Dr Michell Ruiz

Dr Michell Ruiz
Cirugía de hombro y del Manguito rotador

lunes, 16 de marzo de 2015

Should I have a ream and run or a total shoulder?

http://shoulderarthritis.blogspot.mx/2015/02/should-i-have-ream-and-run-or-total_26.html


Should I have a ream and run or a total shoulder?

Should I have a ream and run or a total shoulder?

This is a question that confronts many patients with shoulder arthritis. In both procedures the arthritic ball (humeral head) is replaced with a smooth metal ball (humeral head) attached to a stem that is fitted down the inside of the arm bone (shown below).




The difference in the two procedures is the way in which the glenoid socket side of the joint is managed.

In a total shoulder, the surface of the glenoid bone is covered with a plastic implant that fits the metal humeral head component and that is fixed to the bone beneath it by fluted pegs and a small amount of bone cement. This immediately gives the humeral head a smooth surface to move on – no healing of the surface is required. While range of motion exercises are necessary to achieve and maintain the shoulder’s range of motion, these exercises are not needed to shape the socket. After this procedure it is recommended that the patient avoid impact loading (e.g. chopping wood) and weight workouts (e.g. bench press) to minimize the risk of wear and loosening of the plastic glenoid component.





In the ream and run, the bone of the glenoid socket is reamed to a concavity that fits the metal humeral head component.


Persistent five times daily stretching exercises are necessary to stimulate the reamed surface (below left) to heal over with a layer of fibrocartilage (below right).


At the time of surgery, we assure that the shoulder is stable and capable of an excellent range of motion. However, each person’s healing response is different - some shoulders want to tighten up due to their body's vigorous healing response. As a result the amount of time required for healing varies, but seems to be largely dependent on the daily dedication of the patient to the simple, but critical exercise program. The most successful patients keep a calendar and check off each of their five daily exercise sessions – bringing the calendar to the office for their follow-up visit.




In many cases this healing process is well under way by 6 months after surgery, but in some cases it can take a year or longer. For some individuals these exercises seem easy, while others find them uncomfortable and at times frustrating. The key is to achieve over 150 degrees of elevation of the arm by 6 weeks after surgery and to maintain it. If this goal is not achieved by six weeks, we recommend an outpatient manipulation of the shoulder under anesthesia and muscle relaxation. When rehabilitation is complete, the patient can progressively return to use of the arm as the comfort of the shoulder allows. In this procedure there is not a need for limiting activity to minimize the risk of failure of a plastic implant. In some instances the pain relief with the ream and run is not as complete as with a total shoulder, however in many cases the pain relief is excellent.

Both the total shoulder and the ream and run procedures carry a small, but definite risk of infection from the bacteria that grow on the patient's skin. This risk is higher in male patients and in those shoulders having had prior surgical procedures.

The average patient with shoulder arthritis prefers a total shoulder because for most individuals it gives the best and most rapid relief of pain without a very demanding rehabilitation program. Individuals having this procedure can often return to swimming and golf.  The ream and run is attractive to those individuals who want to return to high levels of activity involving impact and major loads without having to be concerned about wear or loosening of the plastic glenoid socket. While it is a real joy to see patients achieve high levels of function after the ream and run, it is saddening to see some patients struggling with their exercise program. Thus, if the patient is unsure about their ability to stay motivated and dedicated to the rehabilitation program, we counsel the patient to have a total shoulder. The question comes down to how much the patient is willing to dedicate to a possibly difficult, five times daily rehabilitation exercises in exchange for avoiding the potential limitations in activity needed to protect the plastic socket. Often we get a question like "I desire to restore a more normal movement of my shoulder, reduce or eliminate pain and be able to keep riding my off-road motorcycles through the many trails in the Southeast US.   Could the R&R procedure accomplish these goals for me?" The answer is, "no' the ream and run cannot accomplish these goals by itself, but a solid rehabilitation effort after a ream and run procedure can often lead to great shoulder function and improved comfort. In considering this procedure, be sure to read the posts entitled "ream and run: rehabilitation tips from the superstars" to get an idea of the level of commitment.

jueves, 12 de marzo de 2015

La colocación inferior de la Glenosfera reduce las muescas en la escapula en la artroplastia total reversa del hombro / Inferior Glenosphere Placement Reduces Scapular Notching in Reverse Total Shoulder Arthroplasty

Fuente
Este artículo es originalmente publicado en:
http://www.ncbi.nlm.nih.gov/pubmed/25665124
http://www.healio.com/orthopedics/journals/ortho/2015-2-38-2/%7Bd251930a-1fb2-472e-b29e-1ad11102467a%7D/inferior-glenosphere-placement-reduces-scapular-notching-in-reverse-total-shoulder-arthroplasty
De:
Li XDines JSWarren RFCraig EVDines DM.
 2015 Feb 1;38(2):e88-93. doi: 10.3928/01477447-20150204-54.
Todos los derechos reservados para:
Copyright 2015, SLACK Incorporated.


Abstract


Scapular notching is a common complication after reverse shoulder arthroplasty and has been associated with poor clinical outcomes. Factors associated with notching include neck shaft angle and glenosphere position. The goal of this study was to evaluate the incidence of notching with an eccentric glenosphere that allows for inferior offset as well as its effect on clinical outcome. The charts of 82 patients who underwent reverse shoulder arthroplasty with this eccentric glenosphere were retrospectively reviewed. Scapular notching was assessed with standard anteroposterior radiographs of the glenohumeral joint according to the Nerot-Sirveaux classification system. Two experienced observers evaluated all radiographs. The presence of radiolucent lines was also evaluated. Both range of motion (ROM) and Constant-Murley scores were obtained. Average age was 74 years (range, 61-91 years), and follow-up was 26.3 months (range, 19-39 months). According to the Nerot-Sirveaux classification, 73 (89%) had no notching, 5 (6%) had grade I notching, 2 (2.5%) had grade II notching, and 2 (2.5%) had grade III notching. The overall presence of notching was 11% and correlated to the amount of inferior offset. No radiolucent lines were seen around the prosthesis. Both ROM and Constant-Murley scores (from 31.3 to 74.2) improved significantly in all patients from preoperative evaluation to final follow-up (P<.05). No significant differences in ROM and functional outcome were seen between the groups with and without notching. The inferior offset glenosphere created with this glenosphere base plate design reduced the incidence of scapular notching in reverse shoulder arthroplasty. This was particularly true when the glenosphere was maximally offset inferiorly. In the short term, notching does not affect ROM or functional outcome.

Resumen
Las muescas en la es una complicación común después de la artroplastia de hombro invertida y se ha asociado con pobres resultados clínicos. Los factores asociados con muescas incluyen ángulo del eje del cuello y la posición glenosfera. El objetivo de este estudio fue evaluar la incidencia de las muescas con una glenosfera excéntrica que permite un desplazamiento inferior , así como su efecto en el resultado clínico. Los gráficos de 82 pacientes que se sometieron a la artroplastia de hombro invertida con esta glenosfera excéntrica se revisaron retrospectivamente. Las muescas de la escapula se evaluaron con las radiografía anteroposterior estándar de la articulación glenohumeral según el sistema de clasificación Nerot-Sirveaux. Dos observadores experimentados evaluaron todas las radiografías. También se evaluó la presencia de líneas radiolúcidas. Se obtuvieron Tanto la amplitud de movimiento (ROM) y puntuaciones de Constant-Murley. El promedio de edad fue de 74 años (rango, 61-91 años), y el seguimiento fue de 26,3 meses (rango, 19-39 meses). Según la clasificación Nerot-Sirveaux, 73 (89%) no tenían entallar, 5 (6%) tenían muecas grado I , 2 (2,5%) tuvieron muescas grado II, y 2 (2,5%) tenían 
muescas grado III . La presencia global de muescas era 11% y correlaciona con la cantidad de desplazamiento inferior. No hay líneas radiolúcidas fueron vistos alrededor de la prótesis. Tanto ROM y puntuaciones Constant-Murley (31,3-74,2) mejoraron significativamente en todos los pacientes de la evaluación preoperatoria para el seguimiento final (P <0,05). No hay diferencias significativas en la ROM y el resultado funcional se observaron entre los grupos con y sin muescas. El desplazamiento inferior glenosfera creado con este diseño de placa base glenosfera redujo la incidencia de muescas en la escapula en la artroplastia de hombro invertida. Esto fue particularmente cierto cuando la glenosfera fue compensado al máximo inferior. En el corto plazo, las muescas no afecta ROM o el resultado funcional..[Orthopedics. 2015; 38(2):e88-e93.].
Copyright 2015, SLACK Incorporated.
PMID:
 
25665124
 
[PubMed - in process]

miércoles, 11 de marzo de 2015

El trasplante de un aloinjerto osteocondral de tibia para restaurar un gran defecto osteocondral glenoideo / Transplantation of a tibial osteochondral allograft to restore a large glenoid osteochondral defect

Fuente
Este artículo es originalmente publicado en:
http://www.ncbi.nlm.nih.gov/pubmed/25665122
http://www.healio.com/orthopedics/journals/ortho/2015-2-38-2/%7B70bf6345-5043-4fae-a003-b62a49cc4348%7D/transplantation-of-a-tibial-osteochondral-allograft-to-restore-a-large-glenoid-osteochondral-defect#?ecp=318F9B42-3E81-E311-ADF0-A4BADB296AA8
De:
Camp CLBarlow JDKrych AJ.
 2015 Feb 1;38(2):e147-52. doi: 10.3928/01477447-20150204-92.
Todos los derechos reservados para:
Copyright 2015, SLACK Incorporated.


Abstract


Osteochondral disease of the glenoid is a well-known cause of shoulder pain and disability in young and active patients. The etiology can be multifactorial, and disease severity can exist across a wide spectrum. Symptoms can often interfere with athletic performance, job responsibilities, and activities of daily living. Although a number of cartilage restoration techniques exist for other joints, such as the hip, knee, ankle, and elbow, restorative options for glenoid osteochondral defects are currently limited. Given the success of osteochondral allograft transplantation in other joints, the authors hypothesized that osteochondral allograft transplantation may be a reasonable option in treating osteochondral disease of the glenoid if a suitable donor source could be identified. After performing the procedure in a cadaveric model, the authors found the articular geometry of the medial tibial plateau to closely resemble that of the glenoid articular surface. This graft option is advantageous because it is readily accessible from allograft tissue banks, whereas glenoid allografts are not currently available. After failure of extensive nonoperative treatment, a former multisport athlete underwent osteochondral allograft transplantation of a large glenoid defect with a medial tibial plateau osteochondral allograft. After 1 year of follow-up, the patient showed significant improvement in the subjective shoulder value (from 40% to 99%), QuickDASH score (from 36 to 2), and American Shoulder and Elbow Score (from 46 to 92). Ultimately, medial tibial plateau allograft was a viable option for treatment of an osteochondral glenoid defect in this patient, and additional study of this treatment strategy is warranted. [Orthopedics. 2015; 38(2):e147-e152.].



Resumen
La enfermedad osteocondral del glenoideo es una causa bien conocida de dolor en el hombro y la discapacidad en pacientes jóvenes y activos. La etiología puede ser multifactorial, y la gravedad de la enfermedad puede existir en un amplio espectro. Los síntomas a menudo pueden interferir con el rendimiento deportivo, las responsabilidades del trabajo y las actividades de la vida diaria. Aunque una serie de técnicas de restauración del cartílago existe para otras articulaciones, como la cadera, rodilla, tobillo y codo, opciones de reparación de los defectos osteocondrales glenoideos actualmente son limitados. Dado el éxito del trasplante de aloinjerto osteocondral en otras articulaciones, los autores plantearon la hipótesis de que el trasplante de aloinjerto osteocondral puede ser una opción razonable en el tratamiento de la enfermedad osteocondral del glenoideo si una fuente donante adecuada se puede identificar. Después de realizar el procedimiento en un modelo de cadáver, los autores encontraron la geometría articular de la meseta tibial medial a parecerse mucho a la de la superficie articular glenoidea. Esta opción injerto es ventajoso debido a que es fácilmente accesible desde los bancos de tejidos de aloinjerto, mientras que los aloinjertos glenoideos no están disponibles actualmente. Después del fracaso de un extenso tratamiento conservador,  el ex atleta multideporte sometió aloinjerto osteocondral trasplante de un gran defecto glenoideo con un 
aloinjerto osteocondral de meseta tibial medial. Después de 1 año de seguimiento, el paciente mostró una mejoría significativa en el valor hombro subjetiva (de 40% a 99%), la puntuación QuickDASH (36-2), y American Hombro y Codo Score (del 46 a 92). En última instancia, el aloinjerto de meseta tibial medial era una opción viable para el tratamiento de un defecto osteocondral glenoideo en este paciente, y el estudio adicional de esta estrategia de tratamiento se justifica.
Copyright 2015, SLACK Incorporated.
PMID:
 
25665122
 
[PubMed - in process]

viernes, 6 de marzo de 2015

Heterotopic ossification after surgery for distal humeral fractures.

Fuente
Este artículo es originalmente publicado en:
De:
Foruria AM1, Lawrence TM2, Augustin S3, Morrey BF4, Sanchez-Sotelo J4.
Bone Joint J. 2014 Dec;96-B(12):1681-7. doi: 10.1302/0301-620X.96B12.34091.
Todos los derechos reservados para:
Copyright © 2015 THE BRITISH EDITORIAL SOCIETY OF BONE & JOINT SURGERY All Rights Reserved.

Abstract
We retrospectively reviewed 89 consecutive patients (45 men and 44 women) with a mean age at the time of injury of 58 years (18 to 97) who had undergone external fixation after sustaining a unilateral fracture of the distal humerus. Our objectives were to determine the incidence of heterotopic ossification (HO); identify risk factors associated with the development of HO; and characterise the location, severity and resultant functional impairment attributable to the presence of HO. HO was identified in 37 elbows (42%), mostly around the humerus and along the course of the medial collateral ligament. HO was hazy immature in five elbows (13.5%), mature discrete in 20 (54%), extensive mature in 10 (27%), and complete bone bridges were present in two elbows (5.5%). Mild functional impairment occurred in eight patients, moderate in 27 and severe in two. HO was associated with less extension (p = 0.032) and less overall flexion-to-extension movement (p = 0.022); the flexion-to-extension arc was < 100º in 21 elbows (57%) with HO compared with 18 elbows (35%) without HO (p = 0.03). HO was removed surgically in seven elbows. The development of HO was significantly associated with sustaining a head injury (p = 0.015), delayed internal fixation (p = 0.027), the method of fracture fixation (p = 0.039) and the use of bone graft or substitute (p = 0.02).HO continues to be a substantial complication after internal fixation for distal humerus fractures.

Resumen
Se revisaron retrospectivamente 89 pacientes consecutivos (45 hombres y 44 mujeres) con una edad media en el momento de la lesión de 58 años (18 a 97) que habían sido sometidos a fijación externa después de sufrir una fractura unilateral del húmero distal. Nuestros objetivos fueron determinar la incidencia de osificación heterotópica (HO); identificar los factores de riesgo asociados con el desarrollo de HO; y caracterizar la ubicación, la gravedad y el resultado del deterioro funcional atribuible a la presencia de HO. HO fue identificado en 37 codos (42%), sobre todo alrededor de húmero y a lo largo del curso del ligamento colateral medial. HO era inmaduro nebuloso en cinco codos (13,5%), discreta madura en 20 (54%), extensa madura en 10 (27%), y los puentes óseos completos estuvieron presentes en dos codos (5,5%). Deterioro funcional moderada ocurrió en ocho pacientes, moderada en 27 y severa en dos. HO se asoció con menor extensión (p = 0,032) y menos movimiento global-flexión-extensión de (p = 0,022); el arco de flexión-extensión a era <100º en 21 codos (57%) con HO en comparación con 18 codos (35%) sin HO (p = 0,03). HO fue removido quirúrgicamente en siete codos. El desarrollo de HO se asoció significativamente con el mantenimiento de una lesión en la cabeza (p = 0,015), el retraso en la fijación interna (p = 0,027), el método de fijación de la fractura (p = 0,039) y el uso de injerto de hueso o sustituto (p = 0,02) .HO sigue siendo una complicación importante después de la fijación interna de las fracturas de húmero distal.
©2014 The British Editorial Society of Bone & Joint Surgery.
KEYWORDS:
Distal humerus fracture; Ectopic bone; HO; Heterotopic ossification

PMID: 25452373 [PubMed - indexed for MEDLINE]