Faculty Bibliography

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

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.

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: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.

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.

Introduction: Chlorhexidine gluconate (CHX) is widely used as a preoperative surgical skin-preparation solution and intra-wound irrigation agent, with excellent efficacy against wide variety of bacteria. The cytotoxic effect of CHX on local proliferating cells following orthopaedic procedures is largely undescribed. Our aim was to investigate the in vitro effects of CHX on primary fibroblasts, myoblasts, and osteoblasts. Methods: Cells were exposed to CHX dilutions (0%, 0.002%, 0.02%, 0.2%, and 2%) for either a 1, 2, or 3-minute duration. Cell survival was measured using a cytotoxicity assay (Cell Counting Kit-8). Cell migration was measured using a scratch assay: a "scratch" was made in a cell monolayer following CHX exposure, and time to closure of the scratch was measured. Results: All cells exposed to CHX dilutions of ≥ 0.02% for any exposure duration had cell survival rates of less than 6% relative to untreated controls (p < 0.001). Cells exposed to CHX dilution of 0.002% all had significantly lower survival rates relative to control (p < 0.01) with the exception of 1-minute exposure to fibroblasts, which showed 96.4% cell survival (p = 0.78). Scratch defect closure was seen in < 24 hours in all control conditions. However, cells exposed to CHX dilutions ≥ 0.02% had scratch defects that remained open indefinitely. Conclusions: The clinically used concentration of CHX (2%) permanently halts cell migration and significantly reduces survival of in vitro fibroblasts, myoblasts, and osteoblasts. Further in vivo studies are required to examine and optimize CHX safety and efficacy when applied near open incisions or intra-wound application.

STUDY DESIGN: In vitro laboratory study. OBJECTIVE: The purpose of this study was to identify the effect of dilute povidone-iodine (PVI) solutions on human osteoblast, fibroblast and myoblast cells in vitro. SUMMARY OF BACKGROUND DATA: Dilute PVI wound lavage has been used successfully in spine and joint arthroplasty procedures to prevent post-operative surgical site infection, but their biologic effect on host cells is largely unknown. METHODS: Human primary osteoblasts, fibroblasts, and myoblasts were expanded in cell culture and subjected to various concentrations of PVI (0%, 0.001%, 0.01%, 0.1%, 0.35%, 1%) for 3 minutes. To assess the effect of PVI on cell migration, a scratch assay was performed, in which a "scratch" was made by a standard pipette tip in a cell monolayer following PVI exposure, and time to closure of the scratch was evaluated. Cell survival and proliferation was measured 48 hours post-PVI exposure using a cell viability and cytotoxicity assay. RESULTS: Closure of the scratch defect in all cell monolayers was achieved in < 24 hours in untreated controls and following exposure to PVI concentrations < 0.1%. The scratch defect remained open indefinitely following exposure to PVI concentrations of >/= 0.1%. PVI concentrations < 0.1% did not have significant effect on survival rates compared with control for all cell types. Cells exposed to PVI >/= 0.1% had cell survival rates of less than 6% (p < 0.05). CONCLUSIONS: Clinically used concentration of PVI (0.35%) exerts a pronounced cytotoxic effect on osteoblasts, fibroblast, and myoblasts in vitro. Further investigation is required to systematically study the effect of PVI on tissue healing in vivo and also determine a safe and clinically potent concentration for PVI lavage. LEVEL OF EVIDENCE: N/A.

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.

BACKGROUND: Intraoperative anesthetic typically consists of either general anesthesia (GA) or isolated regional anesthesia (RA). METHODS: A retrospective propensity-matched cohort analysis on patients undergoing TSA was performed to determine differences between GA and RA in regard to patient population, complications, LOS and hospital readmission. RESULTS: 4158 patients underwent TSA with GA or isolated RA. Propensity-matching resulted in 912 patients in each cohort. RA had lower overall in-hospital complications and greater homebound discharge disposition with lower 90-day readmission rates than GA. CONCLUSION: After TSA, isolated RA was associated with lower in-hospital complications, readmission rates and odds of hospital readmission than GA.