Wednesday, May 24, 2017

Managing arthritic posterior instability

Many approaches have been suggested for managing the posteriorly decentered humeral head that has come to rest in a pathological posterior concavity. These include posterior bone grafting (a technically difficult procedure with associated problems of hardware failure and graft resorption), reaming the anterior ‘high side” (a procedure that sacrifices bone stock without improving stability), posteriorly augmented plastic glenoid components (devices than increase the force and pressure on the posterior polyethylene with the associated risks of cold flow and increased ‘rocking horse’ lever arm) , and reverse total shoulder (with its associated risks and limitations).

Here are the preoperative x-rays on a heavy set, active patient.  The AP view suggests 'standard' osteoarthritis.

However the axillary 'truth' view shows severe posterior decentering into a pathologic glenoid concavity resulting from severe posterior erosion.

Our approach to this pathoanatomy is to convert the biconcavity into a single concavity by conservative reaming without attempting to change glenoid version, to insert a standard (non-augmented) all polyethylene glenoid, and then to manage any tendency for excessive posterior translation using an anteriorly eccentric humeral head and a rotator interval plication.

The postoperative AP view is shown below

Along with the axillary view that shows the anteriorly eccentric humeral head component to be centered in the glenoid component, which has been inserted in retroversion. Note the slight anterior penetration of the central peg.

At surgery the shoulder was stable to posteriorly directed forces applied to the humeral head. Postoperatively, the patient was able to participate fully in the standard post total shoulder rehabilitation program, including assisted flexion on the evening of surgery.

Of note in this approach is that the head is stabilized in large part by the posterior soft tissues (blue arrows in the figure below),
rather than by loading the posterior aspect of an augmented glenoid component.

Time will tell the best approach for managing this complex pathology. Stay tuned!
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Tuesday, May 23, 2017

Stemless total shoulders and Propionibacterium infections

High incidence of periprosthetic joint infection with Propionibacterium acnes after the use of a stemless shoulder prosthesis with metaphyseal screw fixation - a retrospective cohort study of 241 patients propionibacter infections after eclipse TSA.


These authors investigated infections after the Eclipse stemless total shoulder as well as those after conventional shoulder prostheses.

A consecutive series of two hundred and forty-one patients (54.8% females) were operated with a shoulder arthroplasty and followed for median 2.0 (0.1–5.7) years. One hundred and two (42.3%) had received an Eclipse prosthesis, the remaining patients were operated with other implants. There was an overrepresentation of males in the Eclipse group (63.7% males) when compared with the control group (31.7% males). All arthroplasties were performed by two experienced shoulder surgeons in the same operating rooms and with the same staff. In order to ensure that patients had not been revised elsewhere we cross-validated our database with the Swedish Shoulder Arthroplasty Register where all revision procedures are registered on a national basis. At the time of index surgery all patients received perioperative intravenous  cloxacillin or clindamycin for 24 hours. Skin disinfection was performed with chlorhexidine.

Patients with shoulder pain at rest and without probable other causes were suspected to have a periprosthetic joint infection. Eight of 10 patients with suspected periprosthetic infection in the Eclipse group underwent a diagnostic shoulder arthroscopy before revision surgery was performed with the collection of 4-9 tissue samples for culture. In the remaining 2 of the 10 patients tissue samples were obtained during revision surgery. The patient in the control group with a periprosthetic infection developed a fistula and cultures were obtained from this fistula.
Tissue samples were cultured on chocolate blood agar for aerobic incubation, fastidious anaerobic agar for anaerobic incubation, and two serum broths.

In the Eclipse group 10 (9.8%) patients developed a periprosthetic joint infection, as opposed to 1 (0.7%) in the control group. The most common bacteria was Propionibacterium acnes. Unadjusted infection-free survival after 4 years was 88.8% (CI 82.5–95.7) for Eclipse® patients and 95.7% (CI 87.7–100.0) for controls (p = 0.002). After adjustment for age, gender, diagnosis, and type of shoulder prosthesis (total or hemi), the risk ratio for revision due to infection was 4.3 (CI 0.5–39.1) for patients with the Eclipse® prosthesis.

The authors point out that apart from patient-related factors, the higher-than anticipated rate of infections in patients operated with the Eclipse may be related to the material and structure of this implant. The trunnion and cage screw of this implant are manufactured from a titanium alloy that has high biocompatibility and an increased potential of bacterial colonization and biofilm formation. Furthermore, both bacterial adherence and the capacity for biofilm formation are dependent on surface roughness of the material. The metaphyseal cage screw is made of a roughly textured, porous titanium alloy that is unique to this type of implant. It is possible that  surface roughness and alloy composition exert an important influence on bacterial colonization and biofilm formation.

Comment: This study is rigorous in terms of the consecutive nature of the arthroplasties, the fact that only two surgeons were involved, and the special ability of the authors to followup on their patients using the national registry. 

The Eclipse prosthesis was introduced to the practice in 2008. Beyond that it is not clear how the choice among different prostheses was made.

It is of interest that many of these infections were diagnosed long after the index procedure

The relationship of patient and implant factors to the recovery of Propionibacterium in failed shoulder arthroplasties is of great interest. This paper brings new data to the discussion.

Wednesday, May 17, 2017

Is acromioplasty of value?

Does acromioplasty result in favorable clinical and  radiologic outcomes in the management of chronic  subacromial pain syndrome? A double-blinded randomized clinical trial with 9 to 14 years’ follow-up. 

These authors sought to determine the long-term clinical and radiologic treatment effect of arthroscopic acromioplasty in patients  with chronic "subacromial pain syndrome (SAPS)"  (pain located in the deltoid region for at least 3 months; inability to lie down on the affected shoulder; pain during abduction, backward flexion, or internal rotation; positive Neer or Hawkins impingement test; and positive lidocaine impingement test. In addition, conservative treatment for at least 6 weeks (ie, subacromial infiltration, nonsteroidal anti-inflammatory drugs, and supervised exercises) had to be unsuccessful. The exclusion criteria were calcifying tendinitis, biceps tendinitis, partial- or fullthickness cuff tear, labral tear, signs of glenohumeral instability, passive restriction of glenohumeral motion, osteoarthritis of the acromioclavicular or glenohumeral joint, rheumatic diseases, cervical radiculopathy, history of shoulder trauma, synovitis, and prior surgery on the affected shoulder.)

In this double-blind, randomized clinical trial, 56 patients with chronic SAPS (median age, 47 years; age range, 31-60 years) were randomly allocated to arthroscopic bursectomy alone or to bursectomy combined with acromioplasty and were followed up for a median of 12 years. 

A total of 43 patients (77%) were examined at a median of 12 years’ follow-up. Intention-to treat analysis at 12 years’ follow-up did not show a significant additional treatment effect of acromioplasty
on bursectomy alone in improvement in Constant score, Simple Shoulder Test score, VAS score for pain, or VAS score for shoulder function. 

The chart below shows the SST scores for shoulders with bursectomy alone (hollow bars) and bursectomy along with acromioplasty (solid bars).
The prevalence of rotator cuff tears was not significantly different between the bursectomy group (17%) and acromioplasty group (10%).

The authors concluded that there were no relevant additional effects of arthroscopic acromioplasty on bursectomy alone with respect to clinical outcomes and rotator cuff integrity at 12 years’ follow-up. 

Comment: While it is not clear exactly what entities are included in SAPS, this article again calls in to question the value of acromioplasty using a well-done randomized clinical trial with long term followup. 

This article should be placed in context of three other recent articles on acromioplasty discussed below.

Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder

Acromioplasty for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. This investigation sought high levels of evidence in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment.

The authors conducted a systematic review of articles relevant to the following hypotheses: (1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions, (2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch, (3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders, (4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and (5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch. Three of the authors independently reviewed each article and determined the type of study, the level of evidence, and whether it supported the concept of the impingement syndrome. Articles with level-III or IV evidence were excluded from the final analysis.

These five hypotheses were not supported by high levels of evidence.

The authors concluded that the concept of impingement syndrome was originally introduced to cover the full range of rotator cuff disorders, as it was recognized that rotator cuff tendinosis, partial tears, and complete tears could not be reliably differentiated by clinical signs alone. The current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated. Nonoperative and operative treatments are currently being used for the different rotator cuff abnormalities. Future clinical investigations can now focus on the indications for and the outcome of treatments for the specific rotator cuff diagnoses. It may be time to replace the nonspecific diagnosis of socalled impingement syndrome by using modern methods to differentiate tendinosis, partial tears, and complete tears of the rotator cuff.

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

These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.

The typical pathology in these cases is shown in the figure below.

The surgical approach is through a deltoid splitting incision that preserves the deltoid origin, the acromion and the coracoacromial ligament.

The coracoacromial arch is preserved to avoid the complication of anterosuperior escape that is commonly encountered when acromioplasty is performed in the presence of a large cuff tear.

The surgery includes smoothing of the prominence of the greater tuberosity that is exposed in cuff tears along with resection of adhesions in the humeroscapular motion interface and a gentle manipulation under anesthesia to resolve the stiffness that is commonly associated with chronic cuff tears. Immediate active assisted and active motion are encouraged immediately after surgery. Because no repair or reconstruction has been performed, activities, including deltoid strengthening can be resumed as soon as they are comfortable. 

They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery. The patient data are shown below, contrasting the patients that did and did not improve by the MCID of 2 in the Simple Shoulder Test

In 77 shoulders with previously unrepaired irreparable tears, Simple Shoulder Test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. 

For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.

They provided this case example. A rancher in his mid 60s had a right rotator cuff reconstruction with freeze-dried acellular human dermal collagen tissue matrix that subsequently became infected. He presented to us with a painful stiff right shoulder. At surgery there was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. He had a smooth and move procedure at which time the abundant scar in the humeral scapular motion interface was debrided. The previous sutures and Graft Jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. A manipulation under anesthesia was performed to assure a full passive range of motion. Passive and active range of motion exercises were started immediately after surgery. Three years later he reported excellent shoulder comfort and function and sent us this photo of his return to one of his favorite activities

They concluded that smoothing of the humeroscapular interface can durably improve symptomatic shoulders with irreparable cuff tears and retained active elevation > 100 degrees. They point out that this conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

Comment: Currently surgeons are actively pursing a variety of methods for managing patients with symptomatic irreparable rotator cuff tears, including marginal convergence, patch grafts, superior capsular reconstructions, degrading subacromial 'balloons' tendon transfers and reverse shoulder arthroplasty. Each of these procedures is more complex than the smooth and move procedure described in this article and none offers the opportunity for immediate postoperative resumption of active use of the shoulder.

These results from 151 patients having the smooth and move procedure can be contrasted to those from 24 patients having a 'superior capsular reconstruction' using an 8 mm fascia lata graft harvested from the patients thigh have been reported by Mihata et al (see this link). After the superior capsular reconstruction it is recommended that an abduction pillow be used for 4 weeks after the reconstruction with active exercises not started until 8 weeks after surgery.

Of note is that standard dermal grafts that used instead of fascial lata are often <2mm depending on the company selling them.

While future clinical research will hopefully clarify the indications for the superior capsular reconstruction and other more complex procedures, the advantages of the smooth and move procedure lie in its simplicity, its avoidance of tissue autograft or commercially available decellularized dermal allograft, its lack of postoperative 'down time', its high rate of durable improvement, and the fact that it does not preclude other surgical options should it fail to yield the desired result.

The effect of coracoacromial ligament excision and acromioplasty on the amount of rotator cuff force production necessary to restore intact glenohumeral biomechanics.

These authors point out that coracoacromial ligament (CAL) excision and acromioplasty increase superior and anterosuperior glenohumeral translation. They used a cadaver model to estimate how much of an increase in rotator cuff force is required to re-establish intact glenohumeral biomechanics after acromioplasty.

Nine cadaveric shoulders were subjected to loading in the superior and anterosuperior directions in the intact state after CAL excision, acromioplasty, and recording of the translations. The rotator cuff force was then increased to normalize glenohumeral biomechanics.

At 150 and 200 N of superior and anterosuperior loading, an increase in the rotator cuff force of 25% was required to eliminate the increased translation resulting from CAL excision.

At 150 and 200 N of superior and anterosuperior loading, an increase in the rotator cuff force of 25% and 30%, respectively, was required to eliminate the increased translation resulting from acromioplasty and CAL excision.

The authors concluded that after subacromial decompression, the rotator cuff has to increase  its force production to maintain baseline glenohumeral mechanics. Under many circumstances, in vivo force requirements may be even greater after surgical attenuation of the coracoacromial arch.

Comment: As Codman pointed out in 1934 "The coracoacromial ligament has an important duty and should not be thoughtlessly divided at any operation." 

He recognized then, as we should today, that the coracoacromial arch provides an important stabilizing function resisting the superiorly directed force applied by the deltoid or when pushing up from a chair, bed, floor or bar. He pointed to the normal articulation between the superior aspect of the cuff and the undersurface of the coracoacromial arch. 

The center of curvature of the arch is the same as the center of curvature of the humeral head.

The stabilizing effect of the arch remains the same if there is ossification of part of the coracoacromial ligament.

We have previously demonstrated that the acromion is loaded when superiorly directed force is applied through the humeral head (whether or not the cuff is intact).
 When the superior cuff tissue is absent, superiorly directed loads applied to the humeral head produce superior translation of the head until it is stopped by the coracoacromial arch.
Sacrifice of the coracoacromial arch in the cuff deficient shoulder is a common cause of anterosuperior escape and pseudoparalysis.

Where does that leave the concept of 'impingement'? See this link.

Tuesday, May 16, 2017

Shoulder stiffness and glucose control

The relationship between the incidence of adhesive capsulitis and hemoglobin A1c

These authors determined a "cumulative" HbA1c, that uses HbA1c values over time to estimate the total disease burden that the patient experiences over a period. They evaluated whether a correlation existed between cumulative HbA1c levels in diabetic patients and the prevalence of frozen shoulder using a retrospective review of  patients from a single institution for which HbA1c values were available. The exclusion criteria were age younger than 18 years, HbA1c levels greater than 15, and patients who had 1 year or less of single or consecutively recorded HbA1c levels. A total of 24,417 patients met the inclusion criteria.

They found that cumulative HbA1c was positively associated with adhesive capsulitis.  The effect size of cumulative HbA1c on adhesive capsulitis was significant; for each unit of time that the HbA1c level was greater than 7, there was a 2.77% increase in the risk of adhesive capsulitis.

Comment: The mechanism of joint stiffness in individuals with abnormal sugar metabolism is thought to be non-enzymatic gycosylation, causing abnormal cross links between collagen fibers resulting in increased stiffness. 

Surgeons performing surgical releases for stiff diabetic shoulders often note increased thickness and toughness of the capsular tissue. Surgeons attempting to manage diabetic stiff shoulders with manipulation are often frustrated for the same reason.

This paper would have been stronger if the authors had provided the diagnostic criteria used for making the diagnosis of adhesive capsulitis (if indeed these criteria were standardized across the practice) and if they had performed a multivariate analysis that included all the data they collected: patient age, sex, BMI, length of time over which the HbA1c data were collected (range, 12-207 months), thyroid status, and insulin dosage at the time of diagnosis. 

In any event, this study reminds us that, in addition to its effect on surgical complications, glycemic control may affect the success of procedures designed to improve shoulder motion, including shoulder arthroplasty. 


Monday, May 15, 2017

Imaging the arthritic glenoid

Can glenoid wear be accurately assessed using x-ray imaging? Evaluating agreement of x-ray and magnetic resonance imaging Walch classification

These authors point out that glenohumeral arthritic pathoanatomy is often evaluated using advanced imaging, which is more expensive and less practical than plain radiographs. 

They compared the assessment of the Walch glenoid type using plain x-rays to that using magnetic resonance imaging in 50 patients assessed for shoulder arthroplasty by 5 raters. The inter-rater agreement for x-ray images and MRIs was “moderate” (κ = 0.42 and κ = 0.47, respectively) for the 5-category Walch classification (A1, A2, B1, B2, C) and “moderate” (κ = 0.54 and κ = 0.59, respectively) for the 3-category Walch classification (A, B, C). The agreement between x-ray images and consensus MRI was much lower: “fair-to-moderate” (κ = 0.21-0.51) for the 5-category and “moderate” (κ = 0.36-0.60) for the 3-category Walch classification.
Based on these results the authors concluded that x-ray images are inferior to advanced imaging when assessing glenoid wear.

Comment: The results of this paper do not appear to support its conclusions. The inter-rater agreement for both x-rays and MRI's were essentially identical. 

There are some other important issues in this paper.
First, the axillary views were not taken in a standardized manner (see our recommended technique here).
Second, the example shown in the paper shows the identical glenoid type for both the axillary view and the MRI (even though the authors conclude that the x-ray image is classified as type B2, but magnetic resonance imaging reveals a type C glenoid). No new information was gained from spending the money on the MRI.

Finally, it has not been shown that shoulder arthroplasties performed after expensive imaging (MRI or CT) have superior outcomes to those performed with the less expensive standardized plain radiographs. 

More on this topic here:

Radiographs and computed tomography scans show similar observer agreement when classifying glenoid morphology in glenohumeral arthritis

These authors observe that the Walch classification provides a useful frame of reference when assessing subluxation and glenoid morphology in primary glenohumeral osteoarthritis.

They compared the use of computed tomography (CT) and axillary radiographs to determine arthritic glenoid pathoanatomy (Walch type) in 75 consecutive shoulders with primary glenohumeral osteoarthritis.

The average intraobserver agreement for radiographs was 0.66.
The average intraobserver agreement for CT scans was 0.60.
Pairwise comparisons between observers showed higher agreement for radiographs than for CT scans (0.48 vs. 0.39).

The average agreement for observations on radiographs and CT scans was 0.42 (moderate; 0.40, 0.37, and 0.50).

In their study, the B2 glenoid was found in 40% of the cases.

In their study intraobserver agreement using the Walch classification based on axillary radiographs was substantial and compared favorably with agreement based on CT scans.

Comment: The purpose of imaging of the shoulder is to help establish the diagnosis, to determine the severity of the pathoanatomy, to help in surgical planning, and to enable the surgeon to illustrate the condition of the shoulder for the patient. Unless a specific research protocol is in place, we resist the temptation to ‘over-image’ , i.e. obtaining scans or reconstructions that are not necessary for the care of the patient such as that shown below.

The observation that CT scans may offer a few degrees of increased precision in the measurement of glenoid version does not convince us that this precision improves the quality of the surgery or the clinical outcome. Almost always standardized plain films are sufficient to garner the needed information and, as is shown below, information can be gathered from properly taken plain films that cannot be gathered on CT scans . In that proper radiographic technique (like surgical technique) is necessary to achieve the desired outcome, we take time to assure that our x-ray technologists know what we are seeking in the images.

The first key view is the anteroposterior in the plane of the scapula taken so that the x-ray beam passes through the glenohumeral joint. This view shows the superior-inferior position of the humeral head relative to the glenoid, the presence of osteophytes on the humeral head and glenoid, joint space narrowing, the degree of medial displacement of the humerus in relation to the lateral acromial line, the quality of the humeral and glenoid bone, the presence of loose bodies, and the presence of humeral head collapse or deformity.

The second key view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula and oriented so that both the spinoglenoid notch and the scapular neck are visible. This view shows a different perspective of the humeral anatomy, the amount of glenoid bone, the shape of the glenoid, its version in relation to the plane of the scapula and the relationship of the humeral head to the glenoid fossa. We have named the axillary view taken in with the arm elevated in the plane of the scapula the ‘truth’ view. This is because it demonstrates the glenohumeral relationships in the functional position of elevation; this is in contrast to CT scans, which have the disadvantage of being taken with the arm in the adducted position

Unfortunately, many of the ‘axillary views’ sent to us on patients for consultation are taken without standardization, making it impossible to determine the important features of the glenohumeral joint as  shown below.

When taken properly, the standardized anteroposterior and axillary views indicate the thickness of the cartilage space between the humerus and the glenoid, the relative positions of the humeral head and the glenoid, the presence of osteophytes, the degree of osteopenia, and the extent of bony deformity and erosion.

Since arthritis usually involves the central aspect of the humeral head,

joint space narrowing is most evident on the truth view as opposed to images made with the arm at the side. Of even greater importance is the ability of the axillary ‘truth’ view to show posterior subluxation or ‘functional decentering’ that is not evident in images taken with the arm at the side.

The degree of posterior subluxation can be measured as (a) the position of the center of the humeral head in relation to the plane of the scapula, (b) the position of the center of the humeral head in relation to the glenoid face or (c) the point of contact of the humeral articular surface on the glenoid articular surface. We prefer the latter because it is this point of contact that reflects the degree of centering of the net humeral joint reaction force on the glenoid. It is the malcentering of this joint reaction force that leads to posterior instability, posterior glenoid wear and to rocking horse loosening of prosthetic glenoid components. The standardized axillary view also enables the surgeon to see the shape of the glenoid surface. Three main types have been described: concentric wear (type A)

eccentric posterior wear (type B),

and dysplastic (type C)

In actual practice, there are so many intermediate types of glenoid pathoanatomy that rigorous separation into a few distinct classes is difficult. 

 An important aspect of glenoid pathology is the amount of the glenoid that is involved in the pathologic concavity, known as the ‘neoglenoid. Finally, the standardized axillary view enables the measurement of the degree of glenoid retroversion in relation to the body of the scapula. Thus, on the standardized axillary view, the surgeon can usually determine the major important characteristics of glenohumeral arthritic pathoanatomy: the amount of joint space narrowing, the degree of retroversion, the degree of posterior subluxation with the arm in a functional position, the glenoid shape, the percentage of the glenoid involved in the pathologic concavity and the angle of retroversion.

 Because of their low cost and freedom from metal artifacts, standardized axillary views provide a practical and reliable way to document the postoperative anatomy sequentially over time and to compare it to what was present before surgery.

A third view, the templating view, is obtained when humeral arthroplasty is being considered. This view is an anteroposterior (AP) view of the humerus taken with the arm in 30 degrees of external rotation relative to the x-ray beam with a magnification marker added. This view places the humeral neck in maximal profile and allows a comparison of proximal humeral anatomy with that of various humeral prostheses. In templating, it is important to recognize that the humeral canal is not cylindrical – the medial-lateral dimension is usually wider than the anteroposterior dimension so that the AP view may overestimate the size of the stem that will fit the diaphysis. This view is also useful for determining whether sufficient osteoporosis is present to merit special consideration at the time of arthroplasty 

Advanced imaging may be useful in the unusual case where the anatomy is distorted by prior injury or surgery, when there is concern about the amount of bone available for reconstruction, or when the standardized plain films cannot be obtained. In the great majority of cases, however, the extra cost and radiation of the CT scan can be avoided through the use of these standardized plain films. In that we can learn what we need to know about the status of the rotator cuff from physical examination and plain radiographs, shoulder MRIs are rarely needed unless indicated to exclude avascular necrosis or tumor. An MRI of the neck may be useful in evaluating patients suspected of having cervical radiculopathy, myelopathy, stenosis or a syrinx.


Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at 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 including:shoulder arthritis, total shoulder, ream and runreverse total shoulderreverse total shoulder patient information,  CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.