Hombro/Shoulder. Despegar y osteotomizar el troquín no parecen diferenciarse

Healing rates and subscapularis fatty infiltration after lesser tuberosity osteotomy versus subscapularis peel for exposure during shoulder arthroplasty. Randomized controlled trial

Lapner PL, Sabri E, Rakhra K, Bell K, Athwal GS.

J Shoulder Elbow Surg. 2013 Mar;22(3):396-402. doi: 10.1016/j.jse.2012.05.031. Epub 2012 Sep 1.

Abstract

BACKGROUND: Controversy exists regarding the optimal technique of subscapularis mobilization during shoulder arthroplasty. The purpose of this study was to compare healing rates and subscapularis fatty infiltration in patients undergoing a lesser tuberosity osteotomy (LTO) versus subscapularis peel for exposure during shoulder arthroplasty.

MATERIALS AND METHODS: Eighty-seven patients, with a mean age of 67.8 ± 10.9 years, undergoing shoulder arthroplasty, were randomized to receive either an LTO (n = 43) or peel (n = 44). Computed tomography scans were conducted preoperatively and at 12 months postoperatively. Outcome variables included healing rates and subscapularis Goutallier fatty infiltration grade, as well as subscapularis strength and Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons outcome scores.

RESULTS: Computed tomography imaging was available in 91% (n = 79) of the cohort. The healing rates for the peel (100%) and for the LTO (95%) did not differ significantly (P = .493). Preoperatively, the mean fatty infiltration grade for the peel (mean, 0.53) was not significantly different (P = .925) from the LTO (mean, 0.54). Postoperatively, the Goutallier mean fatty infiltration grade for the peel (mean, 0.95) did not differ significantly (P = .803) from the LTO (mean, 0.9). A significant increase in subscapularis fatty infiltration grade occurred postoperatively from the preoperative status (peel, P = .003; LTO, P = .0002). No statistically significant associations were observed between postoperative fatty infiltration grades and subscapularis strength, Western Ontario Osteoarthritis of the Shoulder Index scores, or American Shoulder and Elbow Surgeons scores.

DISCUSSION: No statistically significant differences were observed in the healing rates or subscapularis fatty infiltration grades between the peel and the LTO. This trial does not show any clear difference in radiologic and clinical outcomes of one subscapularis management technique over the other.

Level II, Randomized Controlled Trial, Treatment Study

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Tasas de cicatrización e infiltración grasa subescapular tras la osteotomía del troquín frente al desprendimiento del tendón subescapular para la exposición durante la artroplastia de hombro.

Ensayo controlado aleatorio

Resumen 

ANTECEDENTES: Existe controversia sobre la técnica óptima de movilización del subscapular durante la artroplastia del hombro. El propósito de este estudio fue comparar las tasas de cicatrización y la infiltración grasa subescapular en pacientes sometidos a una osteotomía del troquín (OT) frente al desprendimiento del tendón del subescapular para la exposición quirúrgic durante la artroplastia del hombro.

MATERIAL Y MÉTODOS: Se asignaron al azar a ochenta y siete pacientes, con una edad media de 67,8 ± 10,9 años, sometidos a artroplastia de hombro para realizar OT (n = 43) o desprendimiento (n = 44). Se realizaron tomografías computarizadas preoperatoriamente y a los 12 meses postoperatorios. Las variables de resultado incluyeron las tasas de cicatrización y el grado de infiltración grasa de Goutallier en el músculo subescapular, así como la fuerza del subescapular y las puntuaciones de la "Western Ontario Osteoarthritis of the Shoulder Index" y la "American Shoulder and Elbow Surgeons".

RESULTADOS: La tomografía computarizada estuvo disponible en el 91% (n = 79) de la cohorte. Las tasas de curación para el desprendimiento tendinoso (100%) y para el OT (95%) no difirió significativamente (P = .493). Preoperatoriamente, la media de grado de infiltración grasa de la infiltración (media, 0,53) no fue significativamente diferente (P = 0,925) de la OT (media, 0,54). Postoperatoriamente, el grado medio de infiltración grasa de Goutallier para el desprendimiento (media, 0,95) no difirió significativamente (P = 0,803) de la OT (media, 0,9). Un aumento significativo en el grado de infiltración grasa subescapular se produjo en el postoperatorio desde el preoperatorio (desprendimiento, P = 0,003; OT, P = .0002). No se observaron asociaciones estadísticamente significativas entre los grados de infiltración grasa postoperatoria y la fuerza del subescapular o las puntuaciones de la "Western Ontario Osteoarthritis of the Shoulder Index" y la "American Shoulder and Elbow Surgeons".

DISCUSIÓN: No se observaron diferencias estadísticamente significativas en las tasas de cicatrización o grados de infiltración grasa subescapular entre el desprendimiento del tendón y la OT. Este ensayo no muestra ninguna diferencia clara en los resultados radiológicos y clínicos de una técnica de tratamiento del subescapular sobre la otra.

Hombro / Shoulder: Mejores resultados si pones muchas prótesis de hombro ¡claro!

The effect of surgeon and hospital volume on shoulder arthroplasty perioperative quality metrics.

Singh A, Yian EH, Dillon MT, Takayanagi M, Burke MF, Navarro RA

J Shoulder Elbow Surg 2014 Feb 3

Abstract

BACKGROUND

There has been a significant increase in both the incidence of shoulder arthroplasty and the number of surgeons performing these procedures. Literature regarding the relationship between surgeon or hospital volume and the performance of modern shoulder arthroplasty is limited. This study examines the effect of surgeon or hospital shoulder arthroplasty volume on perioperative metrics related to shoulder hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty. Blood loss, length of stay, and operative time were the main endpoints analyzed.

METHODS

Prospective data were analyzed from a multicenter shoulder arthroplasty registry; 1176 primary shoulder arthroplasty cases were analyzed. Correlation and analysis of covariance were used to examine the association between surgeon and hospital volume and perioperative metrics adjusting for age, sex, and body mass index.

RESULTS

Surgeon volume is inversely correlated with length of stay for hemiarthroplasty and total shoulder arthroplasty and with blood loss and operative time for all 3 procedures. Hospital volume is inversely correlated with length of stay for hemiarthroplasty, with blood loss for total and reverse shoulder arthroplasty, and with operative time for all 3 procedures. High-volume surgeons performed shoulder arthroplasty 30 to 50 minutes faster than low-volume surgeons did.

CONCLUSIONS

Higher surgeon and hospital case volumes led to improved perioperative metrics with all shoulder arthroplasty procedures, including reverse total shoulder arthroplasty, which has not been previously described in the literature. Surgeon volume had a larger effect on metrics than hospital volume did. This study supports the concept that complex shoulder procedures are, on average, performed more efficiently by higher volume surgeons in higher volume centers.