A substantial portion of older adults with epilepsy who are on Medicare receive prescriptions for antiepileptic drugs (AEDs) and nonepilepsy drugs (NEDs) that can interact to alter their effectiveness or induce toxicity, according to a retrospective analysis of a claims database.

Up to a quarter of all patients had potential interactions between AED and non-AED prescriptions, and these were more likely to occur for patients with comorbid conditions or those who were eligible for Part D Low Income Subsidy, reported Raymond Edward Faught Jr., MD, a professor in the department of neurology at Emory University, Atlanta, and his colleagues. The study was published in Epilepsia.

©Thinkstock.com

[email protected]

SOURCE: Faught E et al. Epilepsia. 2008 Feb 7. doi: 10.1111/epi.14010.

A substantial portion of older adults with epilepsy who are on Medicare receive prescriptions for antiepileptic drugs (AEDs) and nonepilepsy drugs (NEDs) that can interact to alter their effectiveness or induce toxicity, according to a retrospective analysis of a claims database.

Up to a quarter of all patients had potential interactions between AED and non-AED prescriptions, and these were more likely to occur for patients with comorbid conditions or those who were eligible for Part D Low Income Subsidy, reported Raymond Edward Faught Jr., MD, a professor in the department of neurology at Emory University, Atlanta, and his colleagues. The study was published in Epilepsia.

©Thinkstock.com

[email protected]

SOURCE: Faught E et al. Epilepsia. 2008 Feb 7. doi: 10.1111/epi.14010.

A substantial portion of older adults with epilepsy who are on Medicare receive prescriptions for antiepileptic drugs (AEDs) and nonepilepsy drugs (NEDs) that can interact to alter their effectiveness or induce toxicity, according to a retrospective analysis of a claims database.

Up to a quarter of all patients had potential interactions between AED and non-AED prescriptions, and these were more likely to occur for patients with comorbid conditions or those who were eligible for Part D Low Income Subsidy, reported Raymond Edward Faught Jr., MD, a professor in the department of neurology at Emory University, Atlanta, and his colleagues. The study was published in Epilepsia.

©Thinkstock.com

[email protected]

SOURCE: Faught E et al. Epilepsia. 2008 Feb 7. doi: 10.1111/epi.14010.

ABSTRACT

Complex glenoid bone deformities present the treating surgeon with a complex reconstructive challenge. Although glenoid bone loss can be encountered in the primary setting (degenerative, congenital, post-traumatic), severe glenoid bone loss is encountered in most revision total shoulder arthroplasties. Severe glenoid bone loss is treated with various techniques including hemiarthroplasty, eccentric reaming, and glenoid reconstruction with bone autografts and allografts. Despite encouraging short- to mid-term results reported with these reconstruction techniques, the clinical and radiographic outcomes remain inconsistent and the high number of complications is a concern. To overcome this problem, more recently augmented components and patient specific implants were introduced. Using the computer-aided design and computer-aided manufacturing technology patient-specific implants have been created to reconstruct the glenoid vault in cases of severe glenoid bone loss.

In this article we describe a patient specific glenoid implant, its indication, technical aspects and surgical technique, based on the author's experience as well as a review of the current literature on custom glenoid implants.

Continue to: Total shoulder arthroplasty...

Total shoulder arthroplasty (TSA) is an effective operation for providing pain relief and improving function in patients with end-stage degenerative shoulder disease that is nonresponsive to nonoperative treatments.^1-4 With the increasing number of arthroplasties performed, and the expanding indication for shoulder arthroplasty, the number of revision shoulder arthroplasties is also increasing.^5-14 Complex glenoid bone deformities present the treating surgeon with a complex reconstructive challenge. Although glenoid bone loss can be seen in the primary setting (degenerative, congenital, and post-traumatic), severe glenoid bone loss is encountered mostly in revision TSAs.

Historically, patients with severe glenoid bone loss were treated with a hemiarthroplasty.^15-17 However, due to inferior outcomes associated with the use of shoulder hemiarthroplasties compared with TSA in these cases,^18-20 various techniques were developed with the aim of realigning the glenoid axis and securing the implants into the deficient glenoid vault.^21-25 Options have included eccentric reaming, glenoid reconstruction with bone autografts and allografts, and more recently augmented components and patient-specific implants. Studies with eccentric reaming and reconstruction with bone graft during complex shoulder arthroplasty have reported encouraging short- to mid-term results, but the clinical and radiographic outcomes remain inconsistent, and the high number of complications is a concern.^25-28

Complications with these techniques include component loosening, graft resorption, nonunion, failure of graft incorporation, infection, and instability.^25-28

Computer-aided design and computer-aided manufacturing (CAD/CAM) of patient-specific implants have been used successfully by hip arthroplasty surgeons to deal with complex acetabular reconstructions in the setting of severe bone loss. More recently, the same technology has been used to reconstruct the glenoid vault in cases of severe glenoid bone loss.

In this article, we describe a patient-specific glenoid implant, its indication, and both technical aspects and the surgical technique, based on the authors’ experience as well as a review of the current literature on custom glenoid implants.

Continue to: PATIENT-SPECIFIC GLENOID COMPONENT

The Vault Reconstruction System ([VRS], Zimmer Biomet) is a patient-specific glenoid vault reconstruction system developed with the use of CAD/CAM to address severe glenoid bone loss encountered during shoulder arthroplasty. For several years, the VRS was available only as a custom implant according to the US Food and Drug Administration rules, and therefore its use was limited to a few cases per year. Recently, a 510(k) envelope clearance was granted to use the VRS in reverse TSA to address significant glenoid bone defects.

The VRS is made of porous plasma spray titanium to provide high strength and flexibility, and allows for biologic fixation. This system can accommodate a restricted bone loss envelope of about 50 mm × 50 mm × 35 mm according to the previous experience of the manufacturer in the custom scenario, covering 96% of defects previously addressed. One 6.5-mm nonlocking central screw and a minimum of four 4.75-mm nonlocking or locking peripheral screws are required for optimal fixation of the implant in the native scapula. A custom boss can be added in to enhance fixation in the native scapula when the bone is sufficient. To facilitate the surgical procedure, a trial implant, a bone model of the scapula, and a custom boss reaming guide are 3-dimensional (3-D) and printed in sterilizable material. These are all provided as single-use disposable instruments and can be available for surgeons during both the initial plan review and surgery.

PREOPERATIVE PLANNING

Patients undergo a preoperative fine-cut 2-dimensional computed tomography scan of the scapula and adjacent humerus following a predefined protocol with a slice thickness of 2 mm to 3 mm. An accurate 3-D bone model of the scapula is obtained using a 3-D image processing software system (Figure 1). The 3-D scapular model is used to create a patient-specific glenoid implant proposal that is approved by the surgeon (Figure 2). Implant position, orientation, size, screw trajectory, and recommended bone removal, if necessary, are determined to create a more normal glenohumeral center of rotation and to secure a glenoid implant in severely deficient glenoid bone (Figure 3). Once the implant design is approved by the surgeon, the final patient-specific implant is manufactured.

SURGICAL TECHNIQUE

The exposure of the glenoid is a critical step for the successful implantation of the patient-specific glenoid implant. Soft tissue and scar tissue around the glenoid must be removed to allow for optimal fit of the custom-made reaming guide. Also, removal of the entire capsulolabral complex on the anteroinferior rim of the glenoid is essential to both enhance glenoid exposure and to allow a perfect fit of the guide to the pathologic bone stock. Attention should be paid during débridement and/or implant removal in case of revision, to make sure that no excessive bone is removed because the patient-specific guide is referenced to this anatomy. Excessive bone removal can change the orientation of the patient-specific guide and ultimately the fixation of the implant. Once the custom-made patient-specific guide is positioned, a 3.2-mm Steinmann pin is placed through the inserter for temporary fixation. The pin should engage or perforate the medial cortical wall to ensure that the subsequent reamer has a stable cannula over which to ream. After the glenoid is reamed, the final implant can be placed in the ideal position according to the preoperative planning. A central 6.5-mm nonlocking central screw and 4.75-mm nonlocking or locking peripheral screws are required to complete the fixation of the implant in the native scapula. Once the patient-specific glenoid component is positioned and strongly fixed to the bone, the glenosphere can be positioned according to the preoperative planning, and the reverse shoulder arthroplasty can be completed in the usual fashion.

CASE EXAMPLES

A 68-year-old woman underwent a TSA for end-stage osteoarthritis in 2000. The implant failed due to a cuff failure. The patient underwent several surgeries, including an open cuff repair, with no success. She had no active elevation preoperatively. Because of the significant glenoid bone loss, a patient-specific glenoid reconstruction was planned. Within 24 months after this surgery, the patient was able to get her hand to her head and elevate to 90º (Figures 4A-4F).

Continue to: In October 2013...

In October 2013, a 68-year-old man underwent a TSA for end-stage osteoarthritis. After 18 months, the implant failed due to active Propionibacterium acnes infection, which required excisional arthroplasty with insertion of an antibiotic spacer. Significant glenoid bone loss (Figure 5) and global soft-tissue deficiency caused substantial disability and led to an indication for a reverse TSA with a patient-specific glenoid vault reconstruction (Figures 6A-6D) after infection eradication. Within 20 months after this surgery, the patient had resumed a satisfactory range of motion (130º forward elevation, 20º external rotation) and outcome.

DISCUSSION

Although glenoid bone loss is often seen in the primary setting (degenerative, congenital, and post-traumatic), severe glenoid bone loss is encountered in most revision TSAs. The best treatment method for massive glenoid bone defects during complex shoulder arthroplasty remains uncertain. Options have included eccentric reaming, glenoid reconstruction with bone allograft and autograft, and more recently augmented components and patient-specific implants.^21-25 The advent and availability of CAD/CAM technology have enabled shoulder surgeons to create patient-specific metal solutions to these challenging cases. Currently, only a few reports exist in the literature on patient-specific glenoid components in the setting of severe bone loss.^29-32

Chammaa and colleagues²⁹ reported the outcomes of 37 patients with a hip-inspired glenoid component (Total Shoulder Replacement, Stanmore Implants Worldwide). The 5-year results with this implant were promising, with a 16% revision rate and only 1 case of glenoid loosening.

Stoffelen and colleagues³⁰ recently described the successful use of a patient-specific anatomic metal-backed glenoid component for the management of severe glenoid bone loss with excellent results at 2.5 years of follow-up. A different approach was pursued by Gunther and Lynch,³¹ who reported on 7 patients with a custom inset glenoid implant for deficient glenoid vaults. These circular anatomic, custom-made glenoid components were created with the intention of placing the implants partially inside the glenoid vault and relying partially on sclerotic cortical bone. Despite excellent results at 3 years of follow-up, their use is limited to specific defect geometries and cannot be used in cases of extreme bone loss.

CONCLUSION

We have described the use of a patient-specific glenoid component in 2 patients with severe glenoid bone loss. Despite the satisfactory clinical and short-term radiographic results, we acknowledge that longer-term follow-up is needed to confirm the efficacy of this type of reconstruction. We believe that patient-specific glenoid components represent a valuable addition to the armamentarium of shoulder surgeons who address complex glenoid bone deformities.

ABSTRACT

Complex glenoid bone deformities present the treating surgeon with a complex reconstructive challenge. Although glenoid bone loss can be encountered in the primary setting (degenerative, congenital, post-traumatic), severe glenoid bone loss is encountered in most revision total shoulder arthroplasties. Severe glenoid bone loss is treated with various techniques including hemiarthroplasty, eccentric reaming, and glenoid reconstruction with bone autografts and allografts. Despite encouraging short- to mid-term results reported with these reconstruction techniques, the clinical and radiographic outcomes remain inconsistent and the high number of complications is a concern. To overcome this problem, more recently augmented components and patient specific implants were introduced. Using the computer-aided design and computer-aided manufacturing technology patient-specific implants have been created to reconstruct the glenoid vault in cases of severe glenoid bone loss.

In this article we describe a patient specific glenoid implant, its indication, technical aspects and surgical technique, based on the author's experience as well as a review of the current literature on custom glenoid implants.

Continue to: Total shoulder arthroplasty...

Total shoulder arthroplasty (TSA) is an effective operation for providing pain relief and improving function in patients with end-stage degenerative shoulder disease that is nonresponsive to nonoperative treatments.^1-4 With the increasing number of arthroplasties performed, and the expanding indication for shoulder arthroplasty, the number of revision shoulder arthroplasties is also increasing.^5-14 Complex glenoid bone deformities present the treating surgeon with a complex reconstructive challenge. Although glenoid bone loss can be seen in the primary setting (degenerative, congenital, and post-traumatic), severe glenoid bone loss is encountered mostly in revision TSAs.

Historically, patients with severe glenoid bone loss were treated with a hemiarthroplasty.^15-17 However, due to inferior outcomes associated with the use of shoulder hemiarthroplasties compared with TSA in these cases,^18-20 various techniques were developed with the aim of realigning the glenoid axis and securing the implants into the deficient glenoid vault.^21-25 Options have included eccentric reaming, glenoid reconstruction with bone autografts and allografts, and more recently augmented components and patient-specific implants. Studies with eccentric reaming and reconstruction with bone graft during complex shoulder arthroplasty have reported encouraging short- to mid-term results, but the clinical and radiographic outcomes remain inconsistent, and the high number of complications is a concern.^25-28

Complications with these techniques include component loosening, graft resorption, nonunion, failure of graft incorporation, infection, and instability.^25-28

Computer-aided design and computer-aided manufacturing (CAD/CAM) of patient-specific implants have been used successfully by hip arthroplasty surgeons to deal with complex acetabular reconstructions in the setting of severe bone loss. More recently, the same technology has been used to reconstruct the glenoid vault in cases of severe glenoid bone loss.

In this article, we describe a patient-specific glenoid implant, its indication, and both technical aspects and the surgical technique, based on the authors’ experience as well as a review of the current literature on custom glenoid implants.

Continue to: PATIENT-SPECIFIC GLENOID COMPONENT

The Vault Reconstruction System ([VRS], Zimmer Biomet) is a patient-specific glenoid vault reconstruction system developed with the use of CAD/CAM to address severe glenoid bone loss encountered during shoulder arthroplasty. For several years, the VRS was available only as a custom implant according to the US Food and Drug Administration rules, and therefore its use was limited to a few cases per year. Recently, a 510(k) envelope clearance was granted to use the VRS in reverse TSA to address significant glenoid bone defects.

The VRS is made of porous plasma spray titanium to provide high strength and flexibility, and allows for biologic fixation. This system can accommodate a restricted bone loss envelope of about 50 mm × 50 mm × 35 mm according to the previous experience of the manufacturer in the custom scenario, covering 96% of defects previously addressed. One 6.5-mm nonlocking central screw and a minimum of four 4.75-mm nonlocking or locking peripheral screws are required for optimal fixation of the implant in the native scapula. A custom boss can be added in to enhance fixation in the native scapula when the bone is sufficient. To facilitate the surgical procedure, a trial implant, a bone model of the scapula, and a custom boss reaming guide are 3-dimensional (3-D) and printed in sterilizable material. These are all provided as single-use disposable instruments and can be available for surgeons during both the initial plan review and surgery.

PREOPERATIVE PLANNING

Patients undergo a preoperative fine-cut 2-dimensional computed tomography scan of the scapula and adjacent humerus following a predefined protocol with a slice thickness of 2 mm to 3 mm. An accurate 3-D bone model of the scapula is obtained using a 3-D image processing software system (Figure 1). The 3-D scapular model is used to create a patient-specific glenoid implant proposal that is approved by the surgeon (Figure 2). Implant position, orientation, size, screw trajectory, and recommended bone removal, if necessary, are determined to create a more normal glenohumeral center of rotation and to secure a glenoid implant in severely deficient glenoid bone (Figure 3). Once the implant design is approved by the surgeon, the final patient-specific implant is manufactured.

SURGICAL TECHNIQUE

The exposure of the glenoid is a critical step for the successful implantation of the patient-specific glenoid implant. Soft tissue and scar tissue around the glenoid must be removed to allow for optimal fit of the custom-made reaming guide. Also, removal of the entire capsulolabral complex on the anteroinferior rim of the glenoid is essential to both enhance glenoid exposure and to allow a perfect fit of the guide to the pathologic bone stock. Attention should be paid during débridement and/or implant removal in case of revision, to make sure that no excessive bone is removed because the patient-specific guide is referenced to this anatomy. Excessive bone removal can change the orientation of the patient-specific guide and ultimately the fixation of the implant. Once the custom-made patient-specific guide is positioned, a 3.2-mm Steinmann pin is placed through the inserter for temporary fixation. The pin should engage or perforate the medial cortical wall to ensure that the subsequent reamer has a stable cannula over which to ream. After the glenoid is reamed, the final implant can be placed in the ideal position according to the preoperative planning. A central 6.5-mm nonlocking central screw and 4.75-mm nonlocking or locking peripheral screws are required to complete the fixation of the implant in the native scapula. Once the patient-specific glenoid component is positioned and strongly fixed to the bone, the glenosphere can be positioned according to the preoperative planning, and the reverse shoulder arthroplasty can be completed in the usual fashion.

CASE EXAMPLES

A 68-year-old woman underwent a TSA for end-stage osteoarthritis in 2000. The implant failed due to a cuff failure. The patient underwent several surgeries, including an open cuff repair, with no success. She had no active elevation preoperatively. Because of the significant glenoid bone loss, a patient-specific glenoid reconstruction was planned. Within 24 months after this surgery, the patient was able to get her hand to her head and elevate to 90º (Figures 4A-4F).

Continue to: In October 2013...

In October 2013, a 68-year-old man underwent a TSA for end-stage osteoarthritis. After 18 months, the implant failed due to active Propionibacterium acnes infection, which required excisional arthroplasty with insertion of an antibiotic spacer. Significant glenoid bone loss (Figure 5) and global soft-tissue deficiency caused substantial disability and led to an indication for a reverse TSA with a patient-specific glenoid vault reconstruction (Figures 6A-6D) after infection eradication. Within 20 months after this surgery, the patient had resumed a satisfactory range of motion (130º forward elevation, 20º external rotation) and outcome.

DISCUSSION

Although glenoid bone loss is often seen in the primary setting (degenerative, congenital, and post-traumatic), severe glenoid bone loss is encountered in most revision TSAs. The best treatment method for massive glenoid bone defects during complex shoulder arthroplasty remains uncertain. Options have included eccentric reaming, glenoid reconstruction with bone allograft and autograft, and more recently augmented components and patient-specific implants.^21-25 The advent and availability of CAD/CAM technology have enabled shoulder surgeons to create patient-specific metal solutions to these challenging cases. Currently, only a few reports exist in the literature on patient-specific glenoid components in the setting of severe bone loss.^29-32

Chammaa and colleagues²⁹ reported the outcomes of 37 patients with a hip-inspired glenoid component (Total Shoulder Replacement, Stanmore Implants Worldwide). The 5-year results with this implant were promising, with a 16% revision rate and only 1 case of glenoid loosening.

Stoffelen and colleagues³⁰ recently described the successful use of a patient-specific anatomic metal-backed glenoid component for the management of severe glenoid bone loss with excellent results at 2.5 years of follow-up. A different approach was pursued by Gunther and Lynch,³¹ who reported on 7 patients with a custom inset glenoid implant for deficient glenoid vaults. These circular anatomic, custom-made glenoid components were created with the intention of placing the implants partially inside the glenoid vault and relying partially on sclerotic cortical bone. Despite excellent results at 3 years of follow-up, their use is limited to specific defect geometries and cannot be used in cases of extreme bone loss.

CONCLUSION

We have described the use of a patient-specific glenoid component in 2 patients with severe glenoid bone loss. Despite the satisfactory clinical and short-term radiographic results, we acknowledge that longer-term follow-up is needed to confirm the efficacy of this type of reconstruction. We believe that patient-specific glenoid components represent a valuable addition to the armamentarium of shoulder surgeons who address complex glenoid bone deformities.

ABSTRACT

Complex glenoid bone deformities present the treating surgeon with a complex reconstructive challenge. Although glenoid bone loss can be encountered in the primary setting (degenerative, congenital, post-traumatic), severe glenoid bone loss is encountered in most revision total shoulder arthroplasties. Severe glenoid bone loss is treated with various techniques including hemiarthroplasty, eccentric reaming, and glenoid reconstruction with bone autografts and allografts. Despite encouraging short- to mid-term results reported with these reconstruction techniques, the clinical and radiographic outcomes remain inconsistent and the high number of complications is a concern. To overcome this problem, more recently augmented components and patient specific implants were introduced. Using the computer-aided design and computer-aided manufacturing technology patient-specific implants have been created to reconstruct the glenoid vault in cases of severe glenoid bone loss.

In this article we describe a patient specific glenoid implant, its indication, technical aspects and surgical technique, based on the author's experience as well as a review of the current literature on custom glenoid implants.

Continue to: Total shoulder arthroplasty...

Total shoulder arthroplasty (TSA) is an effective operation for providing pain relief and improving function in patients with end-stage degenerative shoulder disease that is nonresponsive to nonoperative treatments.^1-4 With the increasing number of arthroplasties performed, and the expanding indication for shoulder arthroplasty, the number of revision shoulder arthroplasties is also increasing.^5-14 Complex glenoid bone deformities present the treating surgeon with a complex reconstructive challenge. Although glenoid bone loss can be seen in the primary setting (degenerative, congenital, and post-traumatic), severe glenoid bone loss is encountered mostly in revision TSAs.

Historically, patients with severe glenoid bone loss were treated with a hemiarthroplasty.^15-17 However, due to inferior outcomes associated with the use of shoulder hemiarthroplasties compared with TSA in these cases,^18-20 various techniques were developed with the aim of realigning the glenoid axis and securing the implants into the deficient glenoid vault.^21-25 Options have included eccentric reaming, glenoid reconstruction with bone autografts and allografts, and more recently augmented components and patient-specific implants. Studies with eccentric reaming and reconstruction with bone graft during complex shoulder arthroplasty have reported encouraging short- to mid-term results, but the clinical and radiographic outcomes remain inconsistent, and the high number of complications is a concern.^25-28

Complications with these techniques include component loosening, graft resorption, nonunion, failure of graft incorporation, infection, and instability.^25-28

Computer-aided design and computer-aided manufacturing (CAD/CAM) of patient-specific implants have been used successfully by hip arthroplasty surgeons to deal with complex acetabular reconstructions in the setting of severe bone loss. More recently, the same technology has been used to reconstruct the glenoid vault in cases of severe glenoid bone loss.

In this article, we describe a patient-specific glenoid implant, its indication, and both technical aspects and the surgical technique, based on the authors’ experience as well as a review of the current literature on custom glenoid implants.

Continue to: PATIENT-SPECIFIC GLENOID COMPONENT

The Vault Reconstruction System ([VRS], Zimmer Biomet) is a patient-specific glenoid vault reconstruction system developed with the use of CAD/CAM to address severe glenoid bone loss encountered during shoulder arthroplasty. For several years, the VRS was available only as a custom implant according to the US Food and Drug Administration rules, and therefore its use was limited to a few cases per year. Recently, a 510(k) envelope clearance was granted to use the VRS in reverse TSA to address significant glenoid bone defects.

The VRS is made of porous plasma spray titanium to provide high strength and flexibility, and allows for biologic fixation. This system can accommodate a restricted bone loss envelope of about 50 mm × 50 mm × 35 mm according to the previous experience of the manufacturer in the custom scenario, covering 96% of defects previously addressed. One 6.5-mm nonlocking central screw and a minimum of four 4.75-mm nonlocking or locking peripheral screws are required for optimal fixation of the implant in the native scapula. A custom boss can be added in to enhance fixation in the native scapula when the bone is sufficient. To facilitate the surgical procedure, a trial implant, a bone model of the scapula, and a custom boss reaming guide are 3-dimensional (3-D) and printed in sterilizable material. These are all provided as single-use disposable instruments and can be available for surgeons during both the initial plan review and surgery.

PREOPERATIVE PLANNING

Patients undergo a preoperative fine-cut 2-dimensional computed tomography scan of the scapula and adjacent humerus following a predefined protocol with a slice thickness of 2 mm to 3 mm. An accurate 3-D bone model of the scapula is obtained using a 3-D image processing software system (Figure 1). The 3-D scapular model is used to create a patient-specific glenoid implant proposal that is approved by the surgeon (Figure 2). Implant position, orientation, size, screw trajectory, and recommended bone removal, if necessary, are determined to create a more normal glenohumeral center of rotation and to secure a glenoid implant in severely deficient glenoid bone (Figure 3). Once the implant design is approved by the surgeon, the final patient-specific implant is manufactured.

SURGICAL TECHNIQUE

The exposure of the glenoid is a critical step for the successful implantation of the patient-specific glenoid implant. Soft tissue and scar tissue around the glenoid must be removed to allow for optimal fit of the custom-made reaming guide. Also, removal of the entire capsulolabral complex on the anteroinferior rim of the glenoid is essential to both enhance glenoid exposure and to allow a perfect fit of the guide to the pathologic bone stock. Attention should be paid during débridement and/or implant removal in case of revision, to make sure that no excessive bone is removed because the patient-specific guide is referenced to this anatomy. Excessive bone removal can change the orientation of the patient-specific guide and ultimately the fixation of the implant. Once the custom-made patient-specific guide is positioned, a 3.2-mm Steinmann pin is placed through the inserter for temporary fixation. The pin should engage or perforate the medial cortical wall to ensure that the subsequent reamer has a stable cannula over which to ream. After the glenoid is reamed, the final implant can be placed in the ideal position according to the preoperative planning. A central 6.5-mm nonlocking central screw and 4.75-mm nonlocking or locking peripheral screws are required to complete the fixation of the implant in the native scapula. Once the patient-specific glenoid component is positioned and strongly fixed to the bone, the glenosphere can be positioned according to the preoperative planning, and the reverse shoulder arthroplasty can be completed in the usual fashion.

CASE EXAMPLES

A 68-year-old woman underwent a TSA for end-stage osteoarthritis in 2000. The implant failed due to a cuff failure. The patient underwent several surgeries, including an open cuff repair, with no success. She had no active elevation preoperatively. Because of the significant glenoid bone loss, a patient-specific glenoid reconstruction was planned. Within 24 months after this surgery, the patient was able to get her hand to her head and elevate to 90º (Figures 4A-4F).

Continue to: In October 2013...

In October 2013, a 68-year-old man underwent a TSA for end-stage osteoarthritis. After 18 months, the implant failed due to active Propionibacterium acnes infection, which required excisional arthroplasty with insertion of an antibiotic spacer. Significant glenoid bone loss (Figure 5) and global soft-tissue deficiency caused substantial disability and led to an indication for a reverse TSA with a patient-specific glenoid vault reconstruction (Figures 6A-6D) after infection eradication. Within 20 months after this surgery, the patient had resumed a satisfactory range of motion (130º forward elevation, 20º external rotation) and outcome.

DISCUSSION

Although glenoid bone loss is often seen in the primary setting (degenerative, congenital, and post-traumatic), severe glenoid bone loss is encountered in most revision TSAs. The best treatment method for massive glenoid bone defects during complex shoulder arthroplasty remains uncertain. Options have included eccentric reaming, glenoid reconstruction with bone allograft and autograft, and more recently augmented components and patient-specific implants.^21-25 The advent and availability of CAD/CAM technology have enabled shoulder surgeons to create patient-specific metal solutions to these challenging cases. Currently, only a few reports exist in the literature on patient-specific glenoid components in the setting of severe bone loss.^29-32

Chammaa and colleagues²⁹ reported the outcomes of 37 patients with a hip-inspired glenoid component (Total Shoulder Replacement, Stanmore Implants Worldwide). The 5-year results with this implant were promising, with a 16% revision rate and only 1 case of glenoid loosening.

Stoffelen and colleagues³⁰ recently described the successful use of a patient-specific anatomic metal-backed glenoid component for the management of severe glenoid bone loss with excellent results at 2.5 years of follow-up. A different approach was pursued by Gunther and Lynch,³¹ who reported on 7 patients with a custom inset glenoid implant for deficient glenoid vaults. These circular anatomic, custom-made glenoid components were created with the intention of placing the implants partially inside the glenoid vault and relying partially on sclerotic cortical bone. Despite excellent results at 3 years of follow-up, their use is limited to specific defect geometries and cannot be used in cases of extreme bone loss.

CONCLUSION

We have described the use of a patient-specific glenoid component in 2 patients with severe glenoid bone loss. Despite the satisfactory clinical and short-term radiographic results, we acknowledge that longer-term follow-up is needed to confirm the efficacy of this type of reconstruction. We believe that patient-specific glenoid components represent a valuable addition to the armamentarium of shoulder surgeons who address complex glenoid bone deformities.

In a rare show of bipartisanship for the mostly polarized 115th Congress, Republican and Democratic Senate leaders announced a 2-year budget deal that would increase federal spending for defense as well as key domestic priorities, including many health programs.

Not in the deal, for which the path to the president’s desk remains unclear, is any bipartisan legislation aimed at shoring up the Affordable Care Act’s individual health insurance marketplaces. Senate Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R-Maine) a vote on health legislation in exchange for her vote for the GOP tax bill in December. So far, that vote has not materialized.

The deal does appear to include almost every other health priority Democrats have been pushing the past several months, including 2 years of renewed funding for community health centers and a series of other health programs Congress failed to provide for before they technically expired last year.

“I believe we have reached a budget deal that neither side loves but both sides can be proud of,” Senate Minority Leader Chuck Schumer (D-N.Y.) said on the Senate floor. “That’s compromise. That’s governing.”

Said McConnell, “This bill represents a significant bipartisan step forward.”

Senate leaders are still negotiating last details of the accord, including the size of a cut to the ACA’s Prevention and Public Health Fund, which would help offset the costs of this legislation.

According to documents circulating on Capitol Hill, the deal includes $6 billion in funding for treatment of mental health issues and opioid addiction, $2 billion in extra funding for the National Institutes of Health, and an additional 4-year extension of the Children’s Health Insurance Program (CHIP), which builds on the 6 years approved by Congress in January.

In the Medicare program, the deal would accelerate the closing of the “doughnut hole” in Medicare drug coverage that requires seniors to pay thousands of dollars out-of-pocket before catastrophic coverage kicks in. It would also repeal the controversial Medicare Independent Payment Advisory Board (IPAB), which is charged with holding down Medicare spending for the federal government if it exceeds a certain level. Members have never been appointed to the board, however, and its use has not so far been triggered by Medicare spending. Both the closure of the doughnut hole and creation of the IPAB were part of the ACA.

The agreement would also fund a host of more limited health programs – some of which are known as “extenders” because they often ride along with other, larger health or spending bills.

Those programs include more than $7 billion in funding for the nation’s federally funded community health centers. The clinics serve 27 million low-income people and saw their funding lapse last fall – a delay advocates said had already complicated budgeting and staffing decisions for many clinics.

And in a victory for the physical therapy industry and patient advocates, the accord would permanently repeal a limit on Medicare’s coverage of physical therapy, speech-language pathology and outpatient treatment. Previously, the program capped coverage after $2,010 worth of occupational therapy and another $2,010 for speech-language therapy and physical therapy combined. But Congress had long taken action to delay those caps or provide exemptions – meaning they had never actually taken effect.

According to an analysis by the nonpartisan Congressional Budget Office, permanently repealing the caps would cost about $6.47 billion over the next decade.

Lawmakers would also forestall cuts mandated by the ACA to reduce the payments made to so-called Disproportionate Share Hospitals, which serve high rates of low-income patients. Those cuts have been delayed continuously since the law’s 2010 passage.

Limited programs are also affected. The deal would fund for 5 years the Maternal, Infant and Early Childhood Home Visiting Program, a program that helps guide low-income, at-risk mothers in parenting. It served about 160,000 families in fiscal year 2016.

“We are relieved that there is a deal for a 5-year reauthorization of MIECHV,” Lori Freeman, CEO of the Association of Maternal & Child Health Programs – an advocacy group – said in an emailed statement. “States, home visitors, and families have been in limbo for the past several months, and this news will bring the stability they need to continue this successful program.”

And the budget deal funds programs that encourage doctors to practice in medically underserved areas, providing just under $500 million over the next 2 years for the National Health Service Corps and another $363 million over 2 years to the Teaching Health Center Graduate Medical Education program, which places medical residents in Community Health Centers.
 

Kaiser Health News correspondent Emmarie Huetteman contributed to this article. KHN’s coverage of these topics is supported by Heising-Simons Foundation and The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

In a rare show of bipartisanship for the mostly polarized 115th Congress, Republican and Democratic Senate leaders announced a 2-year budget deal that would increase federal spending for defense as well as key domestic priorities, including many health programs.

Not in the deal, for which the path to the president’s desk remains unclear, is any bipartisan legislation aimed at shoring up the Affordable Care Act’s individual health insurance marketplaces. Senate Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R-Maine) a vote on health legislation in exchange for her vote for the GOP tax bill in December. So far, that vote has not materialized.

The deal does appear to include almost every other health priority Democrats have been pushing the past several months, including 2 years of renewed funding for community health centers and a series of other health programs Congress failed to provide for before they technically expired last year.

“I believe we have reached a budget deal that neither side loves but both sides can be proud of,” Senate Minority Leader Chuck Schumer (D-N.Y.) said on the Senate floor. “That’s compromise. That’s governing.”

Said McConnell, “This bill represents a significant bipartisan step forward.”

Senate leaders are still negotiating last details of the accord, including the size of a cut to the ACA’s Prevention and Public Health Fund, which would help offset the costs of this legislation.

According to documents circulating on Capitol Hill, the deal includes $6 billion in funding for treatment of mental health issues and opioid addiction, $2 billion in extra funding for the National Institutes of Health, and an additional 4-year extension of the Children’s Health Insurance Program (CHIP), which builds on the 6 years approved by Congress in January.

In the Medicare program, the deal would accelerate the closing of the “doughnut hole” in Medicare drug coverage that requires seniors to pay thousands of dollars out-of-pocket before catastrophic coverage kicks in. It would also repeal the controversial Medicare Independent Payment Advisory Board (IPAB), which is charged with holding down Medicare spending for the federal government if it exceeds a certain level. Members have never been appointed to the board, however, and its use has not so far been triggered by Medicare spending. Both the closure of the doughnut hole and creation of the IPAB were part of the ACA.

The agreement would also fund a host of more limited health programs – some of which are known as “extenders” because they often ride along with other, larger health or spending bills.

Those programs include more than $7 billion in funding for the nation’s federally funded community health centers. The clinics serve 27 million low-income people and saw their funding lapse last fall – a delay advocates said had already complicated budgeting and staffing decisions for many clinics.

And in a victory for the physical therapy industry and patient advocates, the accord would permanently repeal a limit on Medicare’s coverage of physical therapy, speech-language pathology and outpatient treatment. Previously, the program capped coverage after $2,010 worth of occupational therapy and another $2,010 for speech-language therapy and physical therapy combined. But Congress had long taken action to delay those caps or provide exemptions – meaning they had never actually taken effect.

According to an analysis by the nonpartisan Congressional Budget Office, permanently repealing the caps would cost about $6.47 billion over the next decade.

Lawmakers would also forestall cuts mandated by the ACA to reduce the payments made to so-called Disproportionate Share Hospitals, which serve high rates of low-income patients. Those cuts have been delayed continuously since the law’s 2010 passage.

Limited programs are also affected. The deal would fund for 5 years the Maternal, Infant and Early Childhood Home Visiting Program, a program that helps guide low-income, at-risk mothers in parenting. It served about 160,000 families in fiscal year 2016.

“We are relieved that there is a deal for a 5-year reauthorization of MIECHV,” Lori Freeman, CEO of the Association of Maternal & Child Health Programs – an advocacy group – said in an emailed statement. “States, home visitors, and families have been in limbo for the past several months, and this news will bring the stability they need to continue this successful program.”

And the budget deal funds programs that encourage doctors to practice in medically underserved areas, providing just under $500 million over the next 2 years for the National Health Service Corps and another $363 million over 2 years to the Teaching Health Center Graduate Medical Education program, which places medical residents in Community Health Centers.
 

Kaiser Health News correspondent Emmarie Huetteman contributed to this article. KHN’s coverage of these topics is supported by Heising-Simons Foundation and The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

In a rare show of bipartisanship for the mostly polarized 115th Congress, Republican and Democratic Senate leaders announced a 2-year budget deal that would increase federal spending for defense as well as key domestic priorities, including many health programs.

Not in the deal, for which the path to the president’s desk remains unclear, is any bipartisan legislation aimed at shoring up the Affordable Care Act’s individual health insurance marketplaces. Senate Majority Leader Mitch McConnell (R-Ky.) promised Sen. Susan Collins (R-Maine) a vote on health legislation in exchange for her vote for the GOP tax bill in December. So far, that vote has not materialized.

The deal does appear to include almost every other health priority Democrats have been pushing the past several months, including 2 years of renewed funding for community health centers and a series of other health programs Congress failed to provide for before they technically expired last year.

“I believe we have reached a budget deal that neither side loves but both sides can be proud of,” Senate Minority Leader Chuck Schumer (D-N.Y.) said on the Senate floor. “That’s compromise. That’s governing.”

Said McConnell, “This bill represents a significant bipartisan step forward.”

Senate leaders are still negotiating last details of the accord, including the size of a cut to the ACA’s Prevention and Public Health Fund, which would help offset the costs of this legislation.

According to documents circulating on Capitol Hill, the deal includes $6 billion in funding for treatment of mental health issues and opioid addiction, $2 billion in extra funding for the National Institutes of Health, and an additional 4-year extension of the Children’s Health Insurance Program (CHIP), which builds on the 6 years approved by Congress in January.

In the Medicare program, the deal would accelerate the closing of the “doughnut hole” in Medicare drug coverage that requires seniors to pay thousands of dollars out-of-pocket before catastrophic coverage kicks in. It would also repeal the controversial Medicare Independent Payment Advisory Board (IPAB), which is charged with holding down Medicare spending for the federal government if it exceeds a certain level. Members have never been appointed to the board, however, and its use has not so far been triggered by Medicare spending. Both the closure of the doughnut hole and creation of the IPAB were part of the ACA.

The agreement would also fund a host of more limited health programs – some of which are known as “extenders” because they often ride along with other, larger health or spending bills.

Those programs include more than $7 billion in funding for the nation’s federally funded community health centers. The clinics serve 27 million low-income people and saw their funding lapse last fall – a delay advocates said had already complicated budgeting and staffing decisions for many clinics.

And in a victory for the physical therapy industry and patient advocates, the accord would permanently repeal a limit on Medicare’s coverage of physical therapy, speech-language pathology and outpatient treatment. Previously, the program capped coverage after $2,010 worth of occupational therapy and another $2,010 for speech-language therapy and physical therapy combined. But Congress had long taken action to delay those caps or provide exemptions – meaning they had never actually taken effect.

According to an analysis by the nonpartisan Congressional Budget Office, permanently repealing the caps would cost about $6.47 billion over the next decade.

Lawmakers would also forestall cuts mandated by the ACA to reduce the payments made to so-called Disproportionate Share Hospitals, which serve high rates of low-income patients. Those cuts have been delayed continuously since the law’s 2010 passage.

Limited programs are also affected. The deal would fund for 5 years the Maternal, Infant and Early Childhood Home Visiting Program, a program that helps guide low-income, at-risk mothers in parenting. It served about 160,000 families in fiscal year 2016.

“We are relieved that there is a deal for a 5-year reauthorization of MIECHV,” Lori Freeman, CEO of the Association of Maternal & Child Health Programs – an advocacy group – said in an emailed statement. “States, home visitors, and families have been in limbo for the past several months, and this news will bring the stability they need to continue this successful program.”

And the budget deal funds programs that encourage doctors to practice in medically underserved areas, providing just under $500 million over the next 2 years for the National Health Service Corps and another $363 million over 2 years to the Teaching Health Center Graduate Medical Education program, which places medical residents in Community Health Centers.
 

Kaiser Health News correspondent Emmarie Huetteman contributed to this article. KHN’s coverage of these topics is supported by Heising-Simons Foundation and The David and Lucile Packard Foundation. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

ABSTRACT

Removal of a cemented glenoid component often leads to massive glenoid bone loss, which makes it difficult to implant a new glenoid baseplate. The purpose of this study was to demonstrate the feasibility of revisions with a completely convertible system and to report clinical and radiographic results of a retrospective review of 13 cases.

Between 2003 and 2011, 104 primary total shoulder arthroplasties (TSAs) were performed with an uncemented glenoid component in our group. Of these patients, 13 (average age, 64 years) were revised to reverse shoulder arthroplasty (RSA) using a modular convertible platform system and were included in this study. Average follow-up after revision was 22 months. Outcome measures included pain, range of motion, Constant-Murley scores, Simple Shoulder Tests, and subjective shoulder values. Active flexion increased significantly from a mean of 93° (range, 30°-120°) to 138° (range, 95°-170°) (P = 0.021), and active external rotation increased significantly from 8° (range, −20°-15°) to 25° (range, −10°-60°). Mean pain scores significantly improved from 4.2 to 13.3 points. The mean Constant Scores improved from 21 (range, 18-32) to 63 (range, 43-90). Subjectively, 12 patients rated their shoulder as better or much better than preoperatively. This retrospective study shows that a complete convertible system facilitates conversion of TSAs to RSAs with excellent pain relief and a significant improvement in shoulder function.

Continue to: Polyethylene glenoid components...

Polyethylene glenoid components are the gold standard in anatomic total shoulder arthroplasty (TSA). However, even though TSA survivorship exceeds 95% at 10-year follow-up,¹ glenoid component loosening remains the main complication and the weak link in these implants. This complication accounts for 25% of all complications related to TSA in the literature.² In most cases, glenoid component loosening is not isolated but combined with a rotator cuff tear, glenohumeral instability, or component malposition.^3-5 Therefore, revision of TSA to reverse shoulder arthroplasty (RSA) often requires the removal of both the humeral stem and glenoid component. Removal of the humeral stem can be challenging and can necessitate removal of the cement and osteotomy of the diaphysis, risking fracture and extensive damage to the soft tissue (Figures 1A, 1B).^6-8 Removal of a cemented glenoid component often leads to massive glenoid bone loss, which makes it difficult to implant a new glenoid baseplate. Allografts and specific designs with a longer post can be mandatory to obtain a stable fixation of the new baseplate.^9-12

We hypothesized that a completely convertible platform system on both the humeral and the glenoid side could facilitate the revision of a failed TSA to a RSA. This would enable the surgeon to leave the humeral stem and the glenoid baseplate in place, avoiding the difficulty of stem removal and the reimplantation of a glenoid component, especially in osteoporotic glenoid bone and elderly patients. The revision procedure would then only consist of replacing the humeral head by a metallic tray and polyethylene bearing on the humeral side and by impacting a glenosphere on the glenoid baseplate (Figures 2A, 2B).

The purpose of this study was to demonstrate the feasibility of revisions with this completely convertible system and to report clinical and radiographic results of a retrospective review of 13 cases.

MATERIALS AND METHODS

PATIENT SELECTION

Between 2003 and 2011, 104 primary TSAs were performed with an uncemented glenoid component in our group. Of these patients, 18 underwent revision (17.3%). Among these 18 patients, 13 were revised to RSA using a modular convertible platform system and were included in this study, while 5 patients were revised to another TSA (2 dissociations of the polyethylene glenoid implant, 2 excessively low implantations of the glenoid baseplate, and 1 glenoid loosening). The mean age of the 13 patients (9 women, 4 men) included in this retrospective study at the time of revision was 64 years (range, 50-75 years). The reasons for revision surgery were rotator cuff tear (5, among which 2 were posterosuperior tears, and 3 were tears of the subscapularis), dislocations (5 posterior and 1 anterior, among which 4 had a B2 or C glenoid), suprascapular nerve paralysis (1), and dissociation of the polyethylene (1). The initial TSA was indicated for primary osteoarthritis with a normal cuff (9), primary osteoarthritis with a reparable cuff tear (2), posttraumatic osteoarthritis (1), and chronic dislocation (1). The right dominant shoulder was involved in 10 cases. The mean time interval between the primary TSA and the revision was 15 months (range, 1-61 months).

OPERATIVE TECHNIQUE

PREOPERATIVE PLANNING

Revision of a failed TSA is always a difficult challenge, and evaluation of bone loss on both the humeral and the glenoid sides, as well as the status of the cuff, is mandatory, even with a completely convertible arthroplasty system. The surgeon must be prepared to remove the humeral stem in case reduction of the joint is impossible. We systematically performed standard radiographs (anteroposterior, axillary, and outlet views) and computed tomography (CT) scans in order to assess both the version and positioning, as well as potential signs of loosening of the implants and the status of the cuff (continuity, degree of muscle trophicity, and fatty infiltration). A preoperative leucocyte count, sedimentation rate, and C-reactive protein rates were requested in every revision case, even if a mechanical etiology was strongly suspected.

Continue to: REVISION PROCEDURE

All the implants that had been used in the primary TSAs were Arrow Universal Shoulder Prostheses (FH Orthopedics). All revisions were performed through the previous deltopectoral approach in the beach chair position under general anesthesia with an interscalene block. Adhesions of the deep part of the deltoid were carefully released. The conjoint tendon was released, and the location of the musculocutaneous and axillary nerves was identified before any retractor was placed. In the 10 cases where the subscapularis was intact, it was peeled off the medial border of the bicipital groove to obtain sufficient length for a tension-free reinsertion.

The anatomical head of the humeral implant was disconnected from the stem and removed. All stems were found to be well fixed; there were no cases of loosening or evidence of infection. A circumferential capsular release was systematically carried out. The polyethylene glenoid onlay was then unlocked from the baseplate.

The quality of the fixation of the glenoid baseplate was systematically evaluated; no screw was found to be loose, and the fixation of all baseplates was stable. Therefore, there was no need to revise the glenoid baseplate, even when its position was considered excessively retroverted (Glenoid B2) or high. A glenosphere was impacted on the baseplate, and a polyethylene humeral bearing was then implanted on the humeral stem. The thinnest polyethylene bearing available (number 0) was chosen in all cases, and a size 36 glenosphere was chosen in 12 out of 13 cases. Intraoperative stability of the implant was satisfactory, and no impingement was found posteriorly, anteriorly, or inferiorly.

In one case, the humeral stem was a first-generation humeral implant which was not compatible with the new-generation humeral bearing, and the humeral stem had to be replaced.

In 2 cases, reduction of the RSA was either impossible or felt to be too tight, even after extensive soft-tissue release and resection of the remaining supraspinatus. The main reason for this was an excessively proud humeral stem because of an onlay polyethylene humeral bearing instead of an inlay design. However, removal of the uncemented humeral stem was always possible with no osteotomy or cortical window of the humeral shaft as the humeral stem has been designed with a bone ingrowth surface only on the metaphyseal part with a smooth surface on diaphyseal part. After removal of the stem, a small amount of humeral metaphysis was cut, and a new humeral stem was press-fit in a lower position. This allowed restoration of an appropriate tension of the soft tissue and, therefore, an easier reduction. The subscapularis was medialized and reinserted transosseously when possible with a double-row repair. In 3 cases, the subscapularis was torn and retracted at the level of the glenoid, or impossible to identify to allow its reinsertion.

Continue to: According to our infectious disease department...

According to our infectious disease department, we made a minimum of 5 cultures for each revision case looking for a possible low-grade infection. All cultures in our group are held for 14 days to assess for Propionibacterium acnes.

POSTOPERATIVE MANAGEMENT

A shoulder splint in neutral rotation was used for the first 4 weeks. Passive range of motion (ROM) was started immediately with pendulum exercises and passive anterior elevation. Active assisted and active ROM were allowed after 4 weeks, and physiotherapy was continued for 6 months. Elderly patients were referred to a center of rehabilitation. We found only 1 or 2 positive cultures (Propionibacterium acnes) for 4 patients, and we decided to consider them as a contamination. None of the patients were treated with antibiotics.

CLINICAL AND RADIOLOGICAL ASSESSMENT

Clinical evaluation included pre- and postoperative pain scores (visual analog scale [VAS]), ROM, the Constant-Murley¹³ score, the Simple Shoulder Test (SST),¹⁴ and the subjective shoulder value.¹⁵ Subjective satisfaction was assessed by asking the patients at follow-up how they felt compared with before surgery and was graded using a 4-point scale: 1, much better; 2, better; 3, the same; and 4, worse. Radiographic evaluation was performed on pre- and postoperative standard anteroposterior, outlet, and axillary views. Radiographs were reviewed to determine the presence of glenohumeral subluxation, periprosthetic lucency, component shift in position, and scapular notching.

STATISTICAL ANALYSIS

Descriptive statistics are reported as mean (range) for continuous measures and number (percentage) for discrete variables. The Wilcoxon signed-rank test was used for preoperative vs postoperative changes. The alpha level for all tests was set at 0.05 for statistical significance.

RESULTS

CLINICAL OUTCOME

At a mean of 22 months (range, 7-38 months) follow-up after revision, active ROM was significantly improved. Active flexion increased significantly from a mean of 93° (range, 30°-120°) to 138° (range, 95°-170°) (P = 0.021). Active external rotation with the elbow on the side increased significantly from 8° (range, −20°-15°) to 25° (range, −10°-60°) (P = 0.034), and increased with the arm held at 90° abduction from 13° (range, 0°-20°) to 49° (range, 0°-80°) (P = 0.025). Mean pain scores improved from 4.2 to 13.3 points (P < 0.001). VAS improved significantly from 9 to 1 (P < 0.0001). The mean Constant Scores improved from 21 (range, 18-32) to 63 (range, 43-90) (P = 0.006). The final SST was 7 per 12. Subjectively, 4 patients rated their shoulder as much better, 8 as better, and 1 as the same as preoperatively. No intra- or postoperative complications, including infections, were observed. The mean duration of the procedure was 60 minutes (range, 30-75 minutes).

Continue to: RADIOLOGICAL OUTCOME

No periprosthetic lucency or shift in component was observed at the last follow-up. There was no scapular notching. No resorption of the tuberosities, and no fractures of the acromion or the scapular spine were observed.

DISCUSSION

In this retrospective study, failure of TSA with a metal-backed glenoid implant was successfully revised to RSA. In 10 patients, the use of a universal platform system allowed an easier conversion without removal of the humeral stem or the glenoid component (Figures 3A-3D). Twelve of the 13 patients were satisfied or very satisfied at the last follow-up. None of the patients were in pain, and the mean Constant score was 63. In all the cases, the glenoid baseplate was not changed. In 3 cases the humeral stem was changed without any fracture of the tuberosities of need for an osteotomy. This greatly simplified the revision procedure, as glenoid revisions can be very challenging. Indeed, it is often difficult to assess precisely preoperatively the remaining glenoid bone stock after removal of the glenoid component and the cement. Many therapeutic options to deal with glenoid loosening have been reported in the literature: glenoid bone reconstruction after glenoid component removal and revision to a hemiarthroplasty (HA),^10,16-18 glenoid bone reconstruction after glenoid component removal and revision to a new TSA with a cemented glenoid implant,^16,17,19,20 and glenoid reconstruction after glenoid component removal and revision to a RSA.^12,21 These authors reported that glenoid reconstruction frequently necessitates an iliac bone graft associated with a special design of the baseplate with a long post fixed into the native glenoid bone. However, sometimes implantation of an uncemented glenoid component can be unstable with a high risk of early mobilization of the implant, and 2 steps may be necessary. Conversion to a HA,^10,16-18 or a TSA^16,17,19,20 with a new cemented implant have both been associated with poor clinical outcome, with a high rate of recurrent glenoid loosening for the TSAs.

In our retrospective study, we reported no intra- or postoperative complications. Flury and colleagues²² reported a complication rate of 38% in 21 patients after conversion from a TSA to a RSA with a mean follow-up of 46 months. They removed all the components of the prosthesis with a crack or fracture of the humerus and/or the glenoid. Ortmaier and colleagues²³ reported a rate of complication of 22.7% during the conversion of TSA to RSA. They did an osteotomy of the humeral diaphysis to extract the stem in 40% of cases and had to remove the glenoid cement in 86% of cases with severe damage of the glenoid bone in 10% of cases. Fewer complications were found in our study, as we did not need any procedure such as humeral osteotomy, cerclage, bone grafting, and/or reconstruction of the glenoid. The short operative time and the absence of extensive soft-tissue dissection, thanks to a standard deltopectoral approach, could explain the absence of infection in our series.

Other authors shared our strategy of a universal convertible system and reported their results in the literature. Castagna and colleagues²⁴ in 2013 reported the clinical and radiological results of conversions of HA or TSA to RSA using a modular, convertible system (SMR Shoulder System, Lima Corporate). In their series, only 8 cases of TSAs were converted to RSA. They preserved, in each case, the humeral stem and the glenoid baseplate. There were no intra- or postoperative complications. The mean VAS score decreased from 8 to 2. Weber-Spickschen and colleague²⁵ reported recently in 2015 the same experience with the same system (SMR Shoulder System). They reviewed 15 conversions of TSAs to RSAs without any removal of the implants at a mean 43-month follow-up. They reported excellent pain relief (VAS decreased from 8 to 1) and improvement in shoulder function with a low rate of complications.

Kany and colleagues²⁶ in 2015 had already reported the advantages of a shoulder platform system for revisions. In their series, the authors included cases of failure of HAs and TSAs with loose cemented glenoids and metal-backed glenoids. The clinical and radiological results were similar, with a final Constant score of 60 (range, 42-85) and a similar rate of humeral stems which had to be changed (24%). These stems were replaced either because they were too proud or because there was not enough space to add an onlay polyethylene socket.

Continue to: Despite the encouraging results...

Despite the encouraging results reported in this study, there are some limitations. Firstly, no control group was used. Attempting to address this issue, we compared our results with the literature. Secondly, the number of patients in our study was small. Finally, the follow-up duration (mean 22 months) did not provide long-term outcomes.

CONCLUSION

This retrospective study shows that a complete convertible system facilitates conversion of TSAs to RSAs with excellent pain relief and a significant improvement in shoulder function. A platform system on both the humeral and the glenoid side reduces the operative time of the conversion with a low risk of complications.

ABSTRACT

Removal of a cemented glenoid component often leads to massive glenoid bone loss, which makes it difficult to implant a new glenoid baseplate. The purpose of this study was to demonstrate the feasibility of revisions with a completely convertible system and to report clinical and radiographic results of a retrospective review of 13 cases.

Between 2003 and 2011, 104 primary total shoulder arthroplasties (TSAs) were performed with an uncemented glenoid component in our group. Of these patients, 13 (average age, 64 years) were revised to reverse shoulder arthroplasty (RSA) using a modular convertible platform system and were included in this study. Average follow-up after revision was 22 months. Outcome measures included pain, range of motion, Constant-Murley scores, Simple Shoulder Tests, and subjective shoulder values. Active flexion increased significantly from a mean of 93° (range, 30°-120°) to 138° (range, 95°-170°) (P = 0.021), and active external rotation increased significantly from 8° (range, −20°-15°) to 25° (range, −10°-60°). Mean pain scores significantly improved from 4.2 to 13.3 points. The mean Constant Scores improved from 21 (range, 18-32) to 63 (range, 43-90). Subjectively, 12 patients rated their shoulder as better or much better than preoperatively. This retrospective study shows that a complete convertible system facilitates conversion of TSAs to RSAs with excellent pain relief and a significant improvement in shoulder function.

Continue to: Polyethylene glenoid components...

Polyethylene glenoid components are the gold standard in anatomic total shoulder arthroplasty (TSA). However, even though TSA survivorship exceeds 95% at 10-year follow-up,¹ glenoid component loosening remains the main complication and the weak link in these implants. This complication accounts for 25% of all complications related to TSA in the literature.² In most cases, glenoid component loosening is not isolated but combined with a rotator cuff tear, glenohumeral instability, or component malposition.^3-5 Therefore, revision of TSA to reverse shoulder arthroplasty (RSA) often requires the removal of both the humeral stem and glenoid component. Removal of the humeral stem can be challenging and can necessitate removal of the cement and osteotomy of the diaphysis, risking fracture and extensive damage to the soft tissue (Figures 1A, 1B).^6-8 Removal of a cemented glenoid component often leads to massive glenoid bone loss, which makes it difficult to implant a new glenoid baseplate. Allografts and specific designs with a longer post can be mandatory to obtain a stable fixation of the new baseplate.^9-12

We hypothesized that a completely convertible platform system on both the humeral and the glenoid side could facilitate the revision of a failed TSA to a RSA. This would enable the surgeon to leave the humeral stem and the glenoid baseplate in place, avoiding the difficulty of stem removal and the reimplantation of a glenoid component, especially in osteoporotic glenoid bone and elderly patients. The revision procedure would then only consist of replacing the humeral head by a metallic tray and polyethylene bearing on the humeral side and by impacting a glenosphere on the glenoid baseplate (Figures 2A, 2B).

The purpose of this study was to demonstrate the feasibility of revisions with this completely convertible system and to report clinical and radiographic results of a retrospective review of 13 cases.

MATERIALS AND METHODS

PATIENT SELECTION

Between 2003 and 2011, 104 primary TSAs were performed with an uncemented glenoid component in our group. Of these patients, 18 underwent revision (17.3%). Among these 18 patients, 13 were revised to RSA using a modular convertible platform system and were included in this study, while 5 patients were revised to another TSA (2 dissociations of the polyethylene glenoid implant, 2 excessively low implantations of the glenoid baseplate, and 1 glenoid loosening). The mean age of the 13 patients (9 women, 4 men) included in this retrospective study at the time of revision was 64 years (range, 50-75 years). The reasons for revision surgery were rotator cuff tear (5, among which 2 were posterosuperior tears, and 3 were tears of the subscapularis), dislocations (5 posterior and 1 anterior, among which 4 had a B2 or C glenoid), suprascapular nerve paralysis (1), and dissociation of the polyethylene (1). The initial TSA was indicated for primary osteoarthritis with a normal cuff (9), primary osteoarthritis with a reparable cuff tear (2), posttraumatic osteoarthritis (1), and chronic dislocation (1). The right dominant shoulder was involved in 10 cases. The mean time interval between the primary TSA and the revision was 15 months (range, 1-61 months).

OPERATIVE TECHNIQUE

PREOPERATIVE PLANNING

Revision of a failed TSA is always a difficult challenge, and evaluation of bone loss on both the humeral and the glenoid sides, as well as the status of the cuff, is mandatory, even with a completely convertible arthroplasty system. The surgeon must be prepared to remove the humeral stem in case reduction of the joint is impossible. We systematically performed standard radiographs (anteroposterior, axillary, and outlet views) and computed tomography (CT) scans in order to assess both the version and positioning, as well as potential signs of loosening of the implants and the status of the cuff (continuity, degree of muscle trophicity, and fatty infiltration). A preoperative leucocyte count, sedimentation rate, and C-reactive protein rates were requested in every revision case, even if a mechanical etiology was strongly suspected.

Continue to: REVISION PROCEDURE

All the implants that had been used in the primary TSAs were Arrow Universal Shoulder Prostheses (FH Orthopedics). All revisions were performed through the previous deltopectoral approach in the beach chair position under general anesthesia with an interscalene block. Adhesions of the deep part of the deltoid were carefully released. The conjoint tendon was released, and the location of the musculocutaneous and axillary nerves was identified before any retractor was placed. In the 10 cases where the subscapularis was intact, it was peeled off the medial border of the bicipital groove to obtain sufficient length for a tension-free reinsertion.

The anatomical head of the humeral implant was disconnected from the stem and removed. All stems were found to be well fixed; there were no cases of loosening or evidence of infection. A circumferential capsular release was systematically carried out. The polyethylene glenoid onlay was then unlocked from the baseplate.

The quality of the fixation of the glenoid baseplate was systematically evaluated; no screw was found to be loose, and the fixation of all baseplates was stable. Therefore, there was no need to revise the glenoid baseplate, even when its position was considered excessively retroverted (Glenoid B2) or high. A glenosphere was impacted on the baseplate, and a polyethylene humeral bearing was then implanted on the humeral stem. The thinnest polyethylene bearing available (number 0) was chosen in all cases, and a size 36 glenosphere was chosen in 12 out of 13 cases. Intraoperative stability of the implant was satisfactory, and no impingement was found posteriorly, anteriorly, or inferiorly.

In one case, the humeral stem was a first-generation humeral implant which was not compatible with the new-generation humeral bearing, and the humeral stem had to be replaced.

In 2 cases, reduction of the RSA was either impossible or felt to be too tight, even after extensive soft-tissue release and resection of the remaining supraspinatus. The main reason for this was an excessively proud humeral stem because of an onlay polyethylene humeral bearing instead of an inlay design. However, removal of the uncemented humeral stem was always possible with no osteotomy or cortical window of the humeral shaft as the humeral stem has been designed with a bone ingrowth surface only on the metaphyseal part with a smooth surface on diaphyseal part. After removal of the stem, a small amount of humeral metaphysis was cut, and a new humeral stem was press-fit in a lower position. This allowed restoration of an appropriate tension of the soft tissue and, therefore, an easier reduction. The subscapularis was medialized and reinserted transosseously when possible with a double-row repair. In 3 cases, the subscapularis was torn and retracted at the level of the glenoid, or impossible to identify to allow its reinsertion.

Continue to: According to our infectious disease department...

According to our infectious disease department, we made a minimum of 5 cultures for each revision case looking for a possible low-grade infection. All cultures in our group are held for 14 days to assess for Propionibacterium acnes.

POSTOPERATIVE MANAGEMENT

A shoulder splint in neutral rotation was used for the first 4 weeks. Passive range of motion (ROM) was started immediately with pendulum exercises and passive anterior elevation. Active assisted and active ROM were allowed after 4 weeks, and physiotherapy was continued for 6 months. Elderly patients were referred to a center of rehabilitation. We found only 1 or 2 positive cultures (Propionibacterium acnes) for 4 patients, and we decided to consider them as a contamination. None of the patients were treated with antibiotics.

CLINICAL AND RADIOLOGICAL ASSESSMENT

Clinical evaluation included pre- and postoperative pain scores (visual analog scale [VAS]), ROM, the Constant-Murley¹³ score, the Simple Shoulder Test (SST),¹⁴ and the subjective shoulder value.¹⁵ Subjective satisfaction was assessed by asking the patients at follow-up how they felt compared with before surgery and was graded using a 4-point scale: 1, much better; 2, better; 3, the same; and 4, worse. Radiographic evaluation was performed on pre- and postoperative standard anteroposterior, outlet, and axillary views. Radiographs were reviewed to determine the presence of glenohumeral subluxation, periprosthetic lucency, component shift in position, and scapular notching.

STATISTICAL ANALYSIS

Descriptive statistics are reported as mean (range) for continuous measures and number (percentage) for discrete variables. The Wilcoxon signed-rank test was used for preoperative vs postoperative changes. The alpha level for all tests was set at 0.05 for statistical significance.

RESULTS

CLINICAL OUTCOME

At a mean of 22 months (range, 7-38 months) follow-up after revision, active ROM was significantly improved. Active flexion increased significantly from a mean of 93° (range, 30°-120°) to 138° (range, 95°-170°) (P = 0.021). Active external rotation with the elbow on the side increased significantly from 8° (range, −20°-15°) to 25° (range, −10°-60°) (P = 0.034), and increased with the arm held at 90° abduction from 13° (range, 0°-20°) to 49° (range, 0°-80°) (P = 0.025). Mean pain scores improved from 4.2 to 13.3 points (P < 0.001). VAS improved significantly from 9 to 1 (P < 0.0001). The mean Constant Scores improved from 21 (range, 18-32) to 63 (range, 43-90) (P = 0.006). The final SST was 7 per 12. Subjectively, 4 patients rated their shoulder as much better, 8 as better, and 1 as the same as preoperatively. No intra- or postoperative complications, including infections, were observed. The mean duration of the procedure was 60 minutes (range, 30-75 minutes).

Continue to: RADIOLOGICAL OUTCOME

No periprosthetic lucency or shift in component was observed at the last follow-up. There was no scapular notching. No resorption of the tuberosities, and no fractures of the acromion or the scapular spine were observed.

DISCUSSION

In this retrospective study, failure of TSA with a metal-backed glenoid implant was successfully revised to RSA. In 10 patients, the use of a universal platform system allowed an easier conversion without removal of the humeral stem or the glenoid component (Figures 3A-3D). Twelve of the 13 patients were satisfied or very satisfied at the last follow-up. None of the patients were in pain, and the mean Constant score was 63. In all the cases, the glenoid baseplate was not changed. In 3 cases the humeral stem was changed without any fracture of the tuberosities of need for an osteotomy. This greatly simplified the revision procedure, as glenoid revisions can be very challenging. Indeed, it is often difficult to assess precisely preoperatively the remaining glenoid bone stock after removal of the glenoid component and the cement. Many therapeutic options to deal with glenoid loosening have been reported in the literature: glenoid bone reconstruction after glenoid component removal and revision to a hemiarthroplasty (HA),^10,16-18 glenoid bone reconstruction after glenoid component removal and revision to a new TSA with a cemented glenoid implant,^16,17,19,20 and glenoid reconstruction after glenoid component removal and revision to a RSA.^12,21 These authors reported that glenoid reconstruction frequently necessitates an iliac bone graft associated with a special design of the baseplate with a long post fixed into the native glenoid bone. However, sometimes implantation of an uncemented glenoid component can be unstable with a high risk of early mobilization of the implant, and 2 steps may be necessary. Conversion to a HA,^10,16-18 or a TSA^16,17,19,20 with a new cemented implant have both been associated with poor clinical outcome, with a high rate of recurrent glenoid loosening for the TSAs.

In our retrospective study, we reported no intra- or postoperative complications. Flury and colleagues²² reported a complication rate of 38% in 21 patients after conversion from a TSA to a RSA with a mean follow-up of 46 months. They removed all the components of the prosthesis with a crack or fracture of the humerus and/or the glenoid. Ortmaier and colleagues²³ reported a rate of complication of 22.7% during the conversion of TSA to RSA. They did an osteotomy of the humeral diaphysis to extract the stem in 40% of cases and had to remove the glenoid cement in 86% of cases with severe damage of the glenoid bone in 10% of cases. Fewer complications were found in our study, as we did not need any procedure such as humeral osteotomy, cerclage, bone grafting, and/or reconstruction of the glenoid. The short operative time and the absence of extensive soft-tissue dissection, thanks to a standard deltopectoral approach, could explain the absence of infection in our series.

Other authors shared our strategy of a universal convertible system and reported their results in the literature. Castagna and colleagues²⁴ in 2013 reported the clinical and radiological results of conversions of HA or TSA to RSA using a modular, convertible system (SMR Shoulder System, Lima Corporate). In their series, only 8 cases of TSAs were converted to RSA. They preserved, in each case, the humeral stem and the glenoid baseplate. There were no intra- or postoperative complications. The mean VAS score decreased from 8 to 2. Weber-Spickschen and colleague²⁵ reported recently in 2015 the same experience with the same system (SMR Shoulder System). They reviewed 15 conversions of TSAs to RSAs without any removal of the implants at a mean 43-month follow-up. They reported excellent pain relief (VAS decreased from 8 to 1) and improvement in shoulder function with a low rate of complications.

Kany and colleagues²⁶ in 2015 had already reported the advantages of a shoulder platform system for revisions. In their series, the authors included cases of failure of HAs and TSAs with loose cemented glenoids and metal-backed glenoids. The clinical and radiological results were similar, with a final Constant score of 60 (range, 42-85) and a similar rate of humeral stems which had to be changed (24%). These stems were replaced either because they were too proud or because there was not enough space to add an onlay polyethylene socket.

Continue to: Despite the encouraging results...

Despite the encouraging results reported in this study, there are some limitations. Firstly, no control group was used. Attempting to address this issue, we compared our results with the literature. Secondly, the number of patients in our study was small. Finally, the follow-up duration (mean 22 months) did not provide long-term outcomes.

CONCLUSION

This retrospective study shows that a complete convertible system facilitates conversion of TSAs to RSAs with excellent pain relief and a significant improvement in shoulder function. A platform system on both the humeral and the glenoid side reduces the operative time of the conversion with a low risk of complications.

ABSTRACT

Removal of a cemented glenoid component often leads to massive glenoid bone loss, which makes it difficult to implant a new glenoid baseplate. The purpose of this study was to demonstrate the feasibility of revisions with a completely convertible system and to report clinical and radiographic results of a retrospective review of 13 cases.

Between 2003 and 2011, 104 primary total shoulder arthroplasties (TSAs) were performed with an uncemented glenoid component in our group. Of these patients, 13 (average age, 64 years) were revised to reverse shoulder arthroplasty (RSA) using a modular convertible platform system and were included in this study. Average follow-up after revision was 22 months. Outcome measures included pain, range of motion, Constant-Murley scores, Simple Shoulder Tests, and subjective shoulder values. Active flexion increased significantly from a mean of 93° (range, 30°-120°) to 138° (range, 95°-170°) (P = 0.021), and active external rotation increased significantly from 8° (range, −20°-15°) to 25° (range, −10°-60°). Mean pain scores significantly improved from 4.2 to 13.3 points. The mean Constant Scores improved from 21 (range, 18-32) to 63 (range, 43-90). Subjectively, 12 patients rated their shoulder as better or much better than preoperatively. This retrospective study shows that a complete convertible system facilitates conversion of TSAs to RSAs with excellent pain relief and a significant improvement in shoulder function.

Continue to: Polyethylene glenoid components...

Polyethylene glenoid components are the gold standard in anatomic total shoulder arthroplasty (TSA). However, even though TSA survivorship exceeds 95% at 10-year follow-up,¹ glenoid component loosening remains the main complication and the weak link in these implants. This complication accounts for 25% of all complications related to TSA in the literature.² In most cases, glenoid component loosening is not isolated but combined with a rotator cuff tear, glenohumeral instability, or component malposition.^3-5 Therefore, revision of TSA to reverse shoulder arthroplasty (RSA) often requires the removal of both the humeral stem and glenoid component. Removal of the humeral stem can be challenging and can necessitate removal of the cement and osteotomy of the diaphysis, risking fracture and extensive damage to the soft tissue (Figures 1A, 1B).^6-8 Removal of a cemented glenoid component often leads to massive glenoid bone loss, which makes it difficult to implant a new glenoid baseplate. Allografts and specific designs with a longer post can be mandatory to obtain a stable fixation of the new baseplate.^9-12

We hypothesized that a completely convertible platform system on both the humeral and the glenoid side could facilitate the revision of a failed TSA to a RSA. This would enable the surgeon to leave the humeral stem and the glenoid baseplate in place, avoiding the difficulty of stem removal and the reimplantation of a glenoid component, especially in osteoporotic glenoid bone and elderly patients. The revision procedure would then only consist of replacing the humeral head by a metallic tray and polyethylene bearing on the humeral side and by impacting a glenosphere on the glenoid baseplate (Figures 2A, 2B).

The purpose of this study was to demonstrate the feasibility of revisions with this completely convertible system and to report clinical and radiographic results of a retrospective review of 13 cases.

MATERIALS AND METHODS

PATIENT SELECTION

Between 2003 and 2011, 104 primary TSAs were performed with an uncemented glenoid component in our group. Of these patients, 18 underwent revision (17.3%). Among these 18 patients, 13 were revised to RSA using a modular convertible platform system and were included in this study, while 5 patients were revised to another TSA (2 dissociations of the polyethylene glenoid implant, 2 excessively low implantations of the glenoid baseplate, and 1 glenoid loosening). The mean age of the 13 patients (9 women, 4 men) included in this retrospective study at the time of revision was 64 years (range, 50-75 years). The reasons for revision surgery were rotator cuff tear (5, among which 2 were posterosuperior tears, and 3 were tears of the subscapularis), dislocations (5 posterior and 1 anterior, among which 4 had a B2 or C glenoid), suprascapular nerve paralysis (1), and dissociation of the polyethylene (1). The initial TSA was indicated for primary osteoarthritis with a normal cuff (9), primary osteoarthritis with a reparable cuff tear (2), posttraumatic osteoarthritis (1), and chronic dislocation (1). The right dominant shoulder was involved in 10 cases. The mean time interval between the primary TSA and the revision was 15 months (range, 1-61 months).

OPERATIVE TECHNIQUE

PREOPERATIVE PLANNING

Revision of a failed TSA is always a difficult challenge, and evaluation of bone loss on both the humeral and the glenoid sides, as well as the status of the cuff, is mandatory, even with a completely convertible arthroplasty system. The surgeon must be prepared to remove the humeral stem in case reduction of the joint is impossible. We systematically performed standard radiographs (anteroposterior, axillary, and outlet views) and computed tomography (CT) scans in order to assess both the version and positioning, as well as potential signs of loosening of the implants and the status of the cuff (continuity, degree of muscle trophicity, and fatty infiltration). A preoperative leucocyte count, sedimentation rate, and C-reactive protein rates were requested in every revision case, even if a mechanical etiology was strongly suspected.

Continue to: REVISION PROCEDURE

All the implants that had been used in the primary TSAs were Arrow Universal Shoulder Prostheses (FH Orthopedics). All revisions were performed through the previous deltopectoral approach in the beach chair position under general anesthesia with an interscalene block. Adhesions of the deep part of the deltoid were carefully released. The conjoint tendon was released, and the location of the musculocutaneous and axillary nerves was identified before any retractor was placed. In the 10 cases where the subscapularis was intact, it was peeled off the medial border of the bicipital groove to obtain sufficient length for a tension-free reinsertion.

The anatomical head of the humeral implant was disconnected from the stem and removed. All stems were found to be well fixed; there were no cases of loosening or evidence of infection. A circumferential capsular release was systematically carried out. The polyethylene glenoid onlay was then unlocked from the baseplate.

The quality of the fixation of the glenoid baseplate was systematically evaluated; no screw was found to be loose, and the fixation of all baseplates was stable. Therefore, there was no need to revise the glenoid baseplate, even when its position was considered excessively retroverted (Glenoid B2) or high. A glenosphere was impacted on the baseplate, and a polyethylene humeral bearing was then implanted on the humeral stem. The thinnest polyethylene bearing available (number 0) was chosen in all cases, and a size 36 glenosphere was chosen in 12 out of 13 cases. Intraoperative stability of the implant was satisfactory, and no impingement was found posteriorly, anteriorly, or inferiorly.

In one case, the humeral stem was a first-generation humeral implant which was not compatible with the new-generation humeral bearing, and the humeral stem had to be replaced.

In 2 cases, reduction of the RSA was either impossible or felt to be too tight, even after extensive soft-tissue release and resection of the remaining supraspinatus. The main reason for this was an excessively proud humeral stem because of an onlay polyethylene humeral bearing instead of an inlay design. However, removal of the uncemented humeral stem was always possible with no osteotomy or cortical window of the humeral shaft as the humeral stem has been designed with a bone ingrowth surface only on the metaphyseal part with a smooth surface on diaphyseal part. After removal of the stem, a small amount of humeral metaphysis was cut, and a new humeral stem was press-fit in a lower position. This allowed restoration of an appropriate tension of the soft tissue and, therefore, an easier reduction. The subscapularis was medialized and reinserted transosseously when possible with a double-row repair. In 3 cases, the subscapularis was torn and retracted at the level of the glenoid, or impossible to identify to allow its reinsertion.

Continue to: According to our infectious disease department...

According to our infectious disease department, we made a minimum of 5 cultures for each revision case looking for a possible low-grade infection. All cultures in our group are held for 14 days to assess for Propionibacterium acnes.

POSTOPERATIVE MANAGEMENT

A shoulder splint in neutral rotation was used for the first 4 weeks. Passive range of motion (ROM) was started immediately with pendulum exercises and passive anterior elevation. Active assisted and active ROM were allowed after 4 weeks, and physiotherapy was continued for 6 months. Elderly patients were referred to a center of rehabilitation. We found only 1 or 2 positive cultures (Propionibacterium acnes) for 4 patients, and we decided to consider them as a contamination. None of the patients were treated with antibiotics.

CLINICAL AND RADIOLOGICAL ASSESSMENT

Clinical evaluation included pre- and postoperative pain scores (visual analog scale [VAS]), ROM, the Constant-Murley¹³ score, the Simple Shoulder Test (SST),¹⁴ and the subjective shoulder value.¹⁵ Subjective satisfaction was assessed by asking the patients at follow-up how they felt compared with before surgery and was graded using a 4-point scale: 1, much better; 2, better; 3, the same; and 4, worse. Radiographic evaluation was performed on pre- and postoperative standard anteroposterior, outlet, and axillary views. Radiographs were reviewed to determine the presence of glenohumeral subluxation, periprosthetic lucency, component shift in position, and scapular notching.

STATISTICAL ANALYSIS

Descriptive statistics are reported as mean (range) for continuous measures and number (percentage) for discrete variables. The Wilcoxon signed-rank test was used for preoperative vs postoperative changes. The alpha level for all tests was set at 0.05 for statistical significance.

RESULTS

CLINICAL OUTCOME

At a mean of 22 months (range, 7-38 months) follow-up after revision, active ROM was significantly improved. Active flexion increased significantly from a mean of 93° (range, 30°-120°) to 138° (range, 95°-170°) (P = 0.021). Active external rotation with the elbow on the side increased significantly from 8° (range, −20°-15°) to 25° (range, −10°-60°) (P = 0.034), and increased with the arm held at 90° abduction from 13° (range, 0°-20°) to 49° (range, 0°-80°) (P = 0.025). Mean pain scores improved from 4.2 to 13.3 points (P < 0.001). VAS improved significantly from 9 to 1 (P < 0.0001). The mean Constant Scores improved from 21 (range, 18-32) to 63 (range, 43-90) (P = 0.006). The final SST was 7 per 12. Subjectively, 4 patients rated their shoulder as much better, 8 as better, and 1 as the same as preoperatively. No intra- or postoperative complications, including infections, were observed. The mean duration of the procedure was 60 minutes (range, 30-75 minutes).

Continue to: RADIOLOGICAL OUTCOME

No periprosthetic lucency or shift in component was observed at the last follow-up. There was no scapular notching. No resorption of the tuberosities, and no fractures of the acromion or the scapular spine were observed.

DISCUSSION

In this retrospective study, failure of TSA with a metal-backed glenoid implant was successfully revised to RSA. In 10 patients, the use of a universal platform system allowed an easier conversion without removal of the humeral stem or the glenoid component (Figures 3A-3D). Twelve of the 13 patients were satisfied or very satisfied at the last follow-up. None of the patients were in pain, and the mean Constant score was 63. In all the cases, the glenoid baseplate was not changed. In 3 cases the humeral stem was changed without any fracture of the tuberosities of need for an osteotomy. This greatly simplified the revision procedure, as glenoid revisions can be very challenging. Indeed, it is often difficult to assess precisely preoperatively the remaining glenoid bone stock after removal of the glenoid component and the cement. Many therapeutic options to deal with glenoid loosening have been reported in the literature: glenoid bone reconstruction after glenoid component removal and revision to a hemiarthroplasty (HA),^10,16-18 glenoid bone reconstruction after glenoid component removal and revision to a new TSA with a cemented glenoid implant,^16,17,19,20 and glenoid reconstruction after glenoid component removal and revision to a RSA.^12,21 These authors reported that glenoid reconstruction frequently necessitates an iliac bone graft associated with a special design of the baseplate with a long post fixed into the native glenoid bone. However, sometimes implantation of an uncemented glenoid component can be unstable with a high risk of early mobilization of the implant, and 2 steps may be necessary. Conversion to a HA,^10,16-18 or a TSA^16,17,19,20 with a new cemented implant have both been associated with poor clinical outcome, with a high rate of recurrent glenoid loosening for the TSAs.

In our retrospective study, we reported no intra- or postoperative complications. Flury and colleagues²² reported a complication rate of 38% in 21 patients after conversion from a TSA to a RSA with a mean follow-up of 46 months. They removed all the components of the prosthesis with a crack or fracture of the humerus and/or the glenoid. Ortmaier and colleagues²³ reported a rate of complication of 22.7% during the conversion of TSA to RSA. They did an osteotomy of the humeral diaphysis to extract the stem in 40% of cases and had to remove the glenoid cement in 86% of cases with severe damage of the glenoid bone in 10% of cases. Fewer complications were found in our study, as we did not need any procedure such as humeral osteotomy, cerclage, bone grafting, and/or reconstruction of the glenoid. The short operative time and the absence of extensive soft-tissue dissection, thanks to a standard deltopectoral approach, could explain the absence of infection in our series.

Other authors shared our strategy of a universal convertible system and reported their results in the literature. Castagna and colleagues²⁴ in 2013 reported the clinical and radiological results of conversions of HA or TSA to RSA using a modular, convertible system (SMR Shoulder System, Lima Corporate). In their series, only 8 cases of TSAs were converted to RSA. They preserved, in each case, the humeral stem and the glenoid baseplate. There were no intra- or postoperative complications. The mean VAS score decreased from 8 to 2. Weber-Spickschen and colleague²⁵ reported recently in 2015 the same experience with the same system (SMR Shoulder System). They reviewed 15 conversions of TSAs to RSAs without any removal of the implants at a mean 43-month follow-up. They reported excellent pain relief (VAS decreased from 8 to 1) and improvement in shoulder function with a low rate of complications.

Kany and colleagues²⁶ in 2015 had already reported the advantages of a shoulder platform system for revisions. In their series, the authors included cases of failure of HAs and TSAs with loose cemented glenoids and metal-backed glenoids. The clinical and radiological results were similar, with a final Constant score of 60 (range, 42-85) and a similar rate of humeral stems which had to be changed (24%). These stems were replaced either because they were too proud or because there was not enough space to add an onlay polyethylene socket.

Continue to: Despite the encouraging results...

Despite the encouraging results reported in this study, there are some limitations. Firstly, no control group was used. Attempting to address this issue, we compared our results with the literature. Secondly, the number of patients in our study was small. Finally, the follow-up duration (mean 22 months) did not provide long-term outcomes.

CONCLUSION

This retrospective study shows that a complete convertible system facilitates conversion of TSAs to RSAs with excellent pain relief and a significant improvement in shoulder function. A platform system on both the humeral and the glenoid side reduces the operative time of the conversion with a low risk of complications.

WASHINGTON – The Medicare Hospital Readmissions Reduction Program is working, according to an original analysis of Medicare claims data presented at a meeting of the Medicare Payment Advisory Commission.

“First, readmissions declined,” MedPAC staff member Jeff Stensland, PhD, said during a congressionally mandated staff report to the commissioners. “Second, while observation stays increased, they did not fully offset the decrease in readmissions. Third, while [emergency department] visits also increased, those increases appear to largely be due to factors other than the readmission program. And fourth, in addition, all the evidence we examined suggests that the readmissions program did not result in increased mortality.”

Copyright Kimberly Pack/Thinkstock

[email protected]

WASHINGTON – The Medicare Hospital Readmissions Reduction Program is working, according to an original analysis of Medicare claims data presented at a meeting of the Medicare Payment Advisory Commission.

“First, readmissions declined,” MedPAC staff member Jeff Stensland, PhD, said during a congressionally mandated staff report to the commissioners. “Second, while observation stays increased, they did not fully offset the decrease in readmissions. Third, while [emergency department] visits also increased, those increases appear to largely be due to factors other than the readmission program. And fourth, in addition, all the evidence we examined suggests that the readmissions program did not result in increased mortality.”

Copyright Kimberly Pack/Thinkstock

[email protected]

WASHINGTON – The Medicare Hospital Readmissions Reduction Program is working, according to an original analysis of Medicare claims data presented at a meeting of the Medicare Payment Advisory Commission.

“First, readmissions declined,” MedPAC staff member Jeff Stensland, PhD, said during a congressionally mandated staff report to the commissioners. “Second, while observation stays increased, they did not fully offset the decrease in readmissions. Third, while [emergency department] visits also increased, those increases appear to largely be due to factors other than the readmission program. And fourth, in addition, all the evidence we examined suggests that the readmissions program did not result in increased mortality.”

Copyright Kimberly Pack/Thinkstock

[email protected]

A significant proportion of patients with psoriasis and psoriatic arthritis (PsA) are underdiagnosed and undertreated for cardiovascular risk factors (CVRF), according to Lihi Eder, MD, of the University of Toronto, and her associates.

In a cross-sectional analysis published in the Journal of Rheumatology, researchers examined 2,254 patients (58.9% with PsA, 41.1% with psoriasis only) from eight centers in Canada, the United States, and Israel. They found that 1,017 of the patients had hypertension (PsA: 48.5%, psoriasis: 40.2%), including 233 who were not previously diagnosed with hypertension and were not taking any blood pressure–lowering medications (PsA: 19.9%, psoriasis: 39.1%). Many patients had low adherence to hypertension treatment recommendations: A total of 602 (PsA: 55.9%, psoriasis: 64.8%) were untreated or undertreated. Undertreatment of hypertension occurred in 60.9% patients with cardiovascular disease or diabetes mellitus.

[email protected]

SOURCE: Eder L et al. J Rheumatol. 2018 Feb 1. doi: 10.3899/jrheum.170379.

A significant proportion of patients with psoriasis and psoriatic arthritis (PsA) are underdiagnosed and undertreated for cardiovascular risk factors (CVRF), according to Lihi Eder, MD, of the University of Toronto, and her associates.

In a cross-sectional analysis published in the Journal of Rheumatology, researchers examined 2,254 patients (58.9% with PsA, 41.1% with psoriasis only) from eight centers in Canada, the United States, and Israel. They found that 1,017 of the patients had hypertension (PsA: 48.5%, psoriasis: 40.2%), including 233 who were not previously diagnosed with hypertension and were not taking any blood pressure–lowering medications (PsA: 19.9%, psoriasis: 39.1%). Many patients had low adherence to hypertension treatment recommendations: A total of 602 (PsA: 55.9%, psoriasis: 64.8%) were untreated or undertreated. Undertreatment of hypertension occurred in 60.9% patients with cardiovascular disease or diabetes mellitus.

[email protected]

SOURCE: Eder L et al. J Rheumatol. 2018 Feb 1. doi: 10.3899/jrheum.170379.

A significant proportion of patients with psoriasis and psoriatic arthritis (PsA) are underdiagnosed and undertreated for cardiovascular risk factors (CVRF), according to Lihi Eder, MD, of the University of Toronto, and her associates.

In a cross-sectional analysis published in the Journal of Rheumatology, researchers examined 2,254 patients (58.9% with PsA, 41.1% with psoriasis only) from eight centers in Canada, the United States, and Israel. They found that 1,017 of the patients had hypertension (PsA: 48.5%, psoriasis: 40.2%), including 233 who were not previously diagnosed with hypertension and were not taking any blood pressure–lowering medications (PsA: 19.9%, psoriasis: 39.1%). Many patients had low adherence to hypertension treatment recommendations: A total of 602 (PsA: 55.9%, psoriasis: 64.8%) were untreated or undertreated. Undertreatment of hypertension occurred in 60.9% patients with cardiovascular disease or diabetes mellitus.

[email protected]

SOURCE: Eder L et al. J Rheumatol. 2018 Feb 1. doi: 10.3899/jrheum.170379.

Fetal alcohol spectrum disorders could affect up to 1 in 20 children, according to a cross-sectional study.

Philip A. May, PhD, of the University of North Carolina, Gillings School of Global Public Health, and his coauthors assessed 6,639 first-grade children from four communities in the Rocky Mountain, Midwestern, Southeastern, and Pacific Southwestern regions of the United States.

In their report, published Feb. 6 in JAMA, they identified 222 cases of fetal alcohol spectrum disorders, representing conservative prevalence estimates ranging from 11.3 to 50 cases per 1,000 children (JAMA 2018;319[5]:474-82. doi: 10.1001/jama.2017.21896).

Of these children, 27 met the criteria for fetal alcohol syndrome, 104 met the criteria for partial fetal alcohol syndrome, and 91 met the criteria for alcohol-related neurodevelopmental disorder.

“These prevalence estimates are consistent with mounting evidence that harmful fetal alcohol exposure is common in the United States today and highlight the public health burden due to fetal alcohol spectrum disorders,” the authors wrote.

The finding was much higher than previous estimates of the prevalence of fetal alcohol spectrum disorders in the United States. The authors pointed out that routine surveillance methods may have previously underestimated the prevalence because so many children are either misdiagnosed or not diagnosed at all. But even two previous single-site, active-case ascertainment studies conducted in the United States found prevalence rates of 10 and 24 per 1,000 children.

“This consortium study, to our knowledge, was the first to apply active case ascertainment, common methodology, a single classification system, and expert in-person evaluation for a continuum of fetal alcohol spectrum disorders including alcohol-related neurodevelopmental disorder to a large number of children from communities across the United States,” the authors wrote. “These data have highlighted the need for a larger study with broader representation of U.S. communities with general population samples.”

Only 2 of the 222 children had actually been previously diagnosed with a fetal alcohol spectrum disorder, “although many parents and guardians were aware of the learning and behavioral challenges facing their children,” the researchers noted.

“These data confirm that missed diagnoses and misdiagnoses of children are common,” the authors wrote, pointing to a previous study in U.S. schoolchildren that found only one in seven children identified as having fetal alcohol syndrome had been previously diagnosed.

The assessment of fetal alcohol spectrum disorder was based on four domains: growth, dysmorphology, neurodevelopment, and prenatal alcohol exposure – the latter being assessed by interviewing the mother in person or by telephone.

The lowest prevalence – 11.3 per 1,000 children – was seen in the Midwestern community, while the highest – 50 per 1,000 – was in the Rocky Mountain community.

The main weakness of the study was that no individual sample included the entire eligible population because of differing policies on access to children for recruitment and variability in willingness to consent.

“Consent rates for screening ranged from 36.9% to 92.5% in individual samples and overall consent rates for screening averaged only 59.9% of eligible children,” the authors wrote. “If nonconsented children differed from consented, this could have biased prevalence estimates in either direction.”

The researchers acknowledged that the absence of a definitive biomarker for fetal alcohol spectrum disorder meant it was impossible to know for certain that the observed deficits were actually the result of fetal alcohol exposure, and that the prevalence estimates may therefore be overestimated.

The study was funded by grants from the National Institute on Alcohol Abuse and Alcoholism. One author declared grant support from the National Institute on Alcohol Abuse and Alcoholism and personal fees and honorarium from the Alcohol Center. No conflicts of interest were declared.

[email protected]

SOURCE: May, P et al. JAMA 2018;319[5]:474-82. doi: 10.1001/jama.2017.21896.

Fetal alcohol spectrum disorders could affect up to 1 in 20 children, according to a cross-sectional study.

Philip A. May, PhD, of the University of North Carolina, Gillings School of Global Public Health, and his coauthors assessed 6,639 first-grade children from four communities in the Rocky Mountain, Midwestern, Southeastern, and Pacific Southwestern regions of the United States.

In their report, published Feb. 6 in JAMA, they identified 222 cases of fetal alcohol spectrum disorders, representing conservative prevalence estimates ranging from 11.3 to 50 cases per 1,000 children (JAMA 2018;319[5]:474-82. doi: 10.1001/jama.2017.21896).

Of these children, 27 met the criteria for fetal alcohol syndrome, 104 met the criteria for partial fetal alcohol syndrome, and 91 met the criteria for alcohol-related neurodevelopmental disorder.

“These prevalence estimates are consistent with mounting evidence that harmful fetal alcohol exposure is common in the United States today and highlight the public health burden due to fetal alcohol spectrum disorders,” the authors wrote.

The finding was much higher than previous estimates of the prevalence of fetal alcohol spectrum disorders in the United States. The authors pointed out that routine surveillance methods may have previously underestimated the prevalence because so many children are either misdiagnosed or not diagnosed at all. But even two previous single-site, active-case ascertainment studies conducted in the United States found prevalence rates of 10 and 24 per 1,000 children.

“This consortium study, to our knowledge, was the first to apply active case ascertainment, common methodology, a single classification system, and expert in-person evaluation for a continuum of fetal alcohol spectrum disorders including alcohol-related neurodevelopmental disorder to a large number of children from communities across the United States,” the authors wrote. “These data have highlighted the need for a larger study with broader representation of U.S. communities with general population samples.”

Only 2 of the 222 children had actually been previously diagnosed with a fetal alcohol spectrum disorder, “although many parents and guardians were aware of the learning and behavioral challenges facing their children,” the researchers noted.

“These data confirm that missed diagnoses and misdiagnoses of children are common,” the authors wrote, pointing to a previous study in U.S. schoolchildren that found only one in seven children identified as having fetal alcohol syndrome had been previously diagnosed.

The assessment of fetal alcohol spectrum disorder was based on four domains: growth, dysmorphology, neurodevelopment, and prenatal alcohol exposure – the latter being assessed by interviewing the mother in person or by telephone.

The lowest prevalence – 11.3 per 1,000 children – was seen in the Midwestern community, while the highest – 50 per 1,000 – was in the Rocky Mountain community.

The main weakness of the study was that no individual sample included the entire eligible population because of differing policies on access to children for recruitment and variability in willingness to consent.

“Consent rates for screening ranged from 36.9% to 92.5% in individual samples and overall consent rates for screening averaged only 59.9% of eligible children,” the authors wrote. “If nonconsented children differed from consented, this could have biased prevalence estimates in either direction.”

The researchers acknowledged that the absence of a definitive biomarker for fetal alcohol spectrum disorder meant it was impossible to know for certain that the observed deficits were actually the result of fetal alcohol exposure, and that the prevalence estimates may therefore be overestimated.

The study was funded by grants from the National Institute on Alcohol Abuse and Alcoholism. One author declared grant support from the National Institute on Alcohol Abuse and Alcoholism and personal fees and honorarium from the Alcohol Center. No conflicts of interest were declared.

[email protected]

SOURCE: May, P et al. JAMA 2018;319[5]:474-82. doi: 10.1001/jama.2017.21896.

Fetal alcohol spectrum disorders could affect up to 1 in 20 children, according to a cross-sectional study.

Philip A. May, PhD, of the University of North Carolina, Gillings School of Global Public Health, and his coauthors assessed 6,639 first-grade children from four communities in the Rocky Mountain, Midwestern, Southeastern, and Pacific Southwestern regions of the United States.

In their report, published Feb. 6 in JAMA, they identified 222 cases of fetal alcohol spectrum disorders, representing conservative prevalence estimates ranging from 11.3 to 50 cases per 1,000 children (JAMA 2018;319[5]:474-82. doi: 10.1001/jama.2017.21896).

Of these children, 27 met the criteria for fetal alcohol syndrome, 104 met the criteria for partial fetal alcohol syndrome, and 91 met the criteria for alcohol-related neurodevelopmental disorder.

“These prevalence estimates are consistent with mounting evidence that harmful fetal alcohol exposure is common in the United States today and highlight the public health burden due to fetal alcohol spectrum disorders,” the authors wrote.

The finding was much higher than previous estimates of the prevalence of fetal alcohol spectrum disorders in the United States. The authors pointed out that routine surveillance methods may have previously underestimated the prevalence because so many children are either misdiagnosed or not diagnosed at all. But even two previous single-site, active-case ascertainment studies conducted in the United States found prevalence rates of 10 and 24 per 1,000 children.

“This consortium study, to our knowledge, was the first to apply active case ascertainment, common methodology, a single classification system, and expert in-person evaluation for a continuum of fetal alcohol spectrum disorders including alcohol-related neurodevelopmental disorder to a large number of children from communities across the United States,” the authors wrote. “These data have highlighted the need for a larger study with broader representation of U.S. communities with general population samples.”

Only 2 of the 222 children had actually been previously diagnosed with a fetal alcohol spectrum disorder, “although many parents and guardians were aware of the learning and behavioral challenges facing their children,” the researchers noted.

“These data confirm that missed diagnoses and misdiagnoses of children are common,” the authors wrote, pointing to a previous study in U.S. schoolchildren that found only one in seven children identified as having fetal alcohol syndrome had been previously diagnosed.

The assessment of fetal alcohol spectrum disorder was based on four domains: growth, dysmorphology, neurodevelopment, and prenatal alcohol exposure – the latter being assessed by interviewing the mother in person or by telephone.

The lowest prevalence – 11.3 per 1,000 children – was seen in the Midwestern community, while the highest – 50 per 1,000 – was in the Rocky Mountain community.

The main weakness of the study was that no individual sample included the entire eligible population because of differing policies on access to children for recruitment and variability in willingness to consent.

“Consent rates for screening ranged from 36.9% to 92.5% in individual samples and overall consent rates for screening averaged only 59.9% of eligible children,” the authors wrote. “If nonconsented children differed from consented, this could have biased prevalence estimates in either direction.”

The researchers acknowledged that the absence of a definitive biomarker for fetal alcohol spectrum disorder meant it was impossible to know for certain that the observed deficits were actually the result of fetal alcohol exposure, and that the prevalence estimates may therefore be overestimated.

The study was funded by grants from the National Institute on Alcohol Abuse and Alcoholism. One author declared grant support from the National Institute on Alcohol Abuse and Alcoholism and personal fees and honorarium from the Alcohol Center. No conflicts of interest were declared.

[email protected]

SOURCE: May, P et al. JAMA 2018;319[5]:474-82. doi: 10.1001/jama.2017.21896.

Our CHEST Foundation grantees are doing amazing research and community service projects that are paving the way for change and improvements in chest medicine. How will you help champion lung health?

“This award carries great importance to me as a young clinician who is in the early phase of my career. I’m driven by my passion for researching this disease (PAH). This award helps establish me as a strong clinical researcher – where I see my career heading. It also helps us identify those clues that can lead to changing how this disease state is treated. Everything starts with an idea.”

Sandeep Sahay, MD, FCCP
Houston Methodist Hospital – Houston, Texas
CHEST Foundation Research Grant in Pulmonary Arterial Hypertension

Title: Alterations of Estrogen Metabolism in the Development of Portopulmonary Hypertension

Utilizing Medical-Legal Partnership to Promote Asthma Health Equity

Connecticut Children’s Medical Center – Hartford, Connecticut
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Title: Haitian Pediatric Critical Care Collaborative Training Course

The CHEST Foundation is accepting grant applications now until March 31 in the following areas:



• CHEST Foundation Research Grant in Lung Cancer – $50,000 - $100,000 2-year grant*

• CHEST Foundation Research Grant in Asthma - $15,000 - $30,000 1-year grant*

• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension - $25,000 - $50,000 1-year grant*

• CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency - $25,000 1-year grant

• CHEST Foundation Research Grant in Pulmonary Fibrosis – $50,000 1-year grant

• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease – $50,000 1-year grant

• CHEST Foundation Research Grant in Venous Thromboembolism - $15,000 – $30,000 1-year grant*

• CHEST Foundation Research Grant in Nontuberculous Mycobacteria Disease - $30,000 1-year grant

• CHEST Foundation Research Grant in Women’s Lung Health - $10,000 1-year grant

• CHEST Foundation Research Grant in Cystic Fibrosis – $15,000 – $30,000 1-year grant

• CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP - $2,500- $15,000 1-year grant



*Amount contingent on funding.



Go to chestfoundation.org/grants to apply now.

Our CHEST Foundation grantees are doing amazing research and community service projects that are paving the way for change and improvements in chest medicine. How will you help champion lung health?

“This award carries great importance to me as a young clinician who is in the early phase of my career. I’m driven by my passion for researching this disease (PAH). This award helps establish me as a strong clinical researcher – where I see my career heading. It also helps us identify those clues that can lead to changing how this disease state is treated. Everything starts with an idea.”

Sandeep Sahay, MD, FCCP
Houston Methodist Hospital – Houston, Texas
CHEST Foundation Research Grant in Pulmonary Arterial Hypertension

Title: Alterations of Estrogen Metabolism in the Development of Portopulmonary Hypertension

Utilizing Medical-Legal Partnership to Promote Asthma Health Equity

Connecticut Children’s Medical Center – Hartford, Connecticut
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Title: Haitian Pediatric Critical Care Collaborative Training Course

The CHEST Foundation is accepting grant applications now until March 31 in the following areas:



• CHEST Foundation Research Grant in Lung Cancer – $50,000 - $100,000 2-year grant*

• CHEST Foundation Research Grant in Asthma - $15,000 - $30,000 1-year grant*

• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension - $25,000 - $50,000 1-year grant*

• CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency - $25,000 1-year grant

• CHEST Foundation Research Grant in Pulmonary Fibrosis – $50,000 1-year grant

• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease – $50,000 1-year grant

• CHEST Foundation Research Grant in Venous Thromboembolism - $15,000 – $30,000 1-year grant*

• CHEST Foundation Research Grant in Nontuberculous Mycobacteria Disease - $30,000 1-year grant

• CHEST Foundation Research Grant in Women’s Lung Health - $10,000 1-year grant

• CHEST Foundation Research Grant in Cystic Fibrosis – $15,000 – $30,000 1-year grant

• CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP - $2,500- $15,000 1-year grant



*Amount contingent on funding.



Go to chestfoundation.org/grants to apply now.

Our CHEST Foundation grantees are doing amazing research and community service projects that are paving the way for change and improvements in chest medicine. How will you help champion lung health?

“This award carries great importance to me as a young clinician who is in the early phase of my career. I’m driven by my passion for researching this disease (PAH). This award helps establish me as a strong clinical researcher – where I see my career heading. It also helps us identify those clues that can lead to changing how this disease state is treated. Everything starts with an idea.”

Sandeep Sahay, MD, FCCP
Houston Methodist Hospital – Houston, Texas
CHEST Foundation Research Grant in Pulmonary Arterial Hypertension

Title: Alterations of Estrogen Metabolism in the Development of Portopulmonary Hypertension

Utilizing Medical-Legal Partnership to Promote Asthma Health Equity

Connecticut Children’s Medical Center – Hartford, Connecticut
CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP

Title: Haitian Pediatric Critical Care Collaborative Training Course

The CHEST Foundation is accepting grant applications now until March 31 in the following areas:



• CHEST Foundation Research Grant in Lung Cancer – $50,000 - $100,000 2-year grant*

• CHEST Foundation Research Grant in Asthma - $15,000 - $30,000 1-year grant*

• CHEST Foundation Research Grant in Pulmonary Arterial Hypertension - $25,000 - $50,000 1-year grant*

• CHEST Foundation and the Alpha-1 Foundation Research Grant in Alpha-1 Antitrypsin Deficiency - $25,000 1-year grant

• CHEST Foundation Research Grant in Pulmonary Fibrosis – $50,000 1-year grant

• CHEST Foundation Research Grant in Chronic Obstructive Pulmonary Disease – $50,000 1-year grant

• CHEST Foundation Research Grant in Venous Thromboembolism - $15,000 – $30,000 1-year grant*

• CHEST Foundation Research Grant in Nontuberculous Mycobacteria Disease - $30,000 1-year grant

• CHEST Foundation Research Grant in Women’s Lung Health - $10,000 1-year grant

• CHEST Foundation Research Grant in Cystic Fibrosis – $15,000 – $30,000 1-year grant

• CHEST Foundation Community Service Grant Honoring D. Robert McCaffree, MD, Master FCCP - $2,500- $15,000 1-year grant



*Amount contingent on funding.



Go to chestfoundation.org/grants to apply now.

SAN FRANCISCO – The immune checkpoint inhibitor pembrolizumab is active and well tolerated when used as second-line therapy for hepatocellular carcinoma, according to results of the KEYNOTE-224 trial.

The 104 patients treated on the single-arm, open-label phase 2 trial had advanced hepatocellular carcinoma (HCC) previously treated with sorafenib (Nexavar), the standard of care for first-line therapy. All received monotherapy with pembrolizumab (Keytruda), an anti–programmed death 1 antibody.

SOURCE: Zhu AX et al. GI Cancers Symposium Abstract 209

SAN FRANCISCO – The immune checkpoint inhibitor pembrolizumab is active and well tolerated when used as second-line therapy for hepatocellular carcinoma, according to results of the KEYNOTE-224 trial.

The 104 patients treated on the single-arm, open-label phase 2 trial had advanced hepatocellular carcinoma (HCC) previously treated with sorafenib (Nexavar), the standard of care for first-line therapy. All received monotherapy with pembrolizumab (Keytruda), an anti–programmed death 1 antibody.

SOURCE: Zhu AX et al. GI Cancers Symposium Abstract 209

SAN FRANCISCO – The immune checkpoint inhibitor pembrolizumab is active and well tolerated when used as second-line therapy for hepatocellular carcinoma, according to results of the KEYNOTE-224 trial.

The 104 patients treated on the single-arm, open-label phase 2 trial had advanced hepatocellular carcinoma (HCC) previously treated with sorafenib (Nexavar), the standard of care for first-line therapy. All received monotherapy with pembrolizumab (Keytruda), an anti–programmed death 1 antibody.

SOURCE: Zhu AX et al. GI Cancers Symposium Abstract 209

Are STEMI success rates slowing? Will TAVR replace SAVR in low-risk aortic valve replacement? The key role alcohol and opioids play in suicides, and why your psoriasis patients need to meet a real PEST.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

Are STEMI success rates slowing? Will TAVR replace SAVR in low-risk aortic valve replacement? The key role alcohol and opioids play in suicides, and why your psoriasis patients need to meet a real PEST.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

Are STEMI success rates slowing? Will TAVR replace SAVR in low-risk aortic valve replacement? The key role alcohol and opioids play in suicides, and why your psoriasis patients need to meet a real PEST.

Listen to the MDedge Daily News podcast for all the details on today’s top news.