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JBJS/JSES Webinar–Rotator Cuff Tears: On Whom Should We Operate?

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The prevalence of rotator-cuff tears is reported to be as high as 30% in people over the age of 60 years. Yet there is still no clear consensus on the indications for surgical treatment of these tears.

On Wednesday, May 24, 2017 at 7:00 PM EDT, The Journal of Bone & Joint Surgery (JBJS) and the Journal of Shoulder and Elbow Surgery (JSES) will host a complimentary* webinar that presents findings from two recently published Level I studies of rotator-cuff tears.

  • John Kuhn, MD, discusses findings from a prospective multicenter cohort study in JSES that identifies the characteristics with the greatest influence over whether patients choose surgery for a chronic, symptomatic, full-thickness rotator cuff tear.
  • Stefan Moosmayer, MD, reports results from a randomized controlled trial in JBJS that found interesting clinical-outcome differences between physiotherapy alone and tendon repair in patients with tears ≤3 cm.

This webinar is co-moderated by Andrew Green, MD, JBJS deputy editor and chief of the Division of Shoulder and Elbow Surgery at the Warren Alpert Medical School of Brown University and Bill Mallon, MD, past-president of the American Shoulder and Elbow Surgeons (ASES) and editor-in-chief of the Journal of Shoulder and Elbow Surgery (JSES). The webinar will offer additional perspectives on the authors’ presentations from two rotator-cuff experts—Lawrence Higgins, MD and Leesa Galatz, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all four panelists.

Seats are limited, so register now!

*This webinar is complimentary for those who attend the event live.

Ambulatory Shoulder Arthroplasty Is Safe

swiontkowski-marc-colorIn the April 19, 2017 issue of The Journal, Cancienne et al. compare complication and readmission rates for patients undergoing ambulatory shoulder arthroplasty with those among patients admitted as hospital inpatients postoperatively. Because the analysis was based on data from a large national insurer, we can be quite sure of appropriate coding and accurate data capture.

Similar to our recent report regarding outpatient hand and elbow surgery, in no instance were complications present at a significantly higher rate in the patients who underwent ambulatory shoulder arthroplasty, and the rate of hospital readmission after discharge was not significantly different at 30 or 90 days between the two cohorts.

This definitely is a tip of the hat to orthopaedic surgeons, nurses, and anesthesiologists, who are making sound decisions regarding which patients are appropriate for outpatient arthroplasty. Cancienne et al. found that obesity and morbid obesity were significant demographic risk factors for readmission among the ambulatory cohort, and they also identified the following comorbidities as readmission risk factors in that group:

  • Diabetes
  • Peripheral vascular disease
  • Congestive heart failure
  • Chronic lung disease
  • Depression
  • Chronic anemia

These results offer further documentation regarding the shift away from hospital-based care after orthopaedic surgery. Those of us who perform surgery in dedicated orthopaedic centers as well as general hospital operating rooms understand the concepts of efficiency, focus, maintenance of team skills, and limiting waste. Those objectives in large part drive the move to outpatient surgery. But patients, who almost always prefer to be at home and sleep in their own beds (or recliners in the case of shoulder replacement), may be an even more powerful driver of ambulatory care in the future.

Major advances in postoperative pain management are great enablers in this regard, and I believe the trend will continue. I envision a day when the only patients admitted to hospitals after orthopaedic surgery are those with unstable medical issues who potentially may need ICU care postoperatively.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

After Shoulder Arthroplasty, Interscalene Block Results in Rebound Pain

Bar Graph for O'Buzz.jpegAnecdotally, many patients experience extreme discomfort after shoulder surgery. The April 5, 2017 issue of JBJS features results from a randomized controlled trial comparing morphine consumption and pain during the 24 hours following shoulder arthroplasty among two groups. One group (n=78) received a preoperative interscalene brachial plexus blockade, while the other (n=78) received intraoperative infiltration of bupivacaine liposome suspension.

Mean total postoperative narcotic consumption during the 24 hours after surgery was not significantly different between the two groups, although intraoperative narcotic consumption was significantly lower in the blockade group. The mean VAS pain scores were significantly lower in the blockade group at 0 and 8 hours postoperatively, the same as in the infiltration group at 16 hours postoperatively, and significantly higher than those in the infiltration group at 24 hours postoperatively. That last finding in patients undergoing blockade represents the phenomenon known as “rebound pain.”

The authors, Namdari et al., conclude that the “optimal postoperative pain regimen for shoulder arthroplasty…require[s] further investigation.” But their analysis uncovered four demographic factors that were associated with higher pain scores at 24 hours after surgery, regardless of the analgesic technique used:

  • Younger age
  • History of depression
  • Higher Charlson Comorbidity Score
  • Higher preoperative VAS score

In his commentary on the study, Ranjan Gupta, MD notes that one downside of the block approach is “an inability to assess the patient’s neurologic function after the surgical procedure.” His own early clinical experience leads him to favor the admittedly “laborious” infiltration approach, partly because “both patients and orthopaedic nurses who take care of these patients in the immediate postoperative time period can readily appreciate the lack of rebound pain.”

Reverse TSA Components Are Durable, But Patient Outcomes Decline Over a Decade

Reverse TSA for O'Buzz.jpegReverse total shoulder arthroplasty (RTSA) has yielded promising medium-term outcomes, but what about longer-term results? In the March 15, 2017 edition of The Journal, Bacle et al. look at patient outcomes, prosthetic survival, and complications after a mean follow up of 12.5 years.

The good-news finding from this study was that the overall prosthetic survival rate (using revision as the end point) was 93%, confirming the reliability of the Grammont-style prosthesis. Time, however, took its toll on other outcomes. For example, both mean and absolute Constant scores among the cohort decreased significantly compared with the scores at the medium-term follow up (a minimum of 2 years). The cumulative long-term complication rate was 29%, with 10 of the 47 complications occurring at a mean of 8.3 years. Seven of those 10 delayed complications were attributed to mechanical loosening.

The authors suggest that the deterioration of RTSA outcomes seen in this study “is probably related to patient aging coupled with bone erosion and/or deltoid impairment over time.” They conclude that long-term RTSA outcomes “may be impacted by both the etiology of the shoulder dysfunction and the time since implantation.”

For more peer-reviewed content related to RTSA from JBJS Essential Surgical Techniques, click on the following links:

 

JBJS Classics: Cuff-Tear Arthropathy Spurred Shoulder Prosthetic Technology

JBJS Classics Logo.pngOrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Charles Neer II , a true pioneer in shoulder surgery, coined the term “cuff-tear arthropathy” in 1977. In a landmark 1983 JBJS publication, Dr. Neer, with coauthors Craig and Fukuda (both of whom became internationally recognized experts in shoulder surgery), reported on the pathophysiology and treatment of this previously little-recognized condition that was associated with long-standing massive rotator cuff tears.

Neer’s early work with total shoulder arthroplasty, also reported in JBJS, included a small cohort of patients with cuff-tear arthropathy. In the 1983 article on cuff-tear arthropathy, Neer and his coauthors described the pathologic presentation and treatment with total shoulder arthroplasty, along with a proposed pathophysiologic mechanism. They noted that, although it was a difficult procedure, their preferred treatment was “total shoulder replacement with rotator cuff reconstruction and special rehabilitation.”

Between 1975 and 1983, they surgically treated only 26 patients. Others later recognized that total shoulder replacement was associated with early glenoid failure and recommended treatment with humeral hemiarthroplasty.1 With either approach, success was limited by rotator cuff deficiency and dysfunction. The results were variable, with a small proportion having good outcomes and others achieving some pain relief and limited functional improvement.

Although it was not the first attempt at a reverse shoulder arthroplasty (RSA), Grammont developed an innovative design with improved implant technology and biomechanics to treat massive rotator cuff tears.2 This solved the biomechanical problem that resulted from a deficient rotator cuff and forever revolutionized the care of cuff-deficient shoulders. The Delta 3 prosthesis became available in Europe in the early 1990s but was not widely available in the US until 2004, when it was approved by the FDA.

Initially developed, approved, and used exclusively for cuff-tear arthropathy, early clinical success led to utilization for other conditions with deficient or dysfunctional rotator cuffs, including pseudoparalysis, revision shoulder arthroplasty, acute proximal humerus fractures, fracture sequelae, and chronic glenohumeral dislocations. The results have been so good that the indications have expanded beyond the initial recommendations for use only in elderly low-demand patients. Initial concerns were mollified by the apparent longevity and reported survivorship. Subsequently, there has been such a huge increase in utilization that RSA is approaching 50 percent of the US market share and some of the international market. The implications of expanded indications and increased utilization are yet to be seen.

In 1983, Neer and coauthors reported on what was then a relatively uncommon degenerative condition of the shoulder. Today, rotator cuff-deficient shoulders are much more common and can be better treated due to advances in our understanding of the pathophysiology and biomechanics of the condition, as well as advances in shoulder arthroplasty technology.

Andrew Green, MD
JBJS Deputy Editor

References
1. Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in total shoulder
arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3(1):39-46.

2. Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993 Jan;16(1):65-8

New RCT Data on Midshaft Clavicular Fractures

Clavicle_Fracture_for_OBuzz.pngThe debate continues as to whether midshaft clavicular fractures are optimally treated surgically or nonoperatively. More data about this clinical dilemma is delivered in the January 18, 2017 issue of JBJS, where Woltz et al. report findings from a multicenter controlled trial that randomized 160 clavicular-fracture patients to receive ORIF with a plate or nonoperative treatment with a sling and physical therapy.

The rate of radiographic nonunion was significantly higher in the nonoperatively treated group after 1 year, but no difference was found between the groups with respect to Constant and DASH scores at any time point—6 weeks, three months, and 1 year. Pain scores and general physical health were marginally better after operative treatment, but only at 6 weeks. However, the rate of second operations for adverse events in the ORIF group was considerable, and after 1 year, implant removal was performed in or scheduled for 16.7% of the operatively treated patients.

Based on these findings and other recent data, the authors “do not advocate routine operative treatment for displaced midshaft clavicular fractures,” although they say early plate fixation may offer advantages for patients who have high demands, high pain scores, or a strong preference for surgery. Based on the fact that “neither treatment option is clearly superior for all patients,” the authors conclude that “the clavicular fracture is preemninently suitable for shared treatment decision-making.”

Guest Post: Single-Stage Revision for Failed Shoulder Arthroplasty Is Effective

TSA Infection.gifOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Grigory Gershkovich, MD.

Shoulder arthroplasty continues to grow in popularity, and as the number of shoulder arthroplasties rises, so will the number of revisions. Infection is one major reason for shoulder arthroplasty failure, and Propionibacterium has been increasingly recognized as a major culprit.

However, Propionibacterium infection is difficult to diagnose. Despite improved detection techniques, diagnosis at the time of revision remains elusive because obvious signs of acute infection are often absent. The need to perform explantation in the setting of clinically apparent periprosthetic infection is obvious, but the appropriateness of single-stage revision with antibiotic treatment in shoulders with only apparent mechanical failures remains questionable.

Hsu et al. attempted to address this question in a study published in the December 21, 2016 issue of JBJS. The group retrospectively reviewed the outcomes of 55 shoulders that underwent revision arthroplasty due to continued pain, stiffness, or component loosening without obvious clinical infection. Mean follow up was 48 months. At least five cultures were obtained intraoperatively during each revision, and each case was treated with antibiotics as if were truly infected until the final culture results were received after three weeks. Shoulders were revised to either hemi-arthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty.

Hsu et al. analyzed outcomes according to two groups: the positive cohort (n=27), where shoulders had ≥ 2 cultures positive for Propionibacterium, and the control cohort (n=28), where shoulders had either 0 or 1 positive culture. The two groups were compared by before- and after-revision performance on the simple shoulder test (SST) and pain outcome scores.

Both groups improved postoperatively based on these patient-reported outcome measures, and no significant difference was found between the two groups. Three patients in each group required a return to the OR. Gastrointestinal side effects were the most commonly reported complication from prolonged antibiotic administration.

This study design was limited by its retrospective nature and the lack of a two-stage revision treatment comparison group. Furthermore, this study included only patients with no signs of clinical infection, and the findings may not be applicable to patients with perioperative signs of infection. The study also incorporated three revision surgery implant options, which could have influenced postoperative SST and pain scores. Larger, multicenter controlled trials will be needed to produce a more definitive answer to this complicated question.

Still, there are clear benefits of single-stage revision over two-stage revision, especially with regard to operative time, anesthesia risks, and patient recovery. Given the wide antibiotic sensitivity profile of Propionibacterium and these initial results from Hsu et al., single-stage revision with appropriate antibiotic therapy may be suitable for patients undergoing revision shoulder arthroplasty in the setting of suspected Propionibacterium infection.

Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will complete a hand fellowship at the University of Chicago in 2017-2018.

JBJS Case Connections—Osteochondritis Dissecans: Baseball and Genetics

Shoulder_OCD_12_29_16.png The exact mechanism by which osteochondritis dissecans (OCD) lesions develop is poorly understood. This month’s “Case Connections” spotlights 3 case reports of OCD in young baseball players, 2 of whom developed the condition in the shoulder. A fourth case report details 3 presentations of bilateral OCD of the femoral head that occurred in the same family over 3 generations.

The springboard case report, from the December 28, 2016, edition of JBJS Case Connector, describes a 16-year-old Major League Baseball (MLB) pitching prospect in whom an OCD lesion of the shoulder healed radiographically and clinically after 8 months of non-throwing and physical therapy focused on improving range of motion and throwing mechanics. Three additional JBJS Case Connector case reports summarized in the article focus on:

Among the take-home points emphasized in this Case Connections article:

  • MRI arthrograms are the best imaging modality to determine the stability of most OCD lesions. Radiographs in such cases often appear normal.
  • Early-stage OCD has the potential to heal spontaneously. Activity modification and physical therapy are effective treatments.
  • There is not a “gold-standard” surgical intervention for treating unstable/late-stage OCD. Surgery frequently provides clinical benefits but often does not result in radiographic improvement.

JBJS JOPA Image Quiz: Lateral Clavicle Fracture

clou1.jpgThis month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) presents the case of a 64-year-old woman who fell out of bed while sleeping and landed directly on the lateral aspect of the right shoulder. Based on the image shown here and a Zanca view radiograph, she was diagnosed in the emergency room with a lateral clavicle fracture. After staying in a sling for about two weeks, the patient continued to have shoulder pain when using the arm with overhead activities and when sleeping on the shoulder at night.

Select from among four choices as the next best step in treatment: MRI to evaluate the coracoclavicular ligaments, open reduction/internal fixation, continued sling treatment until pain resolves, or transacromial wire fixation.

Long-Term, Latarjet Beats Bankart for Anterior Shoulder Instability

Barkart vs Latarjet_12_7_16.gifIn a retrospective case-cohort analysis of 364 shoulders that had primary repair of recurrent anterior instability, Zimmermann et al. conclude in the December 7, 2016 issue of JBJS that arthroscopic Bankart repairs were inferior to the open Latarjet procedure, at a mean follow-up of 10 years.

Specific 10-year outcome comparisons included:

  • Redislocations in 13% of the Bankart shoulders vs 1% of the Latarjet shoulders
  • Apprehension (fear of the shoulder dislocating with the arm in abduction and external rotation) in 29% of the Bankart patients vs 9% of the Latarjet patients
  • Cumulative revision rate for recurrent instability of 21% in the Bankart group vs 1% in the Latarjet group
  • Not-satisfied rating from 13.2% of patients in the Bankart group vs 3.2% in the Latarjet group

Overall, there were few early and almost no late failures after the Latarjet procedure, while the arthroscopic Bankart repair was associated with an increasing failure rate over time. The authors say that this study’s longer-term analysis confirms “the contention that arthroscopic Bankart reconstructions fail progressively” and supports “the observation that restoration of stability with the Latarjet procedure is stable over time.”