Faculty Bibliography

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.

Purpose: The intrawound application of lyophilized vancomycin has been reported to significantly decrease the rates of perioperative infection in arthroplasty and spine procedures. The local effect of clinically used supra-therapeutic concentration of intra wound vancomycin on surrounding healing tissue has been a topic of continued investigation. The purpose of this study was to examine the in vitro cytotoxicity profile of vancomycin hydrochloride on osteoblasts, fibroblast, and myoblasts. Methods: Human primary osteoblasts (Lonza), fibroblasts (Lonza), and myoblasts (DV Biologics) were expanded and passaged in sterile polystyrene tissue culture flasks and plated at a density of 10,000 cells/cm2. Cells were exposed to vancomycin hydrochloride (Sigma-Aldrich) at concentrations of 1, 3, 6, or 12 mg/cm2. To assess the effect of vancomycin on cell migration, a scratch assay was performed, in which a "scratch" was made in a cell monolayer following vancomycin exposure, and images were subsequently captured at regular intervals until cellular closure of the scratch. Cell survival was measured 48 hours post-vancomycin exposure using a cell cytotoxicity assay (Cell Counting Kit-8, Dojindo). Results: Vancomycin concentrations greater than or equal to 1 mg/cm2 decreased survival of myoblasts and osteoblasts to less than 11% relative to control. Vancomycin greater than or equal to 3 mg/ cm2 decreased fibroblast survival to less than 8% relative to control (Fig. 1). Vancomycin concentrations of 1 mg/cm2 did not significantly affect the survival of fibroblasts. Closure of the scratch defect was observed in less than 24 hours for all control conditions. In myoblasts and osteoblasts, the scratch defect remained open indefinitely following exposure to vancomycin concentrations greater than or equal to 1 mg/cm2. Closure of the scratch defect in fibroblasts was observed in less than 36 hours following exposure to vancomycin of 1 mg/cm2, and remained opened indefinitely following exposure to vancomycin greater than or equal to 3 mg/cm2. Conclusions: Vancomycin has a significant cytotoxic effect on proliferating osteoblasts and myoblasts at concentrations greater than (Figure Presented) or equal to 1 mg/cm2.Vancomycin has a pronounced cytotoxic effect on fibroblasts at concentrations greater than or equal to 3 mg/cm2. Further in vivo studies are warranted to investigate the effect of high local concentrations of vancomycin on infection, bony fusion, and wound healing

Introduction: While total shoulder arthroplasty (TSA) is generally associated with good to excellent outcomes in majority of patients, the integrity and the function of the subscapularis tendon may be compromised after the procedure and lead to inferior outcomes. Therefore, the efficacy of a subscapularis sparing TSA procedure was evaluated in a prospective, double blinded, randomized study. Methods: With IRB approval, patients with end stage osteoarthritis of the shoulder were enrolled into a prospective clinical trial from 2010 to 2014. These patients were randomized into two groups. Group 1 patients were treated with TSA using the subscapularis sparing surgical approach in which the prosthesis was inserted entirely through the rotator interval without violating the subscapularis tendon (SPARING). Group 2 patients were treated with TSA using the standard surgical approach with subscapularis tenotomy (STANDARD). Both the patient and the evaluators remained "blinded" to the surgical approach throughout the study period. Minimum 2 year outcome data was collected using the visual analog score (VAS) for pain and the American Shoulder and Elbow Surgeon (ASES) outcome score. Results: A total of 107 shoulders were enrolled (57 SPARING, 50 STANDARD). Of these, 14 TSA procedures could not be completed as initially randomized. In addition, 3 patients expired (unrelated to the procedure), 7 patients withdrew from the study, and 2 moved away. Of the remaining 81 patients, 2 year outcome data could not be collected from another 11. Thus, complete 2 year outcome data was collected from 32 SPARING and 38 STANDARD patients at an average follow up of 31.1 and 34.4 months, respectively. The ASES score and VAS for the SPARING group improved significantly from 29.3 +/- 12.5 and 6.6 +/- 2.1 to 82.6 +/- 18.8 and 1.6 +/- 2.2 (mean +/- standard deviation). Similarly, the ASES score and VAS for the STANDARD group also improved significantly from 32.8 +/- 16.1 and 6.3 +/- 2.4 to 87.1 +/- 14.5 and 1.0 +/- 1.7. In comparison to their pre-operative status, the ASES score for the SPARING and the STANDARD groups improved 53.9 +/- 22.3 and 54.0 +/- 18.7 points, respectively. The VAS for the SPARING and the STANDARD groups also improved 5.1 +/- 3.1 and 5.3 +/- 2.5 points, respectively. Neither of these differences between the SPARING and the STANDARD groups reached statistical significance. Complication profiles were similar in both groups with 3 in the SPARING group and 2 patients in the STANDARD group requiring revision surgery during the study period. Discussion: At a short term follow up, the outcome of TSA using the subscapularis sparing surgical approach was similar to that after TSA using the standard surgical approach. Future studies with longer follow up of these patients will be required to document the potential benefits of this surgical technique

Total hip arthroplasty has been utilized for the past 50 years as an effective treatment for degenerative, inflammatory and traumatic disorders of the hip. The design of these implants has generally followed the anatomy of the hip as a ball and socket joint with the femoral head representing the ball and the acetabulum representing the socket. We describe a novel hip arthroplasty design in which the "ball" is located on the acetabular side and the "socket" is located on the femoral side. The results of extensive biomechanical testing are described and document wear and corrosion characteristics that are at least equivalent to standard designs. These results support clinical assessment as the next step of the evaluation.

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)

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

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.