Faculty Bibliography

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.

Background: The aim of this study was to compare outcomes of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) after prior shoulder stabilization versus matched cohorts without previous stabilization surgery. Hypotheses were as follows: (1) patients undergoing aTSA or rTSA after stabilization procedures would have worse outcomes than matched cohorts and (2) patients undergoing TSA would have better outcomes after soft-tissue stabilization procedures (aTSAST or rTSAST) than after bony stabilization procedures (aTSAB or rTSAB). Methods: Retrospective cohort study was performed comparing (1) 36 patients who underwent aTSA and (2) 32 patients who underwent rTSA with prior shoulder stabilization with 3-to-1 matched cohorts (based on age, gender, and follow-up length) with no prior shoulder instability or surgery. Baseline demographics, perioperative data, adverse events (AEs), radiographic outcomes, functional outcome scores, range of motion (ROM), and patient satisfaction were analyzed. Subgroup analyses compared patients who underwent aTSAST or rTSAST with patients who underwent aTSAB or rTSAB. Results: The postoperative AE rate was 8.3% and 4.6% in the aTSA group and matched cohort, respectively (P =.404), with a trend toward a significantly higher incidence of aseptic glenoid loosening in the aTSA group (8.3% vs. 1.9%, P =.067). Functional outcomes, ROM, and patient satisfaction did not differ at follow-up >4 years. In the subgroup analysis, two AEs required reoperation among 25 patients who underwent aTSAST versus one among 11 patients who underwent aTSAB, all related to aseptic loosening. There was a trend toward greater functional outcomes and satisfaction among patients who underwent aTSAST. There was a trend toward a clinically significant difference in active abduction at final follow-up favoring aTSAST (128 vs. 108 degrees, P =.096). The postoperative AE rate was 6.3% and 4.2% among the rTSA group and matched cohort, respectively (P =.632). Functional outcomes, ROM, and patient satisfaction did not differ at 4-year follow-up. In the subgroup analysis, no AEs were reported among 18 patients who underwent rTSAST and 14 patients who underwent rTSAB. A trend toward greater functional outcomes and patient satisfaction favored patients who underwent rTSAB, who achieved greater improvements in ROM from baseline and greater ROM in all planes at the final follow-up. Conclusion: Both aTSA and rTSA are reliable options for the treatment of dislocation arthropathy in appropriately selected patients. aTSA and rTSA after prior shoulder stabilization procedures have nearly equal rates of AEs and yield similar clinical and functional outcomes as matched cohorts. There may be an increased risk of glenoid aseptic loosening in aTSA after prior shoulder stabilization. Functional outcomes tend to be greater for patients who underwent aTSAST than those for patients who underwent aTSAB. On the contrary, rTSA may optimize postoperative function when performed for dislocation arthropathy after bony rather than soft-tissue stabilization procedures. Level of evidence: Level III; Retrospective Cohort Design; Treatment Study

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.

Background: We use machine learning to create predictive models from preoperative data to predict the Shoulder Arthroplasty Smart (SAS) score, the American Shoulder and Elbow Surgeons (ASES) score, and the Constant score at multiple postoperative time points and compare the accuracy of each algorithm for anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA). Methods: Clinical data from 2270 patients who underwent aTSA and 4198 patients who underwent rTSA were analyzed using 3 supervised machine learning techniques to create predictive models for the SAS, ASES, and Constant scores at 6 different postoperative time points using a full input feature set and the 2 different minimal feature sets. Mean absolute errors (MAEs) quantified the difference between actual and predicted outcome scores for each model at each postoperative time point. The performance of each model was also quantified by its ability to predict improvement greater than the minimal clinically important difference (MCID) and the substantial clinical benefit (SCB) patient satisfaction thresholds for each outcome measure at 2-3 years after surgery. Results: All 3 machine learning techniques were more accurate at predicting aTSA and rTSA outcomes using the SAS score (aTSA: ±7.41 MAE; rTSA: ±7.79 MAE), followed by the Constant score (aTSA: ±8.32 MAE; rTSA: ±8.30 MAE) and finally the ASES score (aTSA: ±10.86 MAE; rTSA: ±10.60 MAE). These prediction accuracy trends were maintained across the 3 different model input categories for each of the SAS, ASES, and Constant models at each postoperative time point. For patients who underwent aTSA, the XGBoost predictive models achieved 94%-97% accuracy in MCID with an area under the receiver operating curve (AUROC) between 0.90-0.97 and 89%-94% accuracy in SCB with an AUROC between 0.89-0.92 for the 3 clinical scores using the full feature set of inputs. For patients who underwent rTSA, the XGBoost predictive models achieved 95%-99% accuracy in MCID with an AUROC between 0.88-0.96 and 88%-92% accuracy in SCB with an AUROC between 0.81-0.89 for the 3 clinical scores using the full feature set of inputs. Discussion: Our study demonstrated that the SAS score predictions are more accurate than the ASES and Constant predictions for multiple supervised machine learning techniques, despite requiring fewer input data for the SAS model. In addition, we predicted which patients will and will not achieve clinical improvement that exceeds the MCID and SCB thresholds for each score; this highly accurate predictive capability effectively risk-stratifies patients for a variety of outcome measures using only preoperative data. Level of evidence: Level III; Retrospective Comparative study

»:For shoulder arthroplasty, regional anesthesia is safer when compared with general anesthesia. There is insufficient evidence to demonstrate the superiority of regional anesthesia with respect to pulmonary complications and hospital length of stay. »:Infiltration of the shoulder with local anesthetics offers no additional benefits compared with single-shot or continuous brachial plexus blocks for shoulder arthroplasty. »:There is high-quality evidence (Level I) demonstrating lower pain scores and lower perioperative opioid requirements after a continuous peripheral nerve block compared with a single-shot nerve block. However, catheter dislodgment and logistical issues with catheter insertion are impediments to the widespread usage of a continuous nerve block with an indwelling catheter. »:Liposomal bupivacaine is comparable with non-liposomal local anesthetic agents with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after total shoulder arthroplasty. »:Perioperative dexamethasone administration improves postoperative pain control, decreases perioperative opioid requirements, and reduces postoperative nausea.

Background/UNASSIGNED:Anatomic total shoulder arthroplasty improves pain and function with a reported reoperation rate of approximately 1% per year. With improved glenoid fixation, reverse shoulder arthroplasty implants may outperform anatomic total shoulder arthroplasty. We evaluate the functional outcomes and reoperation rate of anatomic total shoulder arthroplasty versus reverse shoulder arthroplasty at a minimum eight-year follow-up or revision. Methods/UNASSIGNED:Between 2005 and 2010, 187 shoulders (137 anatomic total shoulder arthroplasty, 50 reverse shoulder arthroplasty) were retrospectively reviewed at a mean of 8.8 years. The mean age at surgery was 67 years. Females were more commonly treated with reverse shoulder arthroplasty. Both groups had similar body mass index and comorbidities. Outcome measures evaluated included abduction, forward elevation, external rotation, internal rotation, Simple Shoulder Test, Constant score, American Shoulder and Elbow Score, University of California Los Angeles Shoulder score, and Shoulder Pain and Disability Index. Results/UNASSIGNED:At follow-up, anatomic total shoulder arthroplasty demonstrated greater overhead range of motion and external rotation. All patient-reported outcomes remained similar between groups. Reverse shoulder arthroplasty patients were more likely to rate shoulders as much better or better after surgery (90% versus 67%, p = 0.004). Complications were observed in 24% of anatomic total shoulder arthroplasties and 8% of reverse shoulder arthroplasties (p = 0.02). Reoperation was more common in anatomic total shoulder arthroplasties (23% versus 4%, p = 0.003). Discussion/UNASSIGNED:At mid-to-long-term follow-up, reverse shoulder arthroplasties demonstrated significantly fewer complications and reoperations than anatomic total shoulder arthroplasties. Despite similar patient-reported outcomes, reverse shoulder arthroplasty patients were more likely to be satisfied with their shoulder.