Listen to Andrew Duckworth & our Specialty Editor for Shoulder, Duncan Tennent, discuss three papers published in The Bone & Joint Journal.
Lapner, P., Pollock, J.W., Laneuville, O., Uhthoff, H.K., Zhang, T., Sheikh, A., McIlquham, K. and Trudel, G., 2021. Preoperative bone marrow stimulation does not improve functional outcomes in arthroscopic cuff repair: a prospective randomized controlled trial. The Bone & Joint Journal, 103(1), pp.123-130.
Jenkins, P.J., Stirling, P.H., Ireland, J., Elias-Jones, C. and Brooksbank, A.J., 2020. The changing incidence of arthroscopic subacromial decompression in Scotland. The bone & joint journal, 102(3), pp.360-364.
Cavalier, M., Johnston, T.R., Tran, L., Gauci, M.O. and Boileau, P., 2021. Glenoid erosion is a risk factor for recurrent instability after Hill-Sachs remplissage. The Bone & Joint Journal, 103(4), pp.718-724.
[00:00:00] Welcome everyone. I'm Andrew Duckworth. And I'd like to thank you for joining us for one of our podcasts for the month of June. We hope all of you are keeping safe and well as brighter times do appear to be on the horizon for all of us. We also hope you've enjoyed our podcast so far this year. Last month we had two excellent additions. In the first we were joined by Professor Matt Costa and Professor Xavier Griffin to discuss their paper on the effects of performance based renumeration and outcomes and the treatment of hip fractures using data from the WHiTE hip fracture cohort.
And secondly, we had a great discussion with a star in lineup of Professor Mike Whitehouse, Mr. Nick Clement, Mr. Alex Liddell and Professor Fares Haddad to discuss Mike's paper on the role of patellar resurfacing and risk of revision surgery using data from national joint registries.
As always, we hope you're enjoying the content from the knowledge translation team here at the BJJ, and that we're achieving our aim to improve the accessibility and visibility of the studies we publish here at the journal.
As part of this throughout the year, we're delivering special edition podcasts with our guests being the incredibly hardworking and invaluable specialty editors here at the journal. We've already enjoyed the company [00:01:00] of Mr. Sam Oussedik and Professor Dan Perry as part of this series. And today we are welcomed by another one of our excellent specialty editors.
As many of you know, the aim of these is to give our listeners an insight into the vital work they do here at the journal, what they feel the current research trends are in their area, as well as highlighting some key papers from the past year that we've published that will also be made available temporarily for free following release.
So today I have the great pleasure of being joined by our great Specialty Editor for Shoulder, Professor Duncan Tennent. Welcome Duncan and thank you for taking time to join us today.
Thanks so much. Thanks for asking me.
So Duncan, so the last sort of 12 to 14 months have been strange times and difficult times for all of us. And I've just been asking all of you, you know, can you give us a brief overview of your own insights regarding this both regard your clinical practice, but also in your role at the journal?
Yeah, as you say, it's been a remarkable year or so. The cessation of all elective activity during the first lockdown was interestingly coupled with a [00:02:00] remarkable decrease in emergency activity as well. So sort of everything stopped. The redeployment of the junior doctors certainly round us with the reallocation of the seniors meant that I spent the time covering the wards and being an A&E doctor, which is something I haven't done for about 20 years.
When we restarted sort of August time, what we saw was an awful lot of neglected trauma. I had quite a number of cases, people who'd had shoulder dislocations had been out for three months. So we spent a lot of time doing some really nasty chronic reconstructions. And they don't do brilliantly. I think with the subsequent lockdowns, we've done a bit better and people have carried on with their lives and they've not been frightened. So we've had a real shift into doing some really old-fashioned surgery, but some of my more junior colleagues have just never really come across.
I have been really lucky. I work at The Southwest London Elective Orthopaedic Centre, which has just been amazing. And we've been [00:03:00] really buffered from this whole national disaster of waiting times. We were up and running in late July, at full capacity by early August and ran through till a week before Christmas . I started again in March and I'm running at full capacity. Although what we are seeing is that we're not getting patients into clinic because we're having to spread them all out. We're doing remote consultations. People aren't going to the GP or they can't get to the GP. And actually I'm in the unusual position where my waiting times are going down.
But we are worried because things like rotator cuff tears, they get worse the longer you leave them. They get bigger. And we're starting to pick up more and more big cuff tears, which probably would have been smaller if we got to them a bit earlier.
As a speciality editor it was interesting in the early parts of the first lockdown, it was a chance to catch my breath and spend a bit more time on these [00:04:00] things. And I did exactly what everybody else was doing and went, right I've now got all these papers that need writing, juniors that need chasing , as did the rest of the world. And as I think Sam and everybody else has alluded to, the number of submissions we've had has gone through the roof and the quality of the submissions has been really good as well. Lots and lots of excellent papers that we've just had to turn away because we've not been able to take them in.
And I don't see it slowing down at the moment. I think people's productivity seems to have, you know, they've got on the roll and off they've gone.
Yeah. Yeah, no, I agree. I think it's one of these things, isn't it? Where I think people have got into a bit of a pattern now with this and actually whether they found a new love for it or whatever, but it does seem to be relentless really, in terms of the amount of papers that are being sent in. And like you said, the quality seems to be very high too, doesn't it?
Yeah. I'm really surprised. I thought it'd just be junk sitting in the back of the drawer and you think, oh, I'll just get rid of it. There has been a bit of that but it's really been good.
Absolutely. Absolutely. And how'd you feel has [00:05:00] there been much impact though, in terms of, you know, has there been much sort of COVID-related research, related to shoulder in particular or, you know, maybe shoulder elective surgery restarting or anything like that? And I know you have an interest in education as well. Is there anything there, you know, that you've seen or heard of?
I think while we've had the impact on all of the clinical studies and everything's stopping we've not seen anything particularly shoulder related. And I know it would sort of put all the business with the hip replacements and the pre-operative score being worse than death but we don't see that quite so much in the shoulder. We are seeing bizarrely adhesive capsulitis rates going through the roof. We don't understand it. I'm probably seeing four or five times as many cases as I was a year ago, and this is not just me. This is across the country. So I think there's going to be some COVID work coming out of that. Cause that's got to be the common denominator somehow.
Yeah. The teaching side of things [00:06:00] has been really tricky. We've seen with our trainees in terms of just getting hands on, getting the numbers , with undergraduate teaching, we've had no face to face. They've had no patient contact.
The flip side of all of this though, is it's like doing these sort of things remotely, that we're actually learning new ways of teaching and we're working out what works and we're stumbling our way through it, but there's no doubt there's been some good things.
We're generating for our undergraduates massive amounts of teaching in small groups online and they're really enjoying it. So things are going to change, but somehow we got to get back to that face to face. We've got to get the hands on because it's a craft. At the end of the day.
Yeah. It's interesting. I was speaking to a lot of my colleagues in the university and I think they would agree , we have had o t of adversity obviously positive things come out of it. And one has been like you say, the online teaching thing, but it's just we do need to get back to that hands-on. It's just finding that balance between the two, isn't it? And what's right for getting the right [00:07:00] balance to give them the best result. But I think it has been one of the positives maybe to come out of it.
If we move away from COVID though, what would you say in terms of the shoulder?? Over the past year or two, what are the main themes coming through? What are people looking at and what do people want answers to, do you think?
The big themes that we have are arthroplasty, the cuff and instability. So we actually have three different streams running all the time. And it seems to sort of go up and down in their preference. There's a lot on arthroplasty at the moment. And I think this is going to continue. The numbers are going up steadily and the number of reverse arthroplasty is going through the roof.
Now twice as many reverses of anatomics are being done. And there's a lot of papers being submitted. Interestinly a lot of papers being submitted on the short stem of the metaphyseal anatomics. Cause the data's now starting to come out with sort of [00:08:00] five, eight, nine year. And each month I get another retrospective review of nine years follow-up of a short stem and I'm sort of looking at it again yet we know they work We've got to look at the reverses because there's no doubt there is a complication rate. There's going to be a legacy when they start to fail. The cuff, we'll come to this with the first paper, but we've got all sorts of clever ways of fixing them, but we don't really understand the biology. We know that it doesn't work and we've got to find a way around it. So that's, I think that's a big theme and we are getting these papers.
And also work on alternatives - the tendon transfers, the superior capsules and theres papers trickling through on that.
Now I think they're the big themes. Instability seems to trickle along underneath as well.
And just before we move on to the papers just going back to the reverse, like you say, it seems to have just really over the past five years, the numbers just seem to rise and rise. Do you think [00:09:00] it will balance out? Do you think it will continue to rise? Are we going to run into some problems in a couple of years time? What's your feeling about that?
I think it's an interesting one. I think the numbers are going to keep going up because it is actually a very forgiving operation. You can be an average surgeon and it seems to work. An anatomic is a difficult operation to do. And the registry data is, by definition, going to be skewed, particularly short stem things. It is very, very easy to revise a metaphyseal total shoulder.
It takes me almost no longer than doing a primary reverse. So your likelihood of revising it goes up and therefore the data is skewed and it looks like they fail quicker.
Revising a revision is a nightmare and a lot of people will just park it and go look, you'll be all right. You know, as long as it's [00:10:00] not falling out of the body, you'll be okay. So the revision rate stays low. So I think we've got to be quite careful looking at the data.
We dont go, oh, it obviously works much better. We should all be putting reverses is in.
Yeah, yeah, yeah. There isn't the easy bay, well easier bay, about it, is there?
No you park it so it doesn't get revised. So the numbers look good.
Yeah, absolutely. That's really interesting. So that sort of leads on really nicely to the papers you've kindly chosen for us. We'll start with the paper you just sort of alluded to, which is the RCT and that's from the team in Canada. And they did a prospective randomized controlled trial of patients undergoing rotator cuff repair, arthroscopic cuff repair, and they randomized them to receive either a percutaneous bone channeling of the rotator cuff footprint or a sham procedure under guidance, five to seven days prior to their index surgery. And the primary outcome measure was a disease-specific quality of life measurement. That was the walk index at two years. I think it's really interesting and I think probably for our listeners and can some background to why they sort [00:11:00] of looked at this . There's obviously been some animal studies isn't there and other data about what the potential benefits of this might be.
Yeah. We know that rotator cuff repair has a failure rate. It's pretty unacceptably high really. But we choose to mostly ignore it and given that the implants, the techniques are all pretty good. They're pretty reliable. And we now know much more about fat infiltration and, you know, tear size and that sort of thing, but we still don't know why not a large number of them fail and it's got to be down to biology.
So we've been talking about it for probably 20 years with the crimson duvet that they talk about. But we don't really know what it is that makes the thing heal.
Over the last, probably 10, 15 years there's been a great interest in biologics - activated platelets, stem cells and there are lots of quite poor papers [00:12:00] that promote one thing over another. Although interestingly, the number of studies that say an activated platelets don't help cuff repair healing are quite high and they're expensive. And the idea that you could do something biologically, I mean, autologist is quite appealing. And this group had previously done some work to say that if you drill these little holes in the greater tuberosity, you've got these stem cells and they seem to peak at about seven to 14 days.
And they did some work on a rabbit model that said, actually, you get better healing if you do this. So the logical progression then is, well, if we do this to people, delay their surgery by about a week or so you should be getting maximum numbers of these stem cells hence better healing. I think the background is great.
It's a logical conclusion that you'd want to test. And so they went on, I [00:13:00] think they've designed a really elegant study. So it's rare for the shoulder. It's an RCT. They've got a sham procedure in that they put the K wire in just to drink. I mean they fired the driver. They just didn't drill the hole, you know? So as far as the patient is concerned, they really genuinely are blinded. And then given the constraints of finding like cuff repairs, they did pretty well.
The sizing was reasonable. They made sure they're all infiltration, two or less. They only had two surgeons. They were fellowship trained. They powered it properly. They counted for losses, even with their losses, they still had the numbers. You know, for me what wasn't to like about it?
No, no, I agree. I think it's a re like you say, it's so nice to see somebody come up with a concept from the lab basically, and then they've taken it all that way and say, actually is this going to work? I think the only shame [00:14:00] to my eye was, like you say, when they allocated 47 to the bone channeling and six didn't undergo the procedure because of, I think it was sort of logistical issues, which was just a shame to lose those from that arm.
But as you say, otherwise, they had good follow-up and interesting findings, wasn't it? In terms of, they didn't really find any difference even with the ultrasound determined healing rates.
Yeah. Again, what I liked about and why I wanted to publish it is so often we have that positive publication bias and here's a paper that said, we designed this great study based on really good science and it should work, but it didn't. And I think that's really nice and honest. And you know, for those who may not have had a chance to read paper yet, basically it showed that their outcome measures, the Western Ontario score and their secondary measurements, the ACEs score. No difference. And they looked at another one of their secondary measures was cuff healing. And again, no difference with, I think it was about 75, 80% success. So pretty well [00:15:00] what you would expect in any normal population. Very disappointing, but very, very honest.
They didn't try to massage the data.
I agree. I agree. Just before we move on to the next paper, one thing they do mention in their study, a limitation was they standardized the number of bone channels created and they didn't relate it to the size of the exposed bone. Do you think there's something in that? Is that maybe, and maybe a spare limitation and maybe there's something more there or...
Quite recently, I thought they'd written a really nice discussion as well. Put forward a whole load of hypotheses. Was it that they didn't make enough holes?
Cause they just made four holes in the corners. And should they have pecker potted it and I did a cuff repair yesterday and I did exactly that, you know . That was about eight or nine holes. They also argue that maybe it's mesenchymal stem cell senescence, which I think is a wonderful phrase. Slightly depressing when I look at the population that they operated on and maybe [00:16:00] actually these mesenchymal stem cells are not the answer anyway.
To be very honest I was deeply disappointed. I thought this is the answer.
I think it's a great paper.
No, I agree. I agree. Like you say I loved the way it flowed and they've done that preliminary work. It's great.
So we'll move on to the next paper. That's the sort of big data study and that was actually a podcast discussion for the month of March last year and comes from my good friend, Paul Jenkins and the team in Glasgow. And the aim of that study was to examine the recent trends in delivery of arthroscopic subacromial decompression in Scotland and determine if this varied by geographical location, and they use sort of big data from the National Scottish Morbidity records over a four year period. And this is a really interesting study isn't it, particularly given the recent literature that would have been published over that time?
Yeah, they looked at 2014 to 2018 and they looked at the rate of. Well, the numbers of subacromial decompression and AC joint excision which I thought was very important and the combined codes [00:17:00] and looked at it not only nationally, but then broke it down by the regions.
But the reason I picked this was there were several interesting points that already there was a trend going down, which is what we've seen in unofficial data from England, that the paper that all of this is based on that they referenced quoting numbers that are way higher than any of us actually thought was real.
And we were already doing less for whatever reason. So I think it was interesting that having some national data that demonstrated that with data that's been validated. I thought that was an important point. There was 93.8% accuracy in their coding, which normally when I look at these sorts of things you think, oh, come on, you know. But when you've got data like that, you know you have got good stuff coming in and now, you [00:18:00] know, less than 7% is not going to be significant.
So it was interesting that it went down and the fact that it dipped quite rapidly in the 17, 18 period. And I know Paul's talking about it. Is that because of the Seesaw and the CAT studies? And as he said, potentially people talking about it prior to publication, or is it actually just part of the trend anyway?
And I would love to see this paper with then the 1920 data.
To see if it dips even faster or whether it plateaus off, because that was the trend.
So I thought that that was really interesting. I can't say necessarily per se, this is causation.
But it's a strong correlation.
Yeah. It's interesting that we talked about how it's not even actually the publication of the trial, is it just that it's in people's minds it's happening anyway, and this just pushes it that way. I mean, you sort of get that with the DRAFT study where actually the change [00:19:00] happened even before the trial was published, the plates and the wires crossed. And it's interesting that. Is it just because it's been put into the mind of people to think, actually, do we need to do this procedure? What is the real indication for it? You know, it's interesting.
Whether there's a, I'm sure there's a name for it, a bias from having been involved in something like Cecil, cause that ran for a long time, but already people are starting to think five years in, maybe, you know...
Yeah. And so there's a sort of effect there.
The other thing I thought was very interesting was the regional variation.
Which is what we see. I've looked at the London data. We see massive variation in numbers, you know, with some of their groups being three times the standard deviation, that's a huge difference.
And the fact that in one of the major regions, the numbers dropped by 64% just raised that whole question about our practice. Who's doing what and do we need to educate people?
I thought [00:20:00] it brought that out, that actually even a relatively small population like Scotland, you're getting huge variations.
Yeah. It is fascinating. Isn't it? And that variation in practice and that degree of variation, surely isn't right. For whatever reason that may be. You know, that is just, it's so stark. And like you say, is it an education thing? Is it an indication of the surgery yet? It's really interesting. I thought it was really a really great paper and like you say, sort of the causation with the trials is difficult, but I think that's, again, a really interesting point. That was great.
So if we move on to the third and final paper, I think it's nice because we've had an RCT, we've had a big data study and this is a single centre retrospective study. But a great one. And that comes from the team in Nice. And the aim of their study was to identify risk factors for recurrent instability of the shoulder. And assess their ability to return to sport in patients who had engaging Hill-Sachs lesions, treated with arthroscopic Bankart repair and Hill-Sachs remplissage.
And that was a retrospective study, like I say, of [00:21:00] 133 patients from a single centre. And I think it's a really nice study. Isn't it? I know, you'd say about, we could talk about levels of evidence and things, but actually it's got some really interesting finds.
I think it has. As you say, it is a little bit messy. It's retrospective .They've slightly lumped the patients because they've got less than 10% bone loss and 10 to 20% bone loss which then they're quite broad groups. And this is also from a group who do an awful lot of arthroscopic latarjet and they use this ISIS score. And basically if you get a ISIS score of over three pretty well, you're going to get a laterjet. So it's quite a selected group.
What I liked about it was within the introduction they said, well, you know, remplissage looked like a very attractive thing. The results seem to be good so we started to stretch our indications, which is what we will do. And then to say, well, hang on a minute. We're now doing them more and more. They don't always work. Is there [00:22:00] any common theme that we can see? Can we refine our indications? Which are what I quite liked about it. It was looking at it.
I mean, it's interesting, remplissage has been knocking around now since the late nineties. Eugene Wolfe in the states started talking about it and got ignored for probably eight or nine years. And then everybody jumped on the bandwagon because it's relatively easy to do.
But nobody really knows what the indications are.
And what I thought was nice here was that they've identified two factors really that are going to be a problem. One is that bone loss and, and what they've said is in that 10 to 20% group, remplissage and a label repair is not going to be enough. Which is interesting because actually that very much marries up with the more recent data that says this magic number of 20% bone loss is coming down and the latest papers on the [00:23:00] biomechanical side, the same 13%.
So that fits with this population where they're saying actually, no, they should have a bone operation.
And the other one was the youngsters. That if you're under 23, we know that our youngsters don't do as well with the soft tissue repairs. And this adds to that. So the idea that I'll do it, I'll do an extra bit of soft tissue on it because that'll help. They say actually it doesn't work.
The paper is a little bit limited in that they only had 10 failures.
It's a little hard to make huge assumptions out of 10 failures. Particularly some of their cases were revisions and I couldn't work out whether it was the revisions that failed or not.
Agree. Yeah. Yeah.
So you've gotta be careful not to take the paper too far, but it says we need to be nuanced. We can't do a one size fits all operation.
No, I agree. And as you say, it's a large series, isn't it? And good follow-up and I think it's interesting, like you say, it's [00:24:00] somebody... well the situation where the indications have expanded, like we all know, and then they've tried to refine them down again, saying this isn't for everybody. And we need to figure out why. And I think it's a really nice, like you say, it's it has limitations, but it is a really nice paper.
So if we just move on, finally, Duncan, just to finish this off. What'd you see for the future really in terms of research in the area? What are the next big questions that need to be asked? And I suppose, what are the challenges ahead?
As I say, we've got these three broad areas that are the majority of our work. The arthroplasty, we refined the implants. We're getting short stem reverses, we are doing smaller operations. We're doing them a little earlier. We're bringing the age of the reverses down. We need to be looking at that registry data and having people follow things up to see where it's going.
[00:25:00] And the other part of it is that there were two broad philosophies in reverse - the grim old style where it's medialized and inferealized, and the Frankel model where it lateralized. They are very different concepts. You've got these two competing devices and it's going to be interesting to see whether we keep both or whether we start to sort of bring it all into one implant that's going to work. So I think we're going to see a lot more data coming out on implants. Again, because it's easier to do that stuff like it is with hip and the knee.
I think we're going to see a lot more work on biologics around the shoulder. You know, we are really dependent on that to get our cuffs to work. What can we do to make our rotator cuff repairs work? How can we push the envelope? Because we know we hit 75 and we're all going, okay, that's it. We don't think we should operate, you know, repairing cuff, but then what do you do? So I think we're pushing that. [00:26:00] And I think we're beginning to get a lot more nuanced in our management of instability. It was all soft tissue and then very much the French driven thing. It's all arthroscopic laterjet. And we're starting to say, well, actually there's somewhere in the middle and do we need to be putting small pieces of bone for smaller defects? And can we do it just being a lot more subtle in our surgery?
So I think those are where I see things going over the next few years.
That's really interesting because that's a nice way to finish on. But I think that's all we have time for, but that was really excellent.
I really enjoyed that. And it's a really nice overview of the, the shoulder specialty area here at the journal and the literature in general. And that was really important and great to talk to you. Thanks for joining us.
Well, thank you very much. I really enjoyed it.
And to our listeners, we do hope you've enjoyed joining us today. Do look out for the papers we've talked about here today and feel free to tweet or post about anything we have discussed here. Take care everyone.