Faculty Bibliography

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.

The glenoid is considered a weak link in total shoulder arthroplasty because failure on the glenoid side is one of the most common reasons for revision of total shoulder arthroplasty. Glenoid wear is commonly seen in glenohumeral arthritis and compromises glenoid bone stock and also alters the native version and inclination of the glenoid. It is critical to recognize glenoid wear and correct it intraoperatively to avoid component malposition, which can negatively affect the survivorship of the glenoid implant. The end point of correction for the glenoid wear in shoulder arthroplasty is controversial, but anatomic glenoid component positioning is likely to improve long-term survivorship of the total shoulder arthroplasty. Preoperative three-dimensional (3-D) computer planning software, based on CT, is commercially available. It allows the surgeon to plan implant type (anatomic versus reverse), size, and position on the glenoid, and also allows for templating deformity correction using bone graft and/or augments. Guidance technology in the form of computer-assisted surgery (CAS) and patient-specific instrumentation (PSI) allows the surgeon to execute the preoperative plan during surgery with a greater degree of accuracy and precision and has shown superiority to standard instrumentation. However, the proposed benefits of this technology including improved glenoid survivorship, reduced revision arthroplasty rate and cost-effectiveness have not yet been demonstrated clinically. In this review, we present the current evidence regarding PSI and CAS in managing glenoid deformity in total shoulder arthroplasty.

BACKGROUND:Nonsteroidal anti-inflammatory drugs (NSAIDs) are being increasingly employed as a part of multimodal non-opioid strategies to treat postoperative pain. In the present study, we sought to review the effects of short-term NSAID use on musculoskeletal soft-tissue healing. METHODS:We performed a scoping review of all studies that included the use of NSAIDs and their effect on healing of soft tissues, which for the purpose of this review refers to non-osseous musculoskeletal tissue such as ligament, tendon, labrum, and meniscus. The inclusion criteria encompassed all studies (human, animal, and in vitro) that evaluated the effect of NSAIDs on soft-tissue healing. Subgroup analyses, wherever applicable, were conducted on the basis of the type of NSAID (cyclooxygenase [COX]-specific or nonspecific) and the type of study (human, animal, or in vitro). Relevant metadata from each study were abstracted, and descriptive statistics were used to summarize the results. RESULTS:A total of 44 studies met the inclusion criteria, including 3 human studies, 33 animal studies, and 8 in vitro studies. These studies included 4 different NSAIDs in the human subgroup, 16 different NSAIDs in the animal subgroup, and 7 different NSAIDs in the in vitro subgroup. The majority of reported studies (including 1 of 2 human studies, 10 of 14 animal studies, and 3 of 3 in vitro studies) demonstrated that COX-2-selective inhibitors had negative impact on soft-tissue healing. In contrast, the majority of human and animal studies (2 of 2 and 19 of 30, respectively) demonstrated that nonselective COX inhibitors had no negative effect on the healing of labrum, tendons, and ligaments. The majority of in vitro studies demonstrated that NSAIDs have a harmful effect on biological processes involved in tendon-healing and regeneration (tenocyte proliferation, collagen and glycosaminoglycan synthesis). CONCLUSIONS:Current limited evidence demonstrates that selective COX-2 inhibitors can negatively affect healing of musculoskeletal soft tissue after surgical repair. In contrast, the majority of studies demonstrate that nonselective COX inhibitors have no negative effect on musculoskeletal soft-tissue healing. Additional high-quality human clinical trials are necessary to provide more definitive conclusions.

Background/UNASSIGNED:Preoperative factors that most influence postoperative outcomes of both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) are unknown. The purpose of this study was to identify the preoperative parameters that significantly influence postoperative outcomes of aTSA and rTSA. Methods/UNASSIGNED:The outcomes of 1089 aTSA patients and 1332 rTSA patients (mean follow-up period, 49 months) from an international registry with a single platform system were analyzed. A multiple linear regression model with backward stepwise selection identified the preoperative parameters that were significant predictors of postoperative clinical outcome metric scores and motion measures for both rTSA and aTSA. Results/UNASSIGNED:For both aTSA and rTSA patients, numerous preoperative parameters that influence postoperative outcomes were identified. Greater postoperative range of motion (ROM) was significantly influenced by greater preoperative ROM. For aTSA, greater postoperative American Shoulder and Elbow Surgeons (ASES) scores were significantly influenced by greater preoperative ASES scores, no history of shoulder surgery, and the presence of greater preoperative active external rotation. For rTSA, greater postoperative ASES scores were significantly influenced by greater preoperative ASES scores, no history of shoulder surgery, no history of tobacco use, less preoperative passive external rotation, and greater preoperative active external rotation. Conclusions/UNASSIGNED:This study quantified the preoperative predictors of postoperative clinical outcome metric scores and ROM for both aTSA and rTSA. Numerous significant associations were identified, including demographic and comorbidity risk factors. These associations may be helpful for surgeons to consider when counseling patients regarding aTSA versus rTSA and to establish more accurate expectations prior to surgery.

Background/UNASSIGNED:Little guidance exists regarding the minimum screw length and screw quantity necessary to achieve fixation in reverse total shoulder arthroplasty (rTSA); to that end, this study quantified the displacement of 2 different sizes of glenoid baseplates using multiple different screw lengths and quantities of screws in a low-density polyurethane bone-substitute model. Methods/UNASSIGNED:Testing of rTSA glenoid loosening was conducted according to ASTM F 2028-17. To independently evaluate the impact of screw quantity and screw length on rTSA glenoid fixation for 2 different sizes of glenoid baseplates, baseplates were constructed using 2 screws, 4 screws, or 6 screws (with the latter being used for the larger baseplate only) with 3 different poly-axial locking compression screw lengths. Results/UNASSIGNED:Both sizes of glenoid baseplates remained well fixed after cyclic loading regardless of screw length or screw quantity. Baseplates with 2 screws had significantly greater displacement than baseplates with 4 or 6 screws. No differences were observed between baseplates with 4 screws and those with 6 screws (used for the larger baseplate). Both sizes of baseplates with 18-mm screws had significantly greater displacement than baseplates with 30- or 46-mm screws. For larger baseplates, those with 30-mm screws had significantly greater displacement than those with 46-mm screws in the superior-inferior direction. Discussion/UNASSIGNED:For the 2 different sizes of baseplates tested in this study, rTSA glenoid fixation was impacted by both screw quantity and screw length. Irrespective of screw quantity, longer screws showed significantly better fixation. Irrespective of screw length, the use of more screws showed significantly better fixation, up to a point, as the use of more than 4 screws showed no incremental benefit. Finally, longer screws can be used as a substitute for additional fixation if it is not feasible to use more screws.