Faculty Bibliography

BACKGROUND:An understanding of the substantial clinical benefit (SCB) after total shoulder arthroplasty (TSA) may help to gauge a minimum threshold beyond which a patient perceives his or her outcome as being substantially better. This study quantifies SCB for 7 outcome metrics and active motion measurements after shoulder arthroplasty and determines how these values vary based on prosthesis type, patient age at surgery, sex, and length of follow-up. METHODS:A total of 1,568 shoulder arthroplasties with 2-year minimum follow-up were performed by 13 shoulder surgeons and enrolled in a multicenter registry. The SCB for the American Shoulder and Elbow Surgeons Shoulder Assessment, Constant Score, University of California Los Angeles Shoulder Rating Scale, Simple Shoulder Test, Shoulder Pain and Disability Index, global shoulder function, and visual analog scale pain scores, as well as active abduction, flexion, and external rotation were calculated for different patient cohorts using an anchor-based method. RESULTS:The anchor-based SCB results were American Shoulder and Elbow Surgeons score, 31.5 ± 2.0; Constant Score, 19.1 ± 1.7; University of California Los Angeles Shoulder Rating Scale score, 12.6 ± 0.5; Simple Shoulder Test score,  3.4 ± 0.3; Shoulder Pain and Disability Index score,  45.4 ± 2.2; global shoulder function, 3.1 ± 0.2; visual analog scale, 3.2 ± 0.3; active abduction, 28.5° ± 3.1°; active forward flexion, 35.4° ± 3.5°; and active external rotation, 11.7° ± 1.9°. Anatomic TSA patients, male patients, and patients of longer follow-up duration were associated with higher SCB values than female patients, reverse TSA patients, and patients of shorter follow-up duration. CONCLUSION/CONCLUSIONS:Our analysis demonstrated two-thirds of patients achieved the SCB threshold after TSA. Generally, a change of 30% of the total possible score for each outcome metric approximates or exceeds this SCB threshold.

BACKGROUND:The number of periprosthetic proximal femoral fractures is expected to increase with the increasing prevalence of hip arthroplasties. While native hip fractures have a well-known association with mortality, there are currently limited data on this outcome among the subset of patients with periprosthetic proximal femoral fractures. METHODS:Using the New York Statewide Planning and Research Cooperative System, we identified patients from 60 to 99 years old who were admitted to a hospital in the state with a periprosthetic proximal femoral fracture (n = 1,655) or a native hip (femoral neck or intertrochanteric) fracture (n = 97,231) between 2006 and 2014. Within the periprosthetic fracture cohort, the indication for the existing implant was not available in the data set. We used mixed-effects regression models to compare mortality at 1 and 6 months and 1 year for periprosthetic compared with native hip fractures. RESULTS:The risk of mortality for patients who sustained a periprosthetic proximal femoral fracture was no different from that for patients who sustained a native hip fracture at 1 month after injury (3.2% versus 4.6%; odds ratio [OR], 0.90; 95% confidence interval [CI], 0.68 to 1.19; p = 0.446), but was lower at 6 months (3.8% versus 6.5%; OR, 0.74; 95% CI, 0.57 to 0.95; p = 0.020) and 1 year (9.7% versus 15.9%; OR, 0.71; 95% CI, 0.60 to 0.85; p < 0.001). Among periprosthetic proximal femoral fractures, factors associated with a significantly increased risk of mortality at 1 year included advanced age, male sex, and higher Deyo comorbidity scores. CONCLUSIONS:In the acute phase, any type of hip fracture appears to confer a similar risk of death. Over the long term, however, periprosthetic proximal femoral fractures are associated with lower mortality rates than native hip fractures, even after accounting for age and comorbidities. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background /UNASSIGNED:Evaluation of resident physicians' communications skills is a challenging task and is increasingly accomplished with standardized examinations. There exists a need to identify the effective, efficient methods for assessment of communications skills. Objective /UNASSIGNED:We compared objective structured clinical examination (OSCE) and direct observation as approaches for assessing resident communications skills. Methods /UNASSIGNED:We conducted a retrospective cohort analysis of orthopaedic surgery resident physicians at a single tertiary care academic institution, using the Institute for Healthcare Communication "4 Es" model for effective communication. Data were collected between 2011 and 2015. A total of 28 residents, each with OSCE and complete direct observation assessment checklists, were included in the analysis. Residents were included if they had 1 OSCE assessment and 2 or more complete direct observation assessments. Results /UNASSIGNED: = .16), after adjusting for chance agreement. Conclusions /UNASSIGNED:Our results suggest that OSCE and direct observation tools provide different insights into resident communications skills (simulation of rare and challenging situations versus real-life daily encounters), and may provide useful perspectives on resident communications skills in different contexts.

Introduction: Aseptic glenoid loosening remains a long-term complication of total shoulder arthroplasty (TSA). To improve long-term fixation and decrease the risk of aseptic loosening, glenoid components with hybrid fixation, consisting of a large metal ingrowth central peg and cemented peripheral pegs, have been developed. The purpose of this prospective study is to determine the clinical and radiographic outcomes of a hybrid cage glenoid component compared to an age and gender matched polyethylene (PE) peg glenoid component with a minimum tow year follow-up. Methods: Three hundred and seventy-two patients with a mean age of 65 years were treated with a TSA for osteoarthritis by 7 sur-geons using either a cemented pegged glenoid or a hybrid fixation cage glenoid. 186 patients who received a cage glenoid (94 female and 92 males) were matched for sex and age with 186 patients who received a peg glenoid. The patients were scored preoperatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics; active abduction, forward flexion, and active and passive external rotation were also measured. The average follow-up for all patients was 32 months (cage 31 months; peg 33 months). A St-udent's two-tailed, unpaired t-test was used to identify differences in preoperative, postoperative, and pre-to-post-operative improve-ments in results, where P <.05 denoted a significant difference. IRB approval was obtained at each institution. Results: All patients demonstrated significant improvements in pain and function following TSA with a cage or peg glenoid (P <.0001). For the cage prosthesis, ASES scores improved from 38 to 89, Constant scores from 40 to 76 (P <.0001). Significant improvements were also seen in the SST, UCLA and SPADI scores (P <.001). For the peg glenoid, ASES scores improved from 34 to 81, Constant scores from 36 to 69 (P <.0001), and significant improvements were also seen in the SST, UCLA and SPADI scores (P <.0001). Active forward flexion for a cage glenoid improved from 103degree to 151degree and active external rotation from 24degree to 54degree. Active forward flexion for a peg prosthesis improved from 93degree to 141degree and active external rotation from 18degree to 49degree (all P <.0001). Cemented peg glenoids were noted to have significantly lower preoperative ab-duction, active forward flexion and external rotation measurements (but not clinically meaningful differences) and there were significant differences in the preoperative scoring metrics between the two groups. Postoperatively, the cage prosthesis was significantly higher for all 5 scoring metrics, and significantly better in active forward flexion and external rotation, though unlikely clinically significant. Cage patients had significantly less blood loss than peg patients (mean 224 cc vs 268 cc; P =.0006). Radiographic data was available for 65% of cases. Radiolucent lines (RLL) were noted in 10% of cage glenoid patients and 28% of peg patients (P =.0003). The average RLL score was also significantly less in the cage group compared to the peg patients (.24 vs.51, P =.02). There were 2 revisions in the cage group and 6 in the peg group. The complication rate was 3.2% in the cage glenoid cohort and 8.6% in the peg cohort (P =.028). Discussion: Similar or better clinical outcomes were found at a minimum two years follow-up comparing a hybrid cage glenoid prosthesis with a cemented peg glenoid. Short-term results demon-strate statistically significant clinical improvements in both groups. Radiographically, there was a highly significant decrease in the incidence of RLL and average RLL grade following implantation of a cage glenoid relative to cemented peg glenoid, with an almost 3 times reduction in the appearance of RLL. Less blood loss was seen due to the decreased operative time. Despite widespread use of hybrid glenoids, there is little clinical data demonstrating any differences. This is the largest series to date and the first to demonstrate a decrease in the incidence of radiolucent lines following implantation of a hybrid cage glenoid component. Additional and longer-term follow-up is needed to confirm these early outcomes

Aims The factors that predispose to recurrent instability and revision stabilization procedures after arthroscopic Bankart repair for anterior glenohumeral instability remain unclear. We sought to determine the rate and risk factors associated with ongoing instability in patients undergoing arthroscopic Bankart repair for instability of the shoulder. Materials and Methods We used the Statewide Planning and Research Cooperative System (SPARCS) database to identify patients with a diagnosis of anterior instability of the shoulder undergoing arthroscopic Bankart repair between 2003 and 2011. Patients were followed for a minimum of three years. Baseline demographics and subsequent further surgery to the ipsilateral shoulder were analyzed. Multivariate analysis was used to identify independent risk factors for recurrent instability. Results A total of 5719 patients were analyzed. Their mean age was 24.9 years (sd 9.3); 4013 (70.2%) were male. A total of 461 (8.1%) underwent a further procedure involving the ipsilateral shoulder at a mean of 31.5 months (sd 23.8) postoperatively; 117 (2.1%) had a closed reduction and 344 (6.0%) had further surgery. Revision arthroscopic Bankart repair was the most common subsequent surgical procedure (223; 65.4%). Independent risk factors for recurrent instability were: age < 19 years (odds ratio 1.86), Caucasian ethnicity (hazard ratio 1.42), bilateral instability of the shoulder (hazard ratio 2.17), and a history of closed reduction(s) prior to the initial repair (hazard ratio 2.45). Revision arthroscopic Bankart repair was associated with significantly higher rates of ongoing persistent instability than revision open stabilization (12.4% vs 5.1%, p = 0.041). Conclusion The incidence of a further procedure being required in patients undergoing arthroscopic Bankart repair for anterior glenohumeral instability was 8.1%. Younger age, Caucasian race, bilateral instability, and closed reduction prior to the initial repair were independent risk factors for recurrent instability, while subsequent revision arthroscopic Bankart repair had significantly higher rates of persistent instability than subsequent open revision procedures. Cite this article: Bone Joint J 2018;100-B:324-30.

Purpose: Image-guided joint aspiration is often requested for clinically suspected periprosthetic joint infection (PJI). For "dry taps" when no native joint fluid can be aspirated, a lavage with non-bacteriostatic saline can be performed. The purpose of this study is to determine the diagnostic utility of lavage versus native joint fluid aspiration in the setting of clinically suspected PJI. Materials and Methods: IRB approval was obtained and informed consent was waived for this retrospective study. A PACS search from 2011- 2017 for image-guided aspirations yielded 918 procedures, of which 630 were excluded for non-articular and non-arthroplasty aspirations, antibiotic cement spacers, and lack of clinical information in the electronic medical record. The study cohort included 288 procedures from 173 patients who underwent operative or non-operative management. The reference standard was the intraoperative culture for operative patients and clinical follow-up for conservatively managed patients. A Fisher exact test was used for statistical analysis. Results: The study cohort consisted of 98 females, 75 males, mean age 64 (range 34-90) with the following arthroplasty types: 176 hips, 65 knees, and 47 shoulders. Of 288 procedures, 105 were performed with lavage and 183 were native joint fluid aspirations; 112 were subsequently operatively managed. The mean follow-up for non-operative patients was 5 months (range 0-42). For native joint fluid aspiration versus lavage, accuracy was 81% vs. 73% (p=0.14), sensitivity was 58% vs. 28% (p=0.03), specificity was 88% vs. 91% (p=0.66), negative predictive value was 89% vs. 77% (p=0.02), and positive predictive value was 55% vs. 53% (p=1.00), respectively. Conclusion: Lavage is less sensitive with a lower negative predictive value for the diagnosis of PJI compared to native joint fluid aspirations, possibly due to a lower pretest probability of infection and the inherent dilutional effects of the procedure

The purpose of this study was to examine the influence of topical vancomycin on cell migration and survival of tissue healing cells. Human osteoblasts, myoblasts and fibroblasts were exposed to vancomycin at concentrations of 1, 3, 6, or 12 mg/cm² for either a 1-h or 48-h (continuous) duration. Continuous exposure to all vancomycin concentrations significantly reduced cell survival (<22% cells survived) and migration in osteoblasts and myoblasts (P < 0.001). 1-h vancomycin exposure reduced osteoblast and myoblast survival and migration only at 12 mg/cm² (P < 0.001). Further in vivo studies are warranted to optimize the dosage of intrawound vancomycin.

Purpose: As glenohumeral osteoarthritis progresses, there is increased risk for posterior glenoid bone loss which impacts an increasingly common treatment for these patients, total shoulder arthroplasty. Defining the level of maximum posterior bone loss and accurate assessment of its severity, using glenoid version measurements, are crucial to correctly align the glenoid prosthesis with glenoid to prevent prosthetic failure. While the importance of this information is clear, how these measurements should be performed remains in question with several techniques described in the literature. The purpose of this study was to define the most accurate level to measure glenoid version on CT for the most clinically relevant variants of posterior glenoid bone loss, Walch B2 and B3 types. Materials and Methods: 386 consecutive CT shoulder studies performed for shoulder arthroplasty preoperative planning between 2013- 2016 were retrospectively reviewed. Patients with B2 and B3 glenoid types were included. Two radiologists measured glenoid retroversion independently according to Friedman method on true axial CT images using the "intermediate glenoid line", at three glenoid heights: 25% (upper) 50% (equator) and 75% (lower). Results: 29 B2 and 8 B3 glenoid types were included. There was no statistically significant difference found in the retroversion measurements performed by each reader at the three glenoid levels on the B2 or B3 glenoid types (Mean angles (%) in upper, equator and lower in B2: 16.5, 17,0 and 17.5 and B3: 20.6, 20.7 and 23.2, respectively). There was substantial inter-reader correlation (r>=0.7) in angle measurements. Conclusion: Our study suggests that glenoid version can be accurately measured at any level between 25%-75%of the glenoid height forWalch B2 and B3 types. We recommend that the glenoid equator be used as the reference in order to assure consistent and reliable version measurements in this group of patients

OBJECTIVE: We developed a series of orthopedic unannounced standardized patient (USP) encounters for the purpose of objective assessment of residents during clinic encounters. DESIGN: Consecutive case-series. SETTING: NYU-Langone Multi-center Academic University Hospital System. PARTICIPANTS: NYU-Langone/Hospital for Joint Diseases Orthopedic Surgery residents; 48 consecutive residents assessed. METHODS: Four orthopedic cases were developed. USPs presented themselves as patients in outpatient clinics. Residents were evaluated on communication skills (information gathering, relationship development, and education and counseling). USPs globally rated whether they would recommend the resident. RESULTS: Forty-eight USP encounters were completed over a 2-year period. Communication skills items were rated at 51% (+/-30) "well done." Education and counseling skills were rated as the lowest communication domain at 33% (+/-33). Residents were globally recommended based on communication skills in 63% of the encounters recommended in 70% of encounters based on both professionalism and medical competence. CONCLUSIONS: The USP program has been useful in assessing residents' clinical skills, interpersonal and communications skills, and professionalism. Use of USP in orthopedic surgery training programs can be an objective means for trainee assessment.