Wednesday, October 18, 2017

Be careful of the rotator cuff after shoulder arthroplasty

One our concerns is that patients may stress their rotator cuff after shoulder arthroplasty. It is important to keep in mind that in the arthritic shoulder, the rotator cuff is disused. After shoulder arthroplasty, the joint is freed up and mobile, but the cuff is not ready for heavy use and is at risk for failure as observed here.

The web is wonderful, but it may tempt folks to exercises that are not ideal for their shoulder situation. The following exercises sent to me by one of our patients are NOT recommended after shoulder arthroplasty.










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Thoughts on the rotator cuff

I was recently asked to put together my thoughts on the rotator cuff. Here they are.

Since my six weeks studying with Dr. Neer in 1975, I’ve been trying to put the rotator cuff literature (>10,340 articles at this writing) together along with what I’ve personally seen work and fail over the last 43 years of shoulder practice, I’ve come to the following opinions.

(1) In a large number of people, the rotator cuff degenerates with age. In many of these individuals, the progression of cuff pathology is well accommodated by the shoulder, allowing them to continue to lead functional lives without medical intervention (I am one of these). A small percentage of individuals with cuff tears come to see shoulder surgeons (I am not one of these). Most of our ‘knowledge’ about cuff tears comes from this disproportionately small sample.

(2) While some surgeons have tried to associate various morphologic features of the acromion with cuff disease, evidence that surgical modification of the acromion changes the natural history of cuff disease or improves the outcome of cuff repair is lacking. Furthermore it is evident that acromioplasty increases the risk of pseudoparalysis and anterosuperior escape in patients with cuff deficiency.

(3) For young individuals with acute small cuff tears, surgical repair may be the procedure of choice. There is no evident difference among the different repair approaches.

(4) For individuals with chronic cuff pathology, there is no rush for intervening surgically. In many cases gentle range of motion and strengthening exercises can improve the patient’s comfort and function without the risks, cost and inconvenience of surgery.

(5) When considering surgery for a chronic cuff tear, it is important to assess the shoulder for active and passive range, crepitance, stability, and glenohumeral arthritis. Patients having chronic cuff tears without arthritis, with good active range of motion and with refractory stiffness and crepitance can receive substantial benefit by a smooth and move procedure – a procedure that encourages early active use of the shoulder without the downtime associated with cuff repair. Patients with a preserved coracoacromial arch, retained active motion in the presence of cuff deficiency and arthritis – especially those wishing to avoid the risks and complications of a reverse total shoulder – can consider a hemiarthroplasty with a cuff tear arthropathy humeral head. Finally, patients with cuff deficiency, along with instability, pseudoparalysis and/or anterosuperior escape can consider a reverse total shoulder.


This is what I teach and how I practice.

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Managing glenoid retroversion and biconcavity simply

While it is possible to devote substantial amount of resources 
to trying to classify and quantify the great variation in glenohumeral arthritic pathoanatomy, 
to carry out extensive preoperative planning to develop patient-specific instrumentation and 
to use specialized posteriorly augmented glenoid components, 
we have found that the great majority of our patients are well served by a preoperative assessment that includes a standardized axillary view (avoiding a CT scan) and uses a standard all-polyethylene component. Here's an example of the preoperative and postoperative axillary "truth" views for a patient from yesterday's OR. On his first postoperative day he achieved 145 degrees of assisted elevation with no concern about posterior instability. 



We've included below a reprise of a prior post demonstrating that routine "correction" of glenoid version, preoperative CT scans, and patient specific instrumentation may not be necessary in total shoulder arthroplasty.

A 76 year old man presented to us with severe right shoulder pain, stiffness and the x-rays shown below. While his AP view suggested straightforward osteoarthritis

his axillary, 'truth' view showed what is known as the 'severe arthritic triad': glenoid retroversion, glenoid biconcavity, and posterior decentering of the humeral head on the glenoid. No CT needed to define the pathoanatomy!



He elected to proceed with a total shoulder using a standard glenoid component. At surgery we reamed the glenoid to a single concavity without trying to change glenoid version. We used an anteriorly eccentric humeral component and a rotator interval plication to optimize posterior stability. Immediately after surgery he was started on the standard total shoulder rehabilitation program with continuous passive motion and assisted flexion. At six weeks he started the supine press and active flexion.

At four months he has a comfortable shoulder, no problems with instability, active flexion over 120 degrees, and is continuing his rehab.

His four month films are shown below.






While this is very short term followup, it does demonstrate that immediate postoperative glenohumeral stability can be achieved with this approach. To date we've not had problems with posterior instability using a standard glenoid component inserted in retroversion.

See also:
Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?
That study analyzed the two year outcomes in 71 TSAs, comparing the 21 in a "retroverted" group (the glenoid component was implanted in 15° or greater retroversion (mean ± SD, 20.7° ± 5.3°)) with the 50 in the "non-retroverted group" (the glenoid component was implanted in less than 15° retroversion (mean ± SD, 5.7° ± 6.9°)). The results in the retroverted group were not inferior to those for the non-retroverted group. The mean (± SD) improvement in the SST (6.7 ± 3.6; from 2.6 ± 2.6 to 9.3 ± 2.9) for the retroverted group was not inferior to that for the nonretroverted group (5.8 ± 3.6; from 3.7 ± 2.5 to 9.4 ± 3.0). The percent of maximal possible improvement (%MPI) for the retroverted glenoids (70% ± 31%) was not inferior to that for the nonretroverted glenoids (67% ± 44%).  The 2-year SST scores for the retroverted (9.3 ± 2.9) and the nonretroverted glenoid groups (9.4 ± 3.0) were similar (mean difference, 0.2; 95% CI, - 1.1 to 1.4; p = 0.697). No patient in either group reported symptoms of subluxation or dislocation. The radiographic results for the retroverted glenoid group were similar to those for the nonretroverted group with respect to central peg lucency (four of 21 [19%] versus six of 50 [12%]; p = 0.436; odds ratio, 1.7; 95% CI, 0.4-6.9), average Lazarus radiolucency scores (0.5 versus 0.7, Mann-Whitney U p value = 0.873; Wilcoxon rank sum test W = 512, p value = 0.836), and the mean percentage of posterior humeral head decentering (3.4% ± 5.5% versus 1.6% ± 6.0%; p = 0.223). The percentage of patients with retroverted glenoids undergoing revision (0 of 21 [0%]) was not inferior to the percentage of those with nonretroverted glenoids (three of 50; [6%]; p = 0.251).

In conclusion, glenoid retroversion is a relatively common finding in arthritic glenohumeral joints coming to shoulder arthroplasty. Shoulders with preoperative glenoid retroversion tend to have poorer preoperative shoulder comfort and function, posterior decentering, and glenoid biconcavity, all indicating a more severe form of the disease. There is currently great interest in methods for managing this glenoid retroversion commonly found in osteoarthritic glenohumeral joints using posterior glenoid bone grafts, reaming the anterior aspect of the glenoid, and posteriorly augmented glenoid components. The first study reviewed above reports the result of shoulders managed by altering the glenoid version with a posterior humeral head autograft. The second study reviewed above reports the two year results of a more conservative approach in which minimal glenoid bone is removed by reaming and specific attempts to alter glenoid version are not used.

Here is the two year radiographic followup on a 55 year old patient from our practice. Preoperative films show a type B2 genoid with retroversion, biconcavity and posterior humeral subluxation.



Here are the 2 year films of this shoulder after conservative shoulder arthroplasty using a standard glenoid component without attempts to modify glenoid version. The humeral head is centered in the prosthetic glenoid. At two years after surgery the patient was able to perform all 12 functions of the Simple Shoulder Test.




Note that sufficient bone stock remains to perform a revision total or a reverse total shoulder arthroplasty shoulder these procedures become necessary in the future of this young person.

Long term followup of well-characterized patients treated with the different methods for managing glenoid retroversion will be required to define the relative risks, benefits, effectiveness and durability of each of them.


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Saturday, October 14, 2017

Ream and run for chondrolysis in a young woman - two year outcome

An athletic young woman in her mid 20s was diagnosed with multidirectional instability of her right shoulder. She was treated by surgeons in another state with an arthroscopic anterior and posterior capsulorrhaphy. Three years later she had a repeat surgery after which a pain pump was used to infuse local anesthetics. Eight years later she had a subacromial decompression and biceps tenodesis. At that time glenohumeral chondromalacia was identified. The shoulder was debrided and the repair sutures removed. Five months later another subacromial decompression was performed along with a distal clavicle excision. She had persistent stiffness and pain. At the time of her presentation to us - twelve years after her first surgery - she had flexion limited to 90 degrees, pain ranging from 7-10 on a scale of 10, and reported the inability to perform any of the twelve functions of the Simple Shoulder Test

Her x-rays  show the characteristic appearance of chondrolysis (see this link).




After a thorough discussion of the alternatives, she elected to proceed with a ream and run procedure. Here are her postoperative films.




Although her motion was improved at 6 weeks after surgery, she and her local orthopaedic surgeon decided to proceed with a manipulation under anesthesia in that she had lost some of her early range of motion.

She demonstrated the highest level of dedication to her rehabilitation program, taking it to trackside. 

She has generously allowed us to post some of her photos here.

Here are the photos she sent in at 4 months after surgery, stating that she can now perform 8 of the 12 functions of the Shoulder Test in contrast to 0/12 before surgery.



She is now two years out from the procedure and fully functional as shown by these images she recently sent to us along with this message "Today is my two year anniversary of my ream and run surgery! We did it! I am so happy and proud to say that my shoulder feels better and stronger than it has in 15 years, since before my very first surgery in 2003! Thank you both from the bottom of my heart for giving me the chance at a much greater quality of life! Aloha, "

She adds "I can now perform all 12 functions of the Simple Shoulder test :) (the 8lb one is challenging but I can do it!)" 





It reminds of the important principle: "it is the patient and not the shoulder that we're treating".  In this case the patient was incredibly motivated and worked to earn her result.

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Wednesday, October 11, 2017

Ream and run for severe capsulorrhaphy arthropathy with retroversion

A man in his mid sixties presented with painful stiffness of the right shoulder after a stabilization procedure performed many years ago. He could perform only 1 of 12 of the functions of the Simple Shoulder Test. Here are his preoperative films showing severe arthritis and a retroverted glenoid.



He elected to have a ream and run procedure. At two and a half years after the procedure he can perform all of the SST functions. X-rays at that followup are shown below.



His shoulder motion is shown here.

video

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Information about shoulder exercises can be found at this link.

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