Faculty Bibliography

Recent evidence suggests a substantial rise in the number of revision total joint arthroplasty (TJA) procedures performed. The New York State SPARCS inpatient database was utilized to identify revision total shoulder, knee, and hip arthroplasty procedures between 1993 and 2010. Yearly incidence and related epidemiology were analyzed. A total of 1,806 revision TSA, 26,080 revision TKA, and 35,254 revision THA cases were identified. The population-based incidence of these procedures increased 288%, 246%, and 44% respectively (P<0.001). Revision burden for hip arthroplasty decreased from 16.1% in 2001 to 11.5% in 2010 (P<0.001). The rates of revision TSAs and TKAs increased at a substantially faster rate than that of revision THAs. Revision burden for hip arthroplasty steadily has decreased since 2001.

The relationship between pharmaceutical and biomedical technology companies (industry) and medical practitioners has been a topic of discussion and concern for several de- cades. The large monetary payments and extravagant gifts to physicians from these companies have been regulated and largely stopped; however, there still exists an active rapport between physicians and industry. Little formal instruction is given to medical students and residents on what constitutes a conflict of interest when entering these business partnerships. In this study, we presented a set of scenarios depicting industry-physician interactions to medical students, orthopaedic surgery residents, and attending physicians and asked them to decide whether a conflict of interest is depicted. Our goal was to determine whether a disparity exists in the ability to identify conflicts of interest across the levels of training. Of 200 potential participants, 70 provided responses to the survey (35%). Thirty-five (50%) were attending physicians, 18 (25.7%) residents, 12 (17.1%) medical students, and 8 (11.4%) de- clined to provide level of training. There was no significant difference in the ability to identify a conflict of interest across seniority level for the 13 questions. Our results suggest that both medical students and resident physicians are able to identify which interactions with industry pose a possible conflict of interest as accurately as attending physicians can.

The unsustainable rising cost of medical care is creating financial pressures that will critically alter the way that health care is paid for and delivered. Limited resources dictate that physicians must become more efficient at providing high quality care. In an effort to provide financial incentive for delivering quality care, the federal government instituted value-based purchasing to transform Medicare from a passive payer of claims to an active purchaser of medical care. Healthcare providers must follow the basic tenants of certain quality principles to maximize reimbursement under the value-based purchasing system.

When performing revision shoulder surgery, it is important that the surgeon understands why the index procedure failed and has a clear plan to address problems in the revision procedure. The most common cause of failure after anterior instability shoulder surgery is a failure to treat the underlying glenoid bone loss. For most defects, a Latarjet transfer can effectively restore anterior glenoid bone stock and restore shoulder stability. Persistent anterior shoulder pain after rotator cuff surgery may be the result of missed biceps pathology. This can be effectively treated via a biceps tenodesis. The most difficult failures to treat after acromioclavicular joint reconstruction surgery are those involving fractures of either the coracoid or the clavicle. Clavicle hook plates can be used as supplemental fixation during the treatment of these fractures to help offload the fracture site and allow healing while restoring stability to the acromioclavicular articulation. A failed hemiarthroplasty for a proximal humeral fracture frequently results when the tuberosities fail to heal correctly. This complication can be avoided by paying close attention to the implant position and the tuberosity fixation. If hemiarthroplasty is unsuccessful, the patient is best treated with conversion to a reverse shoulder arthroplasty.

There has been a substantial shift in the assessment of outcomes in medicine, including orthopaedic surgery. The quality movement is redefining the delivery of health care. The effect of these changes on orthopaedic surgery and orthopaedic surgeons has been significant and will become increasingly important. Orthopaedic surgeons must become active participants in the quality movement by understanding the basic principles of the movement and how they apply to patient care. A clear understanding of the different agencies (governmental and private) that are leading these initiatives is also essential. Ultimately, active participation in the quality movement will enhance the care provided to patients with musculoskeletal disorders.

BACKGROUND: The purpose of this study was to examine functional outcomes following ORIF of displaced proxi- mal humerus fractures in patients who received brachial plexus blocks compared to those who underwent general anesthesia. METHODS: We retrospectively reviewed prospectively col- lected data on 92 patients. Patients were grouped according to anesthesia type: regional interscalene brachial plexus block, with or without general anesthesia, or general anes- thesia alone. Patients were asked to complete the Disabili- ties of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion assessments at a minimum of 6-month follow-up. Plain radiographic films were obtained to assess fracture healing. RESULTS: Forty-five (48.9%) patients with 45 proximal humerus fractures received a regional anesthetic, while 47 (51.1%) patients with 48 proximal humerus fractures had general anesthesia. No significant differences existed in demographic information or fracture type. DASH scores at the most recent follow-up were significantly better in the regional block group (38.6) compared to the general anes- thesia group (53.1) (p = 0.003). The regional block group had significantly better passive and active forward elevation and external rotation range and equivalent internal rotation (p = 0.002, 0.005, 0.002, and 0.507, respectively). CONCLUSION: Patients who received regional anesthetic via a brachial plexus interscalene blocks had better functional outcomes and range of motion at the most recent clinical follow-up. Regional anesthesia provides patients with pro- longed postoperative pain relief, which may allow for early mobilization, increasing the likelihood that the patient's function and range of motion will return to baseline.

BACKGROUND: Superior glenoid wear is a common challenge with reverse shoulder arthroplasty and, if left uncorrected, can result in superior glenoid tilt, which increases the risk of aseptic glenoid loosening. This study evaluates the impact of an E2 superior defect on reverse shoulder glenoid fixation in composite scapulae after correction of glenoid tilt by use of 2 different glenoid reaming techniques: eccentric reaming and off-axis reaming. MATERIALS AND METHODS: A superior glenoid defect was created in 14 composite scapulae. The superior defect was corrected by 2 different glenoid reaming techniques: (1) eccentric reaming with implantation of a standard glenoid baseplate and (2) off-axis reaming with implantation of a superior-augment glenoid baseplate. Each corrected superior-defect scapula was then cyclically loaded (along with a control group consisting of 7 non-worn scapulae) for 10,000 cycles at 750 N; glenoid baseplate displacement was measured for each group to quantify fixation before and after cyclic loading. RESULTS: Regardless of the glenoid reaming technique or the glenoid baseplate type, each standard and superior-augment glenoid baseplate remained well fixed in this superior-defect model scenario after cyclic loading. No differences in baseplate displacement were observed either before or after cyclic loading between groups. DISCUSSION: Our results suggest that either glenoid reaming technique may be used to achieve fixation in the clinically challenging situation of superior wear with reverse shoulder arthroplasty.

BACKGROUND: Rotator cuff repairs (RCRs) have become increasingly common. Several studies have shown variation in the indications for this procedure. We chose to track the incidence of RCRs in New York State (NYS) from 1995 to 2009. We hypothesized that after the introduction of the Current Procedural Terminology (CPT) code 29827 for arthroscopic RCR, there would be a significant increase in the rate of RCRs performed in NYS. MATERIALS AND METHODS: The NYS Department of Health's Statewide Planning and Research Cooperative System (SPARCS) database was queried for reported RCRs between the years 1995 and 2009. Using the International Classification of Diseases, Ninth Revision, Clinical Modification procedural code 83.63 and CPT codes 23410, 23412, 23420, and 29827, we collected and analyzed data on RCR procedures. RESULTS: A total of 168,780 RCRs were performed in NYS from 1995 to 2009. In 1995, the population incidence of RCRs was 23.5 per 100,000. In comparison, in 2009, the population incidence was 83.1 per 100,000, an increase of 238% (P < .0001). The percentage of individuals aged between 45 and 65 years undergoing RCR increased from 53.0% to 64.2% during this same period. CONCLUSIONS: There has been a notable increase in the volume of RCRs performed in NYS. In addition, after the introduction of CPT code 29827 in 2003, the increase in the incidence of RCRs became significantly more pronounced.

BACKGROUND: Numerous glenoid implant designs have been introduced into the global marketplace in recent years; however, little comparative biomechanical data exist to substantiate one design consideration over another. MATERIALS AND METHODS: This study dynamically evaluated reverse shoulder glenoid baseplate fixation and compared the initial fixation associated with 2 reverse shoulder designs having an equivalent center of rotation in low-density and high-density bone substitute substrates. RESULTS: Significant differences in fixation were observed between implant designs, where the circular-porous reverse shoulder was associated with approximately twice the micromotion per equivalent test than the oblong-grit-blasted design. Additionally, 6 of the 7 circular-porous reverse shoulders failed catastrophically in the low-density bone model at an average of 2603 +/- 981 cycles. None of the oblong-grit-blasted designs failed in the low-or high-density bone models and none of the circular-porous designs failed in the high-density bone models after 10,000 cycles of loading. CONCLUSION: These results demonstrate that significant differences in initial fixation exist between reverse shoulder implants having an equivalent center of rotation and suggest that design parameters, other than the position of the center of rotation, significantly affect fixation in low-density and high-density polyurethane bone substitutes. Subtle changes in glenoid baseplate design can dramatically affect fixation, particularly in low-density bone substitutes that are intended to simulate the bone quality of the recipient population for reverse shoulders.