Faculty Bibliography

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.

BACKGROUND:This study reports the clinical and radiographic outcomes of a hybrid cage glenoid compared with an age-matched, sex-matched, and follow-up-matched cohort of cemented all-polyethylene peg glenoids in patients undergoing anatomic total shoulder arthroplasty with 2 years' minimum follow-up. MATERIALS AND METHODS/METHODS:We reviewed 632 primary anatomic total shoulder arthroplasty patients from an international multi-institutional database; 316 patients received hybrid cage glenoids and were matched for age, sex, and follow-up with 316 patients with cemented all-polyethylene peg glenoids. Each cohort received the same humeral component. Scoring was performed in all patients preoperatively and at latest follow-up using 5 outcome scoring metrics and 4 active range-of-motion measurements. A Student 2-tailed unpaired t test identified differences in outcomes; P < .05 denoted a significant difference. RESULTS:Cage glenoid patients had significantly lower rates of radiolucent glenoid lines (9.0% vs. 37.6%, P < .0001) and radiolucent humeral lines (3.0% vs. 9.1%, P = .0088) than all-polyethylene peg glenoid patients. In the cage glenoid cohort, 4 cases of aseptic glenoid loosening (1.3%) and 4 cases of articular surface dissociation (1.3%) occurred. In the all-polyethylene peg cohort, 12 cases of aseptic loosening (3.8%) occurred. Cage glenoid patients had a significantly lower revision rate than all-polyethylene peg glenoid patients (2.5% vs. 6.9%, P = .0088). CONCLUSION/CONCLUSIONS:At 50 months' mean follow-up, cage glenoids demonstrated equally good clinical outcomes to all-polyethylene peg glenoids. Cage glenoids had significantly fewer radiolucent lines around both the glenoid and humeral components and a lower revision rate. Longer-term follow-up is required to confirm these promising short-term results.

BACKGROUND:Reducing intraoperative wound contamination is a critical preventive strategy for reducing the risk of prosthetic joint infection in shoulder arthroplasty. The aim of this study was to investigate the potential microbial colonization of subscapularis tagging sutures during shoulder arthroplasty. METHODS:In this prospective study, 50 consecutive patients undergoing primary shoulder arthroplasty (anatomic or reverse) were enrolled. Patients with revision shoulder arthroplasty and proximal humeral fractures were excluded. Nonabsorbable, braided tagging sutures were placed through the subscapularis tendon prior to tenotomy. A similar nonabsorbable, braided suture (control) was placed in a sterile container on the back table, open to the operating room environment. Subscapularis tagging sutures (experimental specimens) and control sutures were collected prior to subscapularis tenotomy repair and submitted for aerobic and anaerobic cultures. Cultures were held for 21 days to account for extended growth of slow-growing bacteria. RESULTS:A total of 12 of 50 experimental and 16 of 50 control sutures had positive cultures. Staphylococcus epidermidis and Cutibacterium acnes were the 2 most commonly isolated organisms. Active tobacco use (P = .038) and procedure length (P = .03) were significantly associated with positive cultures. No significant association between positive subscapularis tagging suture cultures and positive control cultures was found (P = .551). Patient age, sex, body mass index, and significant medical comorbidities were not significantly associated with positive cultures. DISCUSSION/CONCLUSIONS:Subscapularis tagging sutures are a potential source of microbial contaminant in shoulder arthroplasty, and we recommend exchanging the tagging suture with a suture opened immediately prior to subscapularis repair.

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.

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.

Although total shoulder arthroplasty (TSA) is generally associated with good to excellent outcomes in most patients, the integrity and function of the subscapularis tendon (SSC) is of paramount importance because SSC rupture after TSA can lead to inferior outcomes. Therefore, the efficacy of a SSC-sparing TSA procedure was evaluated through a prospective, double-blinded, randomized study. Patients with end-stage osteoarthritis of the shoulder were randomized into 2 groups. Group 1 patients were treated with TSA in which the prosthesis was inserted entirely through the rotator interval without violating the SSC tendon (SPARING). Group 2 patients were treated with TSA using the SSC tenotomy approach (STANDARD). Both the patients and the evaluators remained blinded to the surgical approach throughout the study. Outcome data collected included the visual analog scale score for pain and the American Shoulder and Elbow Surgeons outcome score. Complete 2-year outcome data were collected from 32 SPARING and 38 STANDARD patients at a mean follow-up of 31.1 and 33.4 months, respectively. The American Shoulder and Elbow Surgeons and visual analog scale scores improved significantly for both groups. Differences between groups did not reach statistical significance. Complication profiles were similar for the 2 groups, with 3 patients in the SPARING group and 2 patients in the STANDARD group requiring revision surgery during the study. At short-term follow-up, the outcome of TSA using the SSC-sparing surgical approach was similar to the outcome of TSA using the standard approach. Studies with longer follow-up are required to document the potential benefits of this surgical technique. [Orthopedics. 2019; 42(1):e61-e67.].