Friday, July 28, 2017

Rotator cuff tear: physical exam predicts tear size and reparability!

Accuracy of infraspinatus isometric testing in predicting tear size and tendon reparability:comparison with imaging and arthroscopy

These authors examined the accuracy of external rotation in neutral (0° external position) and in shortened position (45° external position) in relation to rotator cuff tear size, tendon reparability, and other clinical, surgical, and imaging findings (magnetic resonance imaging and arthroscopic surgery).Eighty-five patients (35 female and 50 male, 65 years ±10 years) were found to have the following tear types: sixty patients (71%) had a minor tear (4 small, 56 moderate), and 25 patients
(29%) had a major tear (17 large and 8 massive). Seventy patients (82%) had a full repair, and 15 (18%) patients underwent a partial repair. There were 26 (31%) associated full-thickness tears of the infraspinatus.

The isometric strength testing in both positions had good to excellent accuracy for detecting reparability, tear retraction, infraspinatus atrophic changes observed by the clinician, and infraspinatus fatty infiltration on magnetic resonance images. The shortened position had an overall higher accuracy than the neutral position and was more clinically useful for detecting an infraspinatus fullthickness tear and rotator cuff tear size.

The authors concluded that the strength of isometric external rotation is an accurate test in diagnosing different aspects of rotator cuff disease and specifically of the infraspinatus muscle. The isometric strength at the shortened position was a better predictor of clinical, surgical, and imaging findings.

Comment: This study again highlights that a good history, physical examination and plain radiographs provide much of the information needed to guide treatment of cuff disease without resorting to more expensive advanced imaging. This cost-effective approach was presented decades ago in Practical Evaluation and Management of the Shoulder (see this link). Here is a chart from that book showing the approach that we used then and still use now


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How long do total shoulders last? The Great Paradox

Survival of the pegged glenoid component in shoulder arthroplasty: part II

Theses authors point out that loosening of the glenoid component is a primary reason for failure of an anatomic shoulder arthroplasty. These authors evaluated the midterm clinical and radiographic survival of an in-line pegged glenoid component and identified risk factors for radiographic loosening and clinical failure at an average clinical follow-up of 7.2 years




287 had presurgical, initial postsurgical, and late postsurgical radiographs (mean radiographic follow-up, 7.0 years). At most recent follow-up, 30 glenoid components had been revised for aseptic loosening. The rate of glenoid component survival free from revision for all 330 shoulders of 99% at 5 years and 83% at 10 years. 



Of 287 glenoid components, 120 (42%) were considered loose on the basis of radiographic evaluation. Four humeral components were considered loose. Component survival (Kaplan- Meier) free from radiographic failure at 5 and 10 years was 92% and 43%. 



Severe presurgical glenoid erosion (Walch A2, B2, C) and patient age <65 years were risk factors for radiographic failure. Late humeral head subluxation was associated with radiographic failure.

Comment: This paper shows the importance of longer term followup. Both radiographic failure and the need for surgical revision for this component was not apparent until after five years - a time well after the usual 2-year followup required for publication in most journals. 

This article also points out that the rate of revision at any time point after surgery underestimates the rate of radiographic glenoid failure.

A case example from this paper shows late loosening of an initially well-fixed glenoid component

 The late followup x-ray shows superior displacement of the humeral head with superior angulation of the glenoid component.
This is the type of component loosening that has been associated with rotator cuff failure via the 'rocking horse' mechanism.

The authors point out that their results with this peg configuration were inferior to those they achieved with the corresponding keeled fixation.
One of the challenges we face in clinical orthopaedic research what we refer to as the Great Paradox: the long term data we have relates to components that are no longer in use.

The authoring surgeons have moved on to other designs for which 10 year outcomes are not available:



Nevertheless, the problem of glenoid component failure retains its position as a leading cause of poor total shoulder outcomes. Some of the risk factors for failure identified in this study are likely to remain in effect with any glenoid component design: young age, advanced glenoid erosion, and glenohumeral instability. 

Finally, an understanding of the factors associated with component failure may be most reliably obtained from national registry data such as that provided by the Australian Orthopaedic Association 









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Thursday, July 27, 2017

Health care debate: turmoil, the 'skinny bill', health insurance as a risk factor

Insurance status affects postoperative morbidity and complication rate after shoulder arthroplasty

This is not a political post, although its topic has profound political and economic implications. The authors take a very small slice of the health care pie to illustrate the relation between the health care coverage that a patient can afford and the surgical risk for that patient undergoing a shoulder arthroplasty.

These authors evaluated the effect of patient insurance status on perioperative outcomes after shoulder replacement surgery using data on 103,290 having surgery between 2004 and 2011 identified in the Nationwide Inpatient Sample. The distribution of insurance coverage was 68,578 Medicare, 27,159 private insurance, 3544 Medicaid/uninsured, 4009 other. The overall complication rate was 17.2% (n = 17,810)and the mortality rate was 0.20% (n = 208). Medicare and Medicaid/uninsured patients had a significantly higher rate of medical, surgical, and overall complications compared with private insurance using the controlled match data.
Multivariate regression analysis found that having private  insurance payer status is associated with a lower risk of perioperative medical and surgical complications compared with an age- and sex-matched Medicare and Medicaid/uninsured payer status.



Comment: Insurance status can be a marker for factors affecting surgical risk, such as nutrition status, health maintenance, social support, exercise status, bone quality, compliance, mental health, and traveling distance to a quality medical facility. Insurance status can also affect risk by influencing the accessibility to pre-surgical medical care, experienced surgeons and the availability of postoperative physical therapy and other forms of support. 

This important paragraph is included in the authors' discussion: "The data also showed that the comorbidity index and age are independent risk factors for medical complications after shoulder arthroplasty, with a higher preoperative comorbidity index seen in the government-sponsored insurance groups. In addition, the increased rate of complications seen in the government-sponsored insurance groups (Medicaid and Medicare) resulted in higher hospital charges after shoulder replacement compared with the private insurance group. Furthermore, privately insured patients were more likely to go to a higher-volume hospital for their elective shoulder replacements than patients with government-sponsored insurance. This finding may reflect that ability of patients with private insurance to select their own physicians. In contrast, Medicaid patients may have difficulty finding orthopaedic surgeons that will accept their insurance type and uninsured patients may have an inability to see an orthopaedic surgeon altogether due to lack of insurance coverage and consequently, exorbitant out of pocket cost."

Ironically, increased expenditures are necessary to manage the greater risks associated with patients with less remunerative health care coverage. It seems unlikely that the interaction between surgical risk and insurance coverage identified in this study will be eliminated or even reduced by any of the health care plans under discussion.

Here is a study with a similar conclusion:

Medicaid payer status is linked to increased rates of complications after treatment of proximal humerus fractures

These authors note that low socioeconomic status and Medicaid insurance as a primary payer have been associated with major disparities in resource utilization and risk-adjusted outcomes for patients undergoing totaljoint arthroplasty.

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database they identified patients who were treated for proximal humeral fractures (PHFs) from 2002 to 2012.

In an effort to minimize confounding variables, each Medicaid patient was matched to a privately insured patient on the basis of gender, race, year of procedure, and age (but notably not to fracture type or type of treatment):



Of the 678,831 patients treated with PHF, 4.9% (33,263) had Medicaid as the primary payer during the 10-year period. Medicaid patients were found to have a significantly higher risk (P < .05) of postoperative in-hospital complications, including postoperative infection (odds ratio [OR], 2.00 [1.37-2.93]), wound complications (OR, 1.69 [1.04-2.75]), and acute respiratory distress syndrome (OR, 1.34 [1.15-1.59]).

They concluded that Medicaid patients have a significantly higher risk for certain postoperative hospital complications and consume more resources after treatment for PHFs.

It is apparent that our health care system is on the cusp of change with the new administration. Under most any system, however, the observation that Medicaid insurance (which provides relatively low reimbursement) can be a risk factor for an increased rate of complications and for increased per-case expense will continue to create an ethical, social and economic challenge for the providers. This is especially the case if there are penalties for the increased readmission rates that are likely to be necessary to manage the increased rate of complications. Our hope is that broad-based discussion will lead to a well-informed approach so that our patients can get the care they need.





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The risks associated with total shoulder in patients with diabetes and others

The impact of insulin dependence on short-term postoperative complications in diabetic patients undergoing total shoulder arthroplasty

These authors sought to determine the impact of insulin dependence on the risk profile of diabetic patients having shoulder arthroplasty. Patients were categorized as non–diabetes mellitus (non-DM), non–insulin dependent diabetes mellitus (NIDDM), or insulin-dependent diabetes mellitus (IDDM). 


In bivariate analysis, NIDDM and IDDM were associated with multiple postoperative complications, including stroke, sepsis, wound complications, blood transfusion, and extended LOS. With multivariable logistic regression, however, NIDDM patients did not have significantly greater odds of any study end point relative to non-DM patients. IDDM patients had significantly greater odds for having any postoperative complication (odds ratio [OR], 1.53), stroke (OR, 13.63), blood transfusion (OR, 1.67), and extended LOS (OR, 1.38).

They concluded that after adjustment for demographics and comorbidity burden, NIDDM patients had risk profiles similar to those of non-DM patients. IDDM was an independent predictor of multiple postoperative complications. 

Comment: While the authors did not have HbA1c levels on the patients in this study, they state that "insulin dependence appears to be a more robust risk factor than glycemic control as measured by the HbA1c level." There is currently a re-examination of the value of using oft-quoted target of an HbA1c level of 7. There is some evidence that (1) some patients may not be able to reach this goal and (2) 'forcing' an HbA1c level of 7 may not be safe for the patient. There seems to be a trend toward accepting the more reachable and perhaps safer target of 8. 

It remains unclear to us how much the well-documented increased risk of surgery in patients with IDDM can be modified. The table above demonstrates that a number of important health factors are co-variates with the severity of diabetes making it a challenge to sort the effect of one from the other. 

At minimum, our responsibility is to inform our patients of the potential risk of surgery. One approach is to use the American College of Surgeons' Surgical risk calculator






Interestingly this calculator classes diabetes as "none", "oral", "insulin".

The reader may like to enter "23472 - Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))" into the procedure box at the top and calculate his/her estimated risk.



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Propionibacterium - does preoperative systemic antibiotic prophylaxis work?

Preoperative doxycycline does not decolonize Propionibacterium acnes from the skin of the shoulder: a randomized controlled trial

These authors point out that Propionibacterium is frequently cultured in patients undergoing both primary and revision shoulder surgery. They conducted a prospective, randomized controlled trial of male patients undergoing shoulder arthroscopy to evaluate the efficacy and safety of preoperative oral administration of doxycycline in decreasing the colonization of skin around the shoulder by P. acnes.

Patients were randomized to receive oral doxycycline (100 mg twice a day) for 7 days or to the standard of care (no drug). Before skin incision, 2 separate 3-mm punch biopsy specimens were obtained from the sites of the anterior and posterior arthroscopic portals and were sent for culture in anaerobic and aerobic medium held for 13 days.

To serve as a “negative control,” while wearing sterile gloves, 20 consecutive sterile swabs were opened in the operating room, wiped through the air, and sealed  in a specimen container. 20% of these cultures were positive.

In the overall cohort (74 patients), 38 patients (51.3%) had at least 1 positive culture for Propionibacterium; 22 patients (29.7%) had positive cultures from both the anterior and the posterior portal sites and 16 patients (21.6%) had positive cultures from just 1 site. All patients with a positive culture from the posterior portal also had a positive culture from the anterior portal. The mean time to isolate Propionibacterium from cultures was 5.9 days (range, 2-9 days).

22 of 37 (59.5%) patients in the no-drug group and 16 of 37 (43.2%) patients in the doxycycline group had at least 1 dermal culture positive for P. acnes (P = .245).  The number of shoulders with negative cultures was greater in the Doxyclycline group.


The authors concluded that that a 7-day course of oral doxycycline administration was safe but was only marginally effective in reducing the colonization rate of P. acnes in the dermal layer of the shoulder in male patients. 

Comment: Over half of the dermal cultures obtained from the surgically prepared dermis of shoulder skin of male patients were positive for Propionibacterium. This finding is consistent with prior studies showing that skin surface preparation does not eliminate Propionibacterium from the dermis. As the authors point out, although Propionibacterium is usually sensitive to doxycycline, preoperative administration of this antibiotic had only a modest effect in reducing the positive culture rate. This may be a result of the fact that the sebum in sebaceous glands that harbor Propionibacterium is relatively out of reach of the systemic circulation.

The 20% positive culture rate for Propionibacterium in the 'negative controls' is of interest. It is difficult to know how to factor in this rate of positive 'control' cultures when assessing the positive culture rate of the dermal specimens.  The authors did used 'semiquantitative methods' for reporting the bacteria load in positive dermal cultures (see below), it would be of interest to know the bacterial load found in the 'negative control' cultures. 






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Sunday, July 23, 2017

Reverse total shoulder failure from polyethylene dissociation from humeral implant

Polyethylene dissociation from humeral stem status after reverse total shoulder arthroplasty

These authors present four cases of polyethylene liner dissociation from the humeral component of a  reverse shoulder arthroplasty (RSA).  In a series of 549 patients who underwent RSA, the incidence of this complication was 0.7%.  These patients presented with signs, symptoms, and imaging consistent with dislocation but were found to have a dissociation of the polyethylene from the humeral component, rendering a closed reduction impossible.

All four cases were male with a the same implant. The dissociations were recognized between 3 months and three years after surgery. The images from the four cases are shown here. The authors caution, "surgeons should be aware of this possibility if a closed reduction of an RSA dislocation is not possible."






Comment: Because the polyethylene liner of a reverse total shoulder can experience large, non-compressive loads, it is at risk for displacement from the metal humeral cup. Similar complications have occurred with other implants, so it is not clear whether the design of this system is at particular risk for this complication. With any design, it is important that the liner be vigorously and fully seated in the humeral cup after assuring that the cup is dry and free of any interposed tissue. After insertion, the security of the seating needs to be verified.
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Reverse total shoulder in patients < 55 years of age.

Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up

These authors report on 67 patients (average age, 47.9 years; range, 21-54 years) having a reverse total shoulder (RSA)with an average 62.3 months of follow-up (24-144 months). 35 patients had the RSA for a failed arthroplasty and 32 patients had a primary RSA.



In the revision group, ASES score improved from 24.4 to 40.8 (P = .003), and SST score improved from 1.3 to 3.2  out of a maximum score of 12 (P = .043).




In the primary group, ASES score improved from 28.1 to 58.6 (P < .001), and SST score improved from 1.3 to 4.5 out of a possible 12 (P = .004).





The total complication rate was 22.4%. The total reoperation rate was 13.4%, and the revision rate was 8.9%;  infection the cause of all revisions.

The revision group had a complication rate of 25.7%.2 patients with humeral lucency (1 treated conservatively), 2 with glenoid screw lucency (treated conservatively), 2 with periprosthetic fractures (1 treated conservatively), 1 with humeral dissociation, 1 with infection, and 1 with recurrent instability (treated conservatively). 

The primary group had a complication rate of 18.7%. 1 patient with scapular fracture (healed conservatively), 1 patient with symptomatic hardware after fixation for an os acromiale at the time of index surgery, and 4 patients with periprosthetic infections.

Comment: Young patients with failed prior arthroplasty as well as those with other indications for RSA  (failed rotator cuffs, fractures, arthritis) present a major clinical challenge not only because of the difficulty presented by the pathology, but also because of their expectations and longevity.

This is a forthright presentation of the intermediate term results and complications of these procedures in the hands of a highly experienced surgeon. The relatively high complication rate and the relatively low patient-reported outcomes provide a cautionary tale for us to tell young patients considering this reconstruction.

The interested reader should compare these results with those achieved by the same surgeon for patients with massive cuff tears: Reverse shoulder arthroplasty for massive rotator cuff tear: risk factors for poor functional improvement.

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