Sunday, December 10, 2017

How much money should we spend on imaging rotator cuffs?

Cost-effectiveness of magnetic resonance imaging versus ultrasound for the detection of symptomatic full-thickness supraspinatus tendon tears

These authors sought to determine the value of magnetic resonance imaging (MRI) and ultrasound-based imaging strategies in the evaluation of a hypothetical population with a symptomatic full-thickness supraspinatus tendon tear using formal cost-effectiveness analysis. They used a decision analytic model from the health care system perspective for 60-year-old patients with symptoms secondary to a suspected supraspinatus tear to evaluate the incremental cost-effectiveness of 3 imaging strategies during a 2-year time horizon: MRI, ultrasound, and ultrasound followed by MRI.

Their results shown below show a 0.8% increased effectiveness for MRI which costs 16.5% more than ultrasound.










Comment:  What's really interesting in this paper is the first two sentences of the introduction. "Rotator cuff tears are a common source of shoulder pain, especially for older patients, and full-thickness tendon tears have been reported in up to 21% of the general population. Surgical treatment for rotator cuff disease has increased 238% during a span of 14 years (1995-2009), accounting for approximately 250,000 operations in the United States per year."

In 2012 the Unites States population of individuals over the age of 65 years was 41,506,000 (see this link). From these numbers it can be estimated that there are 8,716,200 individuals (21% times 41,506,000) with cuff tears, but less than 3% (250,000 divided by 8,716,200) of these receive surgery each year. One must ask, "how important is imaging in the decision to perform surgery, what percent of the population should have ultrasound or MRI to evaluate cuff integrity?" The reader can do the math of multiplying the cost of imaging by the number of folks at risk for having cuff tears.

The decision to attempt a cuff repair on a patient needs to be highly individualized. Shared patient-surgeon decision making needs to be based on findings that have been shown to be encouraging or discouraging about the prospect of the shoulder having a durably reparable cuff tear. It is of interest that many of these factors can be determined without ultrasound or MRI. We first published these guidelines in 1994 and have found them as useful today as back then. Note that the decision is based on considering the patient as well as the shoulder.

ENCOURAGING                                    DISCOURAGING

History 
Age less than 55                                        Age over 65
Acute traumatic onset                                Insidious, atraumatic onset
No relation to work                                   Attribution of tear to work
Short duration of weakness                       Weakness over 6 weeks
No history of smoking                               Many smoking pack-years
No steroid injections                                  Repeated steroid injections
No major medications                                Steroids/antimetabolites
No concurrent disease                                Inflammatory joint disease
No infections                                              History of previous infection
No previous shoulder surgery                     Previous cuff surgery
Benign surgical history                               History of failed tissue repairs

Physical Examination 
Good nutrition                                             Poor nutrition/obesity
Mild weakness                                            Severe weakness
No spinatus atrophy                                    Severe spinatus atrophy
Stable shoulder                                           Anterior superior instability
Intact acromion                                           Previous acromioplasty
No stiffness                                                 Stiffness

Radiographs 
Normal radiographs                                    Upwards head displacement
                                                                    Cuff tear arthropathy

MRI or Ultrasound 
Good tendon quality                                   Thin tendon
One tendon tear                                          Multiple tendon involvement
Small gap to close                                       Severe retraction

In our practice, we are depending less and less on rotator cuff imaging and more and more on the factors that can be discerned from a good history, physical examination, and plain radiographs.


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The reader may also be interested in these posts:



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 shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Shoulder range of motion after joint replacement: how much is needed?

Comparing daily shoulder motion and frequency after anatomic and reverse shoulder arthroplasty 

These authors measured the total daily shoulder motion of patients after TSA and RTSA in 36 subjects using a custom instrumented garment that tracked upper extremity motion for the waking hours of 1 day. 

94% of shoulder motion occurred below 80° of elevation for total shoulders, reverse total shoulders and shoulders contralateral to the surgical shoulder. In the diagrams below "O" refers to the surgical shoulder while "N/O" refers to the contralateral shoulder.



Comment: While many surgeons focus on the postoperative range of motion after a shoulder arthroplasty as a measure of the effectiveness of the procedure, this study suggests that the range of motion above 100 degrees is rarely used by the patient. 

The lack of a strong relationship between shoulder motion and function was demonstrated recently by this paper:
Relationship Between Patient-Reported Assessment of Shoulder Function and Objective Range-of Motion Measurements

In 74 male and 30 female patients with osteoarthritis these authors analyzed the relationship between the Simple Shoulder Test patient self-assessments of shoulder function  and objective range-of-motion measurements recorded by the observer-independent Kinect motion capture system



For both female and male patients, they found a poor correlation between objective measurements of active abduction and the total SST scores of osteoarthritic shoulders (square symbols). The relationships between active abduction and total SST score were only fair for the contralateral shoulders (diamond symbols).


Interestingly, these authors found that shoulders unable to perform the different activities of the SST averaged less than 100 degrees of abduction






The key finding in this study was that the active range of motion correlated poorly with the patients' self-assessed function of their osteoarthritic shoulders, meaning that the shoulder function was dependent on characteristics of the shoulder and the patient other than the active range of motion. 100 degrees of active elevation appears to enable patients to perform most of their daily activities.

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The reader may also be interested in these posts:



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 shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.


See the countries from which our readers come on this post.

Saturday, December 9, 2017

CTA arthroplasty rather than a reverse total shoulder for rotator cuff tear arthropathy

Many of our patients with classical cuff tear arthropathy want to lead active lives. They wish to avoid a reverse total shoulder because of concerns about activity limitations, dislocation, screw breakage or humeral shaft fracture should they fall. If these individuals have active elevation > 90 degrees and have no evidence of anterior superior instability, we discuss the option of a CTA prosthesis.

Here's the example of a 71year old lady with a history of prior failed cuff surgery. At the time of presentation to us she could not perform any of the 12 functions of the Simple Shoulder Test. Her x-rays at the time are shown below.



Because of her desired activity levels, she elected a CTA arthroplasty rather than a reverse total shoulder. At surgery she had an irreparable cuff defect involving her supraspinatus and infraspinatus and her subscapularis had detached from her lesser tuberosity.

She worked very hard at her rehabilitation and by 6 weeks after surgery she had regained active elevation of her arm.

At two years after surgery, she could perform all 12 of the SST functions, including tucking in her shirt behind her. Her x-rays show firm support of her CTA prosthesis by the acromion.



Comment:  From our standpoint, the CTA arthroplasty is a most attractive option for consideration by active individuals with cuff tear arthropathy and the ability to actively elevate the arm above 90 degrees without manifesting anterosuperior instability.  Inserting the prosthesis with impaction grafting makes for an easy conversion to a reverse should that be necessary, fortunately this is rarely the case. The cuff tear arthropathy prosthesis is considered for individuals with active elevation of 90 or more degrees without anterosuperior escape – especially those who desire higher levels of physical activity or those who are at increased risk of falls. It is important to realize that this prosthesis has an extended lateral joint surface for articulation with the undersurface of the coracoacromial arch, thus it is distinct from the usual hemiarthroplasty prosthesis. The implant system should allow selection of the appropriate diameter of curvature and should enable fixation by impaction grafting.

The surgical keys to a successful CTA arthroplasty are (1) optimizing stability and (2) matching the prosthetic diameter of curvature to that of the resected humeral head. The patient positioning, anesthetic, prophylactic antibiotics, skin preparation, and skin incision are identical to that for an anatomic arthroplasty. 

 

In exposing the humeral head, we retain as much as possible of the clavipectoral fascia attached to the coracoacromial ligament (the “CA+”) as an additional barrier to anterosuperior instability. 



The subscapularis is carefully incised from the lesser tuberosity taking care to keep the subjacent capsule attached to its deep side. The humerus is exposed by gentle external rotation allowing for debridement of cuff tendon remnants and osteophytes as well as sectioning of the long head tendon of the biceps if it remains intact. The humeral head height and diameter of curvature are measured, ideally before the head is resected.


The humeral head is resected at an angle of 45 degrees with the orthopaedic axis; the proximal humerus is prepared as for a standard humeral arthroplasty. The lateral tuberosity is resected. The humeral head diameter of curvature is chosen to match that of the resected head. Trial reduction is carried out. The height of the prosthesis is selected so that the deltoid is under mild-moderate tension when the arm is adducted. Impaction grafting is carried out using bone from the resected humeral head. If the biceps tendon is present, an in-and-out biceps tenodesis is performed. Drill holes are placed for reattachment of the subscapularis. The is prosthesis assembled and inserted and the mobilized subscapularis is securely repaired.

Active assisted motion is started immediately after surgery. Progressive strengthening exercises are started at 6 weeks.
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The reader may also be interested in these posts:



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 shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Friday, December 8, 2017

Dislocation after reverse total shoulder

Classification of instability after reverse shoulder arthroplasty guides surgical management and outcomes

Recognizing that dislocation is the leading mechanical complication of reverse total shoulder, these authors sought to develop a classification for instability after RSA, to describe the clinical outcomes of patients stabilized operatively, and to identify those patients at higher risk of recurrence.


Their classification system is shown below.



They reviewed 43 revision cases in 34 patients. In the revisions the authors usually upsized the glenosphere to 40 or 44 neutral, often with +6 or +8 mm humeral offset and semiconstrained liners.



Persistent instability most commonly occurred in persistent deltoid dysfunction and postoperative acromial fractures but also in 1 case of soft tissue impingement. Twenty-one patients remained stable at minimum 2 years of follow-up and had significant improvement of clinical outcome scores and range of motion.

Comment: Instability after a reverse total shoulder remains a substantial problem. Additional insight into the factors affecting stability can be gained from this article:

Hierarchy of Stability Factors in Reverse Shoulder Arthroplasty

These authors asked: (1) what is the hierarchy of importance of joint compressive force, prosthetic socket depth, and glenosphere size in relation to stability, and (2) is this hierarchy defined by underlying and theoretically predictable joint contact characteristics? They examined the intrinsic stability in terms of the force required to dislocate the humerosocket from the glenosphere of eight commercially available reverse shoulder arthroplasty devices. The hierarchy of factors was led by compressive force followed by socket depth; glenosphere size played a much lesser role in stability of the reverse shoulder arthroplasty device. Similar results were predicted by a mathematical model, suggesting the stability was determined primarily by compressive forces generated by muscles.
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The reader may also be interested in these posts:



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 shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

Ream and run, results at five to sixteen years after surgery

Functional Outcomes of the Ream-and-Run Shoulder Arthroplasty A Concise Follow-up of a Previous Report

These authors previously reported the results at an average of 4.5 years after treatment of 176 patients with the ream-and-run arthroplasty. In the present study, they present the patient self-reported functional outcomes and clinical implant survival of the original cohort at a mean of 10 years (range, 5 to 16 years). Eleven patients (6%) died, and 30 (17%) had <5 years of follow-up. The Simple Shoulder Test (SST) score at the time of the latest follow-up was a median of 11 points (interquartile range, 9 to 12 points) and a mean (and standard deviation) of 10 ± 2.6 points, out of a possible 12 points. The average 10 year (minimum 2 year)  results were comparable to the average 4.5 year (minimum 5 year0 results



In the initial report, 22 patients had subsequent procedures; these included 2 manipulations under anesthesia, 5 subscapularis repairs, 4 open soft-tissue releases, 1 arthroscopic release, 5 revision ream-and-run procedures, 6 revisions to a total shoulder arthroplasty, and 1 revision to a reverse total shoulder arthroplasty. Since the original report, 6 additional patients had a subsequent procedure: a revision ream-and-run procedure was done in 4 and conversion to a total shoulder arthroplasty in 2. None had revision to a reverse total shoulder arthroplasty. In total, 28 patients had subsequent procedures. This represents 19% of the 146 who had a definitive minimum 5-year follow-up, including the 11 who died without known revision, the 1 who had a stroke, the 28 with subsequent procedures, and the remaining 106 with an unrevised shoulder. Nine had conversion to a total shoulder arthroplasty. Approximately half of the subsequent procedures (n = 15, 54%) were performed in the first 2 years following the ream-and-run procedure, after which the rate of subsequent procedures decreased substantially.





The overall rate of subsequent procedures was 19%, and the rate of prosthetic revision was 12% at a mean of 10 years. These findings are similar to the results of a recent national registry study (see this link) showing a 15% rate of prosthetic revision after total shoulder arthroplasties performed during a comparable time frame (2000 to 2005). In contrast to total shoulder arthroplasties, which have been widely reported to be associated with increasing rates of subsequent procedures and implant revision at 5 to 10 years after surgery, the rate of subsequent procedures declined in this study after the first 2 years. This phenomenon is likely attributable to the lack of mid-term and long-term glenoid component failure.

The authors provide this example case of a patient with a preoperative SST of 3 out of 12 and these films

Seven years after surgery he reported the ability to perform all 12 of the 12 functions of the SST. His seven year x-rays showed remodeling of his glenoid with firm subchondral bone and a regenerated layer of soft tissue between the metal ball and the reamed bone.

Comment: It is of note that a large percentage of the repeat procedures were directed at the management of stiffness (manipulations and soft tissue releases) and subscapularis failure. The risk of these problems may be reduced by (1) avoiding overstuffing the joint, (2) reinforcing the importance of vigorous range of motion exercises in the early rehabilitation period (see this link), and (3) protecting the subscapularis repair (see this link). It is of note that only 9 of the 22 repeat procedures involved conversion to a total shoulder or a reverse total shoulder. 

The details of the ream and run continue to be refined. The current trend is to assure this procedure is performed on carefully selected, highly motivated individuals whose activity levels may put a plastic glenoid component at risk for failure and to use relatively thinner humeral head components to allow for greater joint laxity. 

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The reader may also be interested in these posts:



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 shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.



Thursday, December 7, 2017

Shoulder arthritis in Alaska

We have the opportunity to see many patients with shoulder arthritis from Alaska. It's easy to understand that the Alaskan life style and the weather make managing symptoms of arthritis a challenge; it is a privilege to help these individuals get back to their activities in work and recreation.

Some of our recent patients live on small roadless islands in the the Kodiak Archipelago from which they fish commercially in competition with the taquka-aq (Kodiak Bear) - the largest recognized subspecies of brown bear


some live in Fairbanks, where winter temperatures drop to minus 50 degrees or more while they view the northern lights

some prepare salmon on their docks in Juneau 

some find wolves in their back yard

some prepare for the Iditarod in Willow

some Kayak with a cat while inspecting a napping seal at Halibut Cove

some skate on pristine frozen lakes around protruding icebergs near Cordova



some enjoy playing classical music in Juneau
Pretty amazing folks


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The reader may also be interested in these posts:



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 shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

Wednesday, December 6, 2017

Ream and Run at one month in a 45 year old

A 45 year old presented with pain and stiffness of the right shoulder after a successful ream an run performed on the left shoulder one year ago.

His preoperative films are shown below.

 His immediate post operative films are shown below


We received this photo in an email today. One month after ream and run with perfect motion - the result of the dedicated exercise program carried out by this man.



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The reader may also be interested in these posts:



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 shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.