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.
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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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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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: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.