OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Andrew D. Duckworth, MSc, FRCSEd(Tr&Orth), PhD, in response to a recent study in JBJS.
Propionibacterium acnes (now called Cutibacterium acnes, according to an updated classification) is a ubiquitous microbe in the setting of shoulder surgery and is a well-established cause of indolent infection and prosthetic loosening1,2. In 2016, JBJS published a study by Hsu et al. investigating single-stage revision shoulder replacement in patients with subclinical infection, and the authors reported that almost half of the patients had >2 positive cultures for P. acnes3. However, the exact consequence of positive cultures at the time of primary surgery is unknown, and the efficacy of specific antibiotic prophylaxis against this microbe remains unclear.
In the June 6, 2018 issue of JBJS, Rao et al. randomised 56 patients scheduled to undergo a primary anatomic or reverse total shoulder replacement to receive either preoperative cefazolin alone (n=27) or a combination of cefazolin and doxycycline (n=29) 4. All patients had standard skin preparation at the time of surgery with both alcohol and chlorhexidine.
The primary outcome measure was ≥1positive culture after 14 days of incubation from either superficial and/or deep-tissue samples taken intraoperatively. The authors deemed that a decrease of 50% in the positive culture rate would be clinically significant. However, they found no significant difference between the groups in terms of the primary outcome measure (p=0.99). The authors carried out a secondary analysis to determine which other factors might be associated with ≥1 positive P. acnes culture and found that younger age, male sex, and a lower Charlson Comorbidity Index were predictive. Although this study was potentially underpowered, it demonstrated that in patients undergoing primary shoulder arthroplasty, preoperative doxycycline does not significantly reduce the prevalence of positive culture rates for P. acnes.
These findings are similar to those found in previous research and should lead us to question whether preoperative antibiotics aimed specifically at preventing P. acnes infection associated with shoulder arthroplasty are truly useful. P. acnes infections are difficult to detect both clinically and via culture—which makes any intervention difficult to measure, especially in a potentially underpowered study. Consequently, larger studies in this area would help to more definitively determine whether preoperative antibiotics aimed specifically at P. acnes decrease infection rates or, instead, may be adding to the growing problem of bacterial resistance. In particular, such trials seem most useful when they focus on patients who are at higher risk of these specific infections—in this case, younger, healthy males.
Finally, as Rao et al. wisely observed, doxycycline is a bacteriostatic agent, which slows the growth and production of bacteria, rather than a bactericidal agent, which kills bacteria. Given that antimicrobial limitation, doxycycline might not be the most appropriate prophylactic drug to be investigating for these cases.
Andrew D. Duckworth, MSc, FRCSEd(Tr&Orth), PhD is a consultant orthopaedic trauma surgeon at Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, and he is a member of the JBJS Social Media Advisory Board.
- Gausden EB, Villa J, Warner SJ, Redko M, Pearle A, Miller A, Henry M, Lorich DG, Helfet DL, Wellman DS. Nonunion After Clavicle Osteosynthesis: High Incidence of Propionibacterium acnes. J Orthop Trauma. 2017 Apr;31(4):229-235.
- Chuang MJ, Jancosko JJ, Mendoza V, Nottage WM. The Incidence of Propionibacterium acnes in Shoulder Arthroscopy. 2015 Sep;31(9):1702-7.
- Hsu JE, Gorbaty JD, Whitney IJ, Matsen FA III. Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium. J Bone Joint Surg 2016;98:2047-2051.
- Rao AJ, Chalmers PN, Cvetanovich GL, O’Brien MC, Newgren JM, Cole BJ, Verma NN, Nicholson GP, Romeo AA. Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder Arthroplasty. J Bone Joint Surg Am. 2018 Jun 6;100(11):958-964.
The relative roles of bones and muscles in joint pathologies are often difficult to tease apart. In the March 7, 2018 issue of The Journal, Donohue et al. report findings from their attempt to identify associations between preoperative fatty infiltration in rotator cuff muscles and glenoid morphology among 190 shoulders that underwent total shoulder arthroplasty (TSA) for glenohumeral osteoarthritis.
The painstaking analysis included orthogonal CT images to determine fatty infiltration, joint-line medialization assessments, direct measurements of glenoid version, and grading of glenoid morphology (from A1 through C2) using a modified Walch classification. Here’s what Donohue et al. found:
- High-grade posterior rotator cuff fatty infiltration was present in 55% of the 38 glenoids classified as B3, compared with only 8% fatty infiltration in the 39 A1-classified glenoids.
- Increasing joint-line medialization was associated with increasing fatty infiltration of all rotator cuff muscles.
- Higher fatty infiltration of the infraspinatus, teres minor, and combined posterior rotator cuff muscles was associated with increasing glenoid retroversion.
- After the authors controlled for joint-line medialization and retroversion, B3 glenoids were more likely than B2 glenoids to have fatty infiltration of the supraspinatus and infraspinatus.
The authors say these findings “support the idea that there is a causal association between rotator cuff muscle fatty infiltration and B3 glenoid morphology,” but they are quick to add that “from this study we cannot conclude [whether] these patterns of rotator cuff muscle fatty infiltration precede the progression of bone pathology, or vice versa.” Either way, these findings may inform patient-surgeon discussions about TSA, because both glenoid morphology and rotator cuff muscle quality are factors in glenoid-component longevity.
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Recent Experience in Total Shoulder Replacement
C S Neer, K C Watson, F J Stanton: JBJS, 1982 March; 64 (3): 319
“Recent” in this context refers to more than 30 years ago, but many aspects of this meticulous review of nearly 200 total shoulder replacements, followed for 24 to 99 months, remain instructive. To get a sense of the explosion in research on this topic, compare the 18 references accompanying this study, most citing work by Neer himself, to the 70 references in a 2015 JBJS Reviews article focused on one detail (glenoid bone deficiency) of shoulder replacement.
Fractures of the Odontoid Process of the Axis
L D Anderson and R T D’Alonzo: JBJS, 1974 December; 56 (8): 1663
The basic fracture classification posited in this article has stood the test of time. Since the 1980s, however, surgeons have developed treatments for type-II odontoid fractures that provide direct fixation without the need for fusion and subsequent loss of rotatory motion.
Although the indications for anatomic and reverse total shoulder arthroplasty (TSA) are different, better understanding of the rate of improvement with each type of surgery could help establish more realistic patient expectations for recovery—and help surgeons and physical therapists design different strategies for postoperative care. With those goals in mind, Simovitch et al. use prospectively collected data to compare, at a minimum 2-year follow-up, clinical and range-of-motion (ROM) outcomes among 505 anatomic TSA patients and 678 reverse TSA patients. The findings appear in in the November 1, 2017 issue of JBJS.
The authors tracked five clinical outcome scores (SST, UCLA Shoulder, ASES, Constant, and SPADI), along with 4 relevant ROM measures. In both groups, >95% of patients reported clinical improvement in all 5 clinical metrics by 6 months, and full improvement was noted by 24 months. Not surprisingly, the mean age of patients who underwent reverse TSA was >5 years older and their shoulder-function scores and ROM were generally worse than those of the anatomic TSA patients.
At the time of the latest follow-up, patients who underwent anatomic TSA fared significantly better than patients who underwent reverse TSA in 3 of the 5 clinical outcome metrics and in all 4 ROM measurements. On the other hand, those who had reverse TSAs had significantly larger improvements in the Constant score (which emphasizes strength more than the other 4 clinical metrics) and active forward flexion.
ROM-wise, at approximately 6 years after surgery, the authors noted a progressive decrease in the magnitude of improvement for abduction and forward flexion in both groups. According to Simovitch et al., the observed discrepancies between clinical and ROM outcomes at longer-term follow-up suggest that “subjective (e.g., patient-reported) assessments of outcome and function likely continue to be stable or improve despite range-of-motion worsening and, as such, may imply that patient expectations change with follow-up time.”
Shoulder surgery for complex conditions such as irreparably large rotator cuff tears has been revolutionized by the concept of reverse total shoulder arthroplasty (rTSA). Improved design of rTSA implants by multiple manufacturers has resulted in excellent functional outcomes from these procedures. I have been educated by my shoulder colleagues to the fact that primary rTSA is actually technically less demanding than primary anatomic TSA because of greater exposure of the scapula/ glenoid anatomy.
When anatomic TSA clinically and/or radiographically fails, conversion to rTSA is an alternate to revision anatomic TSA. However, the more expensive and complex rTSA system can be difficult to implant in the revision scenario. In the May 3, 2017 issue of The Journal, Crosby et al. provide the outcomes of conversion from primary anatomic TSA to revision rTSA among two groups: those who originally received a convertible-platform implant system, allowing the humeral stem to be retained during revision, and those whose revision required humeral stem exchange.
Patients with retained-stem revisions had significantly shorter operative times, lower estimated blood loss, lower intraoperative complication rates, and slightly better postoperative ROM. Although the authors caution that “the presence of a convertible-platform humeral component does not guarantee that it can be retained,” they conclude that the data from this study “support the use of a convertible-platform humeral stem when performing primary shoulder arthroplasty.”
Whenever possible, it’s a good idea to design implants where the portions that remain well-fixed can be retained and re-used for the rare revision situation. Such retained, modular parts can save resources, reduce operative time and patient morbidity, and may improve functional outcomes. However, we must be aware that issues with wear debris that have surfaced in modular hip components may also come into play with modular shoulder components.
Marc Swiontkowski, MD
In 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:
- Peripheral vascular disease
- Congestive heart failure
- Chronic lung disease
- 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
Anecdotally, 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 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:
- Patient-Matched Implementation for Reverse Total Shoulder Arthroplasty
- Glenoid Bone-Grafting in Revision to a Reverse Total Shoulder Arthroplasty: Surgical Technique
- Technique for Reverse Total Shoulder Arthroplasty for Primary Glenohumeral Osteoarthritis with a Biconcave Glenoid
OrthoBuzz 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
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
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, Aaron Chamberlain, MD, MSc, a co-author of the October 19, 2016 Specialty Update on Shoulder and Elbow Surgery, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.
Reverse Shoulder Arthroplasty
Optimizing reverse shoulder arthroplasty implant design continues to be a research focus. There is significant variation among different implants with regard to the amount of lateralization of the center of rotation, and how lateralization affects clinical outcomes is of particular interest. Authors randomized patients to undergo reverse shoulder arthroplasty with a center of rotation at the native glenoid face or with lateralization.1 Postoperative functional results at a mean follow-up of 22 months were similar between groups overall. However, when the analysis excluded patients with teres minor muscle degeneration, patients with a more lateralized center of rotation had a greater improvement in external rotation. This may portend a benefit of lateralization in the setting of an intact posterior rotator cuff.
Rotator Cuff Tear Natural History
A Level-I prospective cohort study of patients with asymptomatic rotator cuff tears evaluated patterns of tear progression over time.2 Of specific interest was whether the integrity of the anterior supraspinatus cable influenced tear size and/or risk for tear enlargement. Cable-disrupted tears were 9 mm larger at baseline, but cable integrity did not influence risk for tear enlargement or time to enlargement. This understanding may help inform patient discussions about the risks of nonoperative management of rotator cuff tears.
Rotator Cuff Repair
Do patients with symptomatic degenerative rotator cuff tears fare better with surgery or nonoperative management? Only three prospective randomized trials have been published comparing outcomes after randomizing patients to nonoperative management or surgical repair. This Level-I trial randomized patients (mean age of 61) with degenerative full thickness cuff tears to either a course of non-operative management (corticosteroid injection, physical therapy, and oral analgesics) or surgical rotator cuff repair. 3 Patients who underwent surgery experienced a greater reduction in VAS pain and VAS disability scores compared with the nonoperative cohort at 1 year of follow-up.
In another prospective randomized study, authors randomized patients who were ≥55 years of age with painful degenerative supraspinatus tears into one of three treatments: 1) physical therapy alone, 2) acromioplasty and physical therapy, and 3) rotator cuff repair, acromioplasty, and physical therapy. Patients in this study were older than those in the study mentioned above, with a mean age of 65 (range 55 to 81). At the 2-year follow-up, no significant differences among the three interventions were seen in the Constant score, VAS pain score, or patient satisfaction. This data supports initial conservative treatment in older patients with degenerative atraumatic cuff tears. However, the importance of tear progression over time and the age threshold that separates “older” patients from “younger” patients remain to be determined.
Can we improve the biologic healing environment for rotator cuff repair healing? A Level-I prospective randomized controlled study evaluated leukocyte and platelet-rich fibrin in rotator cuff repairs.4 Patients underwent arthroscopic rotator cuff repair with and without leukocyte and platelet-rich fibrin applied to the repair site. No beneficial effect of leukocyte and platelet-rich fibrin was found in overall clinical outcome, healing rate, postoperative defect size, and tendon quality at the 1-year follow-up. A reliable biological augmentation solution for rotator cuff healing remains elusive.
1 Greiner S, Schmidt C, Herrmann S, Pauly S, Perka C. Clinical performance of lateralized versus non-lateralized reverse shoulder arthroplasty: a prospective randomized study. J. Shoulder Elbow Surg. [Internet]. 2015;24(9):1397–404. Available from: http://www.sciencedirect.com/science/article/pii/S1058274615002864doi:10.1016/j.jse.2015.05.041
2 Keener JD, Hsu JE, Steger-May K, Teefey SA, Chamberlain AM, Yamaguchi K. Patterns of tear progression for asymptomatic degenerative rotator cuff tears. J. Shoulder Elbow Surg. [Internet]. 2015 Dec 1;24(12):1845–1851. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615004759
3 Lambers Heerspink FO, van Raay JJAM, Koorevaar RCT, van Eerden PJM, Westerbeek RE, van ’t Riet E, et al. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J. Shoulder Elbow Surg. [Internet]. 2015;24(8):1274–81. Available from: http://www.sciencedirect.com/science/article/pii/S1058274615002852doi:10.1016/j.jse.2015.05.040
4 Zumstein MA, Rumian A, Thélu CÉ, Lesbats V, O’Shea K, Schaer M, et al. SECEC Research Grant 2008 II: Use of platelet- and leucocyte-rich fibrin (L-PRF) does not affect late rotator cuff tendon healing: a prospective randomized controlled study. J. Shoulder Elbow Surg. [Internet]. 2016 Jan 1;25(1):2–11. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615005388