Faculty Bibliography

BACKGROUND/UNASSIGNED:In the past 20 years, the incidence of total shoulder arthroplasty (TSA) has increased greatly, and it is expected to continue growing. Current literature lacks future projections for the utilization of TSA. These projections can help predict demand quantities and anticipate the future burden on the healthcare system. The aim of this study is to determine the predictions of utilization for TSA, primary and revision, through 2060. METHODS/UNASSIGNED:This analysis used the publicly available 2000-2019 data from the Center for Medicare and Medicaid Services Medicare Part-B National Summary. Procedure volumes, including TSA and revision TSA, were determined using Current Procedural Terminology codes and were uplifted to account for the growing number of Medicare eligible patients covered under Medicare Advantage. Log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average models were applied to the procedural volumes to generate projections from 2020-2060. The Poisson model was chosen to display the data based on error analysis and prior literature. RESULTS/UNASSIGNED:The projected annual growth from 2020 to 2060 rates for primary and revision TSA are 11.65% growth (95% confidence interval 11.60%-11.69%) and 13.89% growth (95% confidence interval 13.35%-14.42%), respectively. By 2060, the demand for primary TSA and revision TSA is projected to be 10,029,260 and 1,690,634, respectively. CONCLUSION/UNASSIGNED:The results of this study concluded that both primary and revision TSA procedures are projected to exponentially increase from 2020 to 2060. Additionally, revision procedures are projected to increase at greater rates than their respective primary counterparts.

BACKGROUND:The goal of this study was to utilize preoperative computed-tomography(CT) scans to identify differences in the Hounsfield units(HU) of the acromion in patients who did and did not develop a postoperative acromial and scapular-spine fracture(ASF) after primary reverse total shoulder arthroplasty (rTSA). METHODS:A retrospective analysis was performed at a single institution. All patients undergoing a rTSA with either a 135° neck/shaft angle(NSA) humeral inlay design combined with a lateralized center-of-rotation(COR) glenosphere or a 145° NSA onlay combined with a medialized COR glenosphere design between 2011-2021 with a minimum follow-up of 24-months were included. Demographic characteristics and clinical outcome metric scores were recorded. Preoperative CT scans were analyzed to obtain acromion trabecular bone density measurements in HU in each zone of the scapula based on the Levy classification. Radiographic parameters were evaluated to determine their association with ASF. RESULTS:In total 263-patients were included, 140-patients with a 135° NSA humeral-inlay design;123-patients with a 145° NSA humeral-onlay design. There were no significant differences in baseline demographics between cohorts. The rate of ASF was 6.4%(9/140) for the 135° NSA-inlay-design versus 2.4%(3/123) in the 145° NSA-onlay design. In the non-fracture cohort there was a linear increase in bone density from zone-1(173.9HU)→zone-3(396.5HU)(lateral→medial). In the fracture cohort there was a decrease in bone density from zone-1(282.6HU)→zone-3(154.5HU). Measuring preoperative bone density in all Levy specific fracture-zones resulted in an AUC of 0.96 correlating to excellent predictive value. A threshold cutoff of 99.9 resulted in a sensitivity of 91.6% and specificity of 75.3%. A HU of 99.9 in any of the three-zones resulted in OR 5.1(p<0.0001) for sustaining an ASF postoperatively. A threshold of<50HU was associated with an 8-times higher-likelihood of developing a fracture in that specific zone. Greater than 5° of superior tilt in combination with ≥24mm of distalization was associated with an OR 6.4(p=0.0004) of sustaining an ASF. CONCLUSION/CONCLUSIONS:The current study demonstrates an accurate method of measuring HU at each of the described Levy fracture zones with excellent predictability of patients who are at risk of an ASF following rTSA. Additionally, we found that a HU threshold of <50 HU at any of the three Levy zones was associated with a nearly 8 times higher likelihood of developing a fracture in that specific zone. Lastly, we found that >5° of superior tilt in combination with ≥24mm of distalization was associated with 6.4 times higher likelihood of sustaining an ASF agnostic to prosthesis design.

BACKGROUND:Guidance technology in total joint arthroplasty has gained popularity over the last few decades. Computer-assisted navigation (CAN) was recently introduced for glenoid implantation in total shoulder arthroplasty (TSA). However, utilization trends of CAN TSA are not currently known. This study aims to determine the prevalence and trends of CAN usage in TSA from its introduction in 2017 until 2023. METHODS:A retrospective review was performed of all TSAs (anatomic TSA [aTSA] or reverse TSA [rTSA]) implanted using a single computer navigation shoulder system (ExactechGPS; Gainseville, FL, USA). Intraoperative navigation was performed for the glenoid component only. Utilization of CAN was reported per year to determine trends in the prevalence of CAN cases, number of users, new users, dropped users, high-volume users (>50 CAN cases/year), and the number of cases completed by high-volume users. The data was also stratified by type of TSA (aTSA vs. rTSA) and type of glenoid component used (augmented or non-augmented). RESULTS:From 2017 to 2023, navigated TSAs increased from 654 to 9777 cases per year, with a greater increase in navigated rTSA than aTSA volume. The number of CAN cases using augmented implants grew 1435% while non-augmented implants grew 1352%. By 2023, the overall number of CAN users increased from 79 to 667 users. High-volume CAN surgeons increased to 50 users by 2023. Over this period, the number of CAN TSA performed by high-volume surgeons increased more rapidly than the actual number of high-volume surgeons per year. CONCLUSIONS:This study demonstrates an exponential increase in the use of CAN for TSA in the last eight years. This increase is driven by progressive growth in both the volume of new users as well as CAN TSAs performed by existing users by several hundred folds. These upwards trends in utilization of guidance technology for TSA are likely to continue in future.

BACKGROUND:Patient-Reported Outcome Measurement Information Systems (PROMIS) is increasingly being utilized across the United States as a patient-reported outcome evaluation tool for a wide variety of musculoskeletal conditions. However, PROMIS Upper Extremity (P-UE) physical function has demonstrated limited responsiveness in the early postoperative period after total shoulder arthroplasty (TSA). The aim of this study is to determine if addition of PROMIS Pain Interference (P-Interference) or Pain Intensity (P-Intensity) scores improve the ability to detect postoperative changes in the 1-year postoperative period following TSA. METHODS:Patients who were indicated for and elected to undergo TSA between 2020 and 2022 were prospectively enrolled. Prospective data were collected for patient surveys (American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test, P-UE, P-Interference and P-Intensity) at the 2-week, 6-week, 3-month, 6-month, and 12-month timepoints. Instrument responsiveness for each PROM was evaluated using the effect size (ES; Cohen d). Responsiveness was defined by the absolute values of each measurement, previously reported as small (0.2), medium (0.5), or large (0.8). Statistical analysis (2 sample t-tests and Fisher's tests) was performed using R studio version 4.2.3 (Boston, MA, USA). RESULTS:A total of 127 subjects were enrolled in this study. All survey instruments demonstrated large responsiveness (>0.8) at 3, 6, and 12 months. P-Intensity was the only instrument to demonstrate large responsiveness at 2-weeks with its addition to P-UE showing an improved responsiveness at all-time points. Moreover, the addition of P-Intensity had a lower response burden at all-time points when compared to the legacy measures (ASES, Simple Shoulder Test, and Oxford Shoulder Score) at all-time points albeit no difference to ASES (P = .55) at 12-months after surgery. P-Interference and other legacy scores demonstrated large responsiveness starting at 6-weeks postoperatively. CONCLUSION/CONCLUSIONS:The responsiveness of PROMIS UE can be improved by coupling the outcome measure to P-Intensity scores with a significantly lower response burden when compared to the legacy measures evaluated at nearly all time points.

BACKGROUND:In the past decade, the prevalence of end-stage inflammatory elbow arthritis has declined with consequential changes in indications and utilization of total elbow arthroplasty (TEA). Current literature lacks future projections for the utilization of TEA. The aim of this study is to review the trends in the utilization of TEA in the last 2 decades and determine the projections of utilization for TEA (primary and revision) through 2060. METHODS:This analysis used the publicly available 2000-2019 data from the CMS Medicare Part-B National Summary. Procedure volumes including TEA, and revision TEA, were determined using Current Procedural Terminology codes and were uplifted to account for the growing number of Medicare eligible patients covered under Medicare Advantage. Using these volumes, log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average models were applied to generate projections from 2020 to 2060. The Poisson model was chosen to display the data based on error analysis and prior literature. RESULTS:The projected annual growth rates from 2020 to 2060 for primary and revision TEAs are 1.03% (95% confidence interval: 0.82%-1.25%) and 5.17% (95% confidence interval: 3.02%-6.97%), respectively. By 2060, the demand for primary TEA and revision TEA is projected to be 2084 procedures (95% forecast interval: 1995-2174) and 3161 procedures (95% forecast interval: 3052-3272), respectively. The procedure volume for revision TEA is estimated to outnumber primary TEA by year 2050. CONCLUSION/CONCLUSIONS:The overall procedural volume of primary TEA and revision TEA continues to be low. Although it is estimated that the incidence of primary and revision TEAs will continue to increase in the next 40 years, the utilization trends only show a mild increase, which is 5 times higher for revision TEA than primary TEA.

BACKGROUND:Although Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (P-UE) has been validated in upper extremity orthopedics, its ability to capture a patient's functional recovery after arthroscopic rotator cuff repair (aRCR), as measured by its responsiveness, is minimal in the early postoperative period. The primary purpose of this study is to determine if the addition of PROMIS Pain Intensity (P-Intensity) or Pain Interference (P-Interference) scores to PROMIS UE improves the responsiveness throughout the 1-year postoperative period after aRCR. METHODS:This prospective, longitudinal study included 100 patients who underwent aRCR. Patients completed P-UE, P-Interference, P-Intensity, American Shoulder and Elbow Surgeons, and Western Ontario Rotator Cuff Index scores preoperatively and at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgery. Responsiveness at each time point relative to preoperative baseline and 1-way analysis of variance with post hoc analysis was conducted for each PROM. The responsiveness of the outcome score was determined using the effect size, graded as small (0.2), medium (0.5), or large (0.8). The Pearson correlation coefficient (r) was determined between these instruments at each time point. RESULTS:In isolation, P-UE, P-Interference, and P-Intensity showed a medium-large ability to detect change (positive and negative) throughout the 1-year postoperative period. The addition of PROMIS pain scores to P-UE improved the responsiveness of the instrument (from medium to a large effect size) starting at 3 months and continued throughout the 12-month follow-up period. Although the addition of pain scores increases the response burden for PROMIS, this was still lower than the response burden for the legacy outcome scores (P < .05). CONCLUSION/CONCLUSIONS:The addition of PROMIS pain instruments improves the responsiveness of the P-UE function score in patients undergoing aRCR.

BACKGROUND/UNASSIGNED:Glenoid component positioning is an important and challenging aspect of total shoulder arthroplasty. The use of freehand technique with standard instrumentation or preoperative planning based on 2-dimensional computed tomography (CT) scans provides an opportunity for improvement in terms of component accuracy, precision, and deformity correction. These techniques have produced varying outcomes. METHODS/UNASSIGNED:Preoperative planning software (PPS), patient specific instrumentation (PSI), and intraoperative navigation (NAV) have been developed to improve the accuracy of implant placement and deformity correction with the ultimate goals of improved patient outcomes and implant longevity. Literature search was conducted on published and available studies comparing the accuracy of glenoid component placement and improvements in surgical and patient outcomes amongst the aforementioned techniques. RESULTS/UNASSIGNED:PPS, PSI, and NAV have demonstrated improved accuracy over freehand techniques with standard instrumentation. However, data demonstrating the clinical benefit and cost effectiveness of these new technologies are lacking. DISCUSSION/UNASSIGNED:In this paper, we reviewed the evidence available to answer the question of whether or not advanced shoulder arthroplasty technologies have been beneficial and reviewed future technologies in development such as virtual/mixed-reality and robotic assisted shoulder surgery. LEVEL OF EVIDENCE/UNASSIGNED:4.

INTRODUCTION/UNASSIGNED:African American, Hispanic, Asian, and Pacific Islanders are groups who are underrepresented in medicine (URM groups). Similarly, although women comprise more than 50% of medical students in the United States, women comprise a smaller percentage of all orthopaedic surgery trainees. Therefore, underrepresented in orthopaedics (URiO) represents the URM groups and women. The purpose of this study is to examine the impact of specific steps to recruit a qualified, diverse trainee complement within a single academic orthopaedic surgery residency program between 2000 and 2023. We aim to explore changes in the representation of URiO during this period as well as explore the strategies and programs implemented by the department that may have impacted recruitment of a diverse complement of trainees. METHODS/UNASSIGNED:Match lists from a large, academic, orthopaedic surgery residency between 2000 and 2023 were collected and reviewed for racial and gender data. Match lists were then divided into 6-year quantiles to identify any trends in the recruitment of URiO students. Self-reported racial and gender data from Electronic Residency Application Service applicant reports and the Accreditation Council for Graduate Medical Education (ACGME) data books between 2018 and 2022 were collected and reviewed. In addition, the department's strategies implemented during the study period with the goal of enhancing URiO exposure to orthopaedic surgery were also explored. RESULTS/UNASSIGNED:The department implemented proactive strategies to increase exposure to orthopaedic surgery for URiO students. An increase in URiO representation was noted between 2000 and 2023 with Hispanic, Black/African American, and Native Hawaiian/Pacific Islander resident representation increasing by 5%, 11%, and 1%, respectively. In addition, women representation increased by 27% between 2000 and 2023. The overall attrition rate among URiO residents was 1% with only one resident not completing the program. Self-reported racial and gender data from ACGME data books demonstrated that Black/African American, Hispanic, and Native Hawaiian/Pacific Islander residents comprised 5%, 4%, and 0.04%, respectively, of orthopaedic surgery residents between 2018 and 2022. CONCLUSIONS/UNASSIGNED:These results provide insight for other programs to use similar strategies to potentially improve recruitment, retain, and provide support to URiO residents.

BACKGROUND:The purpose of this study was to define the optimal combination of surgical technique and postoperative rehabilitation protocol for elderly patients undergoing either hemiarthroplasty (HA) or reverse total shoulder arthroplasty (rTSA) for acute proximal humerus fracture (PHF) by performing a network meta-analysis of the comparative studies in the literature. METHODS:A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2007 to 2023. Inclusion criteria were level I-IV studies utilizing primary HA and/or rTSA published in a peer-reviewed journal, that specified whether humeral stems were cemented or noncemented, specified postoperative rehabilitation protocol, and reported results of HA and/or rTSA performed for PHF. Early range of motion (ROM) was defined as the initiation of active ROM at ≤3 weeks after surgery. Level of evidence was evaluated based on the criteria by the Oxford Centre for Evidence-Based Medicine. Clinical outcomes were compared using a frequentist approach to network meta-analysis with a random-effects model that was performed using the netmeta package version 0.9-6 in R. RESULTS:A total of 28 studies (1119 patients) were included with an average age of 74 ± 3.7 and mean follow-up of 32 ± 11.1 months. In the early ROM cohort (Early), the mean time to active ROM was 2.4 ± 0.76 weeks compared to 5.9 ± 1.04 weeks in the delayed ROM cohort (Delayed). Overall, rTSA-Pressfit-Early resulted in statistically superior outcomes including postoperative forward elevation (126 ± 27.5), abduction (116 ± 30.6), internal rotation (5.27 ± 0.74, corresponding to L3-L1), American Shoulder and Elbow Surgeons score (71.8 ± 17), tuberosity union (89%), and lowest tuberosity nonunion rate (9.6%) in patients ≥65 year old with acute PHF undergoing shoulder arthroplasty (all P ≤ .05). In total there were 277 (14.5%) complications across the cohorts, of which 89/277 (34%) were in the HA-Cement-Delayed cohort. HA-Cement-Delayed resulted in 2-times higher odds of experiencing a complication when compared to rTSA-Cement-Delayed (P = .005). Conversely, rTSA-Cement-Early cohort followed by rTSA-Pressfit-Early resulted in a total complication rate of 4.7% and 5.4% (odds ratios, 0.30; P = .01 & odds ratios, 0.42; P = .05), respectively. The total rate of scapular notching was higher in the cemented rTSA subgroups (16.5%) vs. (8.91%) in the press fit rTSA subgroups (P = .02). CONCLUSION/CONCLUSIONS:Our study demonstrates that patients ≥65 years of age, who sustain a 3-or 4-part PHF achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative ROM when compared to the mainstream preference-rTSA-Cement-Delayed.