There is nothing going to ruin your day like a complication after shoulder arthroplasty, either hemiarthroplasty (HA) anatomical (TSA) or reverse arthroplasty (RTSA). While complications are fortunately uncommon with anatomical shoulder arthroplasty (approximately 8% but as high as 40%), the complication rate for RTSA has been reported as high as 70%. Most complications are multifactorial and cannot all be blamed on the patient. Basically you do not want to operate upon a young patient who is an insulin dependent diabetic, has an ASA of 3 or 4, who smokes, has HIV disease and has a BMI over 40. The most common predictors of failure are determined by the indication for surgery, the type of implant used and the skill of the surgeon. The major risk factors for HA are eccentric glenoids, young age and rotator cuff failure. The biggest risk factors for TSA are metal backed glenoid components, younger age of the patient, rotator cuff pathology and insufficient glenoid bone. The major risk factors for RTSA are the type of component used (Grammont type versus lateral center of rotation designs) and the indication for surgery. Infection risks include previous infected arthroplasty, previous joint infection, immunosuppression (e.g. steroid use, insulin dependent diabetes, HIV disease), ASA 3 or 4 and higher BMI (i.e. over 40). Not all of these risk factors can be prevented in patients but informed consent is critical to the patient understanding the potential outcomes of their surgery.
There are unfortunately many reasons a TSA can be painful after implantation, but the most common reason is sepsis. Making the diagnosis can be a major challenge, but the biggest challenge is to think of that as a diagnosis! The most important steps are to first obtain plain radiographs one week after surgery so that you can compare subsequent radiographs to the immediate post-operative films. Progressive radiolucent lines in the glenoid or especially around the humerus are important hints. A loose humeral component is infected until proven otherwise. Next blood work to include CRP and ESR are critical. Other markers of infection have not been used on a widespread basis. If there is concern that there might be rotator cuff pathology and not sepsis, then we obtain an arthrogram CT scan at the time of aspiration. A cell count is helpful but often there is a dry tap. It is important to create a “p. acnes protocol” at your hospital to take cultures out 15 days. If still not sure and revision is necessary then we aspirate the joint at the time of surgery for cell count. The WBC cell count at the time of surgery keeps changing but over 3000 is considered diagnostic. Multiple specimens are sent for frozen section, culture and permanent section. The more WBC per high powered field the more likely there is an infection. Gram stains are worthless and we do not rely on them. We have no experience with implant sonification or use of IL-6.
The current standard of care in the United States for the treatment of an infected arthroplasty, whether it be a TKA, THA or TSA remains two stage revision. We performed a systematic review of the English literature to answer the question of whether one-stage or two-stage revision of infected shoulder arthroplasty was better in terms of re-infection rate, patient satisfaction and patient function. There were no prospective, randomised studies comparing these two approaches. We found 19 studies with a minimum one year follow up which described 99 patients with two-stage revision, 38 with one-stage revision and 36 with spacers. There were no significant differences between the groups for recurrent infection rate or complication rate. The spacer only group had higher satisfaction than the one-stage group, but the satisfaction rate between the one- and two-stage groups was not statistically different. Unfortunately, the numbers in our study were small and based upon level IV evidence. It is interesting that currently the data do not support two-stage over one-stage revision of an infected TSA. So why do we continue to use two-stage revision? I believe it is the fear of litigation to a certain degree but also historical bias toward two-stage revisions. The only time I would do a one-stage revision is if (1) it is a low virulence organism, (2) the prosthesis can be easily removed and (3) the patient was too sick to tolerate multiple operations.
Previous studies report the neurological complication rate for shoulder arthroplasty to be 4.3% to 5.0%, However, these studies were limited to total shoulder arthroplasty (TSA) and did not include hemiarthroplasty (HA) or reverse prosthesis arthroplasty (RPA). Our hypotheses were that the neurological complication incidence after shoulder arthroplasty would vary by type of procedure performed and that the overall incidence would be higher than previously reported in the literature. We retrospectively reviewed the charts of 307 consecutive patients who had a total of 349 SA by the same surgeon between June 1995 and August 2007. Only patients with over six months follow up were included. The charts were reviewed for any sensory or motor disturbance postoperatively. Those who had EMG confirmation of nerve injury (NI) were placed into the surgical complication group, with a second group composed of patients with neurological symptoms (NS) who did not require electromyography (Dr Ji or Matt---how many in the NI group did not have EMG?). These two groups were statistically compared to those patients without neurological injury using standard statistics software. There were 113 HA, 191 TSA and 45 RPA with over 6 month follow up, and there were 10 (10/349; 2.9%)neurological injuries (NI) There was no significant difference in the incidence between the groups (HA: N=3/113, 2.7%; TSA: N=5/191, 2.6%; RPA:N=2/45, 4.4%). There were an additional 34 neurological symptoms (NS) after shoulder arthroplasy, and if included with the NI then the total rate of neurological complaints after shoulder arthroplasty was 12.6% (44/349). If the NI and NS are combined, multivariate analysis showed that there was a statistically significant association between the development of neurological symptoms and revision surgery. The rate of neurological complications after shoulder arthroplasty was independent of the type of procedure. The incidence of neurological complaints after shoulder arthroplasty is higher than previously reported.
The accuracy of the physical examination for biceps pathology remains controversial. The goal of this study was to investigate the validity and clinical usefulness of various physical tests used for diagnosing partial tears of the biceps tendon.
Distal clavicle excision (DCE) is the treatment of choice for A–C joint arthritis. Isolated DCE., as an open procedure has been considered to be a safe procedure, and it is the gold standard for comparison for arthroscopic distal clavicle excision. This study attempts to define the incidence of complications after isolated, open DCE.
