Faculty Bibliography

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.

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.

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.

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: 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.

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.

Infection in the setting of shoulder arthroplasty can result in significant pain, loss of function, and the need for additional surgery. As the use of shoulder arthroplasty increases, the medical and economic burdens of periprosthetic joint infection increase as well. The ideal management of infected shoulder prostheses has not been established. This report describes 9 patients from a single institution who had an infected shoulder arthroplasty that was definitively managed with a cement spacer. All patients had a minimum of 2 years of follow-up. Of the 9 patients in this study, 6 were men. Mean age was 73+/-9 years. Of the study patients, 1 had diabetes, 2 presented with Parkinson's disease, and 5 had a history of tobacco use. Average body mass index was 27.9+/-7 kg/m(2). After mean follow-up of 4 years, none of the patients had clinical or radiographic evidence of infection. Functional outcomes, as measured by American Shoulder and Elbow Surgeons scores, were good or fair in 89% of patients, and the average American Shoulder and Elbow Surgeons score was 57. A review of recent literature suggested that the current findings were similar to those in studies reporting 1- or 2-stage revision procedures. Although cement spacers are typically used as part of a 2-stage revision procedure, the current findings suggest that cement spacers can be used effectively to eradicate infection and allow for acceptable functional recovery and range of motion in patients who have severe medical comorbidities and cannot tolerate additional surgery. [Orthopedics. 2016; 39(5):e924-e930.].

PURPOSE: To quantify the incidence of and identify the risk factors for subsequent shoulder procedures after isolated SLAP repair. METHODS: New York's Statewide Planning and Research Cooperative System database was searched between 2003 and 2014 to identify individuals with the sole diagnosis of a SLAP lesion who underwent isolated arthroscopic SLAP repair. Patients were longitudinally followed up for a minimum of 3 years to analyze for subsequent ipsilateral shoulder procedures. RESULTS: Between 2003 and 2014, 2,524 patients met our inclusion criteria. After 3 to 11 years of follow-up, 10.1% of patients (254 of 2,524) underwent repeat surgical intervention on the same shoulder as the initial SLAP repair. The mean time to repeat shoulder surgery was 2.3 +/- 2.1 years. Subsequent procedures included subacromial decompression (35%), debridement (26.7%). repeat SLAP repair (19.7%), and biceps tenodesis or tenotomy (13.0%). After isolated SLAP repair, patients aged 20 years or younger were more likely to undergo arthroscopic Bankart repair (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.36-6.21; P = .005), whereas age older than 30 years was an independent risk factor for subsequent acromioplasty (OR, 2.3; 95% CI, 1.4-3.7; P < .001) and distal clavicle resection (OR, 2.5; 95% CI, 1.1-5.5; P = .030). The need for a subsequent procedure was significantly associated with Workers' Compensation cases (OR, 2.4; 95% CI, 1.7-3.2; P < .001). CONCLUSIONS: We identified a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis, suggesting that clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions. In addition, the number of isolated SLAP repairs performed has decreased over time, and management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years. LEVEL OF EVIDENCE: Level III, case-control study.

BACKGROUND: In order to compare open reduction and internal fixation (ORIF) with locked plating to hemiarthroplasty for the treatment of three- and four-part proximal humerus fractures, we compared two groups of patients treated during the same time period. MATERIALS AND METHODS: Sixty-five patients who underwent repair of a three- or four-part proximal humerus fracture with locked plates (Group A) were identified in a prospective database and were compared to 29 patients who underwent hemiarthroplasty for similar injuries (Group B). Data was collected for both groups. Shoulder motion was measured and functional outcomes were obtained using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: The mean length of follow-up for the ORIF group was 16 months compared to 44 months for the hemiarthroplasty group. The average postoperative forward flexion for patients in Group A was 131.1 degrees and 110.4 degrees for Group B (p < 0.047). There were no differences in DASH scores at latest follow-up (p = 0.64). Two patients in Group A had radiographic signs of osteonecrosis but had elected for no further surgery. One patient in Group A and two patients in Group B underwent a conversion to total shoulder arthroplasty. There was no difference in the rate of secondary surgery (p = 0.98). CONCLUSIONS: The results of this study suggest that ORIF using locked plates leads to similar postoperative function compared to hemiarthroplasty. Patients who underwent ORIF did achieve greater forward shoulder flexion. Neither strategy leads to a higher reoperation rate.