Shoulder joint destruction and pain pumps for the shoulder. New study gives better insight in the characteristics of the disease.

There is currently a lot of discussion about the effects of local anesthetic agents in the shoulder joint. Patients often ask: "Was my arthritis caused by the shoulder arthroscopy I had?" Indeed, the young patient with joint destruction due to chondrolysis remains a very difficult problem to treat. Patient and physicians should be aware that to our knowledge the problem of chondrolysis is related to the pain pumps and not the one time joint anesthetic injections. The term chondrolysis refers to an inflammatory destructive process to the cartilage of the shoulder joint due to the toxic effects of the steady and continuous infusion of local anesthetics. Some well respected shoulder surgeons believe that this process may be the final result of a low grade subclinical infection but that theory remains to be proven.

Regardless of the etiology, the shoulder reconstruction in the young and active patient remains a  complicated scenario. Our experience at the University of Washington, Seattle is that patient do not reach the level of satisfaction that we see in patients who are treated with total shoulder replacement for osteoarthritis of the shoulder. Currently, there is no implant that can provide excellent functional result in the very young active patient. In a study that was contacted at the University of Washington in Seattle and published recently in the Journal of Bone and Joint Surgery the risks factors were clearly identified after analyzing arthroscopic procedures of one community surgeon. Ask your doctor to avoid using Marcaine or lidocaine infusion pumps into the joint during the postoperative period. Avoiding such a postoperative infusion may reduce the risk of chondrolysis. This was a Level II study. (about Levels of Evidence please refer to the table below)

Levels of Evidence for Primary Research Question

Levels of Evidence for Primary Research Question1
	Types of Studies
	Therapeutic Studies—Investigating the Results of Treatment	Prognostic Studies—Investigating the Effect of a Patient Characteristic on the Outcome of Disease	Diagnostic Studies—Investigating a Diagnostic Test	Economic and Decision Analyses—Developing an Economic or Decision Model
Level I	High-quality randomized controlled trial with statistically significant difference or no statistically significant difference but narrow confidence intervals Systematic review2 of Level-I randomized controlled trials (and study results were homogeneous3)	High-quality prospective study4 (all patients were enrolled at the same point in their disease with ≥80% follow-up of enrolled patients) Systematic review2 of Level-I studies	Testing of previously developed diagnostic criteria in series of consecutive patients (with universally applied reference "gold" standard) Systematic review2 of Level-I studies	Sensible costs and alternatives; values obtained from many studies; multiway sensitivity analyses Systematic review2 of Level-I studies
Level II	Lesser-quality randomized controlled trial (e.g., <80% follow-up, no blinding, or improper randomization) Prospective4 comparative study5 Systematic review2 of Level-II studies or Level-I studies with inconsistent results	Retrospective6 study Untreated controls from a randomized controlled trial Lesser-quality prospective study (e.g., patients enrolled at different points in their disease or <80% follow-up) Systematic review2 of Level-II studies	Development of diagnostic criteria on basis of consecutive patients (with universally applied reference "gold" standard) Systematic review2 of Level-II studies	Sensible costs and alternatives; values obtained from limited studies; multiway sensitivity analyses Systematic review2 of Level-II studies
Level III	Case-control study7 Retrospective6 comparative study5 Systematic review2 of Level-III studies	Case-control study7	Study of nonconsecutive patients (without consistently applied reference "gold" standard) Systematic review2 of Level-III studies	Analyses based on limited alternatives and costs; poor estimates Systematic review2 of Level-III studies
Level IV	Case series8	Case series	Case-control study Poor reference standard	No sensitivity analyses
Level V	Expert opinion	Expert opinion	Expert opinion	Expert opinion
A complete assessment of the quality of individual studies requires critical appraisal of all aspects of the study design. A combination of results from two or more prior studies. Studies provided consistent results. Study was started before the first patient enrolled. Patients treated one way (e.g., with cemented hip arthroplasty) compared with patients treated another way (e.g., with cementless hip arthroplasty) at the same institution. Study was started after the first patient enrolled. Patients identified for the study on the basis of their outcome (e.g., failed total hip arthroplasty), called "cases," are compared with those who did not have the outcome (e.g., had a successful total hip arthroplasty), called "controls." Patients treated one way with no comparison group of patients treated another way. This chart was adapted from material published by the Centre for Evidence-Based Medicine, Oxford, UK. For more information, please see www.cebm.net.

J Bone Joint Surg Am. 2011 April

Risk Factors for Chondrolysis of the Glenohumeral Joint: A Study of Three Hundred and Seventy-five Shoulder Arthroscopic Procedures in the Practice of an Individual Community Surgeon.

Wiater BP, Neradilek MB, Polissar NL, Matsen FA 3rd.

Source

Department of Orthopedics and Sports Medicine, University of Washington Medical Center, Box 356500, 1959 N.E. Pacific Street, Seattle, WA 98195. matsen@u.washington.edu

What are the dangers of a shoulder replacement?

In a study of 15,288 patients who underwent shoulder arthroplasty it was found that the complication rate was very low. Dangers exist like with every surgery but based on this study from UCLA the complications are minimal. The study was published in the J Shoulder Elbow Surg. 2011 Feb 14 by the Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA. I am attaching the results and conclusion section of the paper:

RESULTS:

During the study period, 15,288 patients underwent shoulder arthroplasty. Patients undergoing total shoulder arthroplasty and hemiarthroplasty had no statistically significant difference in the aggregate risk of 90-day complications or the risk of implant failure within the study period. Fracture patients were shown to have a higher risk of short-term complications (odds ratio, 3.2; P < .001). Implant failure rates were lower in patients with fracture, rheumatoid arthritis, increased comorbidity, and advanced age.

CONCLUSION:

This study reports similar rates of short-term complications and implant failure in patients undergoing total or hemiarthroplasty, an overall mortality rate of 1.3%, and a pulmonary embolism rate of 0.6%. The findings of our study indicate that the risk of short-term complications is highest in patients undergoing total or hemiarthroplasty for a fracture compared with nonfracture indications. Our results also indicate that longer-term, implant survival is largely driven by factors associated with increased activity, such as age. In patients undergoing surgery for arthritis of the shoulder, we found no difference in implant survival rates between total and hemiarthroplasty of the shoulder.

The purpose of having a shoulder and elbow surgery blog

This blog is devoted in providing information to those who have an interest in Shoulder and Elbow Surgery. I am a graduate of the Wake Forest University Orthopaedic Surgery Program (Winston Salem, NC).

My interest in shoulder and elbow surgery grew after having spend an extra year in training in Shoulder and Elbow surgery at the University of Washington in Seattle. Under the supervision of the world-renowned surgeon Dr Frederick Matsen 3rd I explored the world of shoulder and elbow surgery.

I hope that you will find this blog useful either as a patient or physician. Please do not hesitate to email me with questions or suggestions.

The background of this blog is a painting depicting Hippocrates Refusing the Gifts of Artaxerxes I (1792). Artist: Anne- Louis Girodet de Roussy-Trioson.

I decided to start with this picture which is a sketch of the original painting. The sketch that you see here was a source of inspiration for me to find the path to a successful result in informing you about the current advances in shoulder and elbow surgery.

Sincerely,

Anastasios Papadonikolakis, MD