Faculty Bibliography

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.

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.

Today's increasingly complex health-care landscape requires that physicians take an active role in minimizing health-care costs and expenditures. Judicious choice of implants, a fracture-driven treatment algorithm, capitation models, use of generic fracture implants, and reuse of external fixation constructs all represent mechanisms that can result in substantial savings. In some health-care environments, these cost savings programs may be directly linked to physician reimbursement in the form of gainsharing plans. Evidence-based critical evaluations of implant usage patterns are necessary to help control implant-related health-care spending but are lacking in the current literature. Physicians need to acknowledge their influence and responsibility in this realm and assume an active role to help reduce costs.

BACKGROUND: Proximal humeral fractures are commonly encountered injuries. The development of locking plate technology and reverse shoulder arthroplasty may have changed the treatment patterns of these fractures. METHODS: We used the Statewide Planning and Research Cooperative System database in New York State to determine the incidence of proximal humeral fractures from 1990 through 2010 and the choice of treatment: closed reduction-internal fixation, open reduction-internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). RESULTS: The population-adjusted incidence per 100,000 increased from 15.35 in 1990 to 19.4 in 2010 (P < .0001). In patients aged 65 years or older, the incidence increased from 78.9 in 1990 to 101.0 in 2010 (P < .0001). In 1990, 20.4% of proximal humeral fractures were treated operatively; in 2010, this increased to 28.6% (P < .0001). Closed reduction-internal fixation/ORIF accounted for 58.4% of operative cases in 1990, decreasing to 46.6% in 2001 and increasing to 59.4% in 2010. HA was used in 27.1% of operative cases in 1990, increasing to 41% in 2001 and decreasing to 29.4% in 2010. TSA was used in 6.4% of operative cases in 1990, decreasing to 1.5% in 2001 with an increase to 7.5% in 2010. DISCUSSION: The incidence of proximal humeral fractures in patients aged 65 or older increased by 28% between 1990 and 2010, and operative management increased by more than 40%. The use of ORIF increased between 2001 and 2010, corresponding with the use of locking plate technology. There was an associated decrease in HA. TSA increased between 2006 and 2010, corresponding to the use of reverse shoulder arthroplasty.

BACKGROUND: In this glenoid loosening study, we compared the fixation strength of multiple generic reverse shoulder glenoid baseplates that differed only in backside geometry and shape and size to optimize design from a fixation perspective. METHODS: The fixation strength of 4 generic baseplates was quantified in a low-density polyurethane substrate to isolate the contribution of baseplate profile and size (25 mm circular vs 25 x 34 mm oval) and backside geometry (flat back vs curved back) on fixation using 2 center-of-rotation glenospheres (0 mm and 10 mm lateral). The cyclic test simulated 55 degrees of abduction as a 750 N load was continuously applied to induce a variable shear and compressive load. Before and after cyclic loading, baseplate displacement was measured in the directions of the applied static shear and compressive loads. Each generic baseplate was cyclically tested 7 times with each offset glenosphere for a total of 56 samples. RESULTS: Circular baseplates were associated with significantly more shear displacement in both the superior-inferior (SI) and anterior-posterior (AP) directions after cyclic loading than oval baseplates. No such significant differences in fixation were observed between flat-back and curved-back baseplates. Circular baseplates were also associated with significantly more SI and AP shear displacement with 10 mm glenospheres than with 0 mm glenospheres. No significant difference in SI or AP motion was observed with oval baseplates between 0 mm and 10 mm glenospheres. DISCUSSION: Our results suggest that baseplate shape and size affects fixation strength more than backside geometry. The 25 x 34 mm oval baseplates showed better fixation characteristics than their 25 mm circular counterparts; no discernible difference in fixation was observed between flat-back and curved-back baseplates.

Reimbursement continues to decrease for orthopaedic surgeons specializing in total joint arthroplasty (TJA). Practice information from the Medical Group Management Association (MGMA) Cost Survey and Private practice Compensation Survey and CMS locality reimbursement data was used to develop a practice model for a TJA specialist performing 300 TJA per year (66% knees, 33% hips, 15% revision surgery), evaluating 3000 outpatient visits per year based on, current Medicare reimbursement rates. Our model shows that the anticipated physician compensation is well below the mean compensation reported for a TJA specialist irrespective of geographic location. When MGMA practice expense data are applied to the Medicare-only model, the salary level is unsustainable. Further decreases in Medicare Part B reimbursement will only worsen the disparity.

The aging baby boomer generation will soon start using tremendous orthopedic surgical resources. This group has also been identified as a group at high risk for having undiagnosed hepatitis C virus (HCV) infection. We conducted a study to assess the prevalence of HCV among orthopedic surgery patients at our institution-using their demographic data to determine whether they represent a unique cohort at high risk for having undiagnosed HCV. We estimated that we operated on as many as 233 patients with undiagnosed HCV in 2011. A cost-effective, universal preoperative HCV screening program may reduce the risk for occupational exposure in orthopedic surgery and significantly benefit public health by bringing undiagnosed patients to treatment. A robust screening program requires several ethical considerations. By offering routine screening to patients, orthopedic surgeons have an opportunity to maintain intraoperative safety and improve the health of the public.

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.

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.