Painful Shoulder Arthroplasty Research Articles

A narrative review of non-infected painful total shoulder arthroplasty: evaluation and treatment.

The prevalence of shoulder arthroplasty has increased significantly over the past two decades outpacing both total hip and total knee arthroplasty. Total shoulder arthroplasty (TSA) has been shown to significantly improve function and pain in most patients, however, complications after shoulder arthroplasty have been reported to be greater than 10% in anatomic shoulder arthroplasty and 10-47% in reverse shoulder arthroplasty leading to a painful shoulder. As the number of performedprimary shoulder arthroplasty increases, the incidence of painful total shoulders and the need for revision shoulder arthroplasty will see a similar trend. Management of post-operative shoulder arthroplasty pain and complications will be even more essential for the orthopedic surgeon in this growing population. Potential sources of pain after shoulder arthroplasty are variable and include infection, implant related complications, hematoma, nerve injury, rotator cuff failure, instability, fracture, among other less prevalent complications. Treatment options for the painful shoulder arthroplasty differ depending on the source of pain, thus early identification of the cause will lead to expedited and appropriate definitive management. The objectives of this narrative review are to highlight the common causes of pain after TSA, provide surgeons an algorithmic approach for working up the painful total shoulder, and discuss treatment options for each source of pain. A database search of PubMed and Google Scholar was conducted including studies relating to painful shoulder arthroplasty evaluation, management, and treatment. This review presents an in-depth evaluation to the non-infected, painful shoulder arthroplasty, providing treatment options for each source with the goal of assisting practicing physicians in the management of painful post-operative shoulder arthroplasty. With increasing numbers of TSA being performed, a thorough understanding of the potential complications and their treatments is essential. A systematic approach to working up the painful TSA can help identify the source of symptoms more readily. Knowledge of the common complications and their specific causes can help surgeons avoid the painful TSA. This knowledge will also help to successfully treat the painful TSA when it is inevitably encountered.

Functional splenic in vitro glucocorticoid resistance following 19-days of chronic subordinate colony housing (CSC) critically depends on the presence of neutrophils

The purposes of this study were (1) to compare the preoperative complete blood count (with differential), c-reactive protein (cRP), erythrocyte sedimentation rate (ESR), and intraoperative pathology (frozen section) results of patients undergoing surgical treatment for shoulder PJI by C. acnes vs. non-C. acnes bacteria, and (2) to estimate sensitivity, specificity, and positive and negative predictive values of these parameters.Between 2004 and 2016, 167 consecutive shoulder PJIs were treated surgically. Infected implants included hemiarthroplasty in 39, anatomic TSA in 92, and reverse TSA in 36 shoulders. Shoulders were categorized in one of 4 groups: irrigation and débridement (21), one stage reimplantation (14), two-stage reimplantation (124), and permanent resection (8). Medical records were reviewed to record microorganisms isolated, intraoperative pathology, and preoperative cell count, ESR, and c-RP. Shoulders were further grouped into those that were positive only for C. acnes (37 shoulders) and those that were positive for any other microorganism (130 shoulders). In order to calculate sensitivity, specificity, and predictive values, the same data was collected for a separate group of 700 shoulder arthroplasties that underwent revision surgery for noninfectious reasons during the same time period.For the whole group of 167 infected shoulder arthroplasties, values were considered abnormal for leukocyte count in 15%, neutrophil count in 17%, ESR in 42%, cRP in 56% and pathology in 55%. Abnormal values were more common in the non-C. acnes group. The following positive predictive values were obtained: Leukocytes 47% (13% C. acnes, 43% other), ESR 65% (18% C. acnes, 62% other), cRP 70% (29% C. acnes, 66% other), and pathology 73% (30% C. acnes, 63% other). The following negative predictive values were obtained: Leukocytes 79% (94% C. acnes, 93% other), ESR 68% (86% C. acnes, 76% other), cRP 70% (88% C. acnes, 78% other), and pathology 87% (96% C. acnes, 91% other).Bacteria other than C. acnes were responsible for 75% of the shoulder PJI treated consecutively with surgery at a single institution over a 12-year period. Negative predictive values for cell count, ESR, cRP, and pathology ranged between 70% and 81%, but there were much lower for C. acnes infection. Obtaining these tests in the evaluation of a painful shoulder arthroplasty should not be discontinued, since their positive predictive value for non-C. acnes infections seem reasonable and their negative predictive value is high.Level III; Retrospective Comparative Study

Peripheral blood markers and intraoperative pathology may be helpful in predicting non-Cutibacterium acnes shoulder periprosthetic joint infections

IntroductionThe purposes of this study were (1) to compare the preoperative complete blood count (with differential), c-reactive protein (cRP), erythrocyte sedimentation rate (ESR), and intraoperative pathology (frozen section) results of patients undergoing surgical treatment for shoulder PJI by C. acnes vs. non-C. acnes bacteria, and (2) to estimate sensitivity, specificity, and positive and negative predictive values of these parameters. MethodsBetween 2004 and 2016, 167 consecutive shoulder PJIs were treated surgically. Infected implants included hemiarthroplasty in 39, anatomic TSA in 92, and reverse TSA in 36 shoulders. Shoulders were categorized in one of 4 groups: irrigation and débridement (21), one stage reimplantation (14), two-stage reimplantation (124), and permanent resection (8). Medical records were reviewed to record microorganisms isolated, intraoperative pathology, and preoperative cell count, ESR, and c-RP. Shoulders were further grouped into those that were positive only for C. acnes (37 shoulders) and those that were positive for any other microorganism (130 shoulders). In order to calculate sensitivity, specificity, and predictive values, the same data was collected for a separate group of 700 shoulder arthroplasties that underwent revision surgery for noninfectious reasons during the same time period. ResultsFor the whole group of 167 infected shoulder arthroplasties, values were considered abnormal for leukocyte count in 15%, neutrophil count in 17%, ESR in 42%, cRP in 56% and pathology in 55%. Abnormal values were more common in the non-C. acnes group. The following positive predictive values were obtained: Leukocytes 47% (13% C. acnes, 43% other), ESR 65% (18% C. acnes, 62% other), cRP 70% (29% C. acnes, 66% other), and pathology 73% (30% C. acnes, 63% other). The following negative predictive values were obtained: Leukocytes 79% (94% C. acnes, 93% other), ESR 68% (86% C. acnes, 76% other), cRP 70% (88% C. acnes, 78% other), and pathology 87% (96% C. acnes, 91% other). ConclusionBacteria other than C. acnes were responsible for 75% of the shoulder PJI treated consecutively with surgery at a single institution over a 12-year period. Negative predictive values for cell count, ESR, cRP, and pathology ranged between 70% and 81%, but there were much lower for C. acnes infection. Obtaining these tests in the evaluation of a painful shoulder arthroplasty should not be discontinued, since their positive predictive value for non-C. acnes infections seem reasonable and their negative predictive value is high. Level of evidenceLevel III; Retrospective Comparative Study

Diagnostic Accuracy of Synovial Neopterin, TNF-α and Presepsin in Periprosthetic Joint Infection: A Prospective Study.

Due to the lack of specificity of conventional diagnostic tools, the prediction of periprosthetic joint infections (PJI) remains challenging. The purpose of this study was to evaluate the accuracy of synovial fluid neopterin, presepsin, and TNF-α as diagnostic parameters and to compare it to the biomarkers recommended in the 2018 definition of periprosthetic hip and knee infection. Between August 2018 and July 2019, a prospective cohort study was conducted in 80 patients with painful hip, shoulder, and knee arthroplasty. In addition to medical history, clinical and laboratory data were gathered. PJI was diagnosed based on the 2018 definition of periprosthetic hip and knee infection. Synovial joint fluid was analyzed for biomarker measurement using standard quantitative enzyme immunoassay kits. Fifty-three patients (66%) were classified as the aseptic group and twenty-seven patients (34%) as the PJI group. The mean levels of synovial fluid neopterin were significantly higher (p < 0.01) in the PJI group than those in the aseptic group (aseptic 8.3 ± 6.9 vs. PJI 20.9 ± 21.4 nmol/L). The average values of synovial fluid TNF-α and presepsin were not significantly higher in the PJI group than those in the aseptic group (presepsin: aseptic 0.13 ± 0.19 vs. PJI 0.11 ± 0.32 ng/mL, p = 0.08; TNF-α: aseptic 6.6 ± 7.3 vs. PJI 46.3 ± 123.2 pg/mL, p = 0.17). Synovial fluid neopterin was 59% specific and 74% sensitive with a cut-off value of 7.2 nmol/L. The sensitivity and specificity of synovial fluid TNF-α were 63 and 51% with a cut-off value of 3.9 pg/mL. Synovial fluid presepsin was 51% specific and 29% sensitive with a cut-off value above 0.06 ng/mL. Synovial fluid neopterin appears to a reliable diagnostic marker for detection of PJI. In contrast, synovial fluid TNF-α and presepsin are not suitable to exclude or diagnose PJI.

Management of Painful Shoulder Arthroplasty: A Narrative Review.

Despite the recent advances in surgical techniques, the percentage of painful shoulder arthroplasties is still high (more than 10%). The causes of residual pain after shoulder arthroplasty, and the resulting treatment solutions, are many and different. The most common complications of shoulder prosthesis are infections, aseptic loosening, modular components disassembling, metal hypersensitivity, and instability. There are also implant-related complications such as glenoid wear in hemiarthroplasty, rotator cuff tear in anatomical total shoulder arthroplasty, scapular notching, and acromion fracture in reverse shoulder arthroplasty. Several of these complications can be avoided with a careful selection of the implants, a proper surgical technique and a precise implant positioning. The execution of a more accurate preoperative planning and the possible use of patient-specific implants are expected to translate into better clinical results in the future. We provide the reader with recent evidence on the causes and therapeutic options of this condition.

Is Procalcitonin (PCT) a reliable biomarker for preoperative diagnosing of low grade periprosthetic joint infection? A prospective study

BackgroundSince a “gold-standard” is missing, diagnosing periprosthetic joint infection (PJI) remains a challenge in orthopedic surgery. The purpose of this study was to evaluate the accuracy of serum and synovial fluid Procalcitonin (S-PCT and SF-PCT) as a diagnostic parameter and to compare it to the biomarkers recommended in the 2018 Definition of periprosthetic hip and knee infection.MethodsBetween August 2018 and July 2019, a prospective cohort study was conducted in 70 patients with painful hip, shoulder and knee arthroplasty. Besides medical history, clinical and laboratory data was gathered. PJI was diagnosed based on the 2018 Definition of periprosthetic hip and knee infection. Preoperative blood and synovial joint fluid were taken for PCT measurement. S-PCT and SF-PCT levels were measured using standard quantitative PCT enzyme immunoassays.ResultsTwenty three patients (33%) were classified as the PJI group and fourty seven patient (67%) as the aseptic group. The mean levels of S-PCT were significantly (p < 0.001) higher in the PJI group than those in the aseptic group (PJI 0.05 ± 0.21 ng/mL (0.0–1.03) vs. aseptic 0.02 ± 0.03 ng/mL (0.0–0.18)). In synovial fluid, the mean PCT values in the aseptic group were significantly higher (p < 0.001) than those of PJI group (PJI 2.7 ± 1.4 ng/mL (0.53–9.7) vs. aseptic 8.7 ± 2.5 ng/mL (0.25–87.9)). S- PCT, with a cut-off level of 0.5 ng/mL, had a sensitivity of 13.0% and a specificity of 91.0%.SF-PCT, with a cut-off level of 5.0 ng/mL, had a sensitivity of 13.0% and a specificity of 52.0%.ConclusionS-PCT and SF-PCT appeared to be no reliable biomarkers in the differential diagnosis of PJI from aseptic loosening in total joint arthroplasty.

Alpha-defensin lateral flow test does not appear to be useful in predicting shoulder periprosthetic joint infections.

Periprosthetic joint infections (PJIs) remain a challenging complication after shoulder arthroplasty. The antimicrobial peptide α-defensin has been proposed as a new synovial fluid biomarker in diagnosing PJIs. To date, only little data are available on the diagnostic accuracy of α-defensin in shoulder PJIs; thus, we aimed to evaluate its diagnostic value in a cohort of patients with a suspected shoulder PJI. Between June 2016 and June 2018, we prospectively enrolled patients with a diagnostic shoulder aspiration due to painful shoulder arthroplasty or planned revision surgery. PJI diagnostics were performed according to the Musculoskeletal Infection Society (MSIS) criteria. All patients with an antibiotic therapy within twoweeks before enrollment, insufficient amount of synovial aspirate, or bloody aspiration were excluded. α-Defensin was measured in the synovial fluid using the α-defensin lateral flow (ADLF) test (Synovasure®). Out of 60 patients, we could include 29 (59% female) patients with a mean age of 70 (range, 50-92)years. A shoulder PJI was detected in five cases (Staphylococcus aureus, n= 2; Staphylococcus epidermidis, n= 2; Cutibacterium acnes, n= 1). The ADLF test was positive in seven out of 29 cases. According to the MSIS criteria, the ADLF test was false-negative in two patients and false-positive in four patients, resulting in sensitivity, specificity, and positive and negative predictive value of 60%, 83%, 43%, and 91%, respectively. The overall accuracy was 79%. The ALDF test does not appear to be useful in predicting shoulder PJIs but may be used as an additional diagnostic factor in rejecting these infections.

The Role of Arthroscopy in Painful Shoulder Arthroplasty: Is Revision Always Necessary?

To determine whether arthroscopy is an effective means to diagnose and treat postoperative pain in anatomic total shoulder arthroplasty (TSA) and reverse TSA patients. A 2-year retrospective chart review of patients with a painful shoulder arthroplasty was performed. Patients included in the study had a painful shoulder after previous shoulder arthroplasty without gross signs of infection, severely elevated laboratory markers, implant loosening, or glenoid arthrosis after hemiarthroplasty. Visual analog scale scores, physical examination findings, laboratory studies, culture results, pathology reports, operative records, and postoperative treatment data were collected. The study cohort included 6 male and 7 female patients. Between 2016 and 2018, 7 TSA and 6 reverse TSA patients underwent arthroscopic debridement of adhesions and synovitis with tissue biopsy for cultures and fresh-frozen sections. We arthroscopically treated adhesive capsulitis, subacromial impingement, and acromioclavicular joint arthritis in 3 patients. Three patients required extensive debridement for profound synovitis. All 6 patients had negative findings of cultures and frozen sections, and none required revision arthroplasty. Their average follow-up period was 18.6 months (range, 9-32 months), with improvement in the mean visual analog scale score from 8.2 of 10 (range, 6-10) to 2.5 of 10 (range, 2-8). Two patients had arthroscopic cultures showing Cutibacterium acnes infection. Both required revision with an antibiotic spacer. Findings of cultures and fresh-frozen sections at revision were consistent with arthroscopic findings. Arthroscopic evaluation in 5 additional patients identified mechanical implant failure or a rotator cuff tear. Arthroscopy is a viable option to evaluate and treat painful shoulder arthroplasty. We were able to successfully treat 46% of patients (6 of 13) with arthroscopic procedures, preventing the need for revision arthroplasty. Arthroscopic frozen section and culture results had a 100% correlation with open frozen section and culture results in patients who had cultures obtained. Level IV, case series.

Diagnostic Arthroscopy for Detection of Periprosthetic Infection in Painful Shoulder Arthroplasty

To analyze the utility of arthroscopic biopsies for detection of periprosthetic infection in painful shoulder arthroplasty without objective signs of infection. A retrospective analysis of all patients who underwent a diagnostic arthroscopy for painful shoulder arthroplasty from June 2012 through July 2018 was performed. Patients with a subsequent revision shoulder arthroplasty after diagnostic arthroscopy were included. Arthroscopic tissue culture results were compared with the culture results of intraoperative tissue samples obtained at the time of open revision surgery. Aminimum of 3 tissue samples from synovia and bone-prosthesis interface with signs of synovitis or abnormal appearance was routinely collected. Cases with 2 or more positive cultures for the same microorganism obtained at open revision surgery were considered as true presence of infection. The study protocol was reviewed and approved by the institutional ethics committee. Twenty-three cases in 22 patients were included in this study. Five of these 23 cases were classified as true infection based on the samples obtained during open revision surgery, and 16 cases had a positive culture in diagnostic arthroscopy. Cutibacterium acnes was isolated in each case. Classifying any microbiologic growth in the arthroscopic biopsies as positive resulted in a sensitivity and negative predictive value of 100%, specificity of 39%, and positive predictive value of 31.3% for the detection of a periprosthetic shoulder infection (PPSI). If at least 2 positive samples with the same microbiologic growth in the arthroscopic biopsies were considered as positive, sensitivity and negative predictive value dropped to 80% and 94.4%, respectively, but the specificity and positive predictive value increased to 94.4% and 80%, respectively. Diagnostic arthroscopy is a useful diagnostic tool in patients with suspicion but no clear evidence of PPSI. Arthroscopically obtained tissue biopsies for culture offer a high sensitivity and specificity in the diagnosis of PPSI if at least 2 cultures positive for the same microorganism are considered as infection. Level III.

Arthroscopy of the symptomatic shoulder arthroplasty

Assessment of a painful or stiff shoulder arthroplasty can be challenging. The cause of pain can sometimes be easily identified. However, some patients have normal levels of inflammatory markers, normal plain films, and no clinical signs to indicate a diagnosis. Indolent organisms may not raise blood marker levels or result in obvious radiologicfindings such as loosening. We report the utility of performing arthroscopy in these patients for a diagnostic advantage. We retrospectively reviewed the health records of all patients who underwent diagnostic shoulder arthroscopy over a 3-year period. Patients were included if they were aged 18 years or older, had undergone previous arthroplasty surgery, and had symptoms of shoulder pain or stiffness. Patients were excluded if they had any traditional symptoms of infection or had a raised serum white cell countor C-reactive protein level prior to diagnostic arthroscopy. Fourteen patients met the initial inclusion criteria. The mean interval between index surgery and arthroscopic evaluation was 65.4 months (standard deviation, 58 months; range, 17-192 months). Arthroscopic biopsy specimens returned positive culture results in 3 patients (21%). Rotator cuff tears were noted in 8 patients (57%). Capsular contraction requiring release was noted in 2 patients (10%). In all patients, the diagnostic arthroscopy directed the next stage of management. Diagnostic arthroscopy allows a full assessment of implants, the rotator cuff, the native articular surfaces, and scar tissue, as well as biopsy specimens to be obtained for indolent infection, in patients considering revision arthroplasty surgery. This allows a more informative consent process for patients, directs surgical management, andon occasion, allows for therapeutic intervention in a painful or stiff shoulder arthroplasty.

Management of painful reverse shoulder arthroplasty.

Even though reverse shoulder arthroplasty is a very successful procedure, painful complications occur. During the initial postoperative years, the most common reasons for pain are instability, postoperative fracture of the acromion or spine, and periprosthetic infection. Later, aseptic loosening, with humeral loosening being more frequent that glenoid loosening, can be a source of pain and reduction in function. A careful patient history, clinical examination, plain radiographs, computed tomography and blood tests give an explanation for the pain in most cases. The majority of these complications can be successfully treated, maintaining a functional reverse shoulder arthroplasty. However, if all examinations are normal, it is important to remember that nonshoulder conditions such as tumour of the lung or degenerative changes of the cervical spine can give shoulder pain.

Assessment of painful total shoulder arthroplasty using computed tomography arthrography

This study assessed the accuracy of computed tomography (CT) arthrography when evaluating glenoid component stability in the setting of postarthroplasty shoulder pain. We retrospectively reviewed all patients presenting to the clinic during a 5.5-year period to identify those with a painful shoulder arthroplasty more than 1 year after the index procedure. We excluded reverse and hemiarthroplasty procedures, patients with a clearly identifiable cause for pain, such as rotator cuff insufficiency or gross component loosening as seen on plain radiographs, and those with culture-positive aspiration. There were 14 patients with suspected glenoid component loosening but inconclusive plain radiographs. Each of the 14 patients underwent a CT arthrogram that was evaluated by the senior author (J.J.P.W.) for the presence or absence of contrast material underneath the polyethylene component. Operative reports and surgical videos from subsequent arthroscopy were reviewed to assess glenoid component stability as determined by direct arthroscopic visualization. CT arthrography suggested glenoid component loosening in 8 of 14 patients (57.1%), and arthroscopic inspection identified loosening in 10 of 14 patients (71.4%). In 3 of 10 patients (30%), CTA suggested a well-fixed glenoid component, but gross loosening was identified during arthroscopy. In this study, CTA yielded a sensitivity of 70%, a specificity of 75%, a positive predictive value of 87.5%, and a negative predictive value of 50.0%. CTA had a low negative predictive value (50%), and therefore, the prediction of component stability based on the absence of contrast between the glenoid component and the bone-cement interface does not always reflect true stability.

When Is a Positive Culture in Shoulder Surgery Not an Infection? Commentary on an article by William R. Mook, MD, et al.: "The Incidence of Propionibacterium acnes in Open Shoulder Surgery. A Controlled Diagnostic Study".

Propionibacterium acnes represents the most common pathogen in periprosthetic joint infections of the shoulder, accounting for up to 70% of positive culture results at the time of revision surgery1. This diagnosis can be elusive for several reasons. P. acnes is a commensal organism of low virulence that populates the dermal sebaceous glands about the shoulder2. Its clinical presentation is often insidious and delayed and is frequently characterized clinically by persistent shoulder pain and a paucity of cutaneous, systemic, or radiographic signs. Furthermore, the preoperative work-up has been characterized historically by poor sensitivity. Acute-phase serologic markers such as the erythrocyte sedimentation rate and C-reactive protein level are often normal in P. acnes infections and the organism can be difficult to culture, requiring long-duration culture holds in multiple culture media3 for optimal culture yield. The usefulness of intraoperative frozen sections for aiding in the diagnosis of periprosthetic joint infections of the shoulder varies from one pathology laboratory to another, but has been inconsistent at best4. Because of the low virulence of P. acnes and the associated diagnostic delay and uncertainty, surgeons are often confronted with difficult treatment dilemmas at the time of revision surgery, such as determining whether or not a revision should be carried out in a staged fashion until a periprosthetic joint infection can be effectively ruled out. In addition, positive cultures at the time of revision surgery may represent a true periprosthetic joint infection but may also arise unexpectedly as a contaminant during specimen procurement and culture incubation. Mook et al. set out to determine the rate of positive culture growth from deep-tissue specimens obtained from patients undergoing open surgery of the glenohumeral joint as well as the demographic correlates of the culture results. One of the study strengths is …

α-Defensin as a predictor of periprosthetic shoulder infection

Diagnosis of periprosthetic joint infection (PJI) in revision shoulder arthroplasty can be challenging because of the indolent nature of the common offending organisms. The purpose of this study was to evaluate the diagnostic utility of synovial fluid α-defensin levels in identifying PJI of the shoulder. Thirty patients evaluated for painful shoulder arthroplasty were prospectively enrolled and underwent revision surgery (n = 33 cases). Cases were categorized into infection (n = 11) and no-infection (n = 22) groups on the basis of preoperative and intraoperative findings. Synovial fluid was obtained from preoperative aspirations or intraoperative aspiration before arthrotomy. α-Defensin was tested by the Synovasure (CD Diagnostics, Wynnewood, PA, USA) test for joint infection. Synovial fluid was also obtained intraoperatively from a control group undergoing arthroscopic rotator cuff repair (n = 16) for baseline data on normal α-defensin levels in the shoulder. A receiver operating characteristic curve was used to determine the diagnostic utility of synovial fluid α-defensin. Synovial α-defensin had an area under the curve, sensitivity, specificity, and positive and negative likelihood ratios of 0.78, 63%, 95%, 12.1, and 0.38, respectively. There was a significant difference in α-defensin levels between the infection (median, 3.2 S/CO [signal to cutoff ratio]) and no-infection groups (median, 0.21 S/CO; P = .006). Synovial α-defensin was elevated in the presence of a culture positive for Propionibacterium acnes (median, 1.33 S/CO; P = .03) and showed moderate correlation with the number of positive cultures. Synovial fluid α-defensin was more effective than current diagnostic testing in predicting positive cultures and may be an effective adjunct in the workup of shoulder PJI.

Algorithm for the evaluation of the painful total shoulder arthroplasty: Searching for sepsis

One of the most serious complications after shoulder arthroplasty is periprosthetic joint infection. The reported incidence after primary procedures ranges from 0.7% to 4%, and the rates after revision surgery are even higher. Data on periprosthetic joint infection are derived in large part from the reported experience in managing infection at the sites of total knee and total hip arthroplasties; there is much less information available with which to guide decision making for the shoulder. This review focuses specifically on the current and future tools for diagnosing periprosthetic infections after shoulder arthroplasty.

Efficacy of Long-term Effect and Repeat Intraarticular Botulinum toxin in Patients with Painful Total Joint Arthroplasty: A Retrospective Study

Based on recent success of intra-articular (IA) Botulinum neurotoxin type A (BoNT/A; OnabotulinumtoxinA) in patients with osteoarthritis, we examined if repeat IA-BoNT/A is an effective antinociceptive in patients with refractory arthroplasty pain. 11 patients with refractory chronic arthroplasty joint pain without any evidence of infection or prosthesis loosening were referred by orthopedic surgeons. After discussion of off-label use, each patient underwent IA injection of BoNT/A, repeated based on return of pain on numeric rating scale (NRS) and functional limitation on composite validated scales, Western Ontario McMaster Osteoarthritis index (WOMAC) or Shoulder Pain and Disability (SPADI). 11 patients (10 men, 1 woman) with 14 painful arthroplasty joints (3 bilateral; 12 knee and 2 shoulder) underwent ≥1 IA-BoNT/A injections (8 joints injected once, one joint injected twice only, five joints injected thrice) with doses ranging 100-300 units. Mean age was 68 years (standard deviation, 12) and follow-up ranged 1-28 months. Clinically meaningful reduction of 2-units in pain severity and really meaningful reduction in pain severity (50% reduction) were reported by 6/11 patients (6/13 joints) and 3/11 patients (3/13 joints), respectively, 1 month after the first IA-BoNT/A (100-units each). Significant improvements were noted in composite functional scales (WOMAC/SPADI). Pain relief was sustained at 3-4 month follow-up and was reproducible in those who received repeat injections. No significant adverse events were seen in any patients. A single intra-articular injection of BoNT/A improved pain and function in patients with chronic, refractory painful knee or shoulder arthroplasty, which sustained with repeat injections. Patients who were refractory to the first injection, did not respond to subsequent injections of higher dose of IA-BoNT/A.

Intraarticular botulinum toxin reduced joint pain in patients with painful total knee or shoulder arthroplasty

Intraarticular botulinum toxin reduced joint pain in patients with painful total knee or shoulder arthroplasty

Metastatic carcinoma to the acromion in a patient after total shoulder arthroplasty: A case report and review of the literature

J Shoulder Elbow Surg 2002;11:645-7

Magnetic resonance imaging of painful shoulder arthroplasty

Specialized magnetic resonance imaging (MRI) was performed in 42 painful shoulder arthroplasties, 22 of which underwent subsequent revision surgery, allowing surgical confirmation of the pathology identified on MRI. One hemiarthroplasty was excluded because of motion artifact, leaving 21 studies (19 patients) to be correlated retrospectively to the surgical findings. At the time of revision surgery, there were full-thickness rotator cuff tears in 11 of 21 shoulders; MRI correctly predicted these in 10 of 11 shoulders. Full-thickness subscapularis tears were the most common finding (8/11 shoulders). Of the 21 shoulders, 10 did not have a rotator cuff tear, and MRI correctly predicted the absence of a tear in 8 of 10. MRI also correctly predicted glenoid cartilage wear in 8 of 9 shoulders. With limited pulse-sequence parameter modification, the data from this preliminary study suggest that MRI may be a useful technique with which to determine the integrity of the rotator cuff and residual cartilage and, thus, is potentially a tool in the management of painful shoulder arthroplasty. (J Shoulder Elbow Surg 2002;11:315-21)

Arthroscopic assessment of glenoid component loosening after total shoulder arthroplasty

Component loosening after total shoulder arthroplasty is uncommon. Evaluation of the painful total shoulder can be difficult. Radiography may not be accurate enough to assess component loosening. A retrospective study of nine patients undergoing arthroscopy and later open surgery to confirm arthroscopic findings was undertaken. Plain radiographs correlated with component loosening in two of six patients. Arthrography correlated in one of three patients. Arthroscopy accurately evaluated glenoid component loosening in all patients with this problem. After shoulder arthroplasty patients who develop increasing pain and loss of motion require further evaluation. Radiographic studies appear to be less sensitive than arthroscopic techniques in the evaluation of glenoid component loosening. Arthroscopy has proved to be a valuable technique for the evaluation of patients with painful total shoulder arthroplasty.