Faculty Bibliography

The current study aimed to measure perioperative changes in driving performance following arthroscopic shoulder surgery using a validated driving simulator.21 patients who underwent arthroscopic surgery for rotator cuff or labral pathology were tested on a driving simulator preoperatively, and 6 and 12 weeks postoperatively. An additional 21 subjects were tested to establish driving data in a control cohort. The number of collisions, centerline crossings, and off-road excursions were recorded for each trial. VAS and SPADI scores were obtained at each visit.The mean number of collisions in the study group significantly increased from 2.05 preoperatively to 3.75 at 6 weeks (p<0.001), and significantly decreased to 1.95 at 12 weeks (p<0.001). Centerline crossings and off-road excursions did not significantly change from preoperative through 12 weeks, although centerline crossings were statistically different from the controls at each time point (p<0.001). Surgery on the dominant driving arm resulted in greater collisions at 6 weeks than surgery on the non-dominant driving arm (p<0.001).Preliminary data shows that driving performance is impaired for at least 6 weeks postoperatively, with a return to normal driving by 12 weeks. Driving is more profoundly affected in conditions that require avoiding a collision and when the dominant driving arm is involved.

AIMS: Depression can significantly affect quality of life and is associated with higher rates of medical comorbidities and increased mortality following surgery. Although depression has been linked to poorer outcomes following orthopaedic trauma, total joint arthroplasty and spinal surgery, we wished to examine the impact of depression in elective total shoulder arthroplasty (TSA) as this has not been previously explored. PATIENTS AND METHODS: The United States Nationwide Inpatient Sample (NIS) was used to identify patients undergoing elective TSA over a ten-year period. Between 2002 and 2012, 224 060 patients underwent elective TSA. RESULTS: Among the identified patients who had undergone TSA, 12.4% had a diagnosis of a history of depression. A diagnosis of depression was twice as common in women compared with men (16.0% vs 8.0%, p < 0.001), and more frequent in those with low income and Medicaid insurance (p < 0.001). A diagnosis of depression was an independent risk factor for post-operative delirium (odds ratio (OR) 2.29, p < 0.001), anaemia (OR 1.65, p < 0.001), infection (2.09, p = 0.045) and hospital discharge to a placement other than home (OR 1.52, p < 0.001) CONCLUSION: A history of clinical depression is present in 12.4% of patients undergoing elective TSA and the disease burden is projected to increase further in the future. Depression is often underdiagnosed and pre-operative screening and appropriate peri-operative management of patients is encouraged. TAKE HOME MESSAGE: The awareness that clinical depression is associated with increased complications following total shoulder arthroplasty provides physicians an opportunity for early intervention in this at-risk population. Cite this article: Bone Joint J 2016;98-B:818-24.

Marked underutilization rates of total joint arthroplasty in minorities compared with nonminorities exist, with a paucity of literature surrounding inequities related to total shoulder arthroplasty (TSA). Using the Statewide Planning and Research Cooperative System database, patients who underwent elective TSA in New York State (NYS) were identified and characterized by age, race, gender, medical comorbidities, and payor status. Patients were stratified into 4 separate 5-year periods from 1990 to 2009. Comorbidity severity was defined using the Elixhauser criteria. A total of 10,538 elective TSAs were identified, with half of the procedures occurring in the most recent time quartile. Whites accounted for 70% of the procedures, whereas blacks accounted for 5%. During the 20-year period, the age-adjusted incidence of TSA in white men and women increased by 417% and 421%, respectively, whereas the incidence for black men and women increased by 378% and 329%, respectively. Black men had the lowest utilization rate among all subgroups, and overall disparity between races continued to widen over time. Blacks had significantly more comorbid conditions (P<.001) than whites when undergoing TSA. Blacks were more likely to have Medicaid insurance and less participation in Medicare (P<.001). Racial and gender disparities clearly exist in TSA utilization rates in NYS and may be worsening. Although reasons for these disparities are likely multifactorial, a deeper understanding of the factors involved in patient selection and access to care is necessary to appropriately address these disparities and effect change at a system-wide patient and provider level. [Orthopedics. 2016; 39(3):e538-e544.].

BACKGROUND: Although increasing glenosphere diameter has been found to increase passive range of motion (ROM) in simulated models of reverse total shoulder arthroplasty (rTSA), the clinical implications of glenosphere size are unclear. The purpose of our study was to determine the impact that glenosphere size had on short-term and midterm clinical outcomes, specifically American Shoulder and Elbow Surgeons (ASES) scores and ROM. METHODS: Prospectively collected data comparing patients receiving an rTSA with either a 38- or 42-mm glenosphere after a minimum 2-year follow-up were obtained. Clinical outcome measures included active ROM and ASES scores. RESULTS: We included 297 primary rTSAs in 290 patients: a 38-mm-diameter glenosphere was used in 160 shoulders and a 42-mm-diameter glenosphere in 137 shoulders. Of the patients, 191 were women and 99 were men. The mean age at the time of surgery was 72 years (range, 50-88 years). At last follow-up, improvements in active forward elevation (aFE) and active external rotation (aER) were significantly greater in shoulders with a 42-mm glenosphere (+59 degrees vs +44 degrees for aFE and +24 degrees vs +18 degrees for aER). Female shoulders treated with a 42-mm glenosphere had significantly greater improvements in aFE, aER, and functional scores. Male shoulders treated with a 38-mm glenosphere had significantly greater improvements in pain levels and ASES scores but less improvement in aFE. Complications and rates of scapular notching were similar between glenosphere sizes. CONCLUSIONS: Patients treated with 42-mm glenospheres had greater improvements in aFE and aER when compared with 38-mm glenospheres. Our results suggest a potential association among gender, glenosphere size, and improvement in clinical outcome scores. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Design; Treatment Study.

PURPOSE: To investigate the effect of initial varus or valgus surgical neck alignment on outcomes of patients who sustained proximal humerus fractures treated with open reduction and internal fixation (ORIF). METHODS: An institutional review board approved database of proximal humerus fractures treated with locked plates was reviewed. Of 185 fractures in the database, 101 fractures were identified and met inclusion criteria. Initial varus displacement was seen in 47 fractures (OTA types 11.A2.2, A3.1, A3.3, B1.2, B2.2, C1.2, C2.2, or C2.3) and initial valgus displacement was observed in 54 fractures (OTA types 11.A2.3, B1.1, C1.1, or C2.1). All patients were treated in a similar manner and examined by the treating physician at standard intervals. Functional outcomes were quantified via the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and physical examination data at 12 months. Radiographs were reviewed for complications of healing. Additionally, complication rate and reoperation rate were investigated. RESULTS: Patients who presented with initial varus displacement had an average age of 59.3 years, while patients in the valgus group had an average age of 62.4 years. Overall, there was no statistically significant difference in age, sex distribution, BMI, fracture parts, screws used, or implant plate type between the two groups. At a minimum 12 months follow up, there was no significant difference in DASH scores between those presenting with varus versus valgus fracture patterns. In addition, no significant differences were seen in final shoulder range of motion in any plane. Overall, 30 patients included in this study developed a complication. A significantly greater number of patients in the initial varus cohort developed complications (40.4%), as compared to 20.3% of patients in the initial valgus cohort (P=0.03). Fourteen patients in this study underwent reoperation. Nine of these patients were in the varus cohort, while 5 were in the valgus cohort (P=0.15). CONCLUSIONS: In this study, initial surgical neck displacement in varus or valgus was found to not significantly affect functional outcome. Based upon our findings, patients with varus displaced proximal humerus fractures are at a greater risk of developing postoperative complications than those who present with initial valgus displaced fracture patterns.

Leg length discrepancy (LLD) is one of the most common complications of total hip arthroplasty. It may cause pain and disability to the patient, and it is the number one reason for filing a lawsuit against an orthopaedic surgeon. This manuscript reviews the preparation for and execution of the operative plan with emphasis on avoiding pitfalls leading to LLD. It also considers the treatment of LLD in the postoperative period.

OBJECTIVES: Rheumatoid arthritis (RA) is known to be associated with multiple comorbidities and, therefore, overall management is critical for those patients undergoing elective major orthopaedic surgeries, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to compare in-hospital outcomes of elective THA and TKA between patients with and without RA in the US during the last decade. We hypothesised that patients with RA would have similar perioperative outcomes after elective THA and TKA. METHODS: Clinical data were derived from the US Nationwide Inpatient Sample (NIS) between 2000 and 2009. Patients who underwent elective THA and TKA were identified. Data regarding patient- and healthcare system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved. In-hospital outcomes of the procedures were compared between patients with and without RA. RESULTS: Comparison between patients with and without RA showed that patients with RA had significantly lower overall in-hospital complication rates following THA and TKA, and lower in-hospital mortality rate following THA. Patients with RA undergoing THA and TKA had decreased risk of overall in-hospital complications compared to those without RA. CONCLUSIONS: Contrary to our hypothesis, perioperative outcomes of elective THA and TKA in patients with RA were better than those in patients without RA. These results may indicate that patient selection and pre- and perioperative management of patients with RA undergoing elective THA and TKA were well conducted in the US during the last decade.

BACKGROUND: In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would "lead to higher quality, more coordinated care at a lower cost to Medicare." METHODS: A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis. RESULTS: Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline. CONCLUSION: Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings. LEVEL OF EVIDENCE: IV economic and decision analyses-developing an economic or decision model.

Although the Bundled Payments for Care Improvement (BPCI) Initiative began generating data in January 2013, it may be years before the data can determine if the BPCI Initiative enhances value without decreasing quality. Private insurers have implemented other bundled payment arrangements for the delivery of total joint arthroplasty in a variety of practice settings. It is important for surgeons to review the early results of the BPCI Initiative and other bundled payment arrangements to understand the challenges and benefits of healthcare delivery systems with respect to total joint arthroplasty. In addition, surgeons should understand methods of cost control and quality improvement to determine the effect of the BPCI Initiative on the value-quality equation with respect to total joint arthroplasty.

INTRODUCTION/BACKGROUND:Patients who are candidates for a reverse total shoulder arthroplasty (rTSA) may have varying amounts and patterns of glenoid wear. The usual treatment of these deformities has been eccentric reaming or bone grafting. Eccentric reaming often removes a large amount of subchondral bone. Bone grafting is technically more difficult and introduces another mode of failure if the graft does not heal. The purpose of this study is to evaluate patients undergoing a rTSA with concomitant superior or posterior glenoid wear who were treated with a superior augmented baseplate (SAB) or posterior augmented baseplate (PAB) without eccentric reaming or bone grafting. MATERIALS AND METHODS/METHODS:Prospectively obtained data were queried from a multi-institutional IRB-approved database. Preoperative and postoperative data were analyzed from 39 patients who received a primary rTSA with either an 8° PAB or a 10° SAB and a minimum of 2 years follow-up. Twenty-four (10 females and 14 males, aged 72.3 ± 8.2 years) received a primary rTSA shoulder with a PAB. Fifteen patients (4 females and 11 males, aged 71.7 ± 9.2 years) received a primary rTSA shoulder with a SAB. Each patient was scored preoperatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics. Active abduction, forward flexion, and active and passive external rotation with the arm at the side were also measured. The average follow-up for rTSA patients with a PAB was 25.6 ± 3.1 months, and the average follow-up for rTSA patients with a SAB was 32.5 ± 6.5 months. A Student's two-tailed, unpaired t-test was used to identify differences in preoperative and postoperative results, where p < 0.05 denoted a significant difference. RESULTS:All patients in both groups demonstrated significant improvements in pain and function following treatment with the reverse shoulder arthroplasty. The PAB rTSA cohort had a scapular notching rate of 6.3%, whereas the SAB rTSA cohort had a scapular notching rate of 14.3%. The PAB outperformed the SAB with the ASES, Constant, and active forward elevation measures. DISCUSSION/CONCLUSIONS:The PAB group outperformed the SAB group with the ASES and Constant outcome scores and forward flexion. The reason for this is unknown; however, it may be due to the posterior augment baseplate itself tensioning the remaining external rotators better than the superior augment, or it may be that the posterior augment group had a better posterior cuff. Both implant groups had no revisions or dislocations and had a low notching rate. It appears that a SAB for superior glenoid wear and a PAB for posterior glenoid wear are viable simple solutions in patients undergoing a rTSA, where each preserves glenoid bone and eliminates the need for glenoid bone grafting.