Faculty Bibliography

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.

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.

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.

Objective: Poor sleep quality due to nocturnal pain is increasingly reported as a major symptom in advanced glenohumeral arthritis. The current study aimed to evaluate preoperative and postoperative sleep quality, shoulder pain, and function in patients who underwent total shoulder arthroplasty (TSA). Preoperative factors contributing to delayed improvements in sleep quality were examined. Methods: Patients scheduled for anatomic or reverse TSA due to glenohumeral arthritis were included. Patients completed the Pittsburgh Sleep Quality Index (PSQI) and American Shoulder and Elbow Surgeons (ASES) survey preoperatively, and at 6 weeks, 3 months, 6 months, and 1 year following surgery. A higher PSQI score (maximum 21) indicated greater sleep disturbance. Results: Seventy-four patients (34 males, 40 females), with a mean age of 65.8 years were prospectively enrolled. Eighty-four percent of patients reported preoperative PSQI scores indicative of sleep disturbance (6 or greater), with a mean of 10.1 ± 4.3. The PSQI score significantly improved to 7.7 at 6 weeks (P = .003), and to 6.1 at 3 months (P = .08). At 12 months, the PSQI was within normal limits (less than or equal to 5) with a mean score of 4.3. A normal PSQI score was achieved by 40.8%, at 6 weeks, 50% at 3 months, 53.7% at 6 months, and 73.9% at 1 year. The ASES score significantly improved from 32.6 ± 17.2 at baseline to 58.4 at 6 weeks (p < .001), 76.1 at 3 months (p < .001), and 85.3 at 12 months. Linear regression demonstrated that the ASES and PSQI scores were negatively associated with each other at each time point. Body mass index and female gender were associated with a delayed return to baseline sleep quality. Conclusion: Shoulder-related sleep disturbance significantly improved at 6 weeks following TSA, and normalized for most patients by 1 year post-operatively. Enhanced sleep quality after TSA was directly related to improved functional outcomes.

BACKGROUND:The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative. METHODS:The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed. RESULTS:The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%. CONCLUSIONS:These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent. LEVEL OF EVIDENCE/METHODS:Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Resident burnout-the state of exhaustion, maladaptive detachment, and low sense of accomplishment-is a widely documented phenomenon that affects between 27% and 75% of residents in the United States. To our knowledge, no previous study has examined the relationship between resident burnout and performance on the Orthopaedic In-Training Examination (OITE). The current investigation sought to evaluate whether an association exists between indices of orthopaedic surgery resident burnout as assessed by the Maslach Burnout Inventory (MBI) and performance on the OITE. METHODS:In a cross-sectional study of the orthopaedic surgery residents at a single large academic institution, the MBI was completed by all trainees in May 2016. The results of the 2016 OITE were documented for each resident, including the percentage of correctly answered questions and OITE percentile ranking. To control for individual test-taking skills, United States Medical Licensing Examination (USMLE) Step-1 and Step-2 scores also were documented for each resident. The relationship between the MBI subscale scores and OITE performance was evaluated. RESULTS:The analysis included 100% of the 62 orthopaedic surgery residents in training at our institution. Sixteen (25.8%) of the residents experienced at least moderate emotional exhaustion, while 32 (51.6%) of the residents experienced at least moderate depersonalization and 8 (12.9%) of the residents experienced a moderate sense of impaired personal accomplishment. Postgraduate year (PGY)-2 residents had the highest emotional exhaustion and depersonalization scores compared with residents in other years of training. Each of the 3 MBI indices of burnout was associated with worse OITE performance when controlling for general test-taking ability. CONCLUSIONS:In this study of orthopaedic surgery residents at a large academic training program, burnout was present among residents in all PGYs of training; it was most prevalent during the second year of training. Increased levels of the 3 components of burnout were associated with worse performance on the OITE. While there is a lack of consensus in the existing literature, this study provides additional evidence that burnout is negatively associated with 1 aspect of overall resident performance. CLINICAL RELEVANCE/CONCLUSIONS:Orthopaedic surgery residency training is challenging; residents are tasked to acquire a considerable amount of knowledge, develop complex surgical skills, and hone critical clinical thinking in a relatively short period of time. Identifying modifiable contributors to resident burnout and the development of strategies to promote resident wellness during training are important as we strive toward developing the next generation of capable, competent, and well-balanced orthopaedic surgeons.

BACKGROUND:High rates of radiographic glenoid loosening following anatomic total shoulder arthroplasty (TSA) are documented at midterm follow-up. Small studies remain conflicted on the impact of lucent lines on clinical outcomes. This study assesses the impact of radiolucent lines on function and patient-reported outcomes (PROs) following TSA. METHODS:We retrospectively evaluated 492 primary TSAs performed between February 2005 and April 2016. Radiographs were evaluated for glenoid loosening according to the Lazarus grade at a mean of 5.3 years (range, 2-12 years). Clinical outcome measures included range of motion and American Shoulder and Elbow Surgeons, Constant, University of California-Los Angeles, Simple Shoulder Test, and Shoulder Pain and Disability Index scores. Outcomes were compared between patients with and patients without glenoid lucent lines and in relation to lucency grade. RESULTS:At most recent follow-up, 308 glenoids (63%) showed no radiolucent lines (group 0) and 184 demonstrated peri-glenoid lucencies (group 1). The groups were similar regarding age, sex, body mass index, comorbidities, and prior surgery. At follow-up, group 1 demonstrated significantly lower improvements in forward elevation (P = .02) and all PROs (P ≤ .005). Subgroup analysis by radiolucency grade showed that forward elevation diminished with increasing radiolucent score and exceeded the minimal clinically important difference (MCID) above grade 2 lucencies. A similar decline in PROs was observed with increasing lucency grade. These differences did not exceed the MCID below grade 5 lucencies. DISCUSSION/CONCLUSIONS:Peri-implant glenoid lucencies following TSA are associated with lower forward elevation and PROs. Lucencies above grade 2 are associated with clinically important losses in overhead motion. However, differences below the MCID are maintained for PROs below grade 5 glenoid lucencies.

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.

BACKGROUND:The impact of scapula notching on reverse total shoulder arthroplasty (rTSA) clinical outcomes is controversial. The purpose of this study was to conduct a sufficiently statistically powered analysis to quantify the impact of scapular notching on midterm rTSA outcomes. METHODS:There were 324 rTSA patients with 5 years of minimum follow-up evaluated. Patients were stratified according to the presence of a scapular notch at latest follow-up; radiographs were also assessed at each time point for patients with notching to determine the time for notch grade development. A 2-tailed, unpaired t-test compared preoperative, postoperative, and preoperative to postoperative outcomes between cohorts. RESULTS:There were 324 patients having an average follow-up of 75.1 months assessed; 47 (14.5%) patients had scapular notching. For scapular notching patients, the average notching grade was 1.7 ± 0.8 (24 grade 1, 15 grade 2, and 8 grade 3). The average time to notch development was 51.4 ± 24.1 months; grade 1, grade 2, and grade 3 notches developed at 49.0 ± 22.1 months, 57.5 ± 22.6 months, and 71.6 ± 15.8 months, respectively. No preoperative differences were observed between cohorts. At latest follow-up, scapular notching patients had significantly worse outcome scores and significantly less active abduction, forward flexion, and strength. Finally, scapular notching patients had significantly more complications, revisions, and humeral radiolucent lines. CONCLUSIONS:Scapular notching patients had significantly worse clinical outcomes and less range of motion than patients without scapular notching; these differences exceeded the minimal clinically important difference threshold for several outcome metrics. Based on these results, we recommend minimizing scapular notching through patient and implant selection and technique modification.