Faculty Bibliography

BACKGROUND: Scapular notching is a complication unique to reverse total shoulder arthroplasty (rTSA), although its clinical implications are unclear and remains controversial. METHODS: We retrospectively reviewed rTSA patients of a single implant design in 476 shoulders with a minimum 2-year clinical and radiographic follow-up. Clinical measures included active range of motion and American Shoulder and Elbow Surgeons scores, in addition to one or more of the Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test (SST), and University of California, Los Angeles Shoulder Rating Scale. Complications and rates of humeral radiolucencies were also recorded. RESULTS: Scapular notching was observed in 10.1% (48 of 476) of rTSAs and was associated with a longer clinical follow-up, lower body weight, lower body mass index, and when the operative side was the nondominant extremity. Patients with scapular notching had significantly lower postoperative scores on the Shoulder Pain and Disability Index, Constant, Simple Shoulder Test, and University of California, Los Angeles, Shoulder Rating Scale compared with patients without scapular notching. Patients with scapular notching also had significantly lower active abduction, significantly less strength, and trended toward significantly less active forward flexion (P = .0527). Finally, patients with scapular notching had a significantly higher complication rate and trended toward a significantly higher rate of humeral radiolucent lines (P = .0896) than patients without scapular notching. CONCLUSIONS: This large-scale outcome study demonstrates that patients with scapular notching have significantly poorer clinical outcomes, significantly less strength and active range of motion, and a significantly higher complication rate than patients without scapular notching. Longer-term follow-up is necessary to confirm that these statistical observations in the short-term will result in greater clinically meaningful differences over time.

BACKGROUND: Periprosthetic shoulder infections (PSIs) are challenging to treat and often result in significant patient morbidity. Without a standardized treatment protocol, PSIs are often managed similarly to periprosthetic hip and knee infections. Because 2-stage revision is the gold standard for treating periprosthetic hip and knee infections, we performed a case series and literature review to determine its effectiveness in PSIs. METHODS: We identified 19 patients (14 men) from our institution who were treated with a 2-stage revision after presenting with a PSI. Mean patient age was 63 +/- 9 years, and average body mass index was 30.8 +/- 5.8. The average time from the index arthroplasty to treatment was 40 months, 8 of 13 positive cultures were Propionibacterium acnes, and 9 of 19 patients had multiple shoulder operations before presenting with infection. Minimum follow-up for all patients was 2 years. RESULTS: After a mean follow-up of 63 months (range, 25-184 months), 15 of 19 patients in our study were successfully treated for PSI. Average postoperative American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment score was 69 (range, 32-98) and average postoperative forward elevation was significantly increased from 58 degrees to 119 degrees (P < .001). The incidence of recurrent infection was 26%. The rate of noninfection complications was 16%, for a total complication rate of 42%. CONCLUSION: In patients with PSIs, especially those with intractable, chronic infections, a 2-stage revision represents a viable treatment option for eradicating infection and restoring function. However, it is important to recognize the risk of recurrent infection and postoperative complications in this challenging patient population.

BACKGROUND: Revision shoulder arthroplasty is a technically challenging procedure. It is associated with increased blood loss and operative time, and it frequently necessitates revision implants, augments, and bone-grafting. Shoulder arthroplasty systems with a convertible-platform humeral stem have been developed to reduce the complexity of revision procedures by eliminating the need for humeral component explantation when converting from anatomic shoulder arthroplasty (hemiarthroplasty or total shoulder arthroplasty) to reverse total shoulder arthroplasty (rTSA). METHODS: A multicenter, retrospective analysis involving 102 consecutive shoulders (102 patients) that underwent revision of an anatomic shoulder arthroplasty to an rTSA was conducted. During the revision, 73 of the shoulders needed exchange of the humeral stem (the exchange group) and 29 had retention of a convertible-platform humeral component (the retention group). Patient demographics, operative time, blood management, range of motion, complications, and patient-reported outcomes were compared between the 2 groups. RESULTS: Patients with retention had significantly shorter operative time (mean and standard deviation, 130 +/- 48 versus 195 +/- 58 minutes; p < 0.001) and lower estimated blood loss (292 +/- 118 versus 492 +/- 334 mL; p = 0.034). The rate of intraoperative complications was lower in the retention group (0% versus 15%; p = 0.027). Patients with retention had slightly better postoperative range of motion (active external rotation, 26 degrees +/- 23 degrees versus 11 degrees +/- 23 degrees [p = 0.006]; active forward elevation, 112 degrees +/- 37 degrees versus 96 degrees +/- 33 degrees [p = 0.055]). CONCLUSIONS: Shoulder arthroplasty systems that utilize a convertible-platform humeral stem offer an advantage for rTSA conversion in that a well-fixed, well-positioned humeral stem can be retained. There were significantly fewer complications as well as significantly decreased blood loss and operative time when a convertible-platform stem was utilized (p < 0.050). LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Factors contributing to recurrent instability and revision stabilization procedures after isolated arthroscopic stabilization of anterior glenohumeral instability have not been examined in a Statewide cohort. Additionally, practice patterns of the management of the failed Bankart repair are unclear. We sought to identify the type, rate and risk factors associated with subsequent ipsilateral shoulder procedures in a large cohort of individuals undergoing arthroscopic stabilizations for anterior shoulder instability. Methods: The New York State Department of Health's Statewide Planning and Research Cooperative Systems (SPARCS) database was examined from 2003 to 2011 to identify all patients with a primary diagnosis of anterior shoulder instability (ICD-9-CM codes 831.01, 718.81 and 718.31) undergoing outpatient arthroscopic capsulorraphy (CPT code 29806). Patients younger than 10 or older than 60 years of age, and entries with missing data, were excluded. Patients were longitudinally followed for a minimum of three years (through 2014). Baseline demographics and all subsequent ipsilateral outpatient shoulder procedures were collected. SAS version 9.3 (Cary, NC) was used for data collection and statistical analysis. Results: We identified 5,719 unique patients who met the inclusion criteria. Mean patient age was 24.9 + /- 9.3 years, and 70.2% of the sample was male. A total of 461 (8.1%) patients underwent subsequent ipsilateral shoulder instability interventions a mean of 31.5 + /- 23.8 months after the initial stabilization procedure (2.1% had closed reduction alone; 6.0% had repeat instability surgery + /- closed reduction). Repeat arthroscopic capsulorraphy was the most common subsequent procedure (48.8%). Patients undergoing procedures for subsequent shoulder instability were younger (22.6 + /- 8.6 vs. 25.1 + /- 9.4 years of age, P < .001). Evidence of additional instability following arthroscopic Bankart was independently associated with age 19 years or younger (HR 1.82; 95% CI 1.50-2.21; P < .001), Caucasian ethnicity (HR 1.38; 95% CI 1.11-1.71; P = .003), evidence of bilateral shoulder instability (HR 1.54; 95% CI 1.06-2.23; P = .023) and a history of closed reduction(s) prior to initial arthroscopic Bankart repair (HR 2.45; 95% CI 1.90-3.15 P = < .001). Gender and surgeon volume was not associated with subsequent instability procedures. When followup was normalized to three years to allow for between year comparisons, year of surgery did not predict subsequent shoulder instability. Conclusion: Patients undergoing arthroscopic stabilization of anterior glenohumeral instability in New York State had an 8.1% chance of undergoing subsequent ipsilateral instability procedures. Younger age, Caucasian race, bilateral glenohumeral instability and closed reduction prior to initial Bankart repair were independent risk factors for additional instability procedures. The most common second surgical procedure was a repeat arthroscopic stabilization (Table 1). (Table Presented)

Patient care is 1 of the 6 core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). The physical examination (PE) is a fundamental skill to evaluate patients and make an accurate diagnosis. The purpose of this study was to investigate 3 different methods to teach PE skills and to assess the ability to do a complete PE in a simulated patient encounter. DESIGN: Prospective, uncontrolled, observational. SETTING: Northeastern academic medical center. PARTICIPANTS: A total of 32 orthopedic surgery residents participated and were divided into 3 didactic groups: Group 1 (n = 12) live interactive lectures, demonstration on standardized patients, and textbook reading; Group 2 (n = 11) video recordings of the lectures given to Group 1 and textbook reading alone; Group 3 (n = 9): 90-minute modules taught by residents to interns in near-peer format and textbook reading. RESULTS: The overall score for objective structured clinical examinations from the combined groups was 66%. There was a trend toward more complete PEs in Group 1 taught via live lectures and demonstrations compared to Group 2 that relied on video recording. Near-peer taught residents from Group 3 significantly outperformed Group 2 residents overall (p = 0.02), and trended toward significantly outperforming Group 1 residents as well, with significantly higher scores in the ankle (p = 0.02) and shoulder (p = 0.02) PE cases. CONCLUSIONS: This study found that orthopedic interns taught musculoskeletal PE skills by near-peers outperformed other groups overall. An overall score of 66% for the combined didactic groups suggests a baseline deficit in first-year resident musculoskeletal PE skills. The PE should continue to be taught and objectively assessed throughout residency to confirm that budding surgeons have mastered these fundamental skills before going into practice.

Introduction: Periprosthetic shoulder infections (PSIs) are challenging to treat and often result in significant patient morbidity. Without a standardized treatment protocol, PSIs are often managed similarly to periprosthetic hip and knee infections. Because two-stage revision is the gold standard for treating periprosthetic hip and knee infections, we performed a case series and literature review to determine its effectiveness in PSIs. Methods: We identified nineteen patients from our institution that were treated with two-stage revision after presenting with a PSI. Minimum follow-up for all patients was 2 years. Mean patient age was 63 +/- 9 years, 14/19 patients were male, and average BMI was 30.8 +/- 5.8. Average time from index arthroplasty to treatment was 40 months, 8/13 positive cultures were P. acnes, and 9/19 patients had multiple shoulder operations before presenting with infection. Results: After a mean follow up of 63 months (Range 25-184 months), 15/19 patients in our study were successfully treated for PSI. Average postoperative ASES score was 69 (32-98) and average postoperative forward elevation was significantly increased from 58 to 119 degrees (P < .001). The incidence of recurrent infection was 26%; the rate of non-infection complications was 16% for a total complication rate of 42%. Conclusion: In patients with PSIs, especially those with intractable, chronic infections, a two-stage revision represents a viable treatment option for eradicating infection and restoring function. However, it is important to recognize the risk of recurrent infection and postoperative complications in this challenging patient population

INTRODUCTION: Diabetes has been associated with negative outcomes following orthopaedic surgery. While previous studies have reported on diabetes-associated complications in shoulder arthroplasty, those cohorts were heterogeneous in terms of patient population, nature of elective surgery, and arthroplasty type. Given that the number of elective total shoulder arthroplasties (TSAs) performed has grown substantially in volume and is predicted to rise even further, it is important to recognize the role that diabetes may play in developing in-hospital complications within a more homogenous sample of patients undergoing elective TSA. METHODS: The Nationwide Inpatient Sample (NIS) was searched for the year 2012 to identify all patients undergoing elective TSA. Patients with diabetes were identified, and differences regarding demographics and in-hospital outcomes were compared to non-diabetics using multivariate logistic regression. RESULTS: A total of 44,050 patients underwent elective total shoulder arthroplasty (TSA) in 2012. Diabetic patients tended to be older, of minority racial status, and had a greater medical comorbidity burden. When controlling for preoperative factors and comorbidities, diabetes was an independent risk factor for non-home bound discharge (OR 1.285; 95% CI 1.093-1.509, p = 0.002), length of stay in 75th percentile (OR 1.390; 95% CI 1.233-1.567, p < 0.001), total charges in the 75th percentile (OR 1.136; 95% CI 1.006-1.283, p = 0.040), and postoperative acute renal failure (OR 1.460; 1.002-2.128, p = 0.048). CONCLUSION: Diabetes was associated with marginal increases in non-home bound discharge, length of stay, and total charges, following elective TSA. Subgroup analysis revealed that diabetic patients undergoing reverse total shoulder arthroplasty (rTSA) have higher comorbidity burden and worse outcomes than diabetic patients undergoing anatomic total shoulder arthroplasty (aTSA).

BACKGROUND: Repair of the subscapularis with reverse total shoulder arthroplasty (rTSA) is controversial. The purpose of this study is to quantify rTSA outcomes in patients with and without subscapularis repair to determine if there is any impact on clinical outcomes. METHODS: Three hundred forty patients received rTSA and had the subscapularis repaired, whereas 251 patients received rTSA and did not have the subscapularis repaired. The patients were scored preoperatively and at latest follow-up using the Simple Shoulder Test; University of California, Los Angeles; American Shoulder and Elbow Surgeons; Constant; and Shoulder Pain and Disability Index metrics. Motion was also measured. Mean follow-up was 37 months. RESULTS: All patients showed significant improvements in pain and function after treatment with rTSA. For both cohorts, American Shoulder and Elbow Surgeons and Constant scores significantly improved, as did range of motion. The repaired cohort had significantly higher postoperative scores as measured by 4 of the 5 metrics and significantly more internal rotation, whereas the non-repaired cohort had significantly more active abduction and passive external rotation. The complication rate was 7.4% (0% dislocations) for the subscapularis-repaired cohort and 6.8% (1.2% dislocations) for the non-subscapularis-repaired cohort. CONCLUSIONS: Significant clinical improvements were observed for both the subscapularis-repaired and non-repaired cohorts, with some statistical differences observed using a variety of outcome measures. Repair of the subscapularis did not lead to inferior clinical outcomes as predicted by biomechanical models. No difference was noted in the complication or scapular notching rates between cohorts. These clinical results show that rTSA using a lateralized humeral prosthesis delivers reliable clinical improvements with a low risk of instability, regardless of subscapularis repair.