Faculty Bibliography

Background/UNASSIGNED:Humeral stem lucencies are uncommon after uncemented anatomic total shoulder arthroplasty (aTSA), and their clinical significance is unknown. This study compares clinical outcomes of aTSA with and without humeral stem lucencies. Methods/UNASSIGNED:Two-hundred eighty aTSAs using an uncemented grit-blasted metaphyseal-fit humeral stem between 2005 and 2013 were retrospectively evaluated for radiographic humeral stem lucencies. All shoulders were evaluated at a minimum 5-year follow-up from a multicenter database. Clinical outcomes included range of motion (ROM) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Constant score, University of California-Los Angeles Shoulder Score (UCLA), Simple Shoulder Test (SST), and Shoulder Pain and Disability Index (SPADI) scores. Postoperative radiographs were evaluated and complications were recorded. Results/UNASSIGNED:Two-hundred forty-three humeral stems showed no radiolucent lines. Among the 37 humeral stems with lucent lines, lines were most common in zones 8, 4, 7, and 3. Preoperative ROM and functional outcomes were similar between groups. Postoperative change in outcomes exceeded the minimal clinically important difference (MCID) for all ROM and outcomes in both groups. Postoperative change between groups showed no significant difference in ROM or outcome scores, but improved mean abduction exceeded the MCID in the patients without humeral lines. The complication rate after omitting patients with humeral loosening was higher in patients with humeral lucencies, as was the revision rate. There was also a higher glenoid-loosening rate in patients with humeral lucencies. Conclusion/UNASSIGNED:Humeral lucent lines after uncemented stemmed aTSA have a small negative effect on ROM and functional outcomes compared with patients without lucent humeral lines, which may not be clinically significant. The complication and revision rates were significantly higher in patients with humeral lucencies.

OBJECTIVES/OBJECTIVE:To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN/METHODS:Prospective cohort study SETTING:: Seven musculoskeletal care centers with New York City and Long Island. PATIENTS/PARTICIPANTS/METHODS:138 recent and 115 historical hip fracture patients. INTERVENTION/METHODS:Patients with hip fractures occurring between February 1, 2020 and April 15, 2020 or between February 1, 2019 and April 15, 2019 were prospectively enrolled in an orthopedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs) or COVID negative (C-). MAIN OUTCOME MEASUREMENTS/METHODS:Hospital quality measures, inpatient complications and mortality rates. RESULTS:Seventeen (12.2%) patients were confirmed C+ by testing and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared to Cs and C- cohorts, had: an increased mortality rate (35.3% vs 7.1% vs 0.9%), increased length of hospital stay, a greater major complication rate and a greater incidence of ventilator need postoperatively. CONCLUSIONS:COVID-19 had a devastating effect on the care of hip fracture patients during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in hip fracture patients complicated by COVID-19. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

INTRODUCTION/BACKGROUND:Students seek gap years to enhance knowledge and improve chances of professional success. Although many institutions offer research opportunities, no studies have examined outcomes after these experiences. This study evaluates a dedicated year of orthopaedic research on a cohort's ultimate orthopaedic surgery match rate. METHODS:From 2001 to 2018, 129 learners spent a year with our Department of Orthopedic Surgery at a major academic medical center. The students were either completing a gap year after college, during or after medical school, or after an unsuccessful match. Participants were asked to respond to a survey, which included demographics, educational information, and metrics related to the program. For the subcohort of students who ranked orthopaedic surgery, the match rate was compared with the mean for the US orthopaedic surgery match rates from 2006 to 2018 using a chi-square analysis. In addition, a Mann-Whitney U test was used to compare the number of publications before and after the year. RESULTS:One hundred three students (80%) returned completed questionnaires. Of all learners who applied to and ranked orthopaedic surgery, 91% matched into an orthopaedic surgery residency program. These results compared favorably with the US orthopaedic match from 2006 to 2018 (67.9%; P < 0.001), despite a 4-point lower United States Medical Licensing Examination (USMLE) Step 1 score for the research cohort. Finally, the research cohort had a greater percentage of women (23%) and minorities (40%) than the proportion of woman and minority practicing orthopaedic surgeons. CONCLUSION/CONCLUSIONS:Students who completed a gap year in research matched into orthopaedics at a higher rate than the national average, despite a lower Step score. Mentors may also target traditionally underrepresented groups to help increase the pool of diverse applicants.

As the world grapples with the COVID-19 pandemic, we as health care professionals thrive to continue to help our patients, and as orthopedic surgeons, this goal is ever more challenging. As part of a major academic tertiary medical center in New York City, the orthopedic department at New York University (NYU) Langone Health has evolved and adapted to meet the challenges of the COVID pandemic. In our report, we will detail the different aspects and actions taken by NYU Langone Health as well as NYU Langone Orthopedic Hospital and the orthopedic department in particular. Among the steps taken, the department has reconfigured its staff's assignments to help both with the institution's efforts and our patients' needs from reassigning operating room nurses to medical COVID floors to having attending surgeons cover urgent care locations. We have reorganized our residency and fellowship rotations and assignments as well as adapting our educational programs to online learning. While constantly evolving to meet the institution's and our patient demands, our leadership starts planning for the return to a new "normal".

BACKGROUND:We sought to identify the influence of shoulder arthroplasty (SA) type (primary anatomic, primary reverse, revision) and indication (fracture, arthritis) on the risk of postoperative packed red blood cell transfusion (pRBCT) and intravenous fluid bolus (IVFB). METHODS:Patients who underwent SA from 2013 through 2016 at our institution were categorized into four groups: primary anatomic (pTSA; N = 298), primary reverse (pRTSA; N = 292), revision (RevSA; N = 133), and shoulder arthroplasty for fracture (SAF; N = 58). Basic demographics, intraoperative metrics, preoperative lab values, and postoperative interventions (pRBCT and IVFB) were retrieved from electronic records. RESULTS:There were 781 SAs, of which 176 cases involved at least one postoperative intervention: pRBCT (6.3%) or IVFB (18.8%). Compared to pTSA, the odds of pRBCT in pRTSA, revSA, and SAF were: 3.0 (95% CI 0.9-10.0), 3.4 (95% CI 0.9-2.7), and 8.6 (95% CI 2.2-32.9), respectively. Independent risk factors for pRBCT included increasing age (p = 0.003), underweight body mass index (p = 0.019), Charlson Comorbidity Index ≥ 3 (p = 0.002), inpatient discharge to higher level of care (p = 0.011), estimated blood loss (p = 0.003), and preoperative hemoglobin (p ≤ 0.001). Also, compared to pTSA, the odds for IVFB in pRTSA, revSA, and SAF were: 2.8 (95% CI 1.7-4.6), 2.2 (95% CI 1.2-4.0), and 4.7 (95% CI 2.2-9.9), respectively. Other independent risk factors for IVFB included female sex (0.002), CCI ≥ 3 (p = 0.017), and operative time (p = 0.047). CONCLUSION/CONCLUSIONS:Shoulder arthroplasty for fracture is an independent risk factor for higher risk of postoperative pRBCT and IVFB.

OBJECTIVE:The purpose of this study is to quantify the clinical and radiographic outcomes of patients with severe posterior glenoid wear who were treated with reverse total shoulder arthroplasty (rTSA) and a posterior augmented baseplate. METHODS:A total of 67 primary rTSA patients with osteoarthritis and posterior glenoid wear were treated with an 8° posterior augmented glenoid baseplate. All patients had a Walch B2, B3, or C glenoid, 2-year minimum follow-up, and mean follow-up of 40 months. All patients were scored preoperatively and at the latest follow-up using 5 clinical outcome metrics; active range of motion was also measured. A Student's 2-tailed, unpaired t-test quantified differences in outcomes, where P < .05 denoted significance. RESULTS:All patients experienced significant improvements in pain and function after primary rTSA with a posterior augmented glenoid baseplate. Three complications were reported for a rate of 4.5%; no cases of aseptic glenoid loosening occurred. A total of 90% of patients exceeded the minimal clinically important difference threshold, and 80% of patients exceeded the substantial clinical benefit threshold for each clinical outcome metric and range of motion measure. No differences in outcomes or complications were observed between Walch B2 and B3 patients, demonstrating that this full-wedge posterior augmented baseplate was equally good in each type of glenoid deformity. DISCUSSION/CONCLUSIONS:Primary rTSA patients with Walch B2, B3, and C glenoids who received an 8° posterior augmented glenoid baseplate experienced excellent clinical and radiographic outcomes with a low complication rate and no reports of aseptic glenoid loosening at a mean follow-up of 40 months.

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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