mtomaino
11-03-2014, 06:14 PM
Each month I read the contents of the Journal of Shoulder and Elbow Surgery, of which I am an Assistant Editor, and I always make special note of articles which may be particularly impactful on the care that I provide in the future, or which validate /support my current practice. I thought it would be valuable to routinely share my observations as part of the RearmYourself Forum. I plan on making such comments monthly.
The September 2014 issue included 2 articles that caught my attention. The 1st, entitiled “A preoperative scoring system to select patients for arthroscopic subacromial decompression” identified a scoring system that was useful in predicting which patients with shoulder pain consistent with “impingement” would do well after surgery. This is important because we are always very interested in trying to perfect our selection of patients for which we anticipate a good outcome after surgical intervention. The paper identified the following 6 variables that were associated with good outcome after a subacromial decompression:
1. Pain with overhead activities
2. Symptoms for more than 6 months
3. Persistent symptoms despite 3 months of supervised physical therapy
4. A Positive Hawkins test
5. X-ray changes of impingement on the humerus and acromion
6. Improvement for more than 1 week after a steroid injection
The study questioned the impact of surgery with a score of 4 or lower. This study supports my clinical behavior. When I recommend surgery on a patient with the presumed diagnosis of impingement syndrome, they always have a Hawkins sign, pain with overhead activities, symptoms greater than 4-6 months, persistent symptoms despite PT, and failure of a cortisone shot. This would result in a score of 5. More often than not a positive x-ray and confirmatory MRI are noted. If there is any doubt, I perform a subacromial lidocaine test; if this results in a significant if not complete resolution of the Hawkins sign, the prognosis for a favorable outcome with surgery is very high. In summary---this article helps with the selection of patients who may be candidates for arthroscopic surgery. Bottom line---a fairly substantial trial of conservative treatment is worthwhile before considering surgery.
The 2nd article entiltled “Intraoperative Intraarticular injection of gentamycin: will it decrease the risk of infection in total shoulder arthroplasty?” examined whether an intraarticular injection of antibiotic before leaving the operating room would decrease the rate of infection. Between 2005 and 2011, 507 shoulder replacements were performed. In 164 before 2007 intraarticular gentamycin was not used and 5 patients ( 3 %) developed an infection. Between 2007 and 2011 343 cases were performed and only 1 patient developed an infection (.29%). This difference was statistically significant. Given the low cost and safety of this intervention, and the significant cost and potential functional impact of developing an infection after a shoulder replacement, the authors concluded that this practice is a reasonable intervention to try to diminish the incidence of an acute postoperative infection. I agree. 160mg of gentamycin are mixed in 20 ml of saline and delivered through a needle placed percutaneously into the joint. Wound closure precedes injection. In addition to this measure, which I will now routinely perform on all shoulder replacements, both 1st time and revision, I would also advocate the routine use of antibiotic impregnated cement for all revision cases. The literature has shown a decreased risk of infection in revision cases with this practice.
The September 2014 issue included 2 articles that caught my attention. The 1st, entitiled “A preoperative scoring system to select patients for arthroscopic subacromial decompression” identified a scoring system that was useful in predicting which patients with shoulder pain consistent with “impingement” would do well after surgery. This is important because we are always very interested in trying to perfect our selection of patients for which we anticipate a good outcome after surgical intervention. The paper identified the following 6 variables that were associated with good outcome after a subacromial decompression:
1. Pain with overhead activities
2. Symptoms for more than 6 months
3. Persistent symptoms despite 3 months of supervised physical therapy
4. A Positive Hawkins test
5. X-ray changes of impingement on the humerus and acromion
6. Improvement for more than 1 week after a steroid injection
The study questioned the impact of surgery with a score of 4 or lower. This study supports my clinical behavior. When I recommend surgery on a patient with the presumed diagnosis of impingement syndrome, they always have a Hawkins sign, pain with overhead activities, symptoms greater than 4-6 months, persistent symptoms despite PT, and failure of a cortisone shot. This would result in a score of 5. More often than not a positive x-ray and confirmatory MRI are noted. If there is any doubt, I perform a subacromial lidocaine test; if this results in a significant if not complete resolution of the Hawkins sign, the prognosis for a favorable outcome with surgery is very high. In summary---this article helps with the selection of patients who may be candidates for arthroscopic surgery. Bottom line---a fairly substantial trial of conservative treatment is worthwhile before considering surgery.
The 2nd article entiltled “Intraoperative Intraarticular injection of gentamycin: will it decrease the risk of infection in total shoulder arthroplasty?” examined whether an intraarticular injection of antibiotic before leaving the operating room would decrease the rate of infection. Between 2005 and 2011, 507 shoulder replacements were performed. In 164 before 2007 intraarticular gentamycin was not used and 5 patients ( 3 %) developed an infection. Between 2007 and 2011 343 cases were performed and only 1 patient developed an infection (.29%). This difference was statistically significant. Given the low cost and safety of this intervention, and the significant cost and potential functional impact of developing an infection after a shoulder replacement, the authors concluded that this practice is a reasonable intervention to try to diminish the incidence of an acute postoperative infection. I agree. 160mg of gentamycin are mixed in 20 ml of saline and delivered through a needle placed percutaneously into the joint. Wound closure precedes injection. In addition to this measure, which I will now routinely perform on all shoulder replacements, both 1st time and revision, I would also advocate the routine use of antibiotic impregnated cement for all revision cases. The literature has shown a decreased risk of infection in revision cases with this practice.