Thursday, July 20, 2017

Shoulder arthroplasty transfusion and complications, egg vs chicken.

Analysis of complication rates following perioperative transfusion in shoulder arthroplasty

These authors sought to examine the postoperative outcomes of patients receiving blood transfusions following TSA and RTSA using the Medicare Standard Analytic Files database between 2005 and 2010. They identified 7,794 patients who received a perioperative blood transfusion following TSA or RTSA, as well as 34,293 age- and gender-matched controls.

Patients who received a perioperative transfusion were sicker, having statistically significantly higher rates of myocardial infarction, pneumonia, systemic inflammatory response syndrome or sepsis, venous thromboembolic events, cerebrovascular accidents, surgical complications, including periprosthetic infection and mechanical complications.

Comment: This study raises at least three possibilities: (1) that patients with complications and co-morbidities are at increased risk for transfusion, (2) patients with transfusion are at increased risk for complications, or (3) both of these interactions are at play. 

What we'd like to know is whether changing our threshold for using transfusions might affect the complication rate. For example, would the complication risk of a patient with a hematocrit of 25 be lower if transfusion was withheld than if blood was transfused? A partial answer to this question might be available if a multivariate analysis was carried out that investigated the relationship of patient age, sex, comorbidities, preoperative hematocrit, surgical procedure, diagnosis, procedure length, and transfusion to surgical and medication complications.

Some related posts are of interest

Blood transfusion in primary total shoulder arthroplasty: incidence, trends, and risk factors in the United States from 2000 to 2009.

These authors used the National Inpatient Sample between 2000 and 2009 to assess the overall blood transfusion rate as well as trends in transfusion patterns over time and the patient and hospital characteristics that independently influenced the likelihood that a given patient undergoes allogeneic blood transfusion. They found that the overall blood transfusion rate (ie, the proportion of patients who received at least 1 transfusion of any kind) was 6.7%. This rate increased over time, from 4.9% in 2000 to 7.1% in 2009 (P < .001).

With respect to the 4 Ps, the risk of allogeneic blood transfusion was increased for patients over 85 years of age, women, non-white patients, patients with other than private insurance, patients with comorbidities and provider hospitals with low case loads and hospitals in the Northeast.

Comment: There are many factors that influence the use of blood transfusion. This study would have been stronger had a multivariate analysis been carried out to determine the most influential factors among those studied. However, other factors could not be identified in such a study, such as the individual surgeon's threshold for transfusion (?based on hematocrit or symptoms?), the time of surgery, the attention to hemostasis, the use of topical thrombin, the time of implementation of motion after surgery, the method of fixation of the components and many more. 

Our approach has been to attempt to minimize the use of blood so that it is saved for those whose life depends on it. We strive for short wound times and excellent hemostasis. We reserve transfusion for those patients with symptoms of anemia, such as orthostatic hypotension that does not respond to fluids, and for those at high risk for complications related to diminished arterial oxygenation.


Medical comorbidities and perioperative allogeneic red blood cell transfusion are risk factors for surgical site infection after shoulder arthroplasty

These authors sought to determine surgical site infection (SSI) risk due to medical comorbidities or blood transfusion after primary or revision shoulder arthroplasty. They collected data on medical comorbidities, surgical indication, perioperative transfusion, and SSI were obtained for 707 patients who underwent primary or revision hemiarthroplasty or total shoulder.

For the purpose of this study, SSI was defined in a rather particular manner:  either (1) treatment of a superficial infection within 30 days of surgery with d├ębridement by the treating surgeon or with antibiotics by either the treating surgeon or an infectious disease specialist or (2) treatment of a suspected or confirmed deep infection by return to the operating room for d├ębridement, component exchange, or explantation of components or treatment with therapeutic or long-term suppressive antibiotics by an infectious disease specialist. Positive cultures on return to the operating room were not a requirement for diagnosis of SSI.

Using this set of definitions, the SSI rate was 1.9% for primary hemiarthroplasties and 1.3% for primary total shoulder arthroplasties.

Revision arthroplasty or prior open reduction and internal fixation had higher SSI risk than primary arthroplasties (incidence risk ratio [IRR], 11.4; 95% confidence interval [CI], 3.84-34.0; P < .001).

Among primary arthroplasties, SSI risk factors included male gender (IRR, 60.0; CI, 4.39-819; P = .002), rheumatoid arthritis (IRR, 8.63; CI, 1.84-40.4; P = .006), and long-term corticosteroid use (IRR, 37.4; CI, 5.79-242; P < .001). 

Perioperative allogeneic red blood cell transfusion significantly increased SSI risk and was dose dependent (IRR, 1.68 per unit packed red blood cell; CI, 1.21-2.35; P = .002).

The culture results are shown below.



Comment: This series of cases points to the complex and uncertain relationship between cultures and clinical findings. Patients without the characteristic signs of infection can have positive cultures. Patients with characteristic signs of infection can have negative cultures.

The culture protocol used for these patients is not explained. Specifically, we do not know which cases were cultured, how many specimens were submitted for culture, what culture media were used, and how long the cultures were observed. It is known that unless 5 deep specimens are cultured on three different media and observed for 3 weeks, there is a substantial risk of overlooking Propionibacterium in the wound.

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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'







How bad is the shoulder arthritis on x-ray?

Reliability of radiologic glenohumeral osteoarthritis classifications

These authors sought to determine the intraobserver and interobserver reliability of glenohumeral osteoarthritis classification schemes based on plain anteroposterior radiographs of 108 shoulder joints from 96 consecutive patients with glenohumeral osteoarthritis. On two occasions each of two observers graded the film into 6 classification systems. The intraobserver and interobserver reliabilities were 0.907 (observer 1), 0.965 (observer 2), and 0.851 (interobserver) for the Samilson-Prieto grading system;
0.954, 0.948, and 0.869 for the Allain modification;
0.936, 0.830, and 0.791 for the Gerbermodification;
0.887, 0.892, and 0.744 for theKellgren and Lawrence classification;
0.873, 0.964, and 0.935 for theWeinstein; and
0.854, 0.934, and 0.797 for the Guyette grading system.

Comment: Some surgeons and clinical investigators are interested using radiographic classification systems for demographic and outcomes studies.  However, radiographic evaluation is incomplete if it is based on the AP view only.

This is demonstrated by the films of a man in his mid 40s who presented to us with shoulder pain and limited motion. His anteroposterior x-ray suggested mild to moderate arthritis.

However, the 'truth' view (a standardized axillary taken with the arm in the functional position of elevation in the plane of the scapula - see this link), revealed a retroverted, biconcave glenoid with posterior humeral decentering = the bad arthritic triad (BAT - see this link), a much greater degree of pathology than what was suggested on the AP view.

Here are some other cases in which the 'truth' view demonstrated substantially greater pathoanatomy than what could be seen on the AP view













We find that the standardized AP and 'truth' axillary view taken as described in this link usually provide all the necessary imaging information to characterize the arthritic pathoanatomy and plan treatment.

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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'





Wednesday, July 19, 2017

Rotator cuff repair, arthroscopic or open?

Arthroscopic Versus Open Rotator Cuff Repair: Which Has a Better Complication and 30-Day Readmission Profile? 


These authors sought to compare the 30-day postoperative complications and unplanned readmission rates, using the National Surgical Quality Improvement Program database, after open or arthroscopic rotator cuff repair (RCR) performed from 2007 through 2014. 
The open group contained 3,590 cases (21.8%) and the arthroscopic group had 12,882 cases (78.2%), for a total of 16,472 patients undergoing RCR. 

They found that the open RCR group had a higher prevalence of patients aged 65 years or older and comorbidities such as hypertension, diabetes, chronic obstructive pulmonary disease, smoking, and alcoholism (P < .05).



These patients had a higher risk of any adverse event when compared with arthroscopic RCR patients (1.48% vs 0.84%; RR, 1.17; 95% CI, 1.05-1.30; P ¼ .0010). They were also at higher risk of return to the operating room within 30 days (0.70% vs 0.26%; RR, 1.36; 95% CI, 1.09-1.69; P ¼ .0004). Open RCR patients had longer average hospital stay (0.48 2.7 days vs 0.23 4.2 days, P ¼ .0007), whereas arthroscopic RCR had a longer average operative time (90 ± 45 minutes vs 79 ± 45 minutes, P < .0001). 

Comments: Although the authors concluded that "arthroscopy was associated with lower risks of any adverse event and return to the operating room during the initial 30-day postoperative period", this is not actually a comparison of two methods of cuff repair, it is a comparison of two populations of patients, one older and sicker and one younger and healthier. It is not unexpected that the first group had more complications and longer stays overall.

In addition, it is of interest that some of the complications were more prevalent in the arthroscopic group, including thromboembolic events.


It would be of interest to see a multivariate analysis of the effect of the preoperative age and health of the patient on each of these complications.

In conclusion, these data do not provide an argument for arthroscopic RCR as opposed to open surgery. Such an argument would need to be based on a matched set of patients, which was not used in this study.


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Click here to see the new Shoulder Arthritis Book.

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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'

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The ream and run for a B2 glenoid at 7 years after surgery

A 60 year old avid tennis player and active athlete presented with a painful left shoulder and these x-rays


His axillary 'truth' view showed glenoid retroversion biconcavity and posterior humeral decentering.


He elected a ream and run procedure in view of his desired high activity level.

His 7 year followup radiographs are shown here
 







Note that the axillary view shows centering of the prosthetic humeral head in the reamed glenoid socket.

Here is his shoulder motion at 7 years after surgery.

video


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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

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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.

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Tuesday, July 18, 2017

Delayed onset of total shoulder pain and stiffness - suspect Propionibacterium

A 60 year old patient presented after a right total shoulder arthroplasty 20 years earlier. The shoulder had become progressively stiff and painful over the last several years. On examination his shoulder was stiff and painful.  There were no other clinical or laboratory suggestions of inflammation or infection. His SST was only 1/12. His radiographs showed some endosteal bone resorption near the distal end of his stem and some suggestion of thinning of the glenoid polyethlene.

 




At revision surgery the humeral component was somewhat loose, but the glenoid was secure, showing only minimal evidence of surface wear. There were no signs of joint fluid or inflammation within the joint. However, there was a thick leather-like humeral membrane, part of which is shown below.


The pathology on this membrane is shown below.


We performed a single stage exchange to a hemiarthroplasty, redraping and regowning after component removal and debridement and harvesting of five deep specimens for culture.

The new humeral stem was inserted using impaction allograft.

 

Because of our suspicion of infection - even though it had been 20 years since his index procedure, we started him on immediate Ceftriaxone and Vancomycin via a PICC line.

At 6 days after surgery, all of his cultures were positive for Propionibacterium


This case demonstrates the ability of Propionibacterium prosthetic shoulder infections to appear years after the index procedure without clinical or surgical evidence of infection. In male patients with delayed onset of pain and stiffness, we usually perform a single stage exchange to a hemiarthroplasty with a plan for IV antibiotics until the cultures are finalized at 3 weeks to make sure there is no gap in antibiotic coverage. If the cultures are positive, IV antibiotics are continued for 6 weeks followed by a 6 month course of oral antibiotics.

It is important to contrast this case with the following one:
Detritic synovitis can mimic a Propionibacterium periprosthetic infection

These authors illustrate that the clinical findings of detritic synovitis (the macrophage reaction to polyethylene, cement or metal debris) complicating a total shoulder arthroplasty can strongly resemble those of a ‘stealth’ periprosthetic shoulder infection with a low-virulence organism such as Propionibacterium, including a clinical presentation long after the index procedure. At present, the important differentiation between these two etiologies can only be ascertained by awaiting the results of cultures obtained at the time of revision surgery. The surgical and antibiotic treatment decisions must be made before the culture results become available.

Here is an informative case. A 76-year-old right hand dominant man presented with right shoulder pain and decreased range of motion. He had a history of bilateral total shoulder arthroplasties, his left 15 years prior and his right 14 years prior to his visit with us. Following his index surgeries he initially did well with full painless range of motion and was able to return to full activities. Eleven years after his right arthroplasty he experienced the insidious onset of worsening shoulder pain and stiffness with no known injury. He also noted painful catching and locking in his shoulder joint with certain shoulder movements. His symptoms were unresponsive to non-operative treatment, including exercises, anti-inflammatory medications and a corticosteroid injection. His left shoulder had some stiffness but was otherwise asymptomatic. The CBC, sedimentation rate and C-reactive protein were all normal.

Physical examination demonstrated a well-healed surgical scar with no erythema, drainage or evidence of infection. Both active and passive ranges of motion were decreased. There was palpable crepitus on range of motion. Rotator cuff strength was intact, as was neurologic function of the affected extremity. Radiographs demonstrated a thinned glenoid component with surrounding osteolysis, appearing grossly loose. The humeral component was well positioned with surrounding osteolysis of the medial and lateral proximal humeral bone. There were no radiolucencies around the distal stem and the prosthesis did not appear grossly loose.
                           

















The patient was advised to have a revision shoulder arthroplasty to manage his symptoms and loose glenoid component. Because of the high index of suspicion of an infection, the plan included a one-stage revision to hemiarthroplasty followed by a course of intravenous antibiotic therapy until culture results were finalized. At the time of revision surgery, perioperative antibiotics were held until tissue cultures were obtained. There was abundant scar tissue surrounding the shoulder. A synovial fluid aspiration prior to capsulotomy showed grossly cloudy fluid with a negative gram stain, with no polymorphonuclear cells or organisms seen.  










There was diffuse membranous tissue around both the humeral and glenoid components.  There was osteolysis of the proximal humerus, but the humeral component was securely fixed ; it was removed without complication.  The glenoid component was grossly loose and easily removed.  There was significant wear of the glenoid polyethylene and osteolysis of the underlying glenoid bone.  The rotator cuff was intact.
A total of 8 samples for culture were taken from various locations within the glenohumeral joint, including the glenoid membrane, collar membrane between the modular humeral head and stem, humeral canal membrane, bursa, glenoid explant, and stem explant.  Due to preoperative and intraoperative concerns of infection, including cloudy fluid, abundant membrane, glenoid loosening and osteolysis, the patient was treated with a one-stage revision consisting of removal of the loose glenoid and single stage exchange of the humeral component using Vancomycin soaked cancellous allograft to secure the stem by impaction grafting.  The remaining glenoid bone was smoothed, no bone graft was added, and no glenoid component was reimplanted.  Cultures were grown on four types of media: blood agar, chocolate agar, Brucella agar and brain-heart infusion broth as previously published. Postoperatively the patient was placed on IV Ceftriaxone 2g daily and Vancomycin 1g daily via PICC line.  The Vancomycin was discontinued after 2 days when the cultures failed to grow MecA CoNS.  All cultures were negative at 21 days at which time all antibiotics were discontinued.  Permanent pathology of the deep tissues identified fibrotic tissue with chronic inflammation, the absence of neutrophils, and a foreign body giant cell reaction consistent with detritic synovitis


After surgery, he was placed on the standard post arthroplasty rehabilitation program focusing on range of motion in the first six weeks, followed by progressive anterior deltoid strengthening. At his six-month follow up visit, the patient was recovering well with no complaints of pain. His Simple Shoulder Test had improved from 5 out of 12 prior to his revision to 10 of 12, and radiographs showed a well-fixed humeral component.



  


Comment:  In this case, it seems unlikely that the cultures in this were falsely negative – multiple tissue and explant specimens were obtained before antibiotic administration, the specimens were cultured on multiple media and observed for 21 days. Thus, we must consider the possibility that the detritic synovitis from polyethylene debris produced osteolysis and periprosthetic membrane formation similar to that of a Propionibacterium infection. Until better methods become available for differentiating the two conditions, our practice is to continue to treat shoulders with osteolysis and glenoid component loosening as if they were infected until cultures prove this not to be the case.
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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.

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Monday, July 17, 2017

Arthritis with rotator cuff failure in active people

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.

Recently we saw an active physician-rancher who had had bilateral CTA prostheses performed after failed cuff repairs. Because he recognized that his ranching was demanding on his shoulders and carried the risk of falls, he preferred the CTA over the reverse total shoulder.

Before his left shoulder surgery his films were as shown below and he reported the ability to perform only 5 of the 12 Simple Shoulder Test functions. He was able to elevate his arm to over 90 degrees and had no anterosuperior instability.

 

At the time of surgery he had no supraspinatus, no infraspinatus and a detached subscapularis.
We were able to reattach his subscapularis.

At four years after surgery, he could perform 8 of the 12 SST functions and had the radiographs shown below. Note the impaction grafted humeral stem and the articulation of the prosthesis with the undersurface of the coracoacromial arch.

 


Two years ago he presented with a similar situation in his right shoulder. His SST score was 3/12. He had active elevation of 100 degrees without anterosuperior escape. His preoperative x-rays shown below.

Two years after his right shoulder arthroplasty he could perform 8/12 SST functions and was back at work on his ranch. His 2 year films are shown below.

 



His current shoulder function is shown in the video below.


video





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.

Here is a video of an active woman two years after her CTA prosthesis for cuff tear arthropathy.

video

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 medullary canal is entered and progressively larger reamers inserted as sizers until the diaphyseal endosteal cortex is encountered at a depth corresponding to the length of the prosthetic stem (‘love at first bite’); this reamer defines the orthopaedic axis. 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 available, 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 subscapularis is securely repaired.

 


Additional relevant posts can be found here and here and here

We first described our approach over two decades ago in a publication, Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint, which reported on twenty-one shoulders in nineteen patients, fifty-four to eighty-four years old, who had disabling pain attributable to a massive tear of the rotator cuff, accompanied by loss of the surface of the glenohumeral joint. These patients were not candidates for total shoulder replacement because of the massive deficiency in the cuff and the fixed upward displacement of the humeral head. At that time reverse total shoulder was not an option. A prerequisite for hemiarthroplasty was a functionally intact coracoacromial arch to provide superior secondary stability for the prosthesis. One important aspect of the operative technique was the selection of a sufficiently small prosthesis so that excessive tightness of the posterior aspect of the capsule could be avoided. Eighteen shoulders in sixteen patients were available for follow-up, which ranged from twenty-five to 122 months. Pain decreased from marked or disabling in fourteen shoulders preoperatively to none or slight in ten and to pain only after unusual activity in four. Active forward elevation improved from an average of 66 degrees preoperatively to an average of 109 degrees postoperatively. One patient, who had had an excellent result, fell and sustained an acromial fracture, so the functional result changed to poor. Three patients had persistent, substantial pain in the shoulder that led to a revision. Neither infection nor prosthetic loosening nor instability developed in any shoulder.


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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.