Faculty Bibliography

Aims The factors that predispose to recurrent instability and revision stabilization procedures after arthroscopic Bankart repair for anterior glenohumeral instability remain unclear. We sought to determine the rate and risk factors associated with ongoing instability in patients undergoing arthroscopic Bankart repair for instability of the shoulder. Materials and Methods We used the Statewide Planning and Research Cooperative System (SPARCS) database to identify patients with a diagnosis of anterior instability of the shoulder undergoing arthroscopic Bankart repair between 2003 and 2011. Patients were followed for a minimum of three years. Baseline demographics and subsequent further surgery to the ipsilateral shoulder were analyzed. Multivariate analysis was used to identify independent risk factors for recurrent instability. Results A total of 5719 patients were analyzed. Their mean age was 24.9 years (sd 9.3); 4013 (70.2%) were male. A total of 461 (8.1%) underwent a further procedure involving the ipsilateral shoulder at a mean of 31.5 months (sd 23.8) postoperatively; 117 (2.1%) had a closed reduction and 344 (6.0%) had further surgery. Revision arthroscopic Bankart repair was the most common subsequent surgical procedure (223; 65.4%). Independent risk factors for recurrent instability were: age < 19 years (odds ratio 1.86), Caucasian ethnicity (hazard ratio 1.42), bilateral instability of the shoulder (hazard ratio 2.17), and a history of closed reduction(s) prior to the initial repair (hazard ratio 2.45). Revision arthroscopic Bankart repair was associated with significantly higher rates of ongoing persistent instability than revision open stabilization (12.4% vs 5.1%, p = 0.041). Conclusion The incidence of a further procedure being required in patients undergoing arthroscopic Bankart repair for anterior glenohumeral instability was 8.1%. Younger age, Caucasian race, bilateral instability, and closed reduction prior to the initial repair were independent risk factors for recurrent instability, while subsequent revision arthroscopic Bankart repair had significantly higher rates of persistent instability than subsequent open revision procedures. Cite this article: Bone Joint J 2018;100-B:324-30.

OBJECTIVES/OBJECTIVE:To understand the personality factors associated with orthopedic surgery resident performance. DESIGN/METHODS:A prospective, cross-sectional survey of orthopedic surgery faculty that assessed their perceptions of the personality traits most highly associated with resident performance. Residents also completed a survey to determine their specific personality characteristics. A subset of faculty members rated the performance of those residents within their respective program on 5 dimensions. Multiple regression models tested the relationship between the set of resident personality measures and each aspect of performance; relative weights analyses were then performed to quantify the contribution of the individual personality measures to the total variance explained in each performance domain. Independent samples t-tests were conducted to examine differences between the personality characteristics of residents and those faculty identified as relevant to successful resident performance. SETTING/METHODS:throughout the United States. The level of clinical care provided by participating institutions varied. PARTICIPANTS/METHODS:Data from 175 faculty members and 266 residents across 12 programs were analyzed. RESULTS:The personality features of residents were related to faculty evaluations of resident performance (for all, p < 0.01); the full set of personality measures accounted for 4%-11% of the variance in ratings of resident performance. Particularly, the characteristics of agreeableness, neuroticism, and learning approach were found to be most important for explaining resident performance. Additionally, there were significant differences between the personality features that faculty members identified as important for resident performance and the personality features that residents possessed. CONCLUSION/CONCLUSIONS:Personality assessments can predict orthopedic surgery resident performance. However, results suggest the traits that faculty members value or reward among residents could be different from the traits associated with improved resident performance.

BACKGROUND:An understanding of the substantial clinical benefit (SCB) after total shoulder arthroplasty (TSA) may help to gauge a minimum threshold beyond which a patient perceives his or her outcome as being substantially better. This study quantifies SCB for 7 outcome metrics and active motion measurements after shoulder arthroplasty and determines how these values vary based on prosthesis type, patient age at surgery, sex, and length of follow-up. METHODS:A total of 1,568 shoulder arthroplasties with 2-year minimum follow-up were performed by 13 shoulder surgeons and enrolled in a multicenter registry. The SCB for the American Shoulder and Elbow Surgeons Shoulder Assessment, Constant Score, University of California Los Angeles Shoulder Rating Scale, Simple Shoulder Test, Shoulder Pain and Disability Index, global shoulder function, and visual analog scale pain scores, as well as active abduction, flexion, and external rotation were calculated for different patient cohorts using an anchor-based method. RESULTS:The anchor-based SCB results were American Shoulder and Elbow Surgeons score, 31.5 ± 2.0; Constant Score, 19.1 ± 1.7; University of California Los Angeles Shoulder Rating Scale score, 12.6 ± 0.5; Simple Shoulder Test score,  3.4 ± 0.3; Shoulder Pain and Disability Index score,  45.4 ± 2.2; global shoulder function, 3.1 ± 0.2; visual analog scale, 3.2 ± 0.3; active abduction, 28.5° ± 3.1°; active forward flexion, 35.4° ± 3.5°; and active external rotation, 11.7° ± 1.9°. Anatomic TSA patients, male patients, and patients of longer follow-up duration were associated with higher SCB values than female patients, reverse TSA patients, and patients of shorter follow-up duration. CONCLUSION/CONCLUSIONS:Our analysis demonstrated two-thirds of patients achieved the SCB threshold after TSA. Generally, a change of 30% of the total possible score for each outcome metric approximates or exceeds this SCB threshold.

Purpose: Image-guided joint aspiration is often requested for clinically suspected periprosthetic joint infection (PJI). For "dry taps" when no native joint fluid can be aspirated, a lavage with non-bacteriostatic saline can be performed. The purpose of this study is to determine the diagnostic utility of lavage versus native joint fluid aspiration in the setting of clinically suspected PJI. Materials and Methods: IRB approval was obtained and informed consent was waived for this retrospective study. A PACS search from 2011- 2017 for image-guided aspirations yielded 918 procedures, of which 630 were excluded for non-articular and non-arthroplasty aspirations, antibiotic cement spacers, and lack of clinical information in the electronic medical record. The study cohort included 288 procedures from 173 patients who underwent operative or non-operative management. The reference standard was the intraoperative culture for operative patients and clinical follow-up for conservatively managed patients. A Fisher exact test was used for statistical analysis. Results: The study cohort consisted of 98 females, 75 males, mean age 64 (range 34-90) with the following arthroplasty types: 176 hips, 65 knees, and 47 shoulders. Of 288 procedures, 105 were performed with lavage and 183 were native joint fluid aspirations; 112 were subsequently operatively managed. The mean follow-up for non-operative patients was 5 months (range 0-42). For native joint fluid aspiration versus lavage, accuracy was 81% vs. 73% (p=0.14), sensitivity was 58% vs. 28% (p=0.03), specificity was 88% vs. 91% (p=0.66), negative predictive value was 89% vs. 77% (p=0.02), and positive predictive value was 55% vs. 53% (p=1.00), respectively. Conclusion: Lavage is less sensitive with a lower negative predictive value for the diagnosis of PJI compared to native joint fluid aspirations, possibly due to a lower pretest probability of infection and the inherent dilutional effects of the procedure

Purpose: As glenohumeral osteoarthritis progresses, there is increased risk for posterior glenoid bone loss which impacts an increasingly common treatment for these patients, total shoulder arthroplasty. Defining the level of maximum posterior bone loss and accurate assessment of its severity, using glenoid version measurements, are crucial to correctly align the glenoid prosthesis with glenoid to prevent prosthetic failure. While the importance of this information is clear, how these measurements should be performed remains in question with several techniques described in the literature. The purpose of this study was to define the most accurate level to measure glenoid version on CT for the most clinically relevant variants of posterior glenoid bone loss, Walch B2 and B3 types. Materials and Methods: 386 consecutive CT shoulder studies performed for shoulder arthroplasty preoperative planning between 2013- 2016 were retrospectively reviewed. Patients with B2 and B3 glenoid types were included. Two radiologists measured glenoid retroversion independently according to Friedman method on true axial CT images using the "intermediate glenoid line", at three glenoid heights: 25% (upper) 50% (equator) and 75% (lower). Results: 29 B2 and 8 B3 glenoid types were included. There was no statistically significant difference found in the retroversion measurements performed by each reader at the three glenoid levels on the B2 or B3 glenoid types (Mean angles (%) in upper, equator and lower in B2: 16.5, 17,0 and 17.5 and B3: 20.6, 20.7 and 23.2, respectively). There was substantial inter-reader correlation (r>=0.7) in angle measurements. Conclusion: Our study suggests that glenoid version can be accurately measured at any level between 25%-75%of the glenoid height forWalch B2 and B3 types. We recommend that the glenoid equator be used as the reference in order to assure consistent and reliable version measurements in this group of patients

BACKGROUND:Clinician-scientist numbers have been stagnant over the past few decades despite awareness of this trend. Interventions attempting to change this problem have been seemingly ineffective, but research residency positions have shown potential benefit. OBJECTIVE:We sought to evaluate the effectiveness of a clinician-scientist training program (CSTP) in an academic orthopedic residency in improving academic productivity and increasing interest in academic careers. METHODS:Resident training records were identified and reviewed for all residents who completed training between 1976 and 2014 (n = 329). There were no designated research residents prior to 1984 (pre-CSTP). Between 1984 and 2005, residents self-selected for the program (CSTP-SS). In 2005, residents were selected by program before residency (CSTP-PS). Residents were also grouped by program participation, research vs. clinical residents (RR vs. CR). Data were collected on academic positions and productivity through Internet-based and PubMed search, as well as direct e-mail or phone contact. Variables were then compared based on the time duration and designation. RESULTS:Comparing all RR with CR, RR residents were more likely to enter academic practice after training (RR, 34%; CR, 20%; p = 0.0001) and were 4 times more productive based on median publications (RR, 14; CR, 4; p < 0.0001). Furthermore, 42% of RR are still active in research compared to 29% of CR (p = 0.04), but no statistical difference in postgraduate academic productivity identified. CONCLUSIONS:The CSTP increased academic productivity during residency for the residents and the program. However, this program did not lead to a clear increase in academic productivity after residency and did not result in more trainees choosing a career as clinician-scientists.

BACKGROUND:Knowledge of the minimal clinically important difference (MCID) for different shoulder outcome metrics and range of motion after total shoulder arthroplasty (TSA) can be useful to establish a minimum threshold of improvement that defines successful treatment. This study quantifies how MCID varies with different prosthesis types, patient age, gender, and length of follow-up after TSA. METHODS:A total of 466 anatomic TSA (aTSA) and reverse TSA (rTSA) with 2-year minimum follow-up were performed by 13 shoulder surgeons. The MCID for the American Shoulder and Elbow Surgeons, Constant, University of California Los Angeles Shoulder Rating Scale, Simple Shoulder Test, Shoulder Pain and Disability Index, global shoulder function, and visual analog scale for pain scores, as well as active abduction, forward flexion, and external rotation, were calculated for different prosthesis types and patient cohorts using an anchor-based method. RESULTS:The anchor-based MCID results were American Shoulder and Elbow Surgeons = 13.6 ± 2.3, Constant score = 5.7 ± 1.9, University of California Los Angeles Shoulder Rating Scale = 8.7 ± 0.6, Simple Shoulder Test score = 1.5 ± 0.3, Shoulder Pain and Disability Index score = 20.6 ± 2.6, global shoulder function = 1.4 ± 0.3, pain visual analog scale  = 1.6 ± 0.3, active abduction = 7° ± 4°, active forward flexion = 12° ± 4°, and active external rotation = 3° ± 2°. Female gender and rTSA were associated with lower MCID values compared with male gender and aTSA patients. CONCLUSION/CONCLUSIONS:The minimum improvement necessary for patients to achieve a result they believe is clinically meaningful after aTSA and rTSA is nominal and was achieved by at least 80% of the patients. Future endeavors should investigate the influence of different anchor questions on the MCID calculation.

OBJECTIVE: We developed a series of orthopedic unannounced standardized patient (USP) encounters for the purpose of objective assessment of residents during clinic encounters. DESIGN: Consecutive case-series. SETTING: NYU-Langone Multi-center Academic University Hospital System. PARTICIPANTS: NYU-Langone/Hospital for Joint Diseases Orthopedic Surgery residents; 48 consecutive residents assessed. METHODS: Four orthopedic cases were developed. USPs presented themselves as patients in outpatient clinics. Residents were evaluated on communication skills (information gathering, relationship development, and education and counseling). USPs globally rated whether they would recommend the resident. RESULTS: Forty-eight USP encounters were completed over a 2-year period. Communication skills items were rated at 51% (+/-30) "well done." Education and counseling skills were rated as the lowest communication domain at 33% (+/-33). Residents were globally recommended based on communication skills in 63% of the encounters recommended in 70% of encounters based on both professionalism and medical competence. CONCLUSIONS: The USP program has been useful in assessing residents' clinical skills, interpersonal and communications skills, and professionalism. Use of USP in orthopedic surgery training programs can be an objective means for trainee assessment.

BACKGROUND:This study quantifies the rate of improvement after anatomic and reverse total shoulder arthroplasty; a better understanding of the rate of improvement associated with each prosthesis type may better establish patient expectations for recovery. METHODS:Prospectively collected data on 1,183 patients who underwent either anatomic total shoulder arthroplasty (n = 505) or reverse total shoulder arthroplasty (n = 678) were collected. The Simple Shoulder Test (SST), University of California at Los Angeles (UCLA) Shoulder, American Shoulder and Elbow Surgeons (ASES), Constant, and Shoulder Pain and Disability Index (SPADI) scores, along with range of motion, were recorded preoperatively and at routine postoperative time points. All included patients had a minimum follow-up of 2 years. The rate of improvement of these outcome measures was quantified for patients who underwent anatomic total shoulder arthroplasty and those who underwent reverse total shoulder arthroplasty to compare recovery over time. RESULTS:In this study, 3,587 visits by 1,183 patients were analyzed and several differences between prosthesis types were noted. Patients who underwent reverse total shoulder arthroplasty experienced larger improvements in the Constant score and active forward flexion, and patients who underwent anatomic total shoulder arthroplasty demonstrated better improvement in external rotation compared with patients who underwent reverse total shoulder arthroplasty at nearly all time points. By 72 months, improvement in flexion and abduction decreased for each prosthesis type, but in particular for reverse total shoulder arthroplasty. Full improvement was achieved by 24 months, although the majority of improvement was achieved in the first 6 months, with all 5 scoring metrics following a similar rate of improvement. The ASES, SPADI, and UCLA Shoulder scores closely mirrored each other in the magnitude of improvement, and the SST score demonstrated the largest improvement and the Constant score demonstrated the smallest improvement for both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty. CONCLUSIONS:Both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty reliably result in improved patient outcomes. However, anatomic total shoulder arthroplasty more reliably improves range of motion, particularly external rotation. Most improvement occurs by 6 months, with some additional improvement up to 2 years for both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty. Although the indications for anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty are substantially different, in addition to the biomechanical differences, the improvement in outcome scores over time can be expected to be very similar. This study is helpful to patients and health-care providers to establish expectations regarding the rate of recovery after total shoulder arthroplasty. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic SLAP tear repair has become an increasingly used treatment for patients presenting with symptomatic SLAP tears after failed nonoperative management. Debridement, SLAP repair, and open or arthroscopic biceps tenodesis or tenotomy have been used for the treatment of SLAP tears. Various techniques for repair have been described, and furthermore, there is a high incidence of concomitant pathology of the shoulder. Repair remains an excellent option in isolated SLAP tears amenable to repair, with excellent outcomes in well-indicated patients. We present a method for repairing a SLAP tear using standard suture anchor fixation, anterior and posterior portals, and an accessory portal of Wilmington. Adequate labral repair can be achieved with this technique in patients with no concomitant biceps pathology. This report highlights this technique for SLAP repair in patients with isolated symptomatic SLAP tears that have failed conservative management.