Faculty Bibliography

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.

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.

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.

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.

Background: The topical adhesive 2-octyl cyanoacrylate has been used as an alternative to sutures for closure of skin in a variety of surgical procedures. While there have been benefits in terms of ease of application and cosmetic result, a high incidence of allergic contact dermatitis and exothermic reactions has been a barrier to use. Objectives. To investigate the feasibility of using a novel formulation of 2-octyl cyanoacrylate (Actabond-Bergen Medical Products, Morris Plains, New Jersey) for skin closure after surgical excision of cutaneous lesions.
Method(s): We examined the results of office-based surgical excision procedures using a novel formulation of 2-octyl cyanoacrylate for skin closure. Photographs were taken preoperatively, intraoperatively (open wound, before adhesive application, following adhesive application), and 2 weeks after surgery. At follow-up, all incisions were examined for cosmetic result, skin edge separation, erythema, and abscess formation. Patient satisfaction was also assessed.
Result(s): Ten lesions in 9 consecutive patients undergoing cutaneous excision by two surgeons were included in the study. The average age of included patients was 42. Lesions were excised from the trunk (6) and extremities (4). Lesion types included 3 dysplastic nevi, 3 sebaceous cysts, 3 lipomas, and 1 squamous cell carcinoma. At 2-week follow-up, all wounds were healed without any signs of dehiscence or infection. All wounds demonstrated esthetic closure without suture tracts. None of the patients developed allergic contact dermatitis or burns. On a 1-10 scale, respondents' average satisfaction with the method was 7.7. For patients who had previous skin suture closures, 83% preferred adhesive. Conclusion and relevance. A novel formulation of 2-octyl cyanoacrylate topical adhesive demonstrated feasibility as a potential alternative to the use of sutures for skin closure. In this small case series, all patients had an excellent esthetic result with no complications. Compared with previous iterations of 2-octyl cyanoacrylate, there were no allergic or exothermic reactions in this pilot series. Larger studies need to be performed to further determine advantages that may exist using this closure method compared with standard techniques.
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Poor outcomes associated with increased perioperative opioid use have led investigators to seek alternative pain management modalities after total joint arthroplasty. Nonpharmacological approaches, such as electroceuticals, have shown promise. The purpose of this study was to evaluate the effects of "havening," a specific form of psychosensory therapy, on postoperative pain scores and narcotic consumption. In this prospective, randomized controlled trial, the authors compared 19 patients who underwent psychosensory therapy with 22 patients who served as the control group. Visual analog scale scores were collected preoperatively, every day during the hospitalization, and at approximately 1-month follow-up. Narcotic consumption during hospitalization was converted into daily morphine milligram equivalents and compared between the cohorts. In addition, postoperative complications, emergency department visits, and readmissions were compared between the cohorts. No difference in visual analog scale pain scores was reported between cohorts on postoperative day 1 (P=.229), at discharge (P=.434), or at 1-month follow-up (P=.256). Furthermore, there was no significant variance in mean daily morphine milligram equivalents (P=.221), length of stay (P=.313), postoperative complications (P=.255), 90-day readmissions (P=.915), and emergency department visits (P=.46) between the cohorts. This study showed that psychosensory therapy was not effective in reducing pain or narcotic consumption following total joint arthroplasty. Nonetheless, future studies assessing the role of psychosensory therapeutic interventions among patients after total joint arthroplasty are warranted to better understand the clinical implications of innovative therapies aimed at alleviating pain. [Orthopedics. 2018; 41(6):e848-e853.].

BACKGROUND:The complication rate of locked plating for proximal humerus fractures remains stubbornly high. The purpose of this study was to determine if a learning curve exists with the operative treatment of proximal humerus fractures. METHODS:We prospectively followed 161 consecutive patients with proximal humerus fractures treated by a single surgeon with locked plates from 2005 to 2016. Radiographic data, functional outcomes, and complications from the surgeon's first 81 patients were compared to the subsequent 80 patients. RESULTS:There was no statistical difference in the rates of complications (p = 0.29) or screw penetration (p = 0.19). There were no differences in DASH scores (p = 0.64 to 0.79) or tip-apex distance (p = 0.40). Head shaft angles were slightly smaller in patients treated earlier in the surgeon's career (p = 0.02). DISCUSSION/CONCLUSIONS:While surgeon experience is certainly a favorable quality, there does not appear to be a significant "learning curve" in the treatment of proximal humerus fractures.

We integrated and optimized patient-reported outcome measures into the electronic health record to provide quantitative, objective data regarding patients' health status, which is important for patient care, payer contracts, and research. With a multidisciplinary team from information technology, clinical informatics, population health, and physician champions, we used formal human-computer interaction techniques and user-centered design to integrate several technology platforms and computerized adaptive testing for the National Institutes of Health Patient-Reported Outcomes Measurement Information System. The patient-reported outcome measure system leverages software frequently used by health systems and provides data for research and clinical care via a mobile-responsive web application using Symfony, with REDCap for configuring assessments and de-identified data storage. The system incorporates Oracle databases and Epic flowsheets. Patients complete patient-reported outcome measures, with data viewable in MyChart and Epic Synopsis Reports. Researchers can access data portals. The highly usable, successful patient-reported outcome measures platform is acceptable to patients and clinicians and achieved 73 percent overall completion rates.

There is a growing consensus that an accomplished curriculum vitae and prior achievement as an academician may not correlate with success as a chairperson of a contemporary academic orthopaedic department. As surgeons, formal professional education, research expertise, and clinical experience often are inadequate to foster the necessary skills and experience in executive leadership, change management, business administration, and strategy. The recruiting and hiring processes to fill academic leadership roles have been slow to adapt and recognize the skills that are necessary to be a successful chairperson. Recent research has identified emotional competency, resiliency, leadership, communication, results orientation, and personnel development as skills that correlate with success in academic leadership. Formal courses and training in executive leadership and business management may be helpful in enhancing knowledge and skills in these disciplines.