Faculty Bibliography

Background: This study aimed to determine whether there is a long-term difference in outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) performed for proximal humerus fracture (PHF) sequelae. Hypotheses were as follows: (1) patients undergoing aTSA would have improved functional outcomes but a greater incidence of adverse events (AEs) and reoperation than those undergoing rTSA and (2) patients undergoing shoulder arthroplasty after open reduction internal fixation (ORIF) would have worse outcomes with more AEs and reoperations than those undergoing shoulder arthroplasty for sequelae of nonoperatively managed PHF. Methods: A prospectively collected database was queried for patients with PHF sequelae undergoing aTSA or rTSA between 2007 and 2020 with minimum 2-year follow-up. Baseline demographics, perioperative data, postoperative AEs, functional outcomes, and range of motion (ROM) were compared between aTSA and rTSA groups. A secondary analysis was performed to compare patients treated with prior PHF ORIF vs. those treated nonoperatively. Results: There were 17 patients in the aTSA group and 83 patients in the rTSA group. Type I PHF sequelae predominated among patients who underwent aTSA (71% vs. 40%, P = .026). Incidence of total postoperative AEs was greater after aTSA than that after rTSA (12% vs. 5%, P = .277), with a significantly higher rate of glenoid aseptic loosening after aTSA (6% vs. 0%, P = .026). All AEs required reoperation except one in the rTSA group. The mean follow-up was 66 months for aTSA compared with 45 months for rTSA (P = .002). No differences in functional outcomes or ROM between aTSA and rTSA persisted beyond 3 months or at the final follow-up except external rotation, which favored aTSA for 3 years postoperatively. In the secondary analysis, there were 33 patients in the ORIF group and 67 in the non-ORIF group. One (3%) postoperative AE occurred in the ORIF group vs. five (7%) in the non-ORIF group (P = .385). At a mean follow-up of 4 years, there were no differences in functional outcome scores or ROM between ORIF and non-ORIF groups, except for patient-reported shoulder function (6.3 vs. 7.4, respectively, P = .037). Conclusion: For treatment of PHF sequelae, aTSA may result in a higher incidence of postoperative AEs and reoperation than rTSA, particularly due to glenoid aseptic loosening. No difference in functional outcome scores between aTSA and rTSA persists beyond 3 months or at the final follow-up. Although active external rotation is significantly improved after aTSA for the first 3 years postoperatively, no differences in ROM exist beyond 4 years at the final follow-up. Patients undergoing shoulder arthroplasty for PHF sequelae have comparable outcomes regardless of prior ORIF or nonoperative management. Level of evidence: Level III; Retrospective Cohort Design; Treatment Study

The Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test (PROMIS UE CAT) is a newer patient-reported outcome measure for upper extremity physical function. To date, no longitudinal study exists assessing PROMIS UE CAT responsiveness in patients undergoing shoulder arthroplasty. The purpose of this prospective longitudinal study is to report PROMIS UE CAT responsiveness to change and correlation to legacy instruments in patients undergoing total shoulder arthroplasty (TSA). Ninety-six patients (97 shoulders) undergoing TSA completed the PROMIS UE, Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) preoperatively and postoperatively at 6 weeks, 12 weeks, and after 6 months. Spearman's correlation coefficients (r) were calculated between PROMIS UE and other scores at each time-point. Responsiveness to change was assessed using the effect size (Cohen's d) and standardized response mean compared with the preoperative time-point. Floor and ceiling effects were also assessed. PROMIS UE CAT demonstrated positive responsiveness at all time-points after TSA. It demonstrated excellent correlation (range: 0.68-0.84) with ASES, SST, and OSS at all postoperative time-points, but the correlation was weaker (r < 0.6, except OSS) preoperatively. Only OSS and SST showed ceiling effects at the 6-12-month time-point (16.8% and 18.2%, respectively). PROMIS UE CAT responsiveness to change and strength of correlation with legacy instruments improves with time elapsed after TSA. Further quantification of meaningful responsiveness to change will require estimation of the minimal clinically important difference and substantial clinical benefit for PROMIS UE CAT.

PURPOSE/OBJECTIVE:Coracoid fracture is a rare injury. The aim of this study is to present the demographics, clinical and radiologic characteristics, and outcomes of coracoid fracture in a cohort of 32 patients. METHODS:We queried our institutional electronic medical record database (years 2012-2020) to identify patients with coracoid fractures using specific International Classification of Disease-10 codes. Demographic data, injury details including mechanism of injury and associated injuries, imaging performed, and treatment outcomes were obtained from retrospective chart review. A radiologist reviewed all available imaging studies (radiographs/CT/MRI) and classified the fractures according to Ogawa and Eyres classifications. Missed diagnoses were determined by comparing initial imaging reports with the follow-up imaging obtained in the office. RESULTS:Thirty-two patients with coracoid fractures were identified during the study period. Sixteen fractures (50%) occurred in the setting of low-energy trauma. Twelve fractures were missed on initial radiographs, and diagnosis with three-view radiographs (AP, scapular-Y and axillary) was 88% compared to 33% (p < 0.03) with two views (AP, scapular-Y). The majority of fractures were non-displaced (94%), and 56% were Ogawa Type-II fractures. Associated injuries were seen in 81% of patients. Most fractures (94%) were treated without surgery with excellent outcomes. CONCLUSION/CONCLUSIONS:Coracoid fractures continue to be a rare injury. In contrast to previous studies, in this case series of 32 patients, half of the fractures were associated with low-energy trauma, which correlated with higher percentage of non-displaced fractures and Ogawa Type-II fractures. Addition of the axillary view in the trauma radiographic series significantly improved the initial fracture detection rate. LEVEL IV/UNASSIGNED:Retrospective study.

PURPOSE/OBJECTIVE:To assess longer-term (> 5 years) function and outcome in patients treated with anatomic locking plates for proximal humerus fractures. METHODS:This retrospective cohort study was conducted at an urban, academic level 1 trauma center and an orthopedic specialty hospital. Patients treated operatively for proximal humerus fractures with an anatomic locking plate by three orthopedic trauma surgeons and two shoulder surgeons from 2003 to 2015 were reviewed. Patient demographics and injury characteristics, disabilities of the arm, shoulder, and hand (DASH) scores, complications, secondary surgeries, and shoulder range of motion were compared at 1 year and at latest follow-up. RESULTS:Seventy-five of 173 fractures were eligible for analysis. At a minimum 5 years and a mean of 10.0 ± 3.2 years following surgery, DASH scores did not differ from one-year compared to long-term follow-up (16.3 ± 17.4 vs. 15.1 ± 18.2, p = 0.555). Shoulder motion including: active forward flexion (145.5 vs. 151.5 degrees, p = 0.186), internal rotation (T10 vs. T9, p = 0.204), and external rotation measurements (48.4 vs. 57.9, p = 0.074) also did not differ from one year compared to long-term follow-up. By one year, all fractures had healed. After 1-year post-operatively, four patients underwent reoperation, but none for AVN or screw penetration. CONCLUSIONS:Patient-reported functional outcome scores and shoulder range of motion are stable after one year following proximal humerus fracture fixation, and outcomes do not deteriorate thereafter. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms.

Lewis Albert Sayre (1820-1900) is one of the key figures in the history of American orthopedic surgery who left an indelible mark on the field. Sayre dedicated much of his career to teaching and practicing orthopedics in New York City and is considered to be one of the "fathers" of orthopedics in America. Sayre's career was defined by his development of novel, innovative treatments to attempt to improve the lives of his patients. Two of the treatments he is most well-known for developing are "exsection of the hip" for treating "Morbus Coxarius" and the plaster of Paris jacket used for treating spinal deformities caused by Pott's disease or scoliosis. Although Sayre's developments are no longer used today, examining them can help us to reflect on the orthopedic principles he sought to apply in the 19th Century as well as how Sayre's treatments have shaped the interventions that we use to care for patients today.

Introduction: The purpose of this study is to evaluate the relationship between patients"™ own health expectations and treatment outcomes following surgical repair of proximal humerus fractures. Hypothesis: Patients"™ health expectations will correlate with treatment outcomes following surgical repair of proximal humerus fractures. Material and methods: Over a 14-year period, 247 patients with a displaced proximal humerus fracture who underwent ORIF with locking compression plates were prospectively followed at one academic institution. Minimum follow-up period was 12 months. Patient-reported functional outcome data for the latest follow up visit (12 months and greater) was obtained from Disabilities of Arm, Shoulder, and Hand (DASH) questionnaires. Survey responses regarding health expectations were recorded at 3-month follow-up and converted to dichotomous variables. Two groups were identified: the high expectations and the low expectations groups. Statistical analysis comparing the two groups and their functional and clinical outcomes was performed using the independent t-test, using p < 0.05 for significance. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to further statistically characterize the relationship between health expectations at 3 months and long-term outcomes. Results: 185 (75.0%) patients available for analysis with a mean follow-up length of 24.8 months. The cohort included 124 (67%) females and 61 (33%) males and the average age at time of injury was 59.5 years. Eighty-six (46.5%) patients had low expectations for their overall health and 99 (53.5%) patients had high expectations for their health. No significant differences were seen between groups in regards to age, gender, follow-up length, Charlson Comorbidity Index (CCI), smoking and tobacco use, fracture pattern (OTA and Neer classifications), early complications (p > 0.05), fracture healing, and avascular necrosis. The mean DASH score at the latest follow up for patients with low expectations was 31.42 ± 22.8 whereas the mean for those with high expectations was 16.76 ± 20.2 (p < 0.0005). The mean forward flexion of the shoulder for patients with low expectations was 137.8 ± 31.5 degrees as compared to 148.5 ± 26.3 degrees (p < 0.05). The positive predictive value of good expectations correlating with good outcomes was 71,7%. Discussion: Patients with high expectations for their health early following injury had better outcomes in the long term. These high expectations also appeared to have an optimal influence on range of shoulder motion. This data suggests attitudinal and psychological factors that affect patient health expectations early on in the course of treatment may also influence patients"™ functional and clinical outcomes. Level of evidence: II; Retrospective Study.