Faculty Bibliography

INTRODUCTION/BACKGROUND:The purpose of this study is to evaluate the relationship between patients' own health expectations and treatment outcomes following surgical repair of proximal humerus fractures. HYPOTHESIS/OBJECTIVE:Patients' health expectations will correlate with treatment outcomes following surgical repair of proximal humerus fractures. MATERIAL AND METHODS/METHODS:Over a 14-year period, 247 patients with a displaced proximal humerus fracture who underwent ORIF with locking compression plates were prospectively followed at one academic institution. Minimum follow-up period was 12 months. Patient-reported functional outcome data for the latest follow up visit (12 months and greater) was obtained from Disabilities of Arm, Shoulder, and Hand (DASH) questionnaires. Survey responses regarding health expectations were recorded at 3-month follow-up and converted to dichotomous variables. Two groups were identified: the high expectations and the low expectations groups. Statistical analysis comparing the two groups and their functional and clinical outcomes was performed using the independent t-test, using p<0.05 for significance. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to further statistically characterize the relationship between health expectations at 3 months and long-term outcomes. RESULTS:One hundred and eighty-five (75.0%) patients available for analysis with a mean follow-up length of 24.8 months. The cohort included 124 (67%) females and 61 (33%) males and the average age at time of injury was 59.5 years. Eighty-six (46.5%) patients had low expectations for their overall health and 99 (53.5%) patients had high expectations for their health. No significant differences were seen between groups in regards to age, gender, follow-up length, Charlson Comorbidity Index (CCI), smoking and tobacco use, fracture pattern (OTA and Neer classifications), early complications (p>0.05), fracture healing, and avascular necrosis. The mean DASH score at the latest follow up for patients with low expectations was 31.42±22.8 whereas the mean for those with high expectations was 16.76±20.2 (p<0.0005). The mean forward flexion of the shoulder for patients with low expectations was 137.8±31.5 degrees as compared to 148.5±26.3 degrees (p<0.05). The positive predictive value of good expectations correlating with good outcomes was 71.7%. DISCUSSION/CONCLUSIONS:Patients with high expectations for their health early following injury had better outcomes in the long term. These high expectations also appeared to have an optimal influence on range of shoulder motion. This data suggests attitudinal and psychological factors that affect patient health expectations early on in the course of treatment may also influence patients' functional and clinical outcomes. LEVEL OF EVIDENCE/METHODS:II; Retrospective Study.

SUMMARY:There are a variety of treatment options available for proximal humerus fractures, including nonoperative management, open reduction internal fixation with screws, locking plates, intramedullary nailing, or suture fixation, and arthroplasty, including hemiarthroplasty and total shoulder replacements. Fracture characteristics, including the number of fracture parts and involvement of the humeral head and glenoid and the patient's functional status and postoperative goals help dictate the optimal choice. Although the indications for hemiarthroplasty as treatment for severe proximal humerus fractures have narrowed, the authors believe that there is a still a place for this technique in practice.

BACKGROUND:Nonunion of fractures about the proximal humerus represents a rare and complex problem. The purpose of this study was to evaluate the clinical and functional outcomes following proximal humerus fracture (PHF) nonunion repair using a plate and screw construct with a direct comparison to those experienced following operative fixation of acute PHF using a plate and screw construct. METHODS:Two separate patient cohorts were included in this study. The first consisted of 16 patients diagnosed with a non-united PHF who underwent operative nonunion repair treated with a standard algorithmic approach. The comparison group consisted of 173 patients who achieved union following initial open reduction and internal fixation of an acute PHF treated with a proximal humerus locking plate construct. All patients had at least 12 months of postoperative follow-up. Outcomes were assessed for both groups using American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale (VAS) pain scores, and postoperative shoulder range of motion (ROM). Statistical analyses were used to compare these outcome measures between the two cohorts. RESULTS:The nonunion repair cohort consisted of eleven surgical neck nonunions and five nonunions of both the surgical neck and greater tuberosity. Ten patients had undergone surgical treatment for their original fracture, while six were initially treated non-operatively. All patients had Boileau type 3 sequelae of their proximal humerus fracture. Union was achieved in all patients at a mean of 5.4 months following nonunion repair. Complications included hardware failure requiring revision in two patients (12.5%) and avascular necrosis requiring conversion to anatomic total shoulder arthroplasty following union in one patient (6.3%). The nonunion repair and acute fracture cohorts did not differ with respect to mean ASES scores, VAS pain scores, or active shoulder ROM at any postoperative time point. CONCLUSION/CONCLUSIONS:Surgical repair of PHF nonunion is a viable treatment strategy that can lead to consistent bony healing with outcomes comparable to those of patients who achieve fracture union following initial surgical repair of an acute proximal humerus fracture. Surgeons should be cognizant of mechanical considerations that may lead to early failure.

STUDY DESIGN/UNASSIGNED:Retrospective cohort study. OBJECTIVES/UNASSIGNED:The interactions between hip osteoarthritis (OA) and spinal malalignment are poorly understood. The purpose of this study was to assess the influence of total hip arthroplasty (THA) on standing spinopelvic alignment. METHODS/UNASSIGNED:In this retrospective cohort study, patients undergoing THA for OA with pre-and postoperative full-body radiographs were included. Standing spinopelvic parameters were measured. Contralateral hip was graded on the Kellgren-Lawrence scale. Pre-and postoperative alignment parameters were compared by paired t-test. The severity of preoperative thoracolumbar deformity was measured using TPA. Linear regression was performed to assess the impact of preoperative TPA and changes in spinal alignment. Patients were separated into low and high TPA (<20 or >/=20 deg) and change in parameters were compared between groups by t-test. Similarly, the influence of K-L grade, age, and PI were also tested. RESULTS/UNASSIGNED:= .004). Preoperative TPA was significantly associated with the change in PI-LL, SVA, and TPA. High TPA patients significantly decreased SVA more than low TPA patients. There was no significant impact of contralateral hip OA, PI, or age on change in alignment parameters. CONCLUSION/UNASSIGNED:Spinopelvic alignment changes after THA, evident by a reduction in SVA. Preoperative spinal sagittal deformity impacts this change. Level of evidence: III.

Lewis Albert Sayre (1820-1900) is one of the key figures in the history of American orthopedic surgery who left an indelible mark on the field. Sayre dedicated much of his career to teaching and practicing orthopedics in New York City and is considered to be one of the "fathers" of orthopedics in America. Sayre's career was defined by his development of novel, innovative treatments to attempt to improve the lives of his patients. Two of the treatments he is most well-known for developing are "exsection of the hip" for treating "Morbus Coxarius" and the plaster of Paris jacket used for treating spinal deformities caused by Pott's disease or scoliosis. Although Sayre's developments are no longer used today, examining them can help us to reflect on the orthopedic principles he sought to apply in the 19th Century as well as how Sayre's treatments have shaped the interventions that we use to care for patients today.

BACKGROUND:To measure functional outcome, patient reported outcome measures (PROMs) are most often used but biomechanical tests can provide valuable supplementary data. The objective of this study was to investigate instrumented insoles for measuring ground-to-foot forces during basic activities. METHODS:Three groups were evaluated: normal controls, preoperative, and postoperative total knees. The Knee Society Scoring System (KSS) Short Form was used, and with foot pressure sensor insoles, a timed-up-and-go (TUG) test and a sit-to-stand (STS) test was used. RESULTS:Comparing preoperative to postoperative and control groups, there were significant differences in most parameters. There were no significant differences between controls and postoperative knees. Of the 33 correlation coefficients between three PROM parameters and six biomechanical parameters for the three groups, only five coefficients were greater than 0.5. CONCLUSIONS:The biomechanical data was substantially independent of the PROM data and provided additional functional evaluation. The most useful parameters were the left-right force ratios during sit-to stand (STS) and the timed-up-and-go (TUG) time.

BACKGROUND:A machine learning analysis was conducted on 5774 shoulder arthroplasty patients to create predictive models for multiple clinical outcome measures after anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA). The goal of this study was to compare the accuracy associated with a full-feature set predictive model (ie, full model, comprising 291 parameters) and a minimal-feature set model (ie, abbreviated model, comprising 19 input parameters) to predict clinical outcomes to assess the efficacy of using a minimal feature set of inputs as a shoulder arthroplasty clinical decision-support tool. METHODS:Clinical data from 2153 primary aTSA patients and 3621 primary rTSA patients were analyzed using the XGBoost machine learning technique to create and test predictive models for multiple outcome measures at different postoperative time points via the full and abbreviated models. Mean absolute errors (MAEs) quantified the difference between actual and predicted outcomes, and each model also predicted whether a patient would experience clinical improvement greater than the patient satisfaction anchor-based thresholds of the minimal clinically important difference and substantial clinical benefit for each outcome measure at 2-3 years after surgery. RESULTS:Across all postoperative time points analyzed, the full and abbreviated models had similar MAEs for the American Shoulder and Elbow Surgeons score (±11.7 with full model vs. ±12.0 with abbreviated model), Constant score (±8.9 vs. ±9.8), Global Shoulder Function score (±1.4 vs. ±1.5), visual analog scale pain score (±1.3 vs. ±1.4), active abduction (±20.4° vs. ±21.8°), forward elevation (±17.6° vs. ±19.2°), and external rotation (±12.2° vs. ±12.6°). Marginal improvements in MAEs were observed for each outcome measure prediction when the abbreviated model was supplemented with data on implant size and/or type and measurements of native glenoid anatomy. The full and abbreviated models each effectively risk stratified patients using only preoperative data by accurately identifying patients with improvement greater than the minimal clinically important difference and substantial clinical benefit thresholds. DISCUSSION/CONCLUSIONS:Our study showed that the full and abbreviated machine learning models achieved similar accuracy in predicting clinical outcomes after aTSA and rTSA at multiple postoperative time points. These promising results demonstrate an efficient utilization of machine learning algorithms to predict clinical outcomes. Our findings using a minimal feature set of only 19 preoperative inputs suggest that this tool may be easily used during a surgical consultation to improve decision making related to shoulder arthroplasty.

BACKGROUND:With an ongoing opioid epidemic in the United States, it is important to examine if decreased opioid prescribing can affect patient experience, namely satisfaction with pain control. PURPOSE/OBJECTIVE:The purpose of this study was to investigate what effect, if any, decreased opioid prescribing after total shoulder arthroplasty had on Press-Ganey satisfaction surveys. METHODS:A retrospective review was conducted on patients who underwent primary anatomic or reverse total shoulder arthroplasty between October 2014 and October 2019. Patients with complete Press-Ganey survey information, no history of trauma, fracture, connective tissue disease, or prior shoulder arthroplasty surgery were included in the analysis. Patients were segregated into two groups, pre-protocol and post-protocol, based on the date of surgery relative to implementation of an institutional opioid reduction protocol, which occurred in October 2018. Prescriptions were converted to milligram morphine equivalents (MME) for direct comparison between different opioid medications. RESULTS:201 patients met inclusion criteria, and there were 110 reverse total shoulder arthroplasties and 91 anatomic total shoulder arthroplasties. Average opioids prescribed on discharge for the pre-protocol group was 426.3 ± 295 MME (equivalent to 56.8 tablets of oxycodone 5mg), while after initiation of the protocol it was 193.8 ± 199 MME (equivalent to 25.8 tablets of oxycodone 5mg); P<0.0001. Average satisfaction with pain control did not change significantly between pre-and-post protocol (4.71 ± 0.65 pre-protocol and 4.74 ± 0.44 post-protocol, P=0.82). CONCLUSION/CONCLUSIONS:A reduction in opioids prescribed after a total shoulder replacement is not associated with any negative effects on patient satisfaction, as measured by the Press-Ganey survey. LOE: Level III; Retrospective Cohort Comparison; Treatment Study.

BACKGROUND:Complications after anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty can be devastating to a patient's quality of life and require revisions that are costly to both the patient and the health care system. The purpose of this study is to determine the types, incidence, and timing of complications following aTSA and rTSA using an international database of patients who received a single-platform total shoulder arthroplasty system, in order to quantify the types of failure modes and the differences that occur between aTSA and rTSA. METHODS:A total of 2224 aTSA (male-female, 1090:1134) and 4158 rTSA (male-female, 1478:2680) patients were enrolled in an international database of primary shoulder arthroplasty performed by 40 different surgeons in the United States and Europe. Adverse events and revisions reported for these 6382 patients were analyzed to identify the most common failure modes associated for both aTSA and rTSA. RESULTS:For the 2224 aTSA patients, 239 adverse events were reported for a complication rate of 10.7% and 124 revisions for a revision rate of 5.6%. The top 3 complications for aTSA were rotator cuff tear/subscapularis failure (n = 69; complication rate = 3.1%, revision rate = 1.9%), aseptic glenoid loosening (n = 55; complication rate = 2.5%, revision rate = 1.9%), and infection (n = 28; complication rate = 1.3%, revision rate = 0.8%). For the 4158 rTSA patients, 372 adverse events were reported for a complication rate of 8.9% and 104 revisions for a revision rate of 2.5%. The top 3 complications for rTSA were acromial/scapular fracture/pain (n = 102; complication rate = 2.5%, revision rate = 0.0%), instability (n = 60; complication rate = 1.4%, revision rate = 1.0%), and pain (n = 49; complication rate = 1.2%, revision rate = 0.2%). CONCLUSIONS:This large database analysis quantified complication and revision rates for aTSA and rTSA. We found aTSA and rTSA complication rates of 10.7% and 8.9%, respectively; with revision surgery rates of 5.6% and 2.5%, respectively. The 2 most common complications for each prosthesis type (aTSA: subscapularis/rotator cuff tears, aseptic glenoid loosening; rTSA: acromial/scapular fractures, instability) were unique to each device. The rate of infection was similar for both. Future prosthesis and technique development should work to mitigate these common complication types in order to reduce their rate of occurrence.

PURPOSE/OBJECTIVE:To correlate the Patient Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE) score with preexisting validated outcomes scores, American Shoulder and Elbow Surgeons score (ASES), and Constant score (CS) in patients with idiopathic adhesive capsulitis (AC). METHODS:Patients with a clinical diagnosis of idiopathic AC ("freezing" or "frozen" phases) who agreed to complete the ASES, CS, and PROMIS UE scores during their office visit were included in this study. Trained researchers performed the objective clinical assessments on the included patients. Responses to the 3 outcomes scores were statistically analyzed and compared utilizing Pearson correlation coefficients. Floor and ceiling effects were calculated. RESULTS:The final cohort included 100 patients with AC of which there were 72% female and 87% right hand dominant, with a mean age of 55 years. The PROMIS UE required fewer question responses (5.02 ±1.84) compared to the fixed questions burden with ASES (12) and CS (9). The mean outcome scores were 34.6 ± 2.5 (PROMIS UE), 55 ± 22 (ASES), and 51 ± 16 (CS). The PROMIS UE displayed excellent correlation with both the ASES (r = 0.80, 95% [CI: 0.72, 0.86], p < 0.001) and CS (r = 0.76, 95% CI [0.67, 0.83], p < 0.001). Neither ceiling nor floor effects were present. CONCLUSION/CONCLUSIONS:The PROMIS UE displayed comparable efficacy to commonly used legacy outcome scores (ASES and CS) in adhesive capsulitis. A lower question burden with the PROMIS UE carries a potential for wider acceptibility with the researchers and patients with shoulder pathology.