Both Subjective and Objective Measures Tell the Shoulder Story
When surgeons and patients discuss what treatment will work best for a particular musculoskeletal ailment, they often rely on both “subjective” and “objective” outcome data from previously published assessments. Reviewing both types of data is a good idea, because a study among more than 100 patients with shoulder osteoarthritis by Matsen et al. in the March 1, 2017 issue of The Journal of Bone & Joint Surgery found poor correlation between objective measures of active abduction and subjective patient self-assessments using the Simple Shoulder Test (SST).
The authors used a statistical method called “coefficient of determination”
to confirm “a highly variable relationship” between the patient-reported SST (subjective) and motor-sensor range-of-motion (objective) measurements. In less statistical language, many of the shoulders had good motion and poor self-assessed function, while others had poor motion and good self-assessed function.
The findings led the authors to conclude that “studies of treatment outcomes should include separate assessments of these 2 complementary aspects of shoulder function.” That conclusion was seconded and expanded upon in a commentary by Jeffrey S. Abrams, MD, who wrote that “either [subjective or objective] assessment used independently may lead to the wrong impression.”
Guest Post: Single-Stage Revision for Failed Shoulder Arthroplasty Is Effective
OrthoBuzz 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
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:
- Shoulder OCD in a teenage baseball player that was treated arthroscopically
- Early elbow OCD in young throwers
- Three cases of bilateral femoral head OCD that occurred in multiple members of the same family
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
This 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.
Whence P. Acnes in Shoulder Arthroplasty?
Propionibacterium acnes is a frequently isolated pathogen in postoperative shoulder infections, but where exactly does it come from? According to a study by Falconer et al. in the October 19, 2016 Journal of Bone & Joint Surgery, P. acnes derives from the subdermal edges of the surgical incision and spreads through contact with the surgeon’s gloves and surgical instruments.
The authors obtained specimens for microbiological analysis at five different sites from 40 patients undergoing primary shoulder arthroplasty. Thirty-three percent of the patients had at least one culture specimen positive for P. acnes, and the most common site of P. acnes growth was the subdermal layer, followed by forceps.
The authors observed no clinical postoperative infections during the follow-up of 6 to 18 months, although that is a relatively short investigation period for a pathogen that often causes late-onset indolent infections. The authors conclude that “it is likely that surgeon handling of the skin and subdermal layer contaminates the rest of the surgical field.” Although the study did not investigate preventive techniques, based on the findings the authors suggest the following possible prophylactic approaches:
- Minimizing handling of the subdermal layer
- Changing gloves after the dermis is cut
- Avoiding contact between implants and the subdermal layer
- Repeating use of antibacterial agents once the wound is opened
What’s New in Orthopaedic Trauma
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, David Teague, MD, co-author of the July 7, 2016 Specialty Update on orthopaedic trauma, selected the eight most clinically compelling findings from among the 35 studies summarized in the Specialty Update.
Shoulder
–The randomized PROFHER trial found that surgical treatment of acute displaced proximal humeral fractures (with either ORIF or hemiarthroplasty) yielded no difference in patient outcomes compared with nonsurgical sling treatment at time points up to 2 years. Surgery was also significantly more expensive.1
Wrist
–A randomized trial of 461 patients with an acute dorsally displaced distal radial fracture found no difference at one year in primary or secondary outcomes between a group that received ORIF and a group that received Kirschner-wire fixation. K-wire fixation was also more cost-effective.2
Tibia
–A retrospective study of 137 type-III open tibial fractures concluded that both antibiotic prophylaxis and definitive wound coverage should occur as soon as possible for severe open tibial fractures. Prehospital antibiotic administration should be considered when transport is expected to take longer than one hour. 3
Ankle
–A randomized trial of 214 patients who received either supervised physical therapy or engaged in self-directed home exercise after six weeks of immobilization treatment for an ankle fracture found no difference in activity and quality-of-life outcomes at 1, 3, and 6 months.4
Managing Thromboembolism
–A registry study examining the incidence of deep venous thrombosis (DVT)/pulmonary embolism (PE) after surgery for a fracture distal to the knee identified the following risk factors for a thromboembolic event: previous DVT or PE, oral contraceptive use, and obesity.
Wound Care
–A randomized controlled trial of 2,447 patients compared irrigation with normal saline solution at various pressures to castile soap irrigation. Saline was superior in terms of reoperation rates after 12 months but irrigation pressure did not influence the reoperation rate.5
–A retrospective cohort study involving 104 patients who required a fasciotomy found that hospital stays were shorter among patients who underwent delayed primary closure (DPC) or a split-thickness skin graft on the first post-fasciotomy surgery. The authors noted limited utility of repeat surgeries to achieve DPT if fasciotomy wounds were not closed primarily on the first return trip.6
Obesity
–A prospective observational study of 376 trauma patients requiring orthopaedic surgery found that those with a BMI of >30 kg/m2 had an overall complication rate of 38% and had longer hospital stays, longer delays to definitive fixation, and higher infection rates than nonobese patients.7
References
- Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C,Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
- Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, Yu G, Lamb SEUK. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius. Health Technol Assess.2015 Feb;19(17):1-124: v-vi
- Lack WD, Karunakar MA, Angerame MR, Seymour RB, Sims S, Kellam JF, Bosse MJ. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015 Jan;29(1):1-6.
- Moseley AM, Beckenkamp PR, Haas M, Herbert RD, Lin CW; EXACT Team. Rehabilitation after immobilization for ankle fracture: the EXACT randomized clinical trial. JAMA. 2015 Oct 6;314(13):1376-85.
- Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, Schemitsch EH, Anglen J, Della RoccaGJ, Jones C, Kreder H, Liew S, McKay P, Papp S, Sancheti P, Sprague S, Stone TB, Sun X, Tanner SL,Tornetta P 3rd., Tufescu T, Walter S, Guyatt GH; FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015 Dec 31;373(27):2629-41. Epub 2015 Oct 8.
- Weaver MJ, Owen TM, Morgan JH, Harris MB. Delayed primary closure of fasciotomy incisions in the lower leg: do we need to change our strategy? J Orthop Trauma. 2015 Jul;29(7):308-11.
- Childs BR, Nahm NJ, Dolenc AJ, Vallier HA. Obesity is associated with more complications and longer hospital stays after orthopaedic trauma. J Orthop Trauma. 2015 Nov;29(11):504-9.
New JBJS CME Subspecialty Exams
New subspecialty CME exams are now available from The Journal of Bone & Joint Surgery in the following topic areas:
- Adult Hip Reconstruction
- Adult Knee Reconstruction
- Shoulder and Elbow
- Spine
- Sports Medicine
- Trauma
Each exam consists of 10 questions based on articles published in JBJS within the past 12 months. Exams can be used for study purposes at no cost. Each exam activity may be submitted for a maximum of 5 AMA PRA Category 1 Credits™.
JBJS Case Connections—Arthroscopy Solves Ornery Ortho Problems
The indications for arthroscopic treatment of musculoskeletal injuries continue to expand as orthopaedists find new and creative ways to apply this flexible technology. The May 2016 “Case Connections” article springboards from a May 25, 2016 JBJS Case Connector report about an isolated avulsion of the teres minor tendon that was repaired arthroscopically. That unique case is linked to three others from the JBJS Case Connector archive:
- Arthroscopic treatment of a knee flexion contracture
- Arthroscopic reduction/fixation of an acetabular rim fracture
- Arthroscopically assisted medial femoral condyle reduction
As impressive as these minimally invasive solutions are, orthopaedists should always keep in mind that arthroscopy, like any other surgical procedure, is not without its potential complications (see related “Case Connections” article).
What’s New in Sports Medicine
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Warren Dunn, MD, a co-author of the April 20, 2016 Specialty Update on sports medicine, to select the five most clinically compelling findings from among the more than 30 studies cited in the article.
Shoulder
–What happens to asymptomatic rotator cuff tears over time? According to a long-term prospective study of patients who had an asymptomatic tear in one shoulder and a symptomatic contralateral rotator cuff tear, the asymptomatic tears enlarged in almost one-half of the patients over a median of three years. Those patients who experienced tear enlargement tended to have an onset of new pain and progressive degenerative changes within the supraspinatus and infraspinatus muscles. The authors concluded that many formerly asymptomatic tears will progress to become symptomatic.
–Does tendon repair yield better outcomes than physical therapy (PT) when treating rotator cuff tears? A randomized trial of 103 patients with tears not exceeding 3 cm found that 12 of 51 patients (24%) in the PT group subsequently underwent secondary cuff repair over a 5-year follow-up period. Statistically, patients in the primary repair group had significantly better group-mean improvements on the Constant score, ASES score, and VAS for pain and patient satisfaction than those who underwent secondary repair, but the authors noted that these differences “may be below clinical importance.” Thirty-seven percent of those treated with PT only experienced a >5 mm increase in tear size, which was associated with inferior outcomes.
–Are estimates of Propionibacterium acnes colonization rates in surgical shoulder wounds accurate? A controlled diagnostic study examined P. acnes colonization in 117 open shoulder surgeries that utilized the deltopectoral approach. In 20.5% of the procedures, at least one surgical specimen was positive for P. acnes growth, but 13% of cultures from sterile-sponge control samples also had positive growth. This led the authors to surmise that prior estimates of P. acnes incidence may be higher than actual because of frequent culture contamination. Male sex and preoperative corticosteroid injections were associated with a higher likelihood of bacterial growth.
Knee/ACL
–Most people who undergo ACL reconstruction experience significant improvement in physical quality of life and quality-adjusted life years, but who is more or less likely to benefit? A 2- and 6-year longitudinal analysis of a multicenter cohort found that those who underwent revision, smoked cigarettes, had lateral tibial plateau chondromalacia, or had less education were more likely to score lower on the Physical Component Summary of the Short Form-36. Those who tended to have higher postoperative functional scores were those with higher baseline function, younger age, lower BMI, and either no lateral meniscal treatment or >50% lateral meniscectomy.
Hamstring Injuries
–Hamstring injuries are common among soccer players. A Level I randomized controlled trial among 579 high-level amateur soccer players found that 13 weeks of participation in Nordic hamstring exercises significantly reduced injury incidence and risk for injury compared with a control group over a 1-year period. No differences in injury severity were found.1
Reference
- van der Horst N, Smits DW, Petersen J, Goedhart EA, Backx FJG. The preventive effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: a randomized controlled trial. Am J Sports Med. 2015 Jun;43(6):1316-23. Epub 2015 Mar 20.
Psych Distress Magnifies Patient Perception of Shoulder Pain
Most studies investigating the psychosocial determinants of orthopaedic pain and
disability have focused on the spine, hand, hip, and knee. But in the December 16, 2015 JBJS, Menendez et al. looked at psychosocial associations among 139 patients presenting with shoulder complaints. Similar to findings regarding those other anatomical areas, Menendez et al. found that patient variability in perceived symptom intensity and magnitude was more strongly related to psychological distress than to a specific shoulder diagnosis, which included rotator cuff tear, impingement, osteoarthritis, and frozen shoulder.
The authors measured patient pain and disability scores upon presentation using the Shoulder Pain and Disability Index (SPADI). They then analyzed the SPADI scores in relation to sociodemographic data and patient responses to three additional validated tests measuring depression, tendencies to catastrophize, and self-efficacy. They found that disabled and retired work status, higher BMI, catastrophic thinking, and lower self-efficacy (i.e., ineffective coping strategies) were associated with greater patient-reported symptom intensity and magnitude of disability.
Interestingly, BMI was the only biological influence on pain and disability scores. Also, retirement had a negative influence on pain and disability scores, which was somewhat surprising considering that retirement often has positive effects on well-being.
The authors conclude that future research focused on the effect of psychosocial factors on postoperative pain and response to treatment might “allow surgeons to identify patients who are at risk for a treatment-refractory course.” They further surmise that “interventions to decrease catastrophic thinking and to optimize self-efficacy…before shoulder surgery hold potential to ameliorate symptom intensity and the magnitude of disability.”
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