Faculty Bibliography

BACKGROUND:Reducing intraoperative wound contamination is a critical preventive strategy for reducing the risk of prosthetic joint infection in shoulder arthroplasty. The aim of this study was to investigate the potential microbial colonization of subscapularis tagging sutures during shoulder arthroplasty. METHODS:In this prospective study, 50 consecutive patients undergoing primary shoulder arthroplasty (anatomic or reverse) were enrolled. Patients with revision shoulder arthroplasty and proximal humeral fractures were excluded. Nonabsorbable, braided tagging sutures were placed through the subscapularis tendon prior to tenotomy. A similar nonabsorbable, braided suture (control) was placed in a sterile container on the back table, open to the operating room environment. Subscapularis tagging sutures (experimental specimens) and control sutures were collected prior to subscapularis tenotomy repair and submitted for aerobic and anaerobic cultures. Cultures were held for 21 days to account for extended growth of slow-growing bacteria. RESULTS:A total of 12 of 50 experimental and 16 of 50 control sutures had positive cultures. Staphylococcus epidermidis and Cutibacterium acnes were the 2 most commonly isolated organisms. Active tobacco use (P = .038) and procedure length (P = .03) were significantly associated with positive cultures. No significant association between positive subscapularis tagging suture cultures and positive control cultures was found (P = .551). Patient age, sex, body mass index, and significant medical comorbidities were not significantly associated with positive cultures. DISCUSSION/CONCLUSIONS:Subscapularis tagging sutures are a potential source of microbial contaminant in shoulder arthroplasty, and we recommend exchanging the tagging suture with a suture opened immediately prior to subscapularis repair.

HYPOTHESIS/OBJECTIVE:The aim of this meta-analysis was to compare the safety, efficacy, and opioid-sparing effect of liposomal bupivacaine (LB) vs. nonliposomal local anesthetic agents (NLAs) for postoperative analgesia after shoulder surgery. METHODS:A systematic literature review of randomized controlled clinical studies comparing the efficacy of LB with NLAs in shoulder surgery was conducted. Seven level I and II studies were included in the meta-analysis, and shoulder surgical procedures included arthroscopic rotator cuff repair and shoulder arthroplasty. Bias was assessed using The Cochrane Collaboration's tool. The primary outcome measures were visual analog scale pain scores and opioid consumption 24 and 48 hours after shoulder surgery. Subgroup analysis was performed for the method of LB administration (interscalene nerve block vs. local infiltration). RESULTS:A total of 7 studies (535 patients) were included in the final meta-analysis comparing LB (n = 260) with NLAs (n = 275). No significant difference was found between the LB and NLA groups in terms of visual analog scale pain scores at 24 hours (95% confidence interval, -1.02 to 0.84; P = .86) and 48 hours (95% confidence interval, -0.53 to 0.71; P = .78). Both groups had comparable opioid consumption at both 24 hours (P = .43) and 48 hours (P = .78) postoperatively and with respect to length of stay (P = .87) and adverse events (P = .97). Subgroup analysis demonstrated comparable efficacy irrespective of the method of administration of LB. CONCLUSION/CONCLUSIONS:LB is comparable to NLAs with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after arthroscopic rotator cuff repair and total shoulder arthroplasty.

OBJECTIVE:A major factor that impacts the long-term outcome and complication rates of total shoulder arthroplasty is the preoperative posterior glenoid bone loss quantified by glenoid retroversion. The purpose of this study was to assess if glenoid retroversion varies significantly at different glenoid heights in Walch B2 and B3 glenoids. MATERIALS AND METHODS/METHODS:Patients with B2 and B3 glenoid types were included following retrospective review of 386 consecutive CT shoulder studies performed for arthroplasty preoperative planning. True axial CT reconstructions were created using a validated technique. Two readers independently measured the glenoid retroversion angles according to the Friedman method using the "intermediate" glenoid at three glenoid heights: 75% (upper), 50% (equator), and 25% (lower). The variances between the three levels for a given patient were calculated. RESULTS:Twenty-nine B2 and 8 B3 glenoid types were included. There was no significant difference in variance of glenoid version among the three levels in B2 or B3 groups. The mean variance in retroversion degree between equator-lower, upper-equator, and upper-lower glenoid was - 0.4, 0.3, and - 0.2 for B2; and - 0.2, 1.9, and 1.9 for B3 glenoid, respectively. The level of inter-reader agreement was fair to good for variance at equator-lower, and good to excellent for upper-equator and upper-lower glenoid. CONCLUSIONS:Glenoid version can be accurately measured at any level between 25 and 75% of glenoid height for Walch B2 and B3. We recommend that the glenoid equator be used as the reference to assure consistent and reliable version measurements in this group of patients.

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. More than 800 experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form the International Consensus Group. The shoulder workgroup reached consensus on 27 questions related to culture techniques, inflammatory markers, and diagnostic criteria used to evaluate patients for periprosthetic shoulder infection. This document contains the group's recommendations and rationale for each question related to evaluating periprosthetic shoulder infection.

AIMS/OBJECTIVE:The aim of this study was to investigate the effects of preoperative bisphosphonate treatment on the intra- and postoperative outcomes of arthroplasty of the shoulder. The hypothesis was that previous bisphosphonate treatment would adversely affect both intra- and postoperative outcomes. PATIENTS AND METHODS/METHODS:group, there were 52 female and six male patients, with a mean age of 72.1 years (53 to 88). RESULTS:Previous treatment with bisphosphonates was positively associated with intraoperative complications (fracture; odds ratio (OR) 39.40, 95% confidence interval (CI) 2.42 to 6305.70) and one-year postoperative complications (OR 7.83, 95% CI 1.11 to 128.82), but did not achieve statistical significance for complications two years postoperatively (OR 3.45, 95% CI 0.65 to 25.28). The power was 63% for complications at one year. CONCLUSION/CONCLUSIONS:Patients who are treated with bisphosphonates during the three-year period before shoulder arthroplasty have a greater risk of intraoperative and one-year postoperative complications compared with those without this previous treatment.

Introduction: Posttraumatic arthritis (PTA) is a common sequela of proximal humerus fractures that is commonly managed with anatomic or reverse total shoulder arthroplasty (TSA). TSA for PTA is more challenging than that performed for primary osteoarthritis and frequently leads to worse patient outcomes. CPT uniformly classifies all cases of primary TSA, irrespective of procedural complexity and resource utilization. This study analyzes intraoperative differences and 30-day outcomes for anatomic and reverse TSA performed in the posttraumatic shoulder.
Method(s): Patients undergoing TSA from 2008 to 2015 were selected from the National Surgical Quality Improvement Program database and stratified according to concurrent procedures and administrative codes indicating posttraumatic diagnoses. Perioperative parameters and 30-day complications were recorded; multivariate analyses were performed to determine whether PTA was a risk factor for poor outcomes.
Result(s): A total of 8508 primary and 243 posttraumatic TSAs were identified. Posttraumatic TSA patients were slightly younger (P =.003), more likely to be female (P <.001), smokers (P =.029), and diabetic (P =.003). Diagnosis of PTA was an independent risk factor for prolonged operative times >=160 minutes (>=1 standard deviation above the mean, P =.003; odds ratio [OR]: 1.718; 95% confidence interval [CI]: 1.204-2.449) and increased bleeding requiring transfusion (P <.001; OR: 2.719; 95% CI: 1.607-4.600). Although posttraumatic TSA had a tendency for longer hospital admissions, 30-day readmissions were not significantly different between cohorts.
Conclusion(s): Compared with primary osteoarthritis, a preoperative diagnosis of PTA is an independent risk factor for prolonged operative times and postoperative transfusion in anatomic or reverse TSA patients; such patients may be less than optimal candidates for same-day discharges or outpatient shoulder arthroplasty.
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Glenohumeral arthritis has become increasingly prevalent. For patients with glenohumeral arthritis and an intact rotator cuff, an anatomic total shoulder arthroplasty (TSA) has been shown to provide substantial pain relief with consistent, reproducible results. The primary indication is intractable pain that has not responded to nonoperative treatment, resulting in a substantial negative impact on the quality of life of the patient. Other indications for anatomic TSA include posttraumatic glenohumeral arthritis, inflammatory arthritis, and humeral head osteonecrosis. Contraindications include active infection, deltoid insufficiency, severe glenoid bone deficiency, and excessive glenohumeral posterior subluxation or laxity that cannot be surgically corrected. In order to provide the stability necessary to withstand the forces that impact the glenoid, the implant used in TSA should replicate the native anatomy of the individual patient by using a combination of implant modularity with different humeral neck angles and glenoid version augments, as well as dual eccentricity of the neck and head implant. The major steps in TSA include (1) preoperative planning, (2) patient positioning and setup, (3) surgical exposure, (4) accessing the glenohumeral joint, (5) preparation of the humerus, (6) exposure and preparation of the glenoid with component insertion, (7) humeral component insertion and trial reduction, (8) subscapularis reattachment and closure, and (9) postoperative immobilization and rehabilitation. The expected outcomes of TSA include improved quality of life (as indicated by improved outcome and patient satisfaction scores), shoulder active range of motion, and strength. In a large study examining outcomes of TSA in patients >55 years old, Patel et al.¹ reported improved American Shoulder and Elbow Surgeons (48.3 ± 23.0), Constant (33.1 ± 16.7), and University of California Los Angeles (16.7 ± 6.3) shoulder scores, as well as improved active range of motion in active abduction (42° ± 41°), forward flexion (46° ± 40°), external rotation (33° ± 23°), and internal rotation (2.2° ± 1.8°) and decreased visual analog scale scores (-5.1 ± 2.9). Another study² showed increased maximal weight improvement of 7.7 ± 4.0 lbs (3.5 ± 1.8 kg).

Background/UNASSIGNED:The study evaluates patient-reported outcomes in revision shoulder arthroplasty (RevSA) according to etiology. Methods/UNASSIGNED:Twenty-three consecutive RevSA (minimum 2-year follow-up) were retrospectively reviewed. Patient-reported outcome (PRO) scores and range of motion were compared by the type of revision procedure and indication. Results/UNASSIGNED:EQ5D-QOL, VAS-pain, ASES, and forward elevation improved after RevSA. The infection group had least improvements. Revision to a reverse total shoulder arthroplasty (RTSA) demonstrated the most improvement in VAS-pain, forward elevation, and ASES. Conclusions/UNASSIGNED:Revision to RTSA significantly improved PRO scores compared to hemi- or total shoulder arthroplasty. RevSA for infection demonstrated the least improvement in outcomes.

Orthobiologics are organic and synthetic materials that are used in and outside of the operating room to augment both bone and soft tissue healing. The orthobiologics portfolio has vastly expanded over the years, and it has become imperative for orthopedic surgeons to understand the role and function of this new class of biologic adjuvants. This review will highlight key components and product groups that may be relevant for the practicing orthopedic surgeon in any subspecialty. This by no means is an extensive list of the available products but provides an important overview of the most highlighted products available in the market today. Those discussed include, bone void fillers, extracelluar matrix (ECM) products, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). These are further categorized into their uses in several subspecialties including, traumatology, sports medicine, sports surgery, and spine surgery.