Faculty Bibliography

Health-care reform, market competition, cost containment, and pressure for productivity have dramatically impacted the practice of orthopaedic surgery and academic surgical training. Orthopaedic leaders and training programs are striving to identify and solve these contemporary challenges. Herein, we focus on 4 areas that currently pose important challenges to modern orthopaedic surgical departments and academic hospital systems, including the demanding and evolving skill sets that are required of physician leaders, the effects of the changing medical-legal environment on academic medicine, the impact of increased clinical productivity emphasis on surgical education, and departmental leadership transitions.

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

Neuropathic arthropathy, also known as Charcot arthropathy, is a degenerative disorder most commonly characterized by rapid destruction of the joint with extensive involvement of the bone and soft tissue. The underlying pathophysiology is thought to be due to loss of nociception (pain sensation), most frequently caused by diabetes mellitus, syphilitic myelopathy, or syringomyelia. A neuropathic shoulder is rare, with historic case series forming the bulk of the literature. The purpose of this review is to better understand the pathogenesis, clinical presentation, and management of neuropathic arthropathy of the glenohumeral joint. It should be stressed that the identification and management of the underlying etiology is paramount if the disease process is to be positively impacted. Although the mainstay of orthopedic management is non-surgical, little evidence exists to support the use of any specific therapeutic intervention. Recent literature suggests surgical reconstruction may be considered in very select patients.

BACKGROUND:Achieving glenoid fixation with anterior bone loss can be challenging. Limited guidelines have been established for critical defect sizes that can be treated without supplemental bone graft when performing reverse shoulder arthroplasty. METHODS:We quantified the impact of two sizes of anterior glenoid defects on glenoid baseplate fixation in a composite scapula using the ASTM F 2028-14 reverse shoulder glenoid loosening test method. RESULTS:All glenoid baseplates remained well-fixed after cyclic loading in composite scapula without a defect and in scapula with an 8.5 mm anterior glenoid defect; however, one of seven baseplates loosened in a scapula with a 12.5 mm defect. No difference was observed between pre- and post-cyclic baseplate displacements in scapula with 8.5 mm or 12.5 mm defects or in the control group scapula. However, baseplate displacement in scapula with 12.5 mm anterior defects was significantly greater after cyclic loading than that of baseplates in 8.5 mm defects (superior-inferior displacement, p = 0.0004; anterior-posterior displacement, p < 0.0001), where baseplate displacement in 8.5 mm (superior- inferior displacement, p = 0.0003; anterior-posterior displacement, p = 0.0014) and 12.5 mm (superior-inferior displacement, p < 0.0001; anterior-posterior displacement, p < 0.0001) defects after cyclic loading was significantly greater than that of baseplates in scapula without a defect. DISCUSSION/CONCLUSIONS:Adequate and stable fixation can be achieved in scapula with anterior glenoid defects of at least 8.5 mm in this biomechanical model using an established testing methodology; however, supplemental bone grafting should be utilized for anterior glenoid defects of 12.5 mm and larger using the reverse shoulder prosthesis tested in this study.

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.

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.

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:An improved understanding of how gender differences and the natural aging process are associated with differences in clinical improvement in outcome metric scores and ROM measurements after reverse total shoulder arthroplasty (rTSA) may help physicians establish more accurate patient expectations for reducing postoperative pain and improving function. QUESTIONS/PURPOSES/OBJECTIVE:(1) Is gender associated with differences in rTSA outcome scores like the Simple Shoulder Test (SST), the UCLA Shoulder score, the American Shoulder and Elbow Surgeons (ASES) Shoulder score, the Constant Shoulder score, and the Shoulder Pain and Disability Index (SPADI) and ROM? (2) Is age associated with differences in rTSA outcome scores and ROM? (3) What factors are associated with the combined interaction effect between age and gender? (4) At what time point during recovery does most clinical improvement occur, and when is full improvement reached? METHODS:We quantified and analyzed the outcomes of 660 patients (424 women and 236 men; average age, 72 ± 8 years; range, 43-95 years) with cuff tear arthropathy or osteoarthritis and rotator cuff tear who were treated with rTSA by 13 shoulder surgeons from a longitudinally maintained international database using a linear mixed effects statistical model to evaluate the relationship between clinical improvements and gender and patient age. We used five outcome scoring metrics and four ROM assessments to evaluate clinical outcome differences. RESULTS:When controlling for age, men had better SST scores (mean difference [MD] = 1.41 points [95% confidence interval {CI}, 1.07-1.75], p < 0.001), UCLA scores (MD = 1.76 [95% CI, 1.05-2.47], p < 0.001), Constant scores (MD = 6.70 [95% CI, 4.80-8.59], p < 0.001), ASES scores (MD = 7.58 [95% CI, 5.27-9.89], p < 0.001), SPADI scores (MD = -12.78 [95% CI, -16.28 to -9.28], p < 0.001), abduction (MD = 5.79° [95% CI, 2.74-8.84], p < 0.001), forward flexion (MD = 7.68° [95% CI, 4.15-11.20], p < 0.001), and passive external rotation (MD = 2.81° [95% CI, 0.81-4.8], p = 0.006). When controlling for gender, each 1-year increase in age was associated with an improved ASES score by 0.19 points (95% CI, 0.04-0.34, p = 0.011) and an improved SPADI score by -0.29 points (95% CI, -0.46 to 0.07, p = 0.020). However, each 1-year increase in age was associated with a mean decrease in active abduction by 0.26° (95% CI, -0.46 to 0.07, p = 0.007) and a mean decrease of forward flexion by 0.39° (95% CI, -0.61 to 0.16, p = 0.001). A combined interaction effect between age and gender was found only with active external rotation: in men, younger age was associated with less active external rotation and older age was associated with more active external rotation (β0 [intercept] = 11.029, β1 [slope for age variable] = 0.281, p = 0.009). Conversely, women achieved no difference in active external rotation after rTSA, regardless of age at the time of surgery (β0 [intercept] = 34.135, β1 [slope for age variable] = -0.069, p = 0.009). Finally, 80% of patients achieved full clinical improvement as defined by a plateau in their outcome metric score and 70% of patients achieved full clinical improvement as defined by a plateau in their ROM measurements by 12 months followup regardless of gender or patient age at the time of surgery with most improvement occurring in the first 6 months after rTSA. CONCLUSIONS:Gender and patient age at the time of surgery were associated with some differences in rTSA outcomes. Men had better outcome scores than did women, and older patients had better outcome scores but smaller improvements in function than did younger patients. These results demonstrate rTSA outcomes differ for men and women and for different patient ages at the time of surgery, knowledge of these differences, and also the timing of improvement plateaus in outcome metric scores and ROM measurements can both improve the effectiveness of patient counseling and better establish accurate patient expectations after rTSA. LEVEL OF EVIDENCE/METHODS:Level III, therapeutic study.