Faculty Bibliography

BACKGROUND: Nonoperative treatments for glenohumeral osteoarthritis (GH-OA) are limited. Intra-articular therapy with sodium hyaluronate (HA) has been effective in treating OA of the knee. Therefore, we sought to evaluate the efficacy and safety of HA in treating chronic pain associated with GH-OA. METHODS: This double-blind, randomized, controlled multicenter trial enrolled 300 patients with GH-OA: 150 received HA and 150 received phosphate-buffered saline (PBS) in 3 weekly injections and were evaluated over 26 weeks. Primary and secondary outcome measurements were visual analog scale (VAS) for pain and the percentage of Outcome Measures in Rheumatoid Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) high responders. RESULTS: In HA and PBS intent-to-treat (ITT) patients, there was a mean improvement from baseline in VAS of 19.88 mm and 16.29 mm at week 26, respectively. Similarly, the percentage of OMERACT-OARSI high responders in the HA group was higher (40.8% vs 34.9%); however, neither difference was statistically significant (P = .1121 and P = .0690, respectively). In a subset of patients without concomitant shoulder pathologies, the differences of VAS and OMERACT-OARSI high-responder rates between groups were 4.0 mm and 8.37%, respectively, which reached statistical significance. Safety analyses showed comparable rates of adverse events between groups, and neither group reported serious treatment-related adverse events. CONCLUSIONS: A numeric advantage, but without statistical significance, was found for HA ITT patients with GH-OA. Although data for a subset of HA patients without concomitant pathologies reached statistical significance, additional randomized trials are needed to confirm the clinical implication of this outcome.

An accelerometer attached to the anterior proximal tibia was investigated as an evaluation of knee stability of Total Knee Arthroplasty (TKA) patients while performing daily activities. Acceleration data of 38 TKA knees with a minimum follow up of 6months were compared with 34 control knees. The activities performed were: walking three steps forward and coming to a sudden stop; turning in the direction of non-tested knee; sit-to-stand; and stepping up and down from a 7 inch step. The acceleration results showed significant differences between TKA and controls while stepping down and while turning in the non-tested knee direction. The higher accelerations with the TKA group may have represented an objective measure of stability, even if this was not directly discernible to the patient.

BACKGROUND: Little is known about the moral reasoning utilized by orthopaedic surgery residents when resolving moral dilemmas. METHODS: Sixty-three residents in an accredited program took the Defining Issues Test-2, an online examination designed to measure and analyze moral reasoning. Scores approximate how often residents utilize three schemas in their moral reasoning: personal interest, maintaining social norms, and postconventional. Scores were analyzed for differences among years of training, previous literature, and established norms. RESULTS: Approximately 9.5% of residents utilized personal interest heavily in their moral reasoning, 27% utilized maintaining norms, and 63.5% utilized postconventional reasoning. There were no significant differences between years of training. The fourth-year (R4) class recorded the highest utilization of principled reasoning, while the fifth-year (R5) class recorded the lowest. The range of principled reasoning scores narrowed from the first year (R1) to R5. The principled reasoning scores of residents were significantly lower than previously reported scores of professional degree-holders and medical students, and empirically lower than previously reported scores of orthopaedic attendings and medical students. CONCLUSIONS: Residents utilized principled reasoning less frequently than expected for physicians. It remains unclear as to what factors contributed to high utilization of principled reasoning in the R4 class but low utilization in the R5 class. Our cross-sectional data suggest that each year of training homogenizes toward a class-specific utilization of principled reasoning. It remains unclear why residents utilized principled reasoning less than orthopaedic attendings, medical students, and other professional degree-holders.

The education of orthopaedic residents is an important responsibility shared by all those involved in residency training. The education of orthopaedic residents begins with the selection process, which recognizes the importance of choosing qualified individuals who can successfully complete the training program. Education during the 5 years of required training entails the acquisition of a body of knowledge, the development of surgical skills, and the exhibition of a level of professionalism consistent with being a physician and surgeon. Residency training also requires an evaluation of performance and, when necessary, measures to improve performance or correct inappropriate behaviors. The goal at the end of the 5-year training period is to have well-qualified, skilled, and knowledgeable orthopaedic surgeons who can enter practice and provide the highest level of patient care.

BACKGROUND: Injection to the acromioclavicular (AC) joint can be both diagnostic and therapeutic. PURPOSE: The purpose of this study was to evaluate the accuracy of in vivo AC joint injections. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty patients with pain localized to the AC joint were injected with 1 mL of 1% lidocaine and 0.5 mL of radiographic contrast material (Isovue). Radiographs of the AC joint were taken after the injection. Each radiograph was reviewed by a musculoskeletal radiologist and graded as intra-articular, extra-articular, or partially intra-articular. RESULTS: Of the 30 injections performed, 13 (43.3%) were intra-articular, 7 (23.3%) were partially articular, and 10 (33.3%) were extra-articular. When the intra-articular and the partially articular groups were combined, 20 patients (66.7%) had some contrast dye in the AC joint. CONCLUSION: This study demonstrates that despite the relatively superficial location of the AC joint, the clinical accuracy of AC joint injections remains relatively low.

We conducted a study to evaluate the outcomes and complications of open reduction and internal fixation (ORIF) of 2-, 3-, and 4-part proximal humerus fractures using a standard management protocol with locking plates. Of 72 patients with acute proximal humerus fractures managed with ORIF and locking plates, 63 were available at the minimum follow-up of 1 year and met the inclusion criteria. At each follow-up, radiographs were reviewed for healing, hardware failure, osteonecrosis, shoulder range of motion, and DASH (Disabilities of the Arm, Shoulder, and Hand) scores; any complications were recorded. Mean age was 62 years and mean follow-up was 19 months. There were 12 two-part fractures, 42 three-part fractures, and 9 four-part fractures. Thirteen patients had complications. Mean shoulder forward elevation was 135; patients with complications had a significantly lower mean forward elevation (P=.002). DASH scores were significantly lower in patients without complications than in those with complications (P=.01). Although excellent outcomes can be achieved when locking plates are used to manage proximal humerus fractures, complications are possible. Physicians must weigh the functional outcome data when considering management options for these types of injuries.

INTRODUCTION: Shoulder arthroplasty provides excellent outcomes for most patients; however, a subset of these patients with a failed arthroplasty will require revision. Recently, the reverse total shoulder arthroplasty (rTSA) has been used in these difficult clinical situations. Therefore, we sought to examine our initial experience using rTSA as a treatment for failed shoulder arthroplasty. METHODS: During a 5-year period, 31 patients (mean age, 68.7 years) underwent rTSA for treatment of a failed shoulder arthroplasty and their presurgical and operative data were analyzed. Of the 31 patients, 28 were available for an average follow-up of 40.7 months. Their outcomes were assessed with American Shoulder and Elbow Surgeons (ASES), University of California-Los Angeles (UCLA), and Simple Shoulder Test (SST) scores, and the visual analog scale (VAS) for pain. RESULTS: Compared with preoperative status, there were statistically significant improvements in all outcome measurements, including the ASES (24.0 to 66.2), UCLA (7.4 to 23.5), SST (1.5 to 7.6), and VAS (7.0 to 2.6). Active forward elevation improved from 44 degrees preoperatively to 108 degrees postoperatively (P < .001). Results were rated as good or excellent by 19 patients (67.9%), satisfactory by 4 (14.3%), and unsatisfactory by 5 (17.8%). Among the types of failed arthroplasty, patients with failed TSA noted the greatest improvement in their outcome, but this improvement was not statistically significant. CONCLUSIONS: The data suggest that patients can expect improved functional outcome and decreased pain after revision of previous arthroplasty to rTSA and that this procedure can provide a reliable salvage option for a challenging clinical problem.