The growing interest in shoulder replacement surgery. An increase of 445% between 1990s and 2000s.

There is an explosive increase in the number of publications regarding shoulder replacement surgery. The graph above shows the impressive increase. Between 1990-2000 the average number of studies published was 29.5 studies per year. After 2000 this number has increased to the astonishing number of 161 studies per year. This reflects an increase of 445%! This interest may reflect the aging population, may also reflect the increasing number of "free on line journals". One needs to be very careful in interpreting the results of a study. Without a doubt the computer era and the advanced programming techniques have contributed to the better analysis of patient databases. However, with this plethora of information it appears that the quality of information is also affected. Implant companies fund studies in an effort to promote their products. The studies funded by the implant industry are usually seen in peer reviewed journals in which the criteria for publication are no strict or scientifically correct. One needs to be particularly careful about conflicts of interest. We are in an era that the public as well as the physicians have to critically interpret the data, results and the statements made in these published studies. I fear that the pressure of the universities to publish studies, the pressure of the industry to publish studies and the well established need of the society to advance medicine may lead to an overwhelming volume of data and studies that will create more confusion than understanding of the nature of the diseases, the mechanisms of development and the best methods of treatment. In other words, it is time to read articles critically, the same way that you read an article in the newspaper.

Early radiolucent lines after glenoid component insertion for total shoulder arthroplasty

The clinical importance of the early radiolucent lines after glenoid component insertion for total shoulder arthroplasty remains a topic of debate. Our previous comprehensive review of the literature on the clinical importance of the glenoid component radiolucent lines indicated that these lines do progress. Eventually, these lucencies may lead to symptomatic glenoid component loosening. Some surgeons use pressurized and some unpressurized cementing techniques. In an effort to eliminate those lines some surgeons suggest the use of CO2 also known as carbojet to remove blood from the peg holes on the glenoid bone. Others use packing of the peg holes with a sponge embedded in epinephrine solution. The theory behind the packing is that the epinephrine causes vasoconstriction and minimizes bleeding in the glenoid peg holes allowing the pressurized cement to achieve a better incorporation with the bone at the cement-bone interface.

I personally use an epinephrine solution and a sponge technique for glenoid component bone peg hole preparation. These radiographs below are the x-rays of the first shoulder replacement that I performed after finishing my fellowship. No lucent lines are seen. For further reading I recommend the following study:
http://www.ncbi.nlm.nih.gov/pubmed/22960147

The Doctor the NFL Tried to Silence

League physicians sought to discredit Bennet Omalu’s autopsy study showing widespread brain damage in former Steelers star Mike Webster.

More info:

http://www.wsj.com/articles/the-doctor-the-nfl-tried-to-silence-1448399061

Zion receives bilateral hand transplant. We can learn from this young man and the surgical team who treated him

The field of reconstructive microsurgery is an exciting one. Unfortunately, in the western societies there is very little support for the microsurgeons because poor nerve function and scar tissue formation are the biggest enemies of replantation surgery. Long hours in the operating room, extensive use of resources and high cost are obstacles to the great field of reconstructive surgery. James Urbaniak and Panayotis N Soucacos say: "there is no end to the world of microsurgery". However, how to make a replant, such as a hand or finger or arm, functional remains a big challenge. I think that supporting efforts like the efforts of Dr Scott Levin who was the lead physician of the team that performed the bilateral hand transplantation in Philadelphia is of great importance. I see two exciting scenarios for the future of such surgeries. Tissue engineering or advances in the understanding of graft rejection will make this transplantation surgeries a viable solution to many amputees especially the young children who have a great potential for nerve recovery after end to end nerve repair. We are all excited for what is coming in the near future

SLAP tears and paralabral cysts

Paralabral cysts associated with SLAP lesions are frequent findings on MRI of the shoulder. They can be addressed either with direct decompression or by a repair of the SLAP lesion alone. If there is no history of trauma or the patient is older then clinical followup without surgery is the approach of choice. If they produce pain or weakness and are associated with traumatic labral tears then decompression and repair of the SLAP tear is the debridement of choice. Below please see a case that was approached with decompression using percutaneous arthroscopic technique and an 18G spinal needle. Repair of the SLAP lesion is necessary in these cases for the treatment of pain and avoidance of recurrence of the cyst.

Deja vu. 2011 and 2015

In 2011, we published a study highlighting the need to reconsider using the term of "shoulder impingement" Link

 In August of 2015 the JBJS published a commentary about the classic article published by Charles Neer on acromioplasty. Link

We are glad that the leadership of the Journal of Bone and Joint Surgery adopts our suggestion to stop using the term.

Attached please see the last paragraph from the "Classics documentary"

Neer’s hypothesis that impingement caused most rotator cuff tears does not appear to have withstood the test of time, however. Arthroscopy and magnetic resonance imaging arthrography have elucidated many other conditions that cause shoulder pain that were previously misdiagnosed as impingement. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete tear of the rotator cuff, and performing aggressive rehabilitation prior to corrective surgery.

Reverse shoulder replacement for irreparable rotator cuff tear with high riding humeral head

Rotator cuff deficiency with a high riding humeral head remains a challenging problem to solve. Shoulder replacement surgery in those individuals is highly technical in terms of correct positioning of implants or soft tissue balancing. Muscle transfers is an alternative solution in the treatment of the rotator cuff deficient shoulder as they can increase the range of motion of shoulder, however they have unpredictable results and they do not address the arthritic pain. If there is arthritis at the glenohumeral joint then is it unlikely that a muscle transfer will provide better quality of life. 

A reverse shoulder replacement can provide solution in cases that the active elevation of the arm is below 90 degrees. Further reading at the JBJS study:  http://dx.doi.org/10.2106/JBJS.K.01206

It must be highlighted though that if the active elevation of the shoulder is at 90 degrees or more then a reverse shoulder replacement may not provide significant benefits.

Below is an example of an elderly person with loss of motion (<90 degrees) and a high riding humeral head treated with a reverse shoulder replacement. The coronal CT shows the high riding humeral head and the sagittal oblique CT shows the significant atrophy of the supraspinatus and the contact of the humerus with the acromion making the repair of the rotator cuff impossible (Goutallier stage 3)

Nature nanotechnology. Detecting bacteria on implants. Timing!

NATURE NANOTECHNOLOGY | ARTICLE

• 
  

A magneto-DNA nanoparticle system for rapid detection and phenotyping of bacteria

• Hyun Jung Chung,
• Cesar M. Castro,
• Hyungsoon Im,
• Hakho Lee
• & Ralph Weissleder

• Nature Nanotechnology
   
  8,
   
  369–375
   
  (2013)
   

One of the most devastating experiences that an orthopaedic surgeon encounters is the infected implant. More importantly, the patient goes through extensive surgery that most of time is of inferior result compared to the first surgery. The socioeconomic cost of the infections in orthopaedics is tremendous. The annual cost of infected revisions to US hospitals is projected to exceed $1.62 billion by 2020.

Often times it is difficult to confirm the presence of bacteria in a wound just by inspecting the color of the fluid, the odor or the macroscopic appearance of the membranes on the implants. There is promising technology being developed that will give us the opportunity to detect an infection in less than 2 hours when currently a standard microbiology lab can give us an answer in 2-3 days and sometimes depending on the micro-organism in 14-21 days.

The magneto-DNA nanoparticle system provides an answer in less than 2 hours. The ideal test would have been similar to a pregnancy test that will give us an answer at the time of surgery. In that scenario orthopaedic surgeons will be able to manage periprosthetic infections more effectively, develop better algorithms and lower the cost of revision arthroplasty care from a financial and social perspective.

http://www.nature.com/nnano/journal/v8/n5/full/nnano.2013.70.html#f5

My experience at the AANA Masters Elbow Course 2015

Recently, I had the honor to be an invited instructor at theLearning Center of the American Academy of Orthopaedics Surgeons. Masters Course AANA 2015 on elbow arthroscopy.

I recall that in the 1990s many surgeons thought that arthroscopy will be something temporary, a trend that will go away as many "new technologies" do. I also recall that arthroscopic surgery was approached with negativity or even skepticism even in the 1990s. During the time I spend at the AAOS Learning Center as an instructor on elbow arthroscopy I thought that being negative has no place in science and medicine. I remember the lecture of Dr Gary Poehling on elbow arthroscopy at the institution where I was trained (WFUBMC) and the first arthroscopes that were introduced in the US and imported from Japan. They were bulky, they will break and they will not be suitable for small joints. In addition, the quality of imaging was poor for diagnosis.  I do not think anyone would have imagined the potential of arthroscopic surgery at that point. 

Thirty years later arthroscopy of small joints has come long ways. While I was teaching fellows how to establish portals safely around the elbow, which is considered a difficult joint to scope, I realized that arthroscopy has even greater potential. I believe that the cameras and instruments will become smaller in size in the future, the ability to navigate the elbow will improve and the arthroscopic repair of collateral ligament ruptures or even fixation of shear fractures of the capitellum will become a reality. Some may think that I am very optimistic. The ones who belong to the arena of electronics and computer science know that we are not far away from manufacturing surgical instruments and arthroscopes that will have the diameter of a spinal needle. In my opinion it is exciting what the future will bring us. Negativity has no place in medicine.  

Subluxating ulnar nerve

Subluxation of the ulnar nerve at the elbow can be seen in 12-15% of the normal population and can be asymptomatic. The nerve usually subluxes in flexion as seen in this video. If the patient has no symptoms and no neurologic findings then surgery is not indicated. It may be associated with snapping of the medial triceps.

The clinical importance of this condition is the following:

1. In case elbow arthroscopy is planned the proximal medial portal can result in ulnar nerve damage which may lead to permanent dysfunction of the hand/arm

2. If symptomatic and presentation mimics cubital tunnel syndrome findings then it is important to evaluate intra-operatively what makes the ulnar nerve sublux. This is performed by exposing the ulnar nerve proximal to the medial epicondyle and flexing the elbow while inspecting the wound. Sometimes snapping over the medial triceps or intermuscular septum may be seen.

It is commonly seen in throwers and bodybuilders and surgery is necessary if symptomatic.

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Failure of anatomic total shoulder joint replaceme...

Shoulder Arthritis / Rotator Cuff Tears: causes of shoulder pain: Failure of anatomic total shoulder joint replaceme...: One can always learn from studying failure. The study of planes that crash is more educational that the study of planes that land on time. ...

A true healthcare reform is needed. The cost of defensive medicine

"Jackson Healthcare, a healthcare solutions company, surveyed physicians on defensive medicine practices between October 2009 and May 2011. Their survey found that between 73 and 92 percent of all physicians practice some form of defensive medicine, at a cost of between $650 to $850 billion dollars in unnecessary expenditures, accounting for between 24 and 36 percent of our nation’s $2.5 trillion annual healthcare bill."

"A Bullet in the radial head"

Violence and gunshot wounds are a very concerning social phenomenon of our era. A teenager presented with a gunshot wound to the elbow. The entry side was to the lateral aspect of the elbow and no exit wound was found. There was no vascular or nerve damage as the bullet went into the radial head through the Kocher interval. On exam there was limited motion in forearm rotation. Initially, the family was consulted against removal of the bullet. The family insisted to have the bullet removed after explaining risks and benefits of the procedure. The main concerns were (1) AVN due to the trauma (2) Removal of the bullet could lead to collapse of the radial head and eventually radial head excision.

Alternatively, radial head replacement could have been performed, however the risks of capitellar arthritis in the midterm are significant after such procedure.



Treatment consisted of removal of the bullet which demonstated that the radial head was stable.

 Unfortunately, over the course of months the patient developed
(1) AVN, collapse of the head,
(2) limited forearm rotation

The patient was eventually treated with radial head excision.

His course was complicated by a synovial fistula that was repaired.

XR at the time of injury

XR at the time of injury

Postoperative XR after removal of bullet

Postoperative XR after removal of bullet

4 months after removal of bullet there is collapse of the radial head with loss of normal contour

4 months after removal of bullet there is collapse of the radial head with loss of normal contour

4 months after removal of bullet there is collapse of the radial head with loss of normal contour

Radial head excision

Radial head excision

Shear fractures of the capitellum.

This case demonstrates a rare injury to the elbow. Shear fractures of the capitellum can be communicated like in this case. Comminution can make treatment difficult. This is a retired woman in her 50s who fell on the left elbow. She has as seen on plain radiographs and 3D reconstruction a comminuted fracture of the capitellum and anterior subluxation of the radial head. Operative fixation requires preservation of the LCL and a LCL sparing lateral approach.

Tips:

1. Kocher LCL sparing lateral approach to the elbow with the incision on the skin 2cm anteriorly compared to the classic approach

2. Preservation of the LCL. Develop interval between anconeus and ECRB/ECRL. Avoid excessive retraction anteriorly over common extensor mass that can damage the radial nerve.

3. Excision of bone fragments that are too small to be fixed. Visualization of the trochlear - capitellum area to avoid medial step-off at the articular surface

4. Anterior to posterior headless screws have better chances of healing of the fracture compared to posterior to anterior. Vascularity of distal humerus is rich and comes from the posterior aspect of the elbow

5. Disadvantage of AP screws is that in case of AVN or non union the screws can became prominent and lead to DJD of the radial head and elbow.

A similar case of a capitellum shear fracture with free fragments in the joint is demonstrated below. Removal of free fragments was performed and the largest fracture was fixed with "minimal drilling" using a threaded K wire to avoid pin migration and a headless compression screw. The patient had a preoperative QuickDASH score of 79 and postoperative QuickDASH score of 0 (0 means no limitation in function). The patient was pain free with full ROM to the elbow at 6 months postoperatively. 

 Preoperative lateral view

 Preoperative AP view showing the comminution

3D reconstruction of the fracture on CT

 6 months postoperatively

 6 months postoperatively, no AVN

 3 months postoperatively

 3 months postoperatively fracture line still visible

3 months postoperatively fracture line still visible