Faculty Bibliography

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.

INTRODUCTION: Diabetes has been associated with negative outcomes following orthopaedic surgery. While previous studies have reported on diabetes-associated complications in shoulder arthroplasty, those cohorts were heterogeneous in terms of patient population, nature of elective surgery, and arthroplasty type. Given that the number of elective total shoulder arthroplasties (TSAs) performed has grown substantially in volume and is predicted to rise even further, it is important to recognize the role that diabetes may play in developing in-hospital complications within a more homogenous sample of patients undergoing elective TSA. METHODS: The Nationwide Inpatient Sample (NIS) was searched for the year 2012 to identify all patients undergoing elective TSA. Patients with diabetes were identified, and differences regarding demographics and in-hospital outcomes were compared to non-diabetics using multivariate logistic regression. RESULTS: A total of 44,050 patients underwent elective total shoulder arthroplasty (TSA) in 2012. Diabetic patients tended to be older, of minority racial status, and had a greater medical comorbidity burden. When controlling for preoperative factors and comorbidities, diabetes was an independent risk factor for non-home bound discharge (OR 1.285; 95% CI 1.093-1.509, p = 0.002), length of stay in 75th percentile (OR 1.390; 95% CI 1.233-1.567, p < 0.001), total charges in the 75th percentile (OR 1.136; 95% CI 1.006-1.283, p = 0.040), and postoperative acute renal failure (OR 1.460; 1.002-2.128, p = 0.048). CONCLUSION: Diabetes was associated with marginal increases in non-home bound discharge, length of stay, and total charges, following elective TSA. Subgroup analysis revealed that diabetic patients undergoing reverse total shoulder arthroplasty (rTSA) have higher comorbidity burden and worse outcomes than diabetic patients undergoing anatomic total shoulder arthroplasty (aTSA).

Background: Factors contributing to recurrent instability and revision stabilization procedures after isolated arthroscopic stabilization of anterior glenohumeral instability have not been examined in a Statewide cohort. Additionally, practice patterns of the management of the failed Bankart repair are unclear. We sought to identify the type, rate and risk factors associated with subsequent ipsilateral shoulder procedures in a large cohort of individuals undergoing arthroscopic stabilizations for anterior shoulder instability. Methods: The New York State Department of Health's Statewide Planning and Research Cooperative Systems (SPARCS) database was examined from 2003 to 2011 to identify all patients with a primary diagnosis of anterior shoulder instability (ICD-9-CM codes 831.01, 718.81 and 718.31) undergoing outpatient arthroscopic capsulorraphy (CPT code 29806). Patients younger than 10 or older than 60 years of age, and entries with missing data, were excluded. Patients were longitudinally followed for a minimum of three years (through 2014). Baseline demographics and all subsequent ipsilateral outpatient shoulder procedures were collected. SAS version 9.3 (Cary, NC) was used for data collection and statistical analysis. Results: We identified 5,719 unique patients who met the inclusion criteria. Mean patient age was 24.9 + /- 9.3 years, and 70.2% of the sample was male. A total of 461 (8.1%) patients underwent subsequent ipsilateral shoulder instability interventions a mean of 31.5 + /- 23.8 months after the initial stabilization procedure (2.1% had closed reduction alone; 6.0% had repeat instability surgery + /- closed reduction). Repeat arthroscopic capsulorraphy was the most common subsequent procedure (48.8%). Patients undergoing procedures for subsequent shoulder instability were younger (22.6 + /- 8.6 vs. 25.1 + /- 9.4 years of age, P < .001). Evidence of additional instability following arthroscopic Bankart was independently associated with age 19 years or younger (HR 1.82; 95% CI 1.50-2.21; P < .001), Caucasian ethnicity (HR 1.38; 95% CI 1.11-1.71; P = .003), evidence of bilateral shoulder instability (HR 1.54; 95% CI 1.06-2.23; P = .023) and a history of closed reduction(s) prior to initial arthroscopic Bankart repair (HR 2.45; 95% CI 1.90-3.15 P = < .001). Gender and surgeon volume was not associated with subsequent instability procedures. When followup was normalized to three years to allow for between year comparisons, year of surgery did not predict subsequent shoulder instability. Conclusion: Patients undergoing arthroscopic stabilization of anterior glenohumeral instability in New York State had an 8.1% chance of undergoing subsequent ipsilateral instability procedures. Younger age, Caucasian race, bilateral glenohumeral instability and closed reduction prior to initial Bankart repair were independent risk factors for additional instability procedures. The most common second surgical procedure was a repeat arthroscopic stabilization (Table 1). (Table Presented)

Introduction: 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 two-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 nineteen patients from our institution that were treated with two-stage revision after presenting with a PSI. Minimum follow-up for all patients was 2 years. Mean patient age was 63 +/- 9 years, 14/19 patients were male, and average BMI was 30.8 +/- 5.8. Average time from index arthroplasty to treatment was 40 months, 8/13 positive cultures were P. acnes, and 9/19 patients had multiple shoulder operations before presenting with infection. Results: After a mean follow up of 63 months (Range 25-184 months), 15/19 patients in our study were successfully treated for PSI. Average postoperative ASES score was 69 (32-98) and average postoperative forward elevation was significantly increased from 58 to 119 degrees (P < .001). The incidence of recurrent infection was 26%; the rate of non-infection complications was 16% for a total complication rate of 42%. Conclusion: In patients with PSIs, especially those with intractable, chronic infections, a two-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.

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: With this study, we sought to quantify perioperative changes in driving performance among patients who underwent anatomic or reverse shoulder arthroplasty. METHODS: Using a driving simulator, 30 patients (20 anatomic and 10 reverse total shoulder arthroplasties) were tested preoperatively and at 2 weeks (PO2), 6 weeks (PO6), and 12 weeks (PO12) postoperatively. The total number of collisions, centerline crossings, and off-road excursions (when the vehicle traversed the lateral road edge), and scores on a visual analog scale (VAS) for pain and the Shoulder Pain and Disability Index (SPADI) were recorded at each driving trial. RESULTS: The mean number of collisions increased from 5.9 preoperatively to 7.4 at PO2 and subsequently decreased to 5.6 at PO6 and 4.0 at PO12 (p = 0.0149). In addition, the number of centerline crossings decreased from 21.4 preoperatively to 16.3 at PO12 (p < 0.05). Multivariate analysis of the data demonstrated that increased VAS for pain scores, older age, and less driving experience had a negative impact on driving performance. CONCLUSIONS: Driving performance returned to preoperative levels at 6 weeks after shoulder arthroplasty. By 12 weeks postoperatively, patients demonstrated improved driving performance compared with preoperative performance. On the basis of our findings, clinicians can suggest a window of 6 to 12 weeks postoperatively for the gradual return to driving. However, for patients of older age, with less driving experience, or with greater pain, a return to driving at closer to 12 weeks postoperatively should be recommended. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.].

Measurements of shoulder kinematics during activities of daily living (ADL) can be used to evaluate patient function before and after treatment and help define device testing conditions. The purpose of this study was to demonstrate the feasibility of using wearable inertial measurement units (IMUs) to track shoulder joint angles while performing actual ADLs outside of laboratory simulations. IMU data of 5 subjects with normal shoulders was collected for 4h at the subjects' workplace and up to 4h off-work. An Unscented Kalman Filter (UKF) enhanced with gyroscope bias modeling and zero velocity updates demonstrated an accuracy of about 2 degrees and was used to estimate relative upper arm angles from the IMU data. The overall averaged 95th percentile angles were: flexion 128.8 degrees , abduction 128.4 degrees , and external rotation 69.5 degrees . These peaks angles are similar to other investigator's reports using laboratory simulations of ADLs measured with optical and electromagnetic technologies. Additionally, with a Fourier transform the 50th percentile frequency was determined and used to extrapolate the typical number of arm cycles in a 10year period to be 649,000. Application of the UKF with the additional drift correction made substantial improvements in shoulder tracking performance and this feasibility data suggests that IMUs with the UKF are suitable for extended use outside of laboratory settings. The data provides a novel description of arm motion during ADLs including an estimate for the 10 year cycle count of upper arm motion.

PURPOSE: To quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient arthroscopic rotator cuff repair (ARCR). METHODS: We examined the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. The impact of age, sex, insurance, concomitant acromioplasty, and tobacco use on reoperation was explored. RESULTS: Between 2003 and 2012, 30,430 patients underwent isolated ARCR. The mean age was 56.6 +/- 11.5 years, and 55.1% were male patients. A total of 1,826 patients (6.0%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3 +/- 27.1 months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 +/- 10.9 years v 56.8 +/- 11.5 years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%, P = .044) and accelerated time to reoperation (16.9 months v 24.7 months, P < .001). Independent risk factors for subsequent ipsilateral surgery after initial ARCR were presence of a Workers' Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P < .001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval, 1.09-1.34; P < .001). CONCLUSIONS: We identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers' Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery. LEVEL OF EVIDENCE: Level III, retrospective comparative study.