Faculty Bibliography

BACKGROUND/UNASSIGNED:The purpose of our study was to compare the outcomes and complications after a two- vs. six-week duration of sling immobilization following reverse total shoulder arthroplasty (rTSA). METHODS/UNASSIGNED:We conducted a retrospective review from our institutional database on 960 patients treated by primary rTSA between 2011 and 2021. Patients were separated into two cohorts of postoperative sling immobilization (a two-week and six-week group). Multivariate analysis was conducted to evaluate what factors were associated with patients experiencing either a postoperative complication or requiring reoperation. RESULTS/UNASSIGNED: = .73). DISCUSSION/UNASSIGNED:Shorter duration of sling immobilization (two weeks) does not incur additional risk of complications compared to standard duration (six weeks) of sling immobilization following rTSA.

» Treatment of glenoid bone loss continues to be a challenge in total shoulder arthroplasty (TSA). Although correcting glenoid wear to patient's native anatomy is desirable in TSA, there is lack of consensus regarding how much glenoid wear correction is acceptable and necessary in both anatomic and reverse TSA.» Use of augmented glenoid components is a relatively new treatment strategy for addressing moderate-to-severe glenoid wear in TSA. Augmented glenoid components allow for predictable and easy correction of glenoid wear in the coronal and/or axial planes while at the same time maximizing implant seating, improving rotator cuff biomechanics, and preserving glenoid bone stock because of off-axis glenoid reaming.» Augmented glenoid components have distinct advantages over glenoid bone grafting. Glenoid bone grafting is technically demanding, adds to the surgical time, and carries a risk of nonunion and graft resorption with subsequent failure of the glenoid component.» The use of augmented glenoid components in TSA is steadily increasing with easy availability of computed tomography-based preoperative planning software and guidance technology (patient-specific instrumentation and computer navigation).» Although different augment designs (full wedge, half wedge, and step cut) are available and a particular design may provide advantages in specific glenoid wear patterns to minimize bone removal (i.e. a half wedge in B2 glenoids), there is no evidence to demonstrate the superiority of 1 design over others.

PURPOSE/OBJECTIVE:The aim of this study is to evaluate 90-day outcomes and complications following radial head arthroplasty (RHA) for Mason Type III and IV radial head fractures (RHFs) and determine factors predisposing patients to early complications and revision surgery. METHODS:Patients undergoing RHA for Mason Type III and IV RHFs were identified retrospectively from an institutional database. Postoperative complications, reoperations, elbow range of motion, radiographs and concomitant injuries on the ipsilateral upper extremity were reviewed. Additionally, injuries were sub-classified as low-energy trauma (LET) or high-energy trauma (HET). Univariate logistic regression was performed to evaluate the risk for complications using patient factors not limited to the presence of concomitant ligamentous or bony injuries. P values < 0.05 were considered statistically significant. RESULTS:Seventy four patients were included in our study with an average follow-up time of 12.7 months. Complications within 90-days of operation occurred in 8.1% of patients: heterotopic ossification (4.1%), superficial wound dehiscence (2.7%), and posterior interosseous nerve palsy (1.4%). No patients required readmission or revision surgery in the 90-day postoperative period. Univariate regression analysis did not demonstrate a significant association between diabetes, ASA status, HET versus LET, or the presence of concomitant injury. Concomitant injuries were found in 92% of patients. CONCLUSION/CONCLUSIONS:Radial head arthroplasty for RHFs demonstrates a low complication rate in the short-term. Diabetes, ASA class, high versus low energy trauma, and presence of concomitant injury were not found to be associated with higher complication rates in the 90-day postoperative period. LEVEL OF EVIDENCE/METHODS:Level of evidence IV, retrospective case series.

BACKGROUND:Parkinson's Disease (PD) is an established risk factor for higher rates of complications and revision surgery following shoulder arthroplasty, yet the economic burden of PD remains to be elucidated. The purpose of this study is to compare rates of complication and revisions as well as inpatient charges for shoulder arthroplasty procedures between PD and non-PD patients using an all-payer statewide database. METHODS:Patients undergoing primary shoulder arthroplasty from 2010-2020 were identified from the New York (NY) Statewide Planning and Research Cooperative System (SPARCS) database. Study groups were assigned based on concomitant diagnosis of PD at time of index procedure. Baseline demographics, inpatient data, and medical comorbidities were collected. Primary outcomes measured were accommodation, ancillary, and total inpatient charges. Secondary outcomes included postoperative complication and reoperation rates. Logistic regression was performed to evaluate effect of PD on shoulder arthroplasty revision and complication rates. All statistical analysis was performed using R (R Foundation for Statistical Computing; Vienna, Austria). RESULTS:39,011 patients (429 PD versus 38,582 non-PD) underwent 43,432 primary shoulder arthroplasties (477 PD versus 42,955 non-PD) with mean follow-up duration of 2.9 +/- 2.8 years. The PD cohort was older (72.3 +/- 8.0 versus 68.6 +/- 10.4 years, p<0.001), with greater male composition (50.8% versus 43.0%, p=0.001), and higher mean Elixhauser scores (1.0 +/- 4.6 versus 7.2 +/- 4.3, p<0.001). The PD cohort had significantly greater accommodation charges ($10,967 vs $7,661, p<0.001) and total inpatient charges ($62,000 and $56,000, p<0.001). PD patients had significantly higher rates of revision surgery (7.7% versus 4.2%, p=0.002) and complications (14.1% versus 10.5%, p=0.040), as well as significantly higher incidences of readmission at 3- and 12-months postoperatively. After controlling for age and baseline comorbidities, PD patients had 1.64 times greater odds of reoperation compared to non-PD patients (OR = 1.64, 95% CI [1.10, 2.37], p = 0.012) and a hazard ratio of 1.54 for reoperation when evaluating revision-free survival following primary shoulder arthroplasty (HR = 1.54, 95% CI [1.07, 2.20], p = 0.019). CONCLUSIONS:PD confers a longer length of stay, higher rates of postoperative complications and revisions, and greater inpatient charges in patients undergoing TSA. Knowledge of the associated risks and resource requirements of this population will aid surgeons in their decision making as they continue to provide care to a growing number of patients affected by PD.

Background: The exact pathogenesis of idiopathic adhesive capsulitis (IAC) is not fully understood, but an inflammatory profibrotic cascade, largely mediated by transforming growth factor-beta 1 (TGF- β1) has been implicated. Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACE-Is) both decrease the activity of TGF-β1. The aim of this study was to determine the impact of ACE-Is or ARBs use on the need for operative intervention in IAC. Methods: This was a retrospective cohort study of patients from a single institutional database with IAC, divided into two cohorts, with and without ACE-I and/or ARB use as the primary exposure and a minimum 2-year follow-up. The primary outcome measured was the incidence of operative intervention including manipulation under anesthesia (MUA) and arthroscopic capsular release (ACR). Additional multivariable logistic regression analysis was performed to evaluate associations between ACE-I/ARB use and likelihood of undergoing an operative procedure. Results: A total of 17,645 patients met inclusion criteria, with 5424 patients in the ACE-I/ARB cohort and 12,221 in the non-ACE-I/ARB cohort. Overall, 422 (2.4%) patients underwent surgical treatment, 378 (2.1%) ACR, and 74 (0.4%) MUA. There was no significant difference between cohorts in the frequency of surgical procedures or time to procedure since diagnosis. There were no significant differences between individual ACE-Is or ARBs, although Losartan was found to have a trend of decreased rate of intervention (31.7% vs. 36.8%, P = .209) when compared to patients not on losartan that did not reach statistical significance. Patient factors predictive of undergoing MUA/ACR were diabetes (P = .013), obesity (P < .001), and male sex (P < .001). Increasing patient age reduces the likelihood of undergoing operative intervention, with patients aged 50-70 years (P = .022) and age >70 years (P < .001) demonstrating reduced odds as compared to patients aged <30 years. Conclusion: Patients with IAC have an overall low (2.4%) rate of requiring surgical intervention. While the antifibrotic mechanism of ACE inhibitors and ARBs did not significantly affect the rate of requiring surgical intervention, male gender, obesity, younger age, and diabetes, all increased the risk for operative intervention. Losartan, specifically, may have a disease modifying effect on IAC that should be investigated with larger controlled trials.

Background: The purpose of this study was to investigate the impact of high body mass index on the 1-year minimal outcome following arthroscopic shoulder stabilization. Methods: Patients who underwent arthroscopic Bankart repair (ABR) between 2017 and 2021 were identified and assigned to 1 of 3 cohorts based on their preoperative body mass index: normal (18-25), overweight (25-30), and obese (>30). The primary outcomes assessed were postoperative shoulder instability and revision rates. The 3 groups were compared using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, pain intensity, Clinical Global Impression scores, visual analog scale pain scores, and shoulder range of motion at 1 year postoperatively. Results: During the study period, 142 patients underwent ABR and had an average age of 35 ± 10 years. Obese patients had a higher percentage of partial rotator cuff tears (60% vs. 27%, odds ratio: 3.2 [1.1, 9.2]; P = .009), longer mean operative time (99.8 ± 40.0 vs. 75.7 ± 28.5 minutes; P < .001), and shorter time to complication (0.5 ± 0 vs. 7.0 ± 0 months; P = .038). After controlling for confounding factors, obesity was associated with a lesser improvement in upper extremity function scores (obese vs. normal: −4.9 [−9.4, −0.5]; P = .029); although this difference exists, found future studies are needed to determine the clinical significance. There were no differences in patient reported outcome measures, recurrence rate, or revision surgery rates between cohorts at any time point (P > .05). Conclusion: Obesity is an independent risk factor for longer operative times but does not confer a higher risk of recurrent instability, revision surgery, or lower outcome scores 1 year following ABR.

INTRODUCTION/BACKGROUND:The purpose of this study is to compare the 90 day complication rates of primary Total Elbow Arthroplasty (TEA) performed for arthritis (primary-OA; rheumatoid arthritis-RA) versus those performed for distal humerus fractures (DHF). METHODS:Patients who underwent a TEA from 2015 to 2021 were identified from our institutional database and placed into cohorts based on surgical indications (TEA-OA, TEA-RA and TEA-DHF). Chart review was conducted to analyze the prevalence of complications, emergency department (ED) visits, readmissions, and secondary procedures in the first 90 day post-operative period. Complications included but were not limited to wound complications, hematoma, infection (superficial or deep), nerve palsy, periprosthetic fracture/failure and others. RESULTS:49 patients who underwent TEA were included in this study: (DHF = 19, OA = 14, RA = 16). Six complications occurred within the first 90 days of surgery. There were two periprosthetic joint infections (PJI) in the OA group, requiring irrigation and debridement (I & D) within the first 90 days of surgery. There were three post-operative ulnar nerve palsies and one PJI requiring I & D in the TEA-RA group. Compared to the TEA-DHF and TEA-OA groups, the RA group had higher rates of all-cause complications (p = 0.03) and nerve palsy (p = 0.03). There were no significant differences between groups in readmissions (p = 0.27) or secondary interventions (p = 0.27). CONCLUSION/CONCLUSIONS:The 90-day complication/readmission rates of TEA preformed for DHFs is lower than those preformed for OA and RA. These differences could be related to the underlying chronic inflammatory etiology and side effect of treatments (intraarticular steroid injection, and biologics) received by patients with arthritis. LEVEL OF EVIDENCE/METHODS:Retrospective Cohort Study, level IV.

INTRODUCTION/BACKGROUND:The purpose of this series is to report on the one-year clinical outcomes of instability related anterior glenoid fractures treated with open repair utilizing the subscapularis split technique. METHODS:Patients with displaced anterior glenoid fractures who underwent open surgical treatment via deltopectoral incision and subscapularis split were identified from a single surgeons database. Fractures were repaired using screw fixation or with distal tibia osteochondral allograft reconstruction. Patient Reported Outcome Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE), PROMIS Pain interference (PI), PROMIS pain intensity (Pi), American Shoulder and Elbow Surgeons (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value (SSV) scores were obtained at minimum one-year follow-up. RESULTS:Twelve patients with a mean age of 54 (range 28-72) years were included in our study with a follow-up at an average of 16.6 (range 12-30) months. Ten patients underwent internal fixation and two patients underwent allograft reconstruction. Postoperative imaging (n = 10) at latest follow-up demonstrated healed fractures without any hardware complication. Mean postoperative range of motion included forward elevation of 147 ± 44.0° and external rotation of 44 ± 17°. Postoperative PROMs were obtained from nine patients with a mean PROMIS UE, PI, and Pi score of 49.4 ± 4.1, 39.9 ± 3.8 and 35.6 ± 4.3, respectively. The respective mean ASES, VAS, and SSV scores were 91.8 ± 7.2, 1.2 ± 1.0, and 91.0 ± 8.0. CONCLUSION/CONCLUSIONS:Open surgical repair of anterior glenoid fractures utilizing subscapularis split results in good functional outcomes and low complications including risk of recurrent instability. LEVEL OF EVIDENCE/METHODS:III case series.

BACKGROUND:Primary idiopathic adhesive capsulitis (AC) is characterized by shoulder pain and global limitations in range of motion (ROM). The aim of this study was to determine (1) if a spectrum of symptom severity exists during the freezing phase of AC and (2) identify factors associated with patient selection of corticosteroid injection (CSI) for treatment. METHODS:Patients presenting within 6-months of symptom onset of AC (freezing phase) were enrolled in this single-site retrospective case control study. Visual analog pain score (VAS), shoulder ROM, American Shoulder and Elbow Surgeons (ASES) scores, and Patient-Reported Outcomes Measurement Information System (PROMIS function and pain) scores were collected. Each patient was offered oral anti-inflammatory medication, physical therapy, and intraarticular corticosteroid injection (CSI). Patients were divided into two cohorts: those electing versus those deferring CSI. Multivariable logistic regression was performed to identify patient or symptom characteristics predictive of electing CSI. RESULTS:A total of 112 patients [mean age=54.7+/-8.8, female=76 (67.9%), mean symptom duration in weeks=13.2+/-7.9, elected CSI=74 (66.1%)] were included in our analysis. The overall study population demonstrated a wide spectrum of VAS pain scores [6.0+/-2.8 (range: 0-10)] and ROM: forward elevation (FE) [99.1°+/-27.0° (range: 30°-150°)], abduction (Abd) [81.5°+/-23.5° (range: 30°-130°)], external rotation (ER) [46.6°+/-13.0° (range: 0°-90°)], internal rotation (IR) [38.47°+/- 25.9° (range: 5°-90°)]. The CSI group had higher mean VAS pain score [6.6+/-2.5 versus 4.9+/-3.0, p=0.005] and greater limitations in ROM for FE [91.9°+/-26.9° versus 112.9°+/- 24.6°, p = 0.001] and Abd [77.2°+/- 23.6° versus 89.9°+/- 21.1°, p = 0.005] compared to the non-CSI cohort. The CSI group demonstrated significantly worse shoulder function based on Constant (p<.05), ASES (P=0.001), P-UE (P=0.016), P-Intensity (p=0.002), and P-Interference (p=0.004). Logistic regression demonstrated decreased total shoulder ROM in FE and Abd plains [OR=0.98 (95% CI=0.97-0.99), p=0.004)], Hispanic ethnicity and increased VAS pain score [OR=1.20 (95% CI=1.01-1.43), p=0.04] were associated with increased likelihood of electing CSI. CONCLUSION/CONCLUSIONS:A spectrum of symptom severity exists during the freezing phase of primary AC, despite similar etiology. AC patients with greater pain severity, and greater limitations in ROM at initial evaluation were associated with patient selection of CSI.

BACKGROUND:The purpose of this study was to implement a modified Delphi technique among a group of experts affiliated with American Shoulder and Elbow Surgeons (ASES) and European Society for Surgery of the Shoulder and Elbow (SECEC) to determine areas of consensus regarding what factors influence their decision to manage a patient surgically and what specific treatment modalities they utilize for patients ≤ 50 years of age with glenohumeral arthritis (GHA). METHODS:The panel of experts comprised 168 shoulder and elbow specialists, 138 ASES and 30 SECEC members. In the first round, an open-ended questionnaire was utilized to solicit features that are important in making decisions regarding treatment. The second round involved ranking the features identified in the first round as to their importance in helping decision making for surgery. The results of round two were then utilized and 18 complex surgical cases previously treated by one of the lead authors were provided for the study. One additional case was included to address the management of Cutibacterium acne (C.Acne) infection. RESULTS:159 (95.0%) participants completed the round one survey, 142 (89%) responded to the second and third round survey. In total 50 individual factors were positively associated with the decision to proceed with surgery. Ten of these were strongly supportive of surgery. Eight out of 18 clinical cases demonstrated >80% agreement on the surgical treatment modality chosen. Over 90% of respondents chose rTSA to manage pathology when an incompetent rotator cuff was present. Over 90% of respondents managed AVN with hemiarthroplasty (HA). Over 70% of respondents chose aTSA for inflammatory arthritis with low demand on their shoulder. 79% of respondents chose a stemless humeral component when a HA or aTSA was chosen in response to the proposed surgical cases. If arthroscopy was chosen there was good agreement on five core procedures. There was only fair consensus on the approach to C.acnes in patients with GH OA≤ 50 years of age. CONCLUSION/CONCLUSIONS:The optimal treatment of glenohumeral arthritis in patients ≤ 50 years of age remains controversial, and there are many treatment options to consider when responding to the variety of clinical presentations and anatomic pathologies. While physicians and patients engage in the shared decision-making process regarding the final choice for management, this consensus statement serves as a basis for discussion amongst colleagues and between patients and surgeons though it clearly demonstrates that the topic must be further investigated prospectively and with large cohorts.