Faculty Bibliography

BACKGROUND:Osteoarthritis of the glenohumeral joint is often associated with posterior glenoid wear. The purpose of this study was to determine the clinical and radiographic outcomes of a posteriorly augmented glenoid in patients who have a Walch B glenoid deformity when treated with anatomic total shoulder arthroplasty (aTSA). METHODS:At total of 68 primary aTSA patients with osteoarthritis and a Walch B glenoid deformity were treated with an 8° posteriorly augmented glenoid. All patients were evaluated and underwent scoring preoperatively and at latest follow-up with 5 clinical outcome scoring metrics; active range of motion (ROM) was also measured. The mean follow-up period was 50 months, with a 2-year minimum follow-up period. RESULTS:All patients experienced significant improvements in pain and function following aTSA with a posteriorly augmented glenoid, and 90% of patients exceeded the minimal clinically important difference threshold for the clinical outcome metric scores and ROM measures. Two-thirds of patients exceeded the substantial clinical benefit threshold for the clinical outcome metrics and ROM. Preoperatively, the humeral head was posteriorly subluxated an average of 73% for each Walch B glenoid type, and at latest follow-up, all humeral heads were re-centered on the posteriorly augmented glenoid. Two patients with augmented glenoids who had Walch B2 glenoids underwent revision for aseptic glenoid loosening. DISCUSSION/CONCLUSIONS:Anatomic total shoulder arthroplasty patients with Walch B glenoids receiving an 8° posteriorly augmented wedge glenoid experienced excellent clinical and radiographic outcomes with a patient satisfaction rate greater than 97% and a low complication rate at a mean follow-up of 50 months. Humeral head centering was maintained for each type of Walch B glenoid.

Introduction: The prevalence of reverse total shoulder arthroplasty (RTSA) has surpassed anatomic shoulder arthroplasty and is often used in complex cases of severe glenoid erosion including cases with an intact rotator cuff where there may be concerns about addressing glenoid wear with anatomic implants. CT-based preoperative planning software is now available for most commonly-used implants allowing surgeons to virtually determine optimal implant choice and placement in advance of surgery. While there are generally agreed upon ranges of normal glenoid anatomy for version and inclination, standards for an optimal RTSA have yet to be established. This study seeks to quantify surgeon differences in baseplate selection and placement for a series of cases with a range of pathologic glenoids.
Method(s): CT scans from 50 cases submitted for actual preoperative planning were collected and planned for RTSA on 2 separate occasions by 9 fellowship trained shoulder arthroplasty surgeons. One cases was excluded due to extreme glenoid wear leaving 49 cases for a total of 882 preoperative plans. All cases were planned using the same implant system (Equinoxe, Exactech Inc., Gainesville, FL) which offers 4 different baseplates: standard, an 8degree posterior augment, a 10degree superior augment, and a combined posterior/superior augment. Cases ranged from 0.9degree anteversion to -25degree retroversion (average -11.7degree) and from 14.6degree inferior to 15.6degree superior inclination (average 2.4degree superior) as measured by the software relative to the Friedman axis. Surgeons were compared for differences in baseplate selection, version and inclination correction and thresholds for augment use.
Result(s): Standard baseplates were selected in 21% of cases on average (Range: 5-68%). Average retroversion and inclination for use of a standard baseplate were -5.7degree (Range: -2.9 to -8.9degree) and 2.0degree superior (Range: 0.1degree inferior to 4.6degree superior). 8degree posterior augments were used in an average of 32% (Range: 22-67%). Average retroversion and inclination for this baseplate were -14.3degree (Range: -11.3 to -15.5degree) and 1.9degree inferior (Range: 5degree inferior to 2degree superior). 10degree superior augments were used in 16% of cases on average (Range: 3-32%). Average retroversion and inclination for this baseplate were -9.1degree (Range: -5 to -13.6degree) and 7.6degree superior (Range: 0.6 to 8.9degree superior). Posterior superior augments were used in 27% of cases on average (Range: 2-67%). Average retroversion and inclination for this baseplate were -15.9degree (Range: -11 to -21.6degree) and 3.4degree superior (Range: 1degree inferior to 4.8degree superior). Overall surgeons corrected cases to an average retroversion of -1.9degree (Range: 0 to -4.1degree). Maximum residual retroversion averaged -8.7degree (Range: 0 to -16degree). Overall inclination correction was to 0.4degree superior (Range: 0.2degree inferior to 1.8degree superior). Surgeons also differed on baseplate depth up to 1.8mm. [Formula presented] Discussion: This study indicates that surgeons vary substantially in their choice of baseplate and their threshold for augment use for given degrees of version and inclination. Overall use of augmented baseplates ranged from 32-95%. Interestingly, the average version and inclination correction differences for the two surgeons that differed the most in augment use was only 0.7degree and 0.1degree respectively. This may indicate that surgeons can achieve relatively similar goals for implant placement using different strategies of implant choice and position. Future studies should focus on strategies to minimize bone loss when correcting pathologic glenoid morphology as well as determine if certain baseplate position and orientation parameters are biomechanically favorable in terms of fixation especially in complex cases with severe wear patterns.
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Background: Treatment of proximal humerus fractures (PHFs) via reverse total shoulder arthroplasty (RTSA) has shown early promise when compared to historical treatment modalities. Ideal surgical timing remains unclear. The purpose of this study was to compare the outcomes of early versus delayed RTSA for PHF. We hypothesized that acute RTSA would display superior outcomes compared to those receiving delayed surgical intervention.
Method(s): This multicenter study retrospectively analyzed 142 patients who underwent RTSA for fracture. Patients treated within 4 weeks of injury were placed in the acute group (n=102), and patients treated longer than 4 weeks after injury were placed in the chronic group (n=38). A comprehensive panel of patient reported outcome measures, VAS pain scores, range of motion, and patient satisfaction were evaluated.
Result(s): The acute group had significantly better final follow-up SPADI scores (20.8 +/- 23.9 vs. 30.7 +/- 31.7) (p<0.05). The acute group demonstrated higher passive external rotation compared to the chronic group (47.8 +/- 16.5 vs. 40.4 +/- 16.1) (p<0.05). No further differences were detected in other postoperative range of motion measurements, subjective outcomes, or VAS scores. The acute group displayed significantly greater overall improvements (pre vs post) in all range of motion measurements as well as patient-reported outcome and VAS scores. Average follow-up was 51.4 months.
Conclusion(s): Our results suggest that patients treated acutely display similar mid-term outcomes to those who receive delayed treatment. Surgeons may first give consideration to a period of nonoperative treatment.
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BACKGROUND:The aims of this study were to examine variances in inpatient opioid consumption after total shoulder arthroplasty (TSA) and to determine factors influencing inpatient opioid utilization. METHODS:The sample included patients undergoing elective TSA at a tertiary-level institution between January 2016 and April 2018. Opioid consumption during the inpatient stay was converted into morphine milligram equivalents (MMEs), accounting for dosage and route of administration. The MMEs were calculated per patient encounter and used to calculate mean opioid consumption. Bivariate linear regression analysis was performed to assess the impact of patient-related factors and surgery-related factors on inpatient opioid consumption. RESULTS:Altogether 20 surgeons performed 622 TSAs. The average opioid dose per encounter was 47.4 ± 65.7 MME/d. MMEs prescribed varied significantly among surgeon providers (P < .01). Pre-existing psychiatric disorders (P = .00012), preoperative opioid use (P = .0013), highest quartile of median household income (P = .048), current-smoker status (P < .001), age < 60 years (P < .01), and general anesthesia (vs. regional anesthesia, P = .005) were associated with significant inpatient opioid consumption after TSA. Sex, race, American Society of Anesthesiologists status, replacement type (anatomic TSA vs. reverse TSA), and prior shoulder surgery did not show any significant differences. CONCLUSION/CONCLUSIONS:There is considerable variation in inpatient opioid consumption after TSA at the same institution. Knowledge of modifiable and nonmodifiable risk factors that increase inpatient opioid consumption will help to optimize multimodal analgesia protocols for TSA.

BACKGROUND:As part of the Patient Protection and Affordable Care Act, states were given the option of expanding Medicaid coverage to include adults younger than age 65 years with income at or below 138% of the federal poverty level. Although this expansion was intended to provide health care coverage to an estimated 20 million Americans, several studies have shown increased coverage does not equate to increased access to care by specialty providers. METHODS:We queried the New York Statewide Planning and Research Cooperative System database and identified all patients who underwent the 10 most common elective orthopaedic surgeries from January 1, 2012, through March 31, 2016. Medicaid monthly enrollment for the 4-year study period was obtained from NY Department of Health Medicaid Managed Care Enrollment Reports. RESULTS:Our query identified 700,159 patients who underwent the investigated orthopaedic surgeries. Of these, 60,786 were Medicaid recipients. During the 4-year study period, Medicaid enrollment and the number of procedures reimbursed by Medicaid increased significantly (P < 0.001 for both). CONCLUSIONS:Affordable Care Act-supported Medicaid expansion was associated with an increase in Medicaid enrollment and a concomitant increase in the utilization of orthopaedic surgery by Medicaid beneficiaries in New York State.

INTRODUCTION/UNASSIGNED:Stem subsidence and thigh pain can cause significant patient dissatisfaction after cementless THA. The purpose of this study was to examine the effect of proximal-femoral morphology and stem alignment on clinical outcomes using a double-tapered, cementless titanium femoral component. METHODS/UNASSIGNED:We retrospectively reviewed 281 consecutive, primary THAs from 2012 to 2014 with a mean follow-up of 4 years. Preoperative radiographs were used to assess femoral neck shaft angle (FNS), canal flare index (CFI), Dorr classification, and greater trochanter (GT) overhang. Postoperative radiographs were used to determine stem alignment and 6-week follow-up radiographs were used to determine subsidence. Clinical outcomes included thigh pain, leg-length discrepancy (LLD), patient-reported outcome measures (PROMs) and revision surgeries. RESULTS/UNASSIGNED: 0.03) and FNS was inversely associated with postoperative HOOS scores. CONCLUSIONS/UNASSIGNED:Subsidence and proximal-femoral morphology are potential sources of postoperative morbidity in certain cementless THA patients. In accordance with prior studies, CFI was identified as a potential risk factor for intraoperative calcar fractures. More research into preoperative femoral morphologies, such as GT overhang and FNS, is warranted as these may contribute to unsatisfactory results related to cementless THA.

Background: Treatment of proximal humerus fractures (PHFs) via reverse total shoulder arthroplasty (RTSA) has shown early promise when compared to historical treatment modalities. Ideal surgical timing remains unclear. The purpose of this study was to compare the outcomes of early versus delayed RTSA for PHF. We hypothesized that acute RTSA would display superior outcomes compared to those receiving delayed surgical intervention. Methods: This multicenter study retrospectively analyzed 142 patients who underwent RTSA for fracture. Patients treated within 4 weeks of injury were placed in the acute group (n = 102), and patients treated longer than 4 weeks after injury were placed in the chronic group (n = 38). A comprehensive panel of patient reported outcome measures, VAS pain scores, range of motion, and patient satisfaction were evaluated. Results: The acute group had significantly better final follow-up SPADI scores (20.8 ± 23.9 vs. 30.7 ± 31.7) (p<0.05). No further differences were detected in other postoperative range of motion measurements, subjective outcomes, or VAS scores. Conclusions: Our results suggest that patients treated acutely display similar mid-term outcomes to those who receive delayed treatment. With this in mind, surgeons may first give consideration to a period of nonoperative treatment. Level of evidence: Level II.

Hypothesis: The use of intraoperative glenohumeral load sensors has the potential to facilitate an objective, quantitative assessment of the soft tissue tension during reverse total shoulder arthroplasty. Material and Methods: A reverse total shoulder arthroplasty was performed on eight fresh frozen cadaveric shoulders, creating three different tightness conditions for each shoulder by using various shim thicknesses attached to an instrumented, load-sensing humeral trial component. The glenohumeral loads were recorded during four dynamic maneuvers, consisting of maximum internal/external rotation at 0-, 45- and 90-degree abduction and forward elevation. The joint kinematics were synchronously recorded using an optical tracking system. Results: For normal tightness conditions, 98.3% of the observed loads were below 40 lbf. These loads varied through the range of motion with an increase in glenohumeral loads generally observed towards the limits of the range of motion. With increasing shoulder tightness, the range of motion of the joint was not significantly affected, though the average and maximum glenohumeral load significantly increased (p < 0.01 for all). Conclusion: In a cadaveric setting, higher glenohumeral loads were observed at higher tightness conditions, demonstrating the potential of a load-sensing humeral trial component to quantify intraoperative joint load with reverse total shoulder arthroplasty. The glenohumeral loads are increasing towards the limits of the range of motion, indicating the importance of performing dynamic assessment of stability at the extents of the range of motion during implant trialing. Level of Evidence: Basic science study

INTRODUCTION/BACKGROUND:This study examined the relationship between personality traits and interpersonal communication skills among first-year orthopedic surgery residents. METHOD/METHODS:This study performed a retrospective analysis on the data collected in the 2 phases among the 6 cohorts of first-year orthopedic surgery residents (n = 73) during a 6-year period at an urban academic medical hospital. Resident personality was assessed through self-report prior to entry into the program and included a total of 7 personality traits. These traits were broken down into 2 categories, day to day, or usual, tendencies, which measured personality traits when no stress was present and stress tendencies, which measured personality traits when stressed or fatigued. The "day to day" tendencies measured were Emotional Stability, Agreeableness, Conscientiousness and Openness) and "stress" tendencies measured were Excitable, Skeptical and Imaginative. Communication skills were measured across 4 specific dimensions of patient communication (Engage, Empathy, Educate, Enlist) in an Objective Structured Clinical Examination (OSCE). RESULTS:Multiple regression analyses showed that the personality traits identified as "stress" tendencies predicted performance on 2 of the 4 communication skills dimensions measured by the OSCE and accounted for up to 34.8% of the total variance in the ratings of empathic communication and up to 67.2% of the total variance in education-related communication. CONCLUSIONS:Our research identifies specific personality traits that affect resident communication skills related to patient education and empathy in simulated encounters. Three stress-related personality traits (Excitable, Skeptical, Imaginative) had a strong negative influence on communication skills, while day to day personality traits (Emotional Stability, Agreeableness, Conscientiousness) positively influenced communication skills.