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/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.

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.

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.

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.

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: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.