Short-Term Results of a Convertible Diaphyseal-fit Anatomic Shoulder Arthroplasty System.

Objectives: The purpose of this analysis is to present a two-year follow-up of patient-reported outcomes, revision rate, and notable radiographic features of a convertible, diaphyseal-fit anatomic total shoulder arthroplasty system (ATSA). Methods: From June 2012 to June 2015, 100 shoulders were treated with ATSA using a convertible, diaphyseal-fit stem. Functional outcomes and radiographic findings were assessed preoperatively and at 6 months, 1 year, and 2 years postoperatively. Complications and reoperations were also determined. Results: Ninety-three shoulders were analyzed in this study. Patients were 47.3% male and had an average age of 67.3±8.1-years-old (range 44.7-89.1). Two-year clinical outcomes show a revision rate of 4.3%. Average pre-operative ASES was 37.1±18.9 (6.7-86.7), SST (77.4%) was 3.1±2.4 yes responses (0-9), and SANE (88.2) was 25.4±21.5% (0-85.0%). At two years post-operative average (75% follow-up) ASES was 89.3±15.1 (37.0-100), SST was 10.0±2.5 yes responses (0-12), and SANE was 85.6%±17.0% (33.0-100%). Radiographic analysis at two years identified 2 shoulders (4%) with glenoid radiolucency (both Lazarus grade 1), 5 shoulders with at least one humeral radiolucent line (10%), and 9 shoulders (18%) with stress-shielding. There were 12 shoulders (24%) with distal pedestal formation. This finding was associated with the presence of radiolucent lines (P=0.002). Conclusion: This two-year analysis identified improvement in ASES, SST, and SANE scores and a low revision rate. resence of a distal pedestal was associated with increased rates of radiolucent lines. Further analysis with longer-term and more robust follow-up will improve our understanding of the risks and benefits of this shoulder system.

Can Patients Accurately Recall their Preoperative Pain and Functional Scores Following Rotator Cuff Repair and Total Shoulder Arthroplasty?

Objectives: Accurate analysis of preoperative shoulder pain and function is important for understanding treatment efficacy and producing high-quality research. Oftentimes, preoperative patient-reported outcomes (PROs) are missing. Therefore the accuracy of recalled preoperative PROs may be important. We investigate the ability of patients who underwent rotator cuff repair (RCR) or shoulder arthroplasty (TSA) to recall their preoperative PROs. Methods: We identified 145 patients who underwent either RCR or TSA and had preoperative PROs. All patients completed the ASES, SANE, SST, and VAS surveys within 3 months prior to surgery. Patients were contacted between one and four years after surgery and asked to recall their baseline pain and shoulder function prior to surgery. The mean difference was calculated by determining the difference between the mean recalled score and the mean actual score. Intraobserver reliability analysis was performed, comparing recall and actual score for each using the 2-way mixed-effects intraclass correlation coefficient (ICC) model. The ICC values > 0.75 were considered excellent, values between 0.4 and 0.75 were considered moderate, and values of < 0.4 demonstrated a weak agreement. Results: For patients who underwent RCR, the mean differences between actual and recalled ASES, SANE, SST and VAS pain were 6.3 (P=0.004), 2.0 (P=0.155), -0.04 (P=0.625) and - 1.0 (P<0.001), respectively. In patients who underwent TSA, the mean differences between actual and recalled ASES, SANE, SST and VAS pain were 4.5 (P =0.038), -3.9 (P=0.262), -1.2 (P=0.001) and -1.5 (P<0.001), respectively. ASES, SST, and VAS show moderate reliability, and SANE reliability was weak in both RCR and TSA populations. Patients had a tendency to recall higher pain scores than actual preoperative pain scores. Conclusion: In patients who underwent RCR or TSA, there was too much variability between individual patient's ability to accurately recall preoperative pain and function to reliably use recall data for research purposes.

Outcomes of chronic distal biceps reconstruction with tendon grafting: a matched comparison with primary repair.

BACKGROUND: The purpose of this analysis was to analyze outcomes of distal biceps reconstruction with soft tissue allograft in the setting of chronic, irreparable distal biceps ruptures. The outcomes of these cases were then compared with a matched cohort of distal biceps ruptures that were able to be repaired primarily. METHODS: Retrospective review of an institutional elbow surgery database was conducted. All cases of distal biceps repairs were identified by Common Procedural Terminology, ICD-9, and ICD-10 codes from January 2009 to March 2018. A direct review of operative reports was then conducted to identify which cases required allograft reconstruction. After identification of this population, a 2:1 manually matched cohort of patients who underwent primary repair was generated using age, gender, body mass index, and age-adjusted Charlson Comorbidity Index. Finally, the allograft reconstruction and matched primary repair cohorts were compared for reoperation, range of motion, and patient-reported outcomes scores. RESULTS: There were 46 male patients who underwent distal biceps reconstruction with allograft (14 Achilles tendon, 32 semitendinosus) and they were matched to 92 male patients that underwent primary distal biceps repair. Mean patient age (46.9 ± 10.3 vs. 47.0 ± 9.8 years, P = .95), BMI (31.3 ± 5.3 vs. 31.3 ± 4.8 kg/m2, P = .60), and Charlson Comorbidity Index (1.2 ± 1.1 vs. 1.3 ± 0.9, P = .64) were similar between allograft reconstruction and primary repair groups. Disability of the Arm, Shoulder and Hand score (7.4 ± 18.0 vs. 1.6 ± 4.1, P = .23), Mayo Elbow Performance Score (92.1 ± 19.7 vs. 97.3 ± 6.4, P = .36), and Oxford Elbow Score (43.4 ± 11.0 vs. 46.8 ± 3.2, P = .25) were not significantly different between groups at mean 5.1 years (range, 1.5-10.9 years) after surgery. There were 1 of 42 (2.2%) allograft patients who require revision compared with 3 of 92 (3.3%, P = .719) in the primary repair group. In addition, one primary repair required reoperation for scar tissue excision and lateral antebrachial cutaneous neurolysis. Final range of motion data (twelve-week follow-up) for the allograft reconstruction group was similar to primary repair group in flexion (136.1° ± 5.3° vs. 135.9° ± 2.7°, P = .81), extension (0.8° ± 2.9° vs. 0.4° ± 1.7°, P = .53), pronation (78.0° ± 9.0° vs. 76.4° ± 15.4°, P = .50), supination (77.4° ± 10.7° vs. 77.5° ± 11.9°, P = .96). CONCLUSION: Patients who underwent distal biceps reconstruction with a graft had similar failure rates, reoperation rates, final range of motion, and patient-reported outcomes scores as those treated without a graft. Patients can be consulted that direct repair in the acute setting is preferred; however, even in the setting of a distal biceps reconstruction with graft augmentation, they can expect low complications and good functional results.

Outcomes of open reduction and internal fixation of proximal humerus fracture dislocations.

INTRODUCTION: Proximal humeral fracture with associated glenohumeral dislocation (PHFD) is a challenging clinical problem. Outcomes of open reduction and internal fixation (ORIF) of these injuries have not been widely reported. The purpose of this analysis is to report our experience with ORIF of PHFD. METHODS: A retrospective review of our 2 institutions' shoulder surgery databases was conducted to identify all PHFDs that were treated with ORIF from 2008 through 2017. Radiographs were reviewed for fracture healing by 12 weeks postoperatively. All reoperations were recorded. Patient-reported outcomes using Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores at a minimum 2-year follow-up were recorded. RESULTS: There were 20 PHFDs identified: they were 50% male, 55.8 ± 10.3 years old (range 31.3-66.3), and had a body mass index of 29.3 ± 8.2 (15.2-47.8). Seven (35%) patients experienced varus collapse, nonunion, or avascular necrosis and 6 (30%) patients underwent reoperation. Of the 17 patients who did not go on to revision or arthroplasty, 14 (82.3%) had patient-reported outcomes at a mean follow-up of 4.9 ± 2.2 years (2.3-8.8). These patients had an average SST 8.0±4.0 yes responses (0-12) and ASES scores of 71.6 ± 20.4 (20.2-94.9). CONCLUSION: ORIF of PHFD carries a high rate of reoperation. In patients who achieve healing, functional scores are satisfactory. This information is important for proper patient counseling prior to surgery.

Early postoperative complications after Latarjet procedure: a single-institution experience over 10 years.

BACKGROUND: The Latarjet procedure is an effective procedure for the treatment of anterior glenohumeral joint instability; however, the complications are concerning. The purpose of this study was to review a single institution's experience with the Latarjet procedure for recurrent anterior glenohumeral instability specifically focusing on early complications. METHODS: This was a retrospective review of all Latarjet procedures performed at a single institution from August 2008 to July 2018. The 90-day complication rate and associated risk factors for all complications and graft failure were recorded. Postoperative radiographs were reviewed for coracoid graft position and screw divergence. RESULTS: During the study period, 190 Latarjet procedures were performed with 90-day follow-up. The average age was 28.7 ± 11.3 years, male patients comprised 84.2% of the population, and 62.6% of patients had undergone a prior stabilization procedure. We observed 15 complications, for a 90-day complication rate of 9.0%; of the patients, 8 (4.2%) underwent reoperations. Graft or hardware failure occurred in 9 patients (4.7%) with loosened or broken screws, and 6 required reoperations (revision Latarjet procedure in 4, distal tibia allograft in 1, and iliac crest autograft in 1). Fixation with only 1 screw (P < .001) and an increased screw divergence angle (37° ± 8° vs. 24° ± 11°, P = .0257) were statistically associated with graft failure, whereas the use of cannulated screws (P = .487) was not. There were 6 nerve injuries (3.2%), including 2 combined axillary and suprascapular nerve injuries, 1 musculocutaneous nerve injury, 1 brachial plexopathy, 1 peripheral sensory nerve deficit (likely axillary), and 1 sensory plexopathy. Suprascapular nerve injury at the spinoglenoid notch was associated with a longer superior screw (41.0 ± 1.4 mm vs. 33.5 ± 3.5 mm, P = .035) and increased screw divergence angle (40° ± 6° vs. 24° ± 11°, P = .0197). The coracoid graft was correctly positioned in the axial plane in 71% of cases and in the coronal plane in 73% of cases. CONCLUSION: The Latarjet procedure is a procedure that can reliably restore shoulder stability; however, graft- and nerve-related complications are relatively common. Two-thirds of the graft failures required reoperations, and half of the nerve injuries in this study led to residual symptoms. Fixation with only 1 screw and an increased screw divergence angle were significant predictors of graft failure. Suprascapular nerve injury at the spinoglenoid notch was associated with an increased screw divergence angle and longer superior screw.

Failure to restore the calcar and locking screw cross-threading predicts varus collapse in proximal humerus fracture fixation.

BACKGROUND: Varus collapse is a common failure mode of proximal humerus fracture (PHF) fixation. The purpose of this study was to analyze predictors of varus collapse of PHF after open reduction, internal fixation (ORIF). METHODS: All patients who underwent ORIF of a PHF from January 2008 to July 2018 were identified. Known predictors of fixation failure were assessed, including calcar distance, calcar ratio, and calcar restoration. Additionally, the presence of cross-threaded screws was determined. The primary outcome analyzed was varus collapse of the fracture defined as a change in neck shaft angulation to less than 120°. RESULTS: There were 112 patients identified who underwent ORIF of a PHF that met inclusion criteria. The population was 75.0% female (84/112), average age was 62.5 ± 10.4 years (range 40.0-87.9), and average body mass index was 28.0 ± 5.5 (17.5-46.4). There were 17 with varus collapse. In 11 of the 17 patients (64.7%), there was screw cross-threading (vs. 31/95 [32.6%] in those that did not collapse); P = .012. In addition, 8 of the 17 (47.1%) did not have restoration of the calcar (vs. 16/95 [16.8%]; P = .005). CONCLUSION: This study identifies 2 surgeon-controlled variables that can contribute to varus collapse after ORIF of PHFs. Cross-threading of locking screws and failure to restore the medial calcar can be a function of implant design, surgeon technical skill, and/or bone quality.

Outcomes of shoulder arthroplasty following axillary lymph node dissection.

INTRODUCTION: Shoulder arthroplasty with previous axillary lymph node dissection historically has unsatisfactory outcomes. We analyzed outcomes of primary shoulder arthroplasty in patients with previous axillary lymph node dissection. METHODS: Thirty-two primary shoulder arthroplasties after prior axillary lymph node dissection were performed. These patients were analyzed for patient-reported outcomes, range of motion, complications, and reoperations. RESULTS: Average age was 70.8 ± 7.5 years old. There were 19 anatomic total shoulder arthroplasties, four hemiarthroplasties, and nine reverse total shoulder arthroplasties. Eight were performed by a superior approach while 24 were performed by a deltopectoral approach with cephalic vein preservation. There were three complications (one deltoid dehiscence, one axillary nerve palsy, and one postoperative pneumonia). There was one revision (hemiarthroplasty to reverse total shoulder arthroplasty for cuff failure at 91 weeks), two reoperations, and no infections. Patient-reported outcomes were available for 21/26 (80.1%) of the surviving shoulders at 4.8 ± 2.0 years. Average visual analog scale pain score was 7.1 ± 14.5, Simple Shoulder Test score 8.3 ± 2.6 "yes" responses, Single Assessment Numeric Evaluation score 80.2 ± 17.4, and American Shoulder and Elbow Surgeons score 83.6 ± 14.1. CONCLUSION: Axillary lymph node dissection is not a contraindication to shoulder arthroplasty. A deltopectoral exposure can be utilized without substantial risk of worsening lymphedema or wound complications. While a superior approach avoids cephalic vein injury, important approach-related complications (deltoid dehiscence and axillary nerve palsy) were observed.Level of evidence: Level IV-case series.

Comparison of Short-term Outcomes After Lumbar Fusion Between an Orthopedic Specialty Hospital and Tertiary Referral Center.

STUDY DESIGN: A retrospective review of all elective single-level lumbar fusions performed at a single orthopedic specialty hospital (OSH) and tertiary referral center (TRC). OBJECTIVE: This study compared the perioperative outcomes for lumbar fusion procedures performed at an OSH and TRC. SUMMARY OF BACKGROUND DATA: The role of an OSH for lumbar fusion procedures has not been defined. METHODS: A large institutional database was searched for single-level lumbar fusions performed between 2013 and 2016. Comparisons were made between procedures performed at the OSH and TRC in terms of operative time, total operating room (OR) time, length of stay (LOS), inpatient rehabilitation utilization, postoperative 90-day readmission, reoperation, and mortality rates. RESULTS: A total of 101 patients at the OSH and 481 at the TRC were included. There was no difference in gender, age, age adjusted Charlson comorbidity Index (AACCI), body mass index, mean number of concomitant levels decompressed, and use of interbody fusion between OSH and TRC patients. The mean operative time (149.5 vs. 179.7 minutes, P < 0.001), total OR time (195.1 vs. 247.9 minutes, P < 0.001), and postoperative LOS (2.61 vs. 3.73 days, P < 0.001) were significantly shorter at the OSH. More patients required postoperative inpatient rehabilitation at the TRC (7.1% vs. 2%, P < 0.001). There was no difference in 90-day readmission or reoperation rates. There was one mortality at the TRC and two patients required transfer from the OSH to the TRC due to medical complications. Regression analysis demonstrated that procedures performed at the TRC (P < 0.001), total OR time (P = 0.004), AACCI (P < 0.001), current smokers (P = 0.048), and number of decompressed levels (P = 0.032) were independent predictors of LOS. CONCLUSION: Lumbar fusion procedures may be safely performed at both the OSH and TRC. OSH utilization may demonstrate safe reduction in operative time, total OR time, and postoperative LOS in the appropriately selected patients. LEVEL OF EVIDENCE: 3.

Failure of Anatomic Total Shoulder Arthroplasty with Revision to another Anatomic Total Shoulder Arthroplasty.

BACKGROUND: While outcomes of primary anatomic total shoulder arthroplasty (aTSA) are generally favorable, results after revision procedures are less reliable. This study examines the functional outcomes, complications, and implant survival in patients who underwent revision of aTSA to aTSA. METHODS: Patients who underwent revision aTSA were identified from 2008-2015. Demographic, clinical, surgical, and outcomes data were analyzed. Patient-reported outcomes including the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numerical Evaluation (SANE), Visual Analog Scale for pain (VAS), the Short Form-12 Health Survey (SF-12), and patient satisfaction were recorded. RESULTS: Twenty patients underwent revision from a primary aTSA to aTSA (55% male, 62.0±6.8 years-old). Revision aTSA occurred at 2.5±3.4 years after index surgery. Seven (35%) required future revision at 1.8±1.9 years after revision aTSA. Among the 13 patients who did not undergo revision, twelve (92.3%) had over two-year follow-up (4.0±2.4 years). Average ASES score was 70.1±23.5, SANE 66.0±29.4, VAS 2.7±3.0, SF-12 Mental 52.4±10.5, SF-12 Physical 36.8±8.9, and satisfaction of 3.6±1.2. CONCLUSION: Results of revision aTSA to aTSA were unpredictable and the revision rate was high. The cases that do not undergo revision had satisfactory, but inconsistent functional results. Reverse arthroplasty may be more reliable in this patient population.

Headless Screw Fixation of Metacarpal Neck Fractures: A Mechanical Comparative Analysis.

BACKGROUND: The purpose of this study was to compare the mechanical properties of metacarpal neck fracture fixation by headless compression screw (HCS) with that of Kirschner wire (KW) cross-pinning and locking plate (LP) fixation. METHODS: A metacarpal neck fracture was created in 30 fourth-generation composite Sawbones metacarpal models. A volar-based wedge was removed using a custom jig to simulate a typical apex dorsal fracture, unstable in flexion. The models were divided into 3 equal groups based on the method of fixation: retrograde cross-pinning with two 1.2-mm KWs, 2.0-mm dorsal T-plate with six 2.0-mm locking screws (LP), and a 3.0-mm retrograde HCS. Models were fixed at the proximal end, mounted in a material testing machine, and loaded through a cable tensioned over the metacarpal head, simulating grip loading. Cyclic loading from 0 to 40 N was performed, followed by loading to failure. Load, displacement, and failure mode were recorded. RESULTS: Stiffness of the HCS (7.3 ± 0.7 N/m) was significantly greater than the KW (5.8 ± 0.5 N/m) but significantly less than the LP (9.5 ± 1.9 N/m). With cyclic loading to 40 N, the LP exhibited significantly less displacement (0.2 ± 1.3 mm) compared with the HCS (2.5 ± 2.3 mm) and KW (2.8 ± 1.0 mm). Load to failure for the HCS (215.5 ±3 9.0 N) was lower than that of the KW (279.7 ± 100.3 N) and of the LP (267.9 ± 44.1 N), but these differences were not statistically significant. CONCLUSIONS: The HCS provided mechanical fracture fixation properties comparable with KW fixation. The LP construct allowed significantly less displacement and had the highest strength of the 3 fixation methods.

Shoulder Arthroplasty Utilization Based on Race - Are Black Patients Underrepresented?

BACKGROUND: This study aimed to analyze national and institutional trends in shoulder arthroplasty utilization based on patient race. METHODS: The Nationwide Inpatient Sample (NIS) was employed to determine racial trends in shoulder arthroplasty utilization at a national level. An institutional database was then utilized to retrospectively identify all patients, undergoing shoulder arthroplasty within 2011-2013. Descriptive statistics were used to compare self-identified black and non-black subpopulations. RESULTS: The NIS identified 256,832 primary shoulder arthroplasties within 2005-2011. Black patients constituted 3.92% (n=10,074) of cases. Utilization increased from 3.36% in 2005 to 4.49% in 2011. Locally, a total number of 1,174 primary shoulder arthroplasties were performed, the recipients of 5.96% (n=70) of which were black. Females accounted for 48/70 (68.6%) of black patients. Black patients had a higher body mass index (33.6 vs. 30.1, P<0.0001) and were younger (62.6 vs. 67.2 years, P<0.0001), compared to the non-black patients. Regarding insurance type, 1,074 patients (i.e., 65 black and 1,009 non-black) had comprehensive insurance data. Chi-square analysis of five major insurance categories, including private, Medicare, Medicaid, workers' compensation, and personal injury, indicated no difference in insurance patterns (χ2=3.658, P=0.454). CONCLUSION: The findings revealed significant racial disparity in shoulder arthroplasty utilization both at national and institutional levels. This disparity exists despite the similar rates of osteoarthritis in both white and black patients. Black patients in our institution had similar clinical, demographic, and socioeconomic characteristics as in our non-black patients. The obtained results highlighted the need for the expansion of black patients' access to care services related to major joint reconstruction.

The effect of an orthopedic specialty hospital on operating room efficiency in shoulder arthroplasty.

BACKGROUND: Operating room (OR) time is a major cost to the health care system. Therefore, increasing OR efficiency to save time may be a cost-saving tool. This study analyzed OR efficiency in shoulder arthroplasty at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC). METHODS: All primary shoulder arthroplasties performed at our OSH and TRC were identified (2013-2015). Manually matched cohorts from the OSH and TRC were compared for OR times. Three times (minutes) were recorded: anesthesia preparation time (APT; patient in room to skin incision), surgical time (ST; skin incision to skin closed), conclusion time (CT; skin closed to patient out of room). RESULTS: There were 136 primary shoulder arthroplasties performed at the OSH and matched with 136 at the TRC. OSH and TRC patients were similar in age (P = .95), body mass index (P = .97), Charlson Comorbidity Index (P = 1.000), sex (P = 1.000), procedure (P = 1.000), insurance status (P = .714), discharge destination (P = .287), and diagnoses (P = .354). These matched populations had similar ST (OSH: 110.0 ± 26.6 minutes, TRC: 113.4 ± 28.7 minutes; P = .307). APT (39.2 ± 8.0 minutes) and CT (7.6 ± 3.8 minutes) were shorter in the OSH patients than APT (46.3 ± 8.8 minutes; P < .001) and CT (11.2 ± 4.7 minutes; P < .001) in TRC patients. Total nonoperative time (sum of APT and CT) at the OSH (46.8 ± 8.9 minutes) was shorter than at the TRC (57.5 ± 10.4 minutes; P < .001). CONCLUSIONS: Despite similar patient populations and case complexity, the OR efficiency at an OSH was superior to a TRC. Further analysis is needed to determine the financial implications of this superior OR efficiency.

Clinical Outcomes After Four-Level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Anterior cervical discectomy and fusion (ACDF) demonstrates reliable improvement in neurologic symptoms associated with anterior compression of the cervical spine. There is a paucity of data on outcomes following 4-level ACDFs. The purpose of this study was to evaluate clinical outcomes for patients undergoing 4-level ACDF. METHODS: All 4-level ACDFs with at least 1-year clinical follow-up were identified. Clinical outcomes, including fusion rates, neurologic outcomes, and reoperation rates were determined. RESULTS: Retrospective review of our institutional database revealed 25 patients who underwent 4-level ACDF with at least 1-year clinical follow-up. Average age was 57.5 years (range 38.2-75.0 years); 14 (56%) were male, and average body mass index was 30.2 kg/m2 (range 19.9-43.4 kg/m2). Two (8%) required secondary cervical surgery at an average of 94.5 days postoperatively while the remaining 23 did not with an average follow-up of 19 months. Of 23 patients not requiring revision surgery, 16 (69%) patients fused by definition of less than 1 mm of spinous process motion per fused level in flexion and extension. Fifteen (65%) had at least one muscle group with one grade of weakness preoperatively. Nineteen of these patients (83%) had improved to full strength while no patients lost muscle strength. CONCLUSIONS: Review of our institution's experience demonstrated a low rate of revision cervical surgery for any reason of 8% at mean 19 months follow-up, and neurological examinations consistently improved, despite a high rate of radiographic nonunion (31%).

Treatment of periprosthetic joint infection of the elbow: 15-year experience at a single institution.

BACKGROUND: Total elbow arthroplasty (TEA) can be complicated by periprosthetic joint infection (PJI) with potentially catastrophic failure. The purpose of this study was to describe the results of elbow PJI treatment at a tertiary-care referral center. METHODS: An institutional TEA database was queried for infection and reoperation after TEA. Patients who underwent irrigation and débridement (I&D) with component retention were compared with those who underwent component explantation, antibiotic spacer placement, and reimplantation of a revision TEA. RESULTS: A total of 26 patients (10 men; mean age, 64.3 years) were treated for PJI of TEA. There were 3 polymicrobial infections (11.5%) and 13 Staphylococcus aureus infections (50%) (4 methicillin resistant); 6 patients (23.1%) had negative culture results. Ten patients (38.5%) underwent I&D and component retention, with 5 of those patients (5 of 10, 50%) having recurrent infection at an average of 3.1 years (range, 0.25-7.8 years) after I&D. Of 16 patients who underwent antibiotic spacer placement, 12 (75%) underwent 2-stage reimplantation of a TEA. Among those with reimplantation, 4 of 12 (33.3%) required reoperation. In 3 of 12 (25.0%), reoperation was required for infection, whereas 1 of 12 (8.3%) required surgery for mechanical complications. CONCLUSION: Two-stage revision results in a decreased rate of recurrent PJI. Certain patients (those with poor health or well-fixed components) may be more suitable for I&D and component retention, with a demonstrated 50% success rate over a period of 3 years. Longer-term follow-up may result in higher reinfection rates in both groups.

Outcomes of an anatomic total shoulder arthroplasty with a contralateral reverse total shoulder arthroplasty.

BACKGROUND: It is common for patients to require staged bilateral shoulder arthroplasties. There is a unique cohort of patients who require an anatomic total shoulder arthroplasty (TSA) and a contralateral reverse shoulder arthroplasty (RSA). This study compared the outcomes of patients with a TSA in 1 shoulder and an RSA in the contralateral shoulder. METHODS: Our institutional database was queried to identify all patients with a TSA and a contralateral RSA. Data collection included patient demographics, preoperative and latest follow-up shoulder range of motion, radiographic analysis, and postoperative complications. Identified patients were assessed at follow-up visits or contacted by phone for functional outcome scores. RESULTS: Nineteen patients met our inclusion/exclusion criteria. There was statistically significant greater internal rotation in the TSA shoulder (P= .044) but no significant difference in forward elevation (P = .573) or external rotation (P= .368). There was no radiographic evidence of humeral or glenoid component loosening of any arthroplasty implants. There were no significant differences between TSA and RSA shoulders for the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (P= .381), Simple Shoulder Test (P = .352), Single Assessment Numerical Evaluation (P = .709), and visual analog scale satisfaction (P= .448) or pain scores (P= .305). Thirteen patients (68.4%) preferred the RSA side, 1 patient (5.3%; z = 4.04, P < .001) patient preferred the TSA side, and 5 patients expressed no preference. CONCLUSION: Despite known limitations and differences between TSA and RSA designs, patients who have received both implants are highly satisfied with both. The only parameter in which the TSA had superior outcomes was internal rotation.

Trends and Variability in the Use of Total Shoulder Arthroplasty for Medicare Patients.

INTRODUCTION: As policies are implemented to encourage high-quality care, it is important to identify any persistent limitations to the uniform delivery of anatomic and reverse total shoulder arthroplasty (TSA). The study's goal was to assess current TSA use and identify predictors of geographic variability. METHODS: We used data from 2012 through 2014 that was obtained from public Medicare databases to identify the case volume, locations, and names of surgeons performing >10 TSAs annually. We also recorded regional characteristics of the Medicare population, including demographic characteristics and health factors. RESULTS: From 2012 through 2014, the number of surgeons performing >10 TSAs annually increased from 824 to 1,060-an increase ranging from 0.75 to 0.95 TSAs per 1,000 beneficiaries. In 2012, there were 59 hospital referral regions with no TSAs performed; the number of regions decreased to 35 by 2014 (P = 0.009). The use of TSA varied widely across regions (range, 0.1 to 6.4 per 1,000 beneficiaries). A larger proportion of white patients and a smaller proportion of patients eligible for Medicaid were independent predictors for increased use of TSA. Despite this finding, 74.4% and 96.9% of the US population resided within 50 km and 200 km, respectively, of a surgeon performing at least 20 TSAs in Medicare patients annually. DISCUSSION: TSA utilization in the Medicare population is increasing across the country. Although notable geographic disparities in the use of TSA persist, increased TSA utilization has provided greater access to surgeons with high-volume TSA caseloads. CONCLUSION: Substantial geographic variation in TSA use remains, largely due to socioeconomic factors.

Short-term Outcomes of Total Knee Arthroplasty Performed at an Orthopedic Specialty Hospital.

This study compared perioperative outcomes for total knee arthroplasty (TKA) at an orthopedic specialty hospital and a tertiary referral center. The authors identified all primary TKA procedures performed in 2014 at the 2 facilities. Each patient at the orthopedic specialty hospital was manually matched to a patient at the tertiary referral center according to demographic and clinical variables. Matching was blinded to outcomes. Outcomes were 90-day readmission, mortality rate, reoperation, length of stay, and use of inpatient rehabilitation. Each group had 215 TKA patients. The 2 groups of patients were similar in age (66.8 years, P=.98), body mass index (30.4 kg/m2, P=.99), age-adjusted Charlson Comorbidity Index (3.4, P=1.00), and sex (46.0% male, P=1.00). Mean length of stay was 1.47±0.62 days at the orthopedic specialty hospital vs 1.87±0.75 days (P<.01) at the tertiary referral center. There were 3 readmissions at the orthopedic specialty hospital and 6 readmissions at the tertiary referral center (P=.31). There were 6 reoperations at the orthopedic specialty hospital and 5 at the tertiary referral center (P=.76). In addition, 8 patients at the orthopedic specialty hospital used inpatient rehabilitation vs 15 patients at the tertiary referral center (P=.08). One patient who was treated at the orthopedic specialty hospital required transfer to a tertiary referral center. This study found that perioperative outcomes were similar for matched patients who underwent primary TKA at an orthopedic specialty hospital and a tertiary referral center. Patients treated at the orthopedic specialty hospital spent 0.4 fewer days in the hospital compared with matched patients who were treated at the tertiary referral center. This equals 2 fewer hospital nights for every 5 TKA patients. [Orthopedics. 2018; 41(1):e84-e91.].

Antibiotic Spacers in Shoulder Arthroplasty: Comparison of Stemmed and Stemless Implants.

BACKGROUND: Antibiotic spacers in shoulder periprosthetic joint infection deliver antibiotics locally and provide temporary stability. The purpose of this study was to evaluate differences between stemmed and stemless spacers. METHODS: All spacers placed from 2011 to 2013 were identified. Stemless spacers were made by creating a spherical ball of cement placed in the joint space. Stemmed spacers had some portion in the humeral canal. Operative time, complications, reimplantation, reinfection, and range of motion were analyzed. RESULTS: There were 37 spacers placed: 22 were stemless and 15 were stemmed. The stemless spacer population was older (70.9 ± 7.8 years vs. 62.8 ± 8.4 years, p = 0.006). The groups had a similar percentage of each gender (stemless group, 45% male vs. stemmed group, 40% male; p = 0.742), body mass index (stemless group, 29.1 ± 6.4 kg/m2 vs. stemmed group, 31.5 ± 8.3 kg/m2; p = 0.354) and Charlson Comorbidity Index (stemless group, 4.2 ± 1.2 vs. stemmed group, 4.2 ± 1.7; p = 0.958). Operative time was similar (stemless group, 127.5 ± 37.1 minutes vs. stemmed group, 130.5 ± 39.4 minutes). Two stemless group patients had self-resolving radial nerve palsies. Within the stemless group, 15 of 22 (68.2%) underwent reimplantation with 14 of 15 having forward elevation of 109° ± 23°. Within the stemmed group, 12 of 15 (80.0%, p = 0.427) underwent reimplantation with 8 of 12 having forward elevation of 94° ± 43° (range, 30° to 150°; p = 0.300). Two stemmed group patients had axillary nerve palsies, one of which self-resolved but the other did not. One patient sustained dislocation of reverse shoulder arthroplasty after reimplantation. One stemless group patient required an open reduction and glenosphere exchange of dislocated reverse shoulder arthroplasty at 6 weeks after reimplantation. CONCLUSIONS: Stemmed and stemless spacers had similar clinical outcomes. When analyzing all antibiotic spacers, over 70% were converted to revision arthroplasties. The results of this study do not suggest superiority of either stemmed or stemless antibiotic spacers.

Survivorship of Hemiarthroplasty With Concentric Glenoid Reaming for Glenohumeral Arthritis in Young, Active Patients With a Biconcave Glenoid.

INTRODUCTION: Hemiarthroplasty with concentric glenoid reaming (known as "ream and run") may be an option for treating glenohumeral arthritis in younger patients with a biconcave glenoid. The goal of this study was to evaluate early results of this technique. METHODS: Two senior, fellowship-trained shoulder surgeons (G.R.W. and M.D.L.) performed a retrospective review of 23 patients (24 shoulders) with a biconcave glenoid and end-stage degenerative glenohumeral arthritis treated with hemiarthroplasty with concentric glenoid reaming. The mean patient age at the time of surgery was 50 years. We evaluated the Penn Shoulder Score (PSS), Single Assessment Numeric Evaluation (SANE) score, and Simple Shoulder Test (SST) score or the time to revision surgery. RESULTS: Twenty-four humeral hemiarthroplasties with concentric glenoid reaming were performed in 23 patients. Twenty patients (21 shoulders) reached the end point of 2-year follow-up or revision surgery. Six shoulders (25%) required revision surgery at an average of 2.7 years (range, 0.7 to 7.2 years), and three were lost to follow-up. The remaining 14 patients (15 shoulders) were followed up for an average of 3.7 years (range, 2.3 to 4.9 years). At 2-year follow-up, these 15 shoulders did not require revision surgery and had an average SANE score, PSS, and SST score of 74.5%, 82.9, and 10.4, respectively. Increasing age correlated positively with the SANE score (r = 0.62; P = 0.015), PSS (r = 0.52; P = 0.047), and SST score (r = 0.63; P = 0.012). Early postoperative forward elevation correlated weakly with the PSS (r = 0.24; P = 0.395), and early postoperative external rotation correlated moderately with the PSS (r = 0.53; P = 0.044). Final external rotation correlated moderately with the PSS (r = 0.69; P = 0.005). DISCUSSION: Modest results were achieved with a hemiarthroplasty and concentric glenoid reaming in young patients with end-stage glenohumeral arthritis and a biconcave glenoid. Younger age and stiffness were associated with worse outcomes. Given the high revision rate and the percentage of patients who had unsatisfactory results, this procedure should be performed only after careful patient selection. Patients who are willing and able to undergo aggressive physical therapy focused on achieving early range of motion are more likely to have a satisfactory outcome after humeral hemiarthroplasty with concentric glenoid reaming.

Total Ankle Arthroplasty: Comparing Perioperative Outcomes When Performed at an Orthopaedic Specialty Hospital Versus an Academic Teaching Hospital.

BACKGROUND: The number of total ankle arthroplasties (TAAs) performed in the United States has risen significantly in recent years, as has utilization of orthopaedic specialty hospital (OSH) to treat healthy patients undergoing elective surgery. The purpose of this study was to compare postoperative outcomes following TAA at an OSH when compared with a matching population of patients undergoing TAA at an academic teaching hospital (ATH). METHODS: We identified all TAA from January 2014 to December 2014 at the OSH and January 2010 to January 2016 at the ATH. Each OSH patient was manually matched with a corresponding ATH patient by clinical variables. Outcomes analyzed were length of stay (LOS), 30-day readmissions, mortality, reoperation, and inpatient rehabilitation utilization. RESULTS: There were 40 TAA patients in each group. OSH and ATH patients were similar in age, body mass index, age-adjusted Charlson Comorbidity Index, and gender. Average LOS for TAA at the OSH was 1.28 ± 0.51 compared with 2.03 ± 0.89 (P < .001) at the ATH. There were no OSH patients readmitted within 30 days, compared with 2 ATH patients readmitted (5.0%; P = .15). Two OSH patients (5.0%) and 2 ATH patients (5.0%; P = 1.00) required reoperation. There were no mortalities in either group. There were no OSH patients requiring transfer. CONCLUSIONS: Primary TAA performed at an OSH had significantly shorter LOS when compared with a matched patient treated at an ATH with no significant difference in readmission or reoperation rates and may offer a potential source of significant health care savings. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.