Faculty Bibliography

BACKGROUND: Large glenoid defects pose difficulties in shoulder arthroplasty. Structural grafts consisting of a humeral head autograft, iliac crest, and allograft have been described. Few series describe grafts used with reverse total shoulder arthroplasty (RTSA). METHODS: We retrospectively reviewed patients who had undergone primary or revision RTSA. We identified 44 patients (20 men and 24 women; mean age, 69 years) as having a bulk structural graft to the glenoid behind the baseplate. The grafts consisted of a humeral head autograft in 29, iliac crest autograft in 1, or femoral head allograft in 14. Range of motion data, American Shoulder and Elbow Surgeons score, simple shoulder test, shoulder pain and disability index, and Constant scores were obtained from preoperative and the latest follow-up visits. Radiographs were reviewed from the initial postoperative visit and the latest follow-up. The grafting cohort was compared with an age- and sex-matched cohort of RTSA patients without glenoid grafting. RESULTS: Improvements were seen in the functional outcome scores at the latest follow-up. No significant differences were found in the preoperative or postoperative data between allografts and autografts. Postoperative scores for the bone graft cohort were significantly lower than those in the cohort without grafting. Complete or partial incorporation was shown radiographically in 81% of grafts. Six baseplates were considered loose. Complications included 2 infections, 1 dislocation, 1 humeral loosening, and 2 instances of clinical aseptic baseplate loosening. Six patients showed mild scapular notching. CONCLUSIONS: The use of bulk structural grafts is a promising treatment option. Allografts may yield equally acceptable results compared with autografts.

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.

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.

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.

Subscapularis tenotomy for anatomic total shoulder arthroplasty has been the standard approach for shoulder surgeons that use the deltopectoral approach. The risk of subscapularis insufficiency after this approach has been well documented. In order to avoid subscapularis complications, subscapularis sparing approaches through the rotator interval have been developed. We present two alternative subscapularis preserving techniques that are performed through the deltopectoral interval and allow more complete osteophyte excision and accurate humeral head sizing. These techniques require modified instrumentation and are facilitated by the use of an adaptable prosthesis with dual eccentricity. Future studies will examine the comparative clinical and radiographic outcomes of these techniques.

BACKGROUND:Revision total shoulder arthroplasty to a reverse system without removing the humeral component-- i.e., a platform system--has been in use since 2006. This preliminary report compares the outcomes of revision total shoulder replacement in patients who underwent revision utilizing a platform system as compared to those patients requiring stem removal. METHODS:The data banks from two academic centers were utilized to review patients who underwent revision total shoulder surgery requiring removal of a well fixed humeral stem and those revised with a well fixed platform humeral stem. All patients underwent revision to reverse total shoulder arthroplasty. Measured variables were pre and postoperative Constant scores, blood loss, operating room time, complications, and cost. RESULTS:The use of a platform system resulted in fewer complications, less operating room time, and a decrease in blood loss (p < 0.05). The Constant scores were not significantly different between the two groups. The cost of implants and operating room time was also less in the platform system group. CONCLUSION/CONCLUSIONS:Revision total shoulder arthroplasty utilizing a platform system that does not require humeral component removal resulted in a significant decrease in complications, blood loss, and operating room time compared with revisions that did not utilize a platform system. The Constant score was similar between the two groups. The overall cost of the procedure was less when the platform system was used.

INTRODUCTION/BACKGROUND:The aim of this study was to evaluate the preliminary outcomes of a hybrid cage glenoid design in comparison to pegged all-polyethylene glenoid components in anatomic total shoulder arthroplasty (aTSA). MATERIALS AND METHODS/METHODS:Ninety-two patients undergoing primary anatomic total shoulder arthroplasty with minimum two-year follow-up were reviewed. Forty-six patients had an ultra-high molecular weight polyethylene (UHMWPE) cemented pegged glenoid component, and 46 had a hybrid cage glenoid component. Patient data was retrospectively reviewed from prospectively acquired data in a multi-institutional IRB approved database. These age, gender, and follow-up matched patients were evaluated and scored preoperatively and a latest follow-up using the SST, UCLA, ASES, Constant, and SPADI scoring metrics. Additional measures included active abduction, elevation, and external rotation. Radiolucent line assessment of the glenoid was performed by use of a Grashey and axillary radiograph at latest follow-up. 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 demonstrated significant improvements in pain and function following treatment with the primary aTSA. The database contained three complications for the aTSA patients with a cage glenoid, and three complications for patients with a UHMWPE pegged glenoid. Radiographic data was available for 37 of 46 cage glenoid patients and 29 of 46 UHMWPE pegged glenoid patients. Five of 37 cage glenoid patients had a radiolucent line (13.5%) with an average radiographic line score of 0.22. Eight of 29 UHMWPE peg glenoid patients had a radiolucent line (27.6%) with an average radiographic line score of 0.57. Cage aTSA patients were associated with significantly less blood loss than aTSA UHMWPE pegged glenoid patients (avg. blood loss = 242 vs. 337; p = 0.022). CONCLUSION/CONCLUSIONS:At minimum two-year follow-up, hybrid cage aTSA components show equal clinical outcomes to UHMWPE pegged glenoids. However, the hybrid cage components had significantly fewer radiolucent lines and less intra-operative blood loss. Additional and longer-term clinical and radiographic follow-up is necessary to confirm these promising early results.

INTRODUCTION/BACKGROUND:ASTM F2028-14 was adopted to recom mend a cyclic eccentric glenoid edge loading test that simulates the rocking horse loading mechanism beleived to cause aTSA glenoid loosening. While this method accurately simulates that failure mechanism, the recommended 750 N load may not be sufficient to simulate worst-case loading magnitudes, and the recommended 100,000 cycles may not be sufficient to simulate device fatigue-related failure modes. Finally, if greater loading magnitude or a larger number of cycles is performed, the recommended substrate density may not be sufficiently strong to support the elevated loads and cycles. To this end, a new test method is proposed to supplement ASTM F2028-14. METHODS:A series of cyclic tests were performed to evaluate the long-term fixation strength of two different hybrid glenoid designs in both low (15 pcf) and high (30 pcf) density polyurethane blocks at elevated loads relative to ASTM F2028-14. To simulate a worst case clinical condition in which the humeral head is superiorly migrated, a cyclic load was applied to the superior glenoid rim to induce a maximum torque on the fixation pegs for three different cyclic loading tests: 1. 1,250 N load for 0.75 M cycles in a 15 pcf block, 2. 1,250 N load for 1.5 M cycles in a 30 pcf block, and 3. 2,000 N load for 0.65 M cycles in a 30 pcf block. RESULTS:All devices completed cyclic loading without failure, fracture, or loss of fixation regardless of glenoid design, polyurethane density, loading magnitude, or cycle length. No significant difference in post-cyclic displacement was noted between designs in any of the three tests. Post-cyclic radiographs demonstrated that each device maintained fixa - tion with the metal pegs within the bone-substitute blocks with no fatigue related failures. DISCUSSION/CONCLUSIONS:These results demonstrate that both cemented hybrid glenoids maintained fixation when tested according to each cyclic loading scenario, with no difference in post-cyclic displacement observed between designs. The lack of fatigue-related failures in these elevated load and high cycle test scenarios are promising, as are the relatively low displacements given the extreme nature of each test. This cyclic loading method is intended to supplement the ASTM F2028-14 standard that adequately simulates the rocking horse loading mechanism but may not adequately simulate the fatigue-related failure modes.