Faculty Bibliography

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).

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.

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)

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.

The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle.For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.

Following a failed course of conservative management, arthroscopic rotator cuff repair (ARCR) has become the gold standard treatment for patients presenting with symptomatic rotator cuff (RC) tears. Traditionally, the single-row repair technique was used. Although most patients enjoy good to excellent clinical outcomes, structural healing to bone remains problematic. As a result, orthopaedic surgeons have sought to improve outcomes with various technological and technical advancements. One such possible advancement is the double-row technique. We present a method for repairing an RC tear using double-row suture anchors in a transosseous equivalent suture bridge technique. The double-row technique is believed to more effectively re-create the anatomic footprint of the tendon, as well as increase tendon to bone surface area, and apposition for healing. However, it requires longer operating times and is costlier. This report highlights this technique for ARCR in an adult by using a double-row transosseous equivalent suture bridge.

INTRODUCTION: To date, no study has reported on the public's opinion of orthopaedic resident duty-hour requirements (DHR). METHODS: A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism. RESULTS: Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic. DISCUSSION: Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.