicable the UCLA and ASES scores were to their Portuguese-speaking patients.


Of possible interest to them is this link.
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Click here to see the new Shoulder Arthritis Book

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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 including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Thursday, March 16, 2017

Shoulder Fellowship: the future of our specialty.

The American Shoulder and Elbow Surgeons, our national organization, is concluding this year's matching system by which the 58 young orthopaedic surgeons wishing advanced training in shoulder and elbow surgery will be paired with the 27 programs offering 42 fellowship positions. As can be seen from these numbers, there is strong competition for the available fellowships.

At the University of Washington we offer two fellowship positions each year and have just concluded our interviews with 21 of the most competitive candidates for our program. Those paired with us by the fellowship matching program will become the 49th and 50th University of Washington Shoulder Fellows. These surgeons will spend a year with us learning, teaching, caring for patients, discovering new knowledge and enjoying the beautiful Pacific Northwest (see this link).

Our fellowship was started 30 years ago and has produced truly outstanding shoulder surgeons who have now established robust practices both near and far, including Vancouver, New Hampshire, Miami, and San Diego. They have made and continue to make meaningful contributions to the evaluate and management of individuals troubled with shoulder and elbow problems. Half of our graduates have earned admission to the prestigious American Shoulder and Elbow Surgeons society. One of our alumni, Tony Romeo, is the current president. Here are a few of our older fellows, perhaps you recognize some of them.


From left to right, Steve Lippitt, John Sidles, Mark Lazarus, Kevin Smith, David Duckworth, the late Doug Harryman, Michael Pearl, Rick Matsen, Dean Ziegler, Craig Arntz, and Tony Romeo.

We are most grateful to the alumni of our fellowship for their research - which includes many foundational contributions to the literature, for their help in the care of our patients, and for their ongoing work to make tomorrow's patient care better than yesterday's.

We invite you to learn more about our fellowship by visiting this link.