Faculty Bibliography

BACKGROUND CONTEXT: The discussion regarding value based care has evolved in recent years, yet the ability to report Health Related Quality of Life (HRQoL) between different disease states has been limited by lack of validated standardized metrics to compare them. The recent advent of computer adaptive Patient Reported Outcome Information System (PROMIS), which allows for standardized assessment across health conditions, provides the ability to compare differing disease states and procedures. PURPOSE: To compare baseline and postoperative PROMIS scores for patients undergoing common single-level spinal surgery procedures, total hip arthroplasty (THA) and total knee arthroplasty (TKA). STUDY DESIGN/SETTING: Retrospective clinical cohort study of patients undergoing common single-level spine surgery procedures, THA and TKA at 6-month postoperative follow-up. PATIENT SAMPLE: A total of 505 orthopedic surgical patients were included who underwent either: single level anterior cervical discectomy and fusion (ACDF, N=37), lumbar laminectomy (Lami, N=31), microscopic lumbar discectomy (MLD, N=58), transforaminal lumbar interbody fusion (TLIF, N=46), total hip arthroplasty (THA, N=131), or total knee arthroplasty (TKA, N=202) at a single institution. OUTCOME MEASURES: Baseline (BL) and 6 month (6M) PROMIS metrics (Physical Function, Pain Interference, Pain Intensity). Patients were compared by T-values, which is age and gender adjusted to give a normal distribution of the general population, as the mean is scored at 50, and each 10 point deviation reflects 1SD of the population in improving or worsening function.
METHOD(S): Patients>18 years old who underwent spine surgery (ACDF, Lami, MLD, TLIF) or adult reconstruction surgery (THA or TKA) with BL & 6M PROMIS scores of physical function, pain interference and pain intensity were separately grouped based on surgery type. Paired t-tests compared differences in BL, 6M and the change in PROMIS scores for spine vs adult reconstruction procedures.
RESULT(S): A total of 172 spine surgery patients (age=54.6+/-15.6; 42.9% female) and 333 adult reconstruction patients were compared (age=65.8+/-9.5; 59.8% female). Spine surgery patients were significantly younger (p<.01) than adult reconstruction patients. Spine surgery patients undergoing ACDF, laminectomy, MLD or TLIF all had more disability and pain at baseline than THA and TKA patients, according to physical function ([20.1, 8.71, 14.2, 9.26] vs [35.9, 35.01], p<.01), pain interference ([84.1, 89.8, 91.8, 91.0)]vs [63.9, 63.8], p<.01) and pain intensity metrics ([53.6, 58.1, 58.2, 56.1] vs [53.4, 53.8], p<.01). At 6M, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients; However, patients across all spine procedures experienced greater improvements than THA and TKA patients in terms of physical function ([+8.1, +12.1, +15.2, +12.9] vs [+5.24, +3.9], p<.01) and pain interference scores ([-15.1, -14.1, -12.5, -11.9] vs [-8.1, -6.0] p<.01). Similar improvements in pain intensity scores were seen.
CONCLUSION(S): Patients undergoing single level spinal surgery had lower initial and 6 month postoperative PROMIS scores compared to those undergoing total hip and knee arthroplasty. All procedure cohorts demonstrated meaningful improvement after orthopaedic surgical treatment, but spinal surgery patients demonstrated more improvement in physical function and pain interference scores compared to arthroplasty patients. Future study is required to assess the value base of spinal and adult reconstruction surgery, including durability. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND:In total joint arthroplasty, variation in implant use can be driven by vendor relationships, surgeon preference, and technological advancements. Our institution developed a preferred single-vendor program for primary hip and knee arthroplasty. We hypothesized that this initiative would decrease implant costs without compromising performance on quality metrics. METHODS:The utilization of implants from the preferred vendor was evaluated for the first 12 months of the contract (September 1, 2017, to August 31, 2018; n = 4,246 cases) compared with the prior year (September 1, 2016, to August 31, 2017; n = 3,586 cases). Per-case implant costs were compared using means and independent-samples t tests. Performance on quality metrics, including 30-day readmission, 30-day surgical site infection (SSI), and length of stay (LOS), was compared using multivariable-adjusted regression models. RESULTS:The utilization of implants from the preferred vendor increased from 50% to 69% (p < 0.001), with greater use of knee implants than hip implants from the preferred vendor, although significant growth was seen for both (from 62% to 81% for knee, p < 0.001; and from 38% to 58% for hip, p < 0.001). Adoption of the preferred-vendor initiative was greatest among low-volume surgeons (from 22% to 87%; p < 0.001) and lowest among very high-volume surgeons (from 61% to 62%; p = 0.573). For cases in which implants from the preferred vendor were utilized, the mean cost per case decreased by 23% in the program's first year (p < 0.001), with an associated 11% decrease in the standard deviation. Among all cases, there were no significant changes with respect to 30-day readmission (p = 0.449) or SSI (p = 0.059), while mean LOS decreased in the program's first year (p < 0.001). CONCLUSIONS:The creation of a preferred single-vendor model for hip and knee arthroplasty implants led to significant cost savings and decreased cost variability within the program's first year. Higher-volume surgeons were less likely to modify their implant choice than were lower-volume surgeons. Despite the potential learning curve associated with changes in surgical implants, there was no difference in short-term quality metrics. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

AIMS/OBJECTIVE:non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. PATIENTS AND METHODS/METHODS:(13.3 to 57.6, sd 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. RESULTS:There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. CONCLUSION/CONCLUSIONS:2019;101-B(6 Supple B):2-8.

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.

Purpose: The use of a posterior augmented glenoid to correct posterior wear, subluxation and retroversion remains controversial. The purpose of this study is to compare the clinical and radiographic outcomes of patients with significant posterior glenoid wear treated with a posterior augmented glenoid and compare them to age/gender/follow-up matched patients without glenoid wear treated with a non-augmented pegged glenoid in anatomic total shoulder arthroplasty (aTSA). Method(s): 182 patients undergoing primary aTSA with 2 year minimum follow-up (mean 42 months)were reviewed. 91 patients (mean age = 66 yrs; 37F/54M)received a posterior augmented pegged glenoid and 91 age/gender/follow-up matched patients received a non-augmented pegged glenoid. Patient data was retrospectively reviewed from a multi-institutional WIRB approved registry. Each patient was evaluated preoperatively and at latest follow-up using SST, UCLA, ASES, Constant, and SPADI scoring metrics; active abduction, forward flexion, and internal/external rotation were measured. Radiolucent glenoid line assessment was performed from radiographs at latest follow up. A Student's two tailed unpaired t-test (P <.05)quantified differences. Result(s): Each cohort demonstrated significant improvements in pain and function following primary aTSA. At latest follow-up, augmented glenoids were generally better than non-augmented glenoids; however, few differences were noted in pre-to-postoperative improvement between augmented and non-augmented glenoids. Augmented glenoids were associated with significantly more improvement in active abduction, forward flexion, and external rotation as compared to non-augmented glenoids. The overall complication rate was 6.6%, where augmented patients had 1 aseptic glenoid loosening compared to 3 cases in the non-augmented group. Radiographic data was available for 70% of the patients. There were no significant differences in the rate of glenoid radiolucent lines (35% augmented, 40% non-augmented)or the average line grade (0.68 augmented, 0.86 non-augmented)between the two cohorts. There were no differences in humeral radiolucent line rates between the two groups. Discussion(s): At a mean follow-up of 3.5 years, few clinically relevant differences were observed between the augmented and non-augmented cohorts, despite the augment cohort being disadvantaged by posterior glenoid wear. This is likely due to the correction of the retroversion and posterior subluxation, with improved tensioning of the rotator cuff. There were no patients in which the humeral head re-subluxated posteriorly. Complication rates and radiographic outcomes were similar between the two groups. Posterior augmented glenoids are a viable option for the posteriorly worn osteoarthritic glenoid; however, longer follow-up is necessary to determine how these early results hold up over time.

BACKGROUND:The results of anatomic total shoulder arthroplasty (TSA) in younger patients have not been clearly elucidated. The purpose of this study was to compare early outcomes after TSA in patients aged 55 years or younger versus patients older than 55 years. METHODS:A total of 1135 patients who were treated with TSA for glenohumeral arthritis and had a mean follow-up period of over 4 years were retrospectively reviewed. Etiologies included osteoarthritis (n = 1044), osteonecrosis (n = 35), inflammatory arthritis (n = 34), and post-traumatic arthritis (n = 22). Validated outcome measures, range of motion, and patient satisfaction were recorded. Preoperative and postoperative metrics were compared, and a multivariate analysis was performed to isolate age from sex, body mass index, previous surgery, and diagnosis as independent factors. RESULTS:Female patients, patients with a history of surgery, and patients with a diagnosis of osteonecrosis were more likely to undergo TSA when aged 55 years or younger. Both age groups showed similar preoperative range of motion and showed no differences in recorded outcome scores. Postoperatively, patients older than 55 years had slightly greater active abduction (P = .004) and internal rotation (P = .030). A higher percentage of patients older than 55 years rated their outcome as better or much better compared with those aged 55 years or younger (P = .003). CONCLUSIONS:Female sex, a history of surgery, and a diagnosis of osteonecrosis were associated with undergoing TSA when aged 55 years or younger. Despite similar preoperative function and minor differences in postoperative range of motion and outcome scores, patients aged 55 years or younger reported lower overall satisfaction with their TSA.

Hypothesis/UNASSIGNED:Among patients undergoing shoulder arthroplasty (SA), female patients would have worse outcomes than their male counterparts. Methods/UNASSIGNED:A multicenter prospective cohort of 2364 patients (1365 female and 999 male patients) treated with total SA or reverse total SA from 2007 to 2015 was retrospectively analyzed. Results were assessed using several validated outcome measures and range-of-motion testing. A multivariable analysis identified differences in preoperative values, postoperative values, and preoperative-to-postoperative improvements while adjusting for possible confounders. Results/UNASSIGNED:< .01). Conclusion/UNASSIGNED:This study found that female patients undergo SA at an older age and begin with worse shoulder range of motion and outcome scores than male patients. Although women experienced a greater improvement postoperatively in outcome scores and range of motion, this improvement did not reach the minimal clinically important difference. These findings suggest that male and female patients can expect similar improvements in function after undergoing SA; however, the incidence of complications may vary depending on sex.

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.

OBJECTIVES/OBJECTIVE:To evaluate tuberosity union rate and clinical outcome after 3- and 4-part proximal humerus fractures in the elderly. DESIGN/METHODS:Retrospective, multicenter database cohort study. SETTING/METHODS:Level I and Level II trauma centers. PATIENTS/METHODS:Fifty-five patients older than 65 years had insertion of reverse shoulder arthroplasty (RTSA) for OTA/AO 11-B and 11-C proximal humerus fractures. INTERVENTION/METHODS:Treatment with RTSA using a dedicated low profile onlay fracture stem using variable tuberosity fixation. MAIN OUTCOME MEASURES/METHODS:Constant score, the American Shoulder and Elbow Surgeons score, Shoulder Pain and Disability Index score, University of California at Los Angeles score, Simple Shoulder Test score, visual analog pain score, shoulder function score, active range of motion, external rotation (ER)-specific tasks and position, rate of greater tuberosity healing, effect of tuberosity healing on overall clinical metrics, incidence of humeral lucency, and scapular notching. RESULTS:Eighty-three percent of the greater tuberosities that were repaired united. Greater tuberosity union resulted in greater active ER (P = 0.0415). There was a statistically significant difference in the ability to do ER-type activities between the 2 cohorts reflected in the ability to position one's hand behind their head with the elbow forward (P = 0.002) and comb their hair (P < 0.001). CONCLUSION/CONCLUSIONS:The use of a low profile onlay fracture stem in RTSA for acute 3- and 4-part proximal humerus fractures in the elderly can result in a high tuberosity union rate. Greater tuberosity healing significantly influences ER and ER-type activities that are not apparent by analysis of the overall metrics studied. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.