Sunday, October 9, 2011

The 2nd most common orthopaedic procedure performed in the US!


http://www.jbjs.org/article.aspx?articleid=35833
After reviewing close to 2500 papers on the subject of impingement syndrome of the shoulder our team at the University of Washington in Seattle found that there is lack of evidence to support that acromioplasty is superior to physical therapy for the treatment of impingement syndrome of the shoulder. In the last issue of the Journal of Bone and Joint Surgery our team under the mentorship of Dr Frederick Matsen published the results of our hypothesis based meta-analysis. We found that the tests that used for the diagnosis of this condition are not specific and there is an increasing number of acromioplasties performed in the US. Based on our metanalysis the term is impingement syndrome should be replaced with a specific diagnosis. It was originally introduced by Dr Neer who actually performed only 10 acromioplasties per year and did not have advance imaging to differentiate between tendinosis, tight posterior capsule and partial or full thickness tears of the cuff. This a Level II study and demonstrates the need to provide a specific diagnosis whenever possible. This study provides high levels of evidence to change the practice on the 2nd most common orthopaedic procedure performed in the US.
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Saturday, June 25, 2011

Exercises for the shoulder

Recently, an executive from Microsoft was seen in our clinic that "was working through pain to make the shoulder pain better". I was impressed by the motivation towards the wrong approach!

Often times patients request a set of exercises to rehab their shoulder. The physical therapy program depends on the preferences of the orthopaedic surgeon and the surgery the patient had. I have seen many patients having problems with their physical therapy either because the therapist is "trying something different that works better" or because the exercise is intense and makes the shoulder more painful. The cornerstone of physical therapy for the shoulder is the "comfortable" exercise. When the exercises cause pain then it is unlikely that the shoulder will recover. The physical therapy should cause discomfort and tolerable pain but it should not cause inflammation from increased intensity. The slow and frequent exercises are key to a successful recovery. For your information the following link is provided that explains the correct set of exercises for the most frequent shoulder pathologic conditions.
http://orthoinfo.aaos.org/topic.cfm?topic=A00067

Shoulder Surgery Exercise Guide
Regular exercises to restore your normal shoulder motion and flexibility and a gradual return to everyday work and recreational activities are important for your full recovery.
Your orthopaedic surgeon and physical therapist may recommend that you exercise from 10 to 15 minutes 2 or 3 times a day during your early recovery period. They may suggest some of the following exercises.
This guide can help you better understand your exercise and activity program.
Pendulum, Circular

Pendulum, Circular
Bend forward 90 degrees at the waist, using a table for support. Rock body in a circular pattern to move arm clockwise 10 times, then counterclockwise 10 times.
Do 3 sessions a day.
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Shoulder Flexion (Assistive)
Clasp hands together and lift arms above head. Can be done lying down (drawing A) or sitting (drawing B). Keep elbows as straight as possible.
Repeat 10 to 20 times.
Do 3 sessions a day.
Shoulder Flexion (Assistive)
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Supported Shoulder Rotation
Keep elbow in place and shoulder blades down and together. Slide forearm back and forth.
Repeat 10 times.
Do 3 sessions a day.
Supported Shoulder Rotation
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Walk Up Exercise (Active)
With elbow straight, use fingers to " crawl " up wall or door frame as far as possible. Hold 10 seconds. Repeat 3 times.
Do 3 sessions a day.
Walk Up Exercise (Active)
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Shoulder Internal Rotation (Active)
Bring hand behind back and across to opposite side.
Repeat 10 times.
Do 3 sessions a day.
Shoulder Internal Rotation (Active)
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Shoulder Flexion (Active)
Raise arm to point to ceiling, keeping elbows straight. Hold 10 seconds.
Repeat 3 times.
Do 3 sessions a day.
Shoulder Flexion (Active)
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Shoulder Abduction (Active)
Raise arm out to side, elbow straight and palm downward. Do not shrug shoulder or tilt trunk. Hold 10 seconds.
Repeat 3 times.
Do 3 sessions a day.
Shoulder Abduction (Active)
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Shoulder Extension (Isometric)
Stand with your back against the wall and your arms straight at your sides. Keeping your elbows straight, push your arms back into the wall. Hold for 5 seconds, and then relax.
Repeat 10 times.
Shoulder Extension (Isometric)
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Shoulder External Rotation (Isometric)
Stand with the involved side of your body against a wall. Bend your elbow 90 degrees. Push your arm into the wall. Hold for 5 seconds, and then relax.
Repeat 10 times.
Shoulder External Rotation (Isometric)
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Shoulder Internal Rotation (Isometric)
Stand at a corner of a wall or in a door frame. Place the involved arm against the wall around the corner, bending your elbow 90 degrees. Push your arm into the wall. Hold for 5 seconds, and then relax.
Repeat 10 times.
Shoulder Internal Rotation (Isometric)
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Shoulder Internal Rotation
Keep elbow bent at 90 degrees. Holding light weight, raise hand toward stomach. Slowly return.
Repeat 10 times.
Do 3 sessions a day.
Shoulder Internal Rotation
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Shoulder External Rotation
Keep elbow bent at 90 degrees at side. Holding light weight, raise hand away from stomach. Slowly return.
Repeat 10 times.
Do 3 sessions a day.
Shoulder External Rotation
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Shoulder Adduction (Isometric)
Press upper arm against a small pillow alongside your body. Hold 5 seconds.
Repeat 10 times.
Do 3 sessions a day.
Shoulder Adduction (Isometric)
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Shoulder Abduction (Isometric)
Resist upward motion to the side, push arm against back of chair. Hold 5 seconds.
Repeat 10 times.
Do 3 sessions a day.
Shoulder Abduction (Isometric)
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Wednesday, May 11, 2011

The babe boomers

It is a common observation that the "baby boom generation" will place a significant demand on health care systems around the world. Orthopaedic surgery is not inexpensive and if it becomes it is usually of low quality especially when it comes to joint replacement. Total knee, total hip and lastly shoulder replacement will have a significant impact on our society in the years to come. Older people will stay more active than the previous generation but on the other hand the cost of health care will likely increase. The American Academy of Orthopaedic Surgery (AAOS) predicts that "there will not be enough orthopaedic surgeons to perform these procedures". Those who are involved in economics know what happens when the demand exceeds the supply. I am attaching you a recent publication of the AAOS for your information:

Orthopaedic Surgeon Shortage Predicted Due to Soaring Joint Replacement Procedures
Two studies find patient demand will soon surpass the number of orthopaedic surgeons available
Las Vegas, NV
In the near future, there may not be enough orthopaedic surgeons to provide joint replacements to all who need them. According to two new studies presented at the 2009 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), the number of patients requiring hip or knee replacement surgery is likely to soon outpace the number of surgeons who can perform the procedure.
According to a study co-authored by Thomas K. Fehring, M.D., if the number of orthopaedic surgeons able to perform total joint replacements continues at its current rate:
“I was somewhat shocked at the shortfall that we predicted,” says Dr. Fehring, an orthopaedic surgeon at OrthoCarolina Hip and Knee Center in Charlotte. “This is life-changing surgery, offering patients the chance to be mobile, and a very high percentage of patients may not be able to receive it.”
Joint replacement, also known as arthroplasty, is considered by many to be one of the most successful medical innovations of the 20th century. Total joint replacement is a surgical procedure in which the patient’s natural joint is replaced with an artificial one.
  • More than 700,000 primary total hip and knee replacements are performed each year in the United States, and demand for the surgery is expected to double in the next 10 years.
A second study co-authored by Steven M. Kurtz, Ph.D., found that a major reason for the growth in patient demand for joint replacement is the increase in younger patients.
  • Projections show that by 2011, more than 50 percent of patients requiring hip replacements will be under the age of 65; the knee-replacement patient population will reach that threshold by 2016.
  • For primary total knee replacement, the fastest growing group of patients is in the 45-54 age category; the number of procedures performed in this age group is projected to grow from 59,077 in 2006 to 994,104 (an increase of 17 times) by 2030.
“Joint replacement is generally thought of as a procedure for older people, over 65,” says Dr. Kurtz, corporate vice president and office director at Exponent, Inc., in Philadelphia. “Our projections show that younger people make up a big piece of the pie, and that is only going to increase if historical trends continue.”
Both researchers believe that the key to stemming this supply-side crisis is for policymakers to reconsider the rates at which total joint replacements are reimbursed. The reimbursement rates have consistently gone down over the years, even as the costs of providing health care have gone up.
However, Dr. Kurtz notes that the possibility of new technologies may offer a glimmer of hope. “It’s hard to predict what changes will come about in the next 20 years,” he says. “Hopefully, we will have some new tools in the future to help address this problem, which could be of epidemic proportions.”
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Sunday, May 1, 2011

What Lamborghini, Nobel prizes and Pioneers in Shoulder Surgery have in common?


I am often surprised by the high quality research and and the pioneers at the University of Washington. I had the chance to see the Lamborghini Lab which was very impressive. Of the record I found out that the following Nobel prizes were given here at the University of Washington.

UW School of Medicine Nobel Prize Winners in Physiology or Medicine

2004: Linda B. Buck for discoveries of odorant receptors and the organization of the olfactory system
2001: Leland H. Hartwell for discoveries of key regulators of the cell cycle
1992: Edmond H. Fischer and Edwin G. Krebs for discoveries concerning reversible protein phosphorylation as a biological regulatory mechanism
1990: E. Donnall Thomas for discoveries concerning organ and cell transplantation in the treatment of human disease
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Friday, April 29, 2011

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
    1. A complete assessment of the quality of individual studies requires critical appraisal of all aspects of the study design.
    2. A combination of results from two or more prior studies.
    3. Studies provided consistent results.
    4. Study was started before the first patient enrolled.
    5. 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.
    6. Study was started after the first patient enrolled.
    7. 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."
    8. 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
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    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.
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    Thursday, April 28, 2011

    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
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