Limited reliability of grading scapular notching according to Nerot-Sirveaux on anteroposterior radiographs.

INTRODUCTION: Incidences of scapular notching (SN) in reverse shoulder arthroplasty (RSA) range between 0% and 96%, and controversy remain as to its relevance for patient outcome. We assessed the reliability of scapular notching (SN) grading based on the Sirveaux classification system using anteroposterior radiographs. MATERIALS AND METHODS: 206 RSA procedures with 5-year postoperative anteroposterior shoulder radiographs were classified independently by seven assessors according to Sirveaux (session 1). After a review meeting, three assessors re-classified the radiographs along with quality criteria (session 2). SN grading by the majority of assessors was taken as the reference. Classification interobserver reliability was analyzed using Kappa statistics. RESULTS: The incidence of SN was estimated at 53% and 37% at the first and second sessions, respectively. Interobserver reliability Kappa coefficients resulting from the first and second sessions were 0.27 and 0.43, respectively. Case selection based on radiographic quality criteria did not improve SN grading reliability in the second session. CONCLUSION: Agreement between individual surgeons was low when grading SN in RSA according to Sirveaux using anteroposterior radiographs. Consensus among several assessors may increase reliability in research settings.

Shoulder arthroplasty volume standards: the more the better?

INTRODUCTION: The wide use of hip and knee arthroplasty has led to implementation of volume standards for hospitals and surgeons. For shoulder arthroplasty, the effect of volume on outcome has been researched, but no volume standard exists. This review assessed literature reporting on shoulder arthroplasty volumes and its relation to patient-reported and functional outcomes to define an annual volume threshold. MATERIALS AND METHODS: MEDLINE and EMBASE were searched for articles published until February 2018 reporting on the outcome of primary shoulder arthroplasty in relation to surgeon or hospital volume. The primary outcome was predefined as any patient-reported outcome. The secondary outcome measures were length of stay, costs, rates of mortality, complications, readmissions, and revisions. A meta-analysis was performed for outcomes reported by two or more studies. RESULTS: Eight retrospective studies were included and did not consistently show any associations of volume with in-hospital complications, revision, discharge to home or cost. Volume was consistently associated with length of stay (shorter length of stay for higher volume) and in-hospital complications (fewer in-hospital complications for higher volume). It was not consistently associated with mortality. Functional outcomes were not reported. CONCLUSIONS: There is insufficient evidence to support the concept that only the number of shoulder arthroplasties annually performed (either per hospital or per surgeon) results in better patient-reported and functional outcomes. Currently, published volume thresholds are only based on short-term parameters such as length and cost of hospital stay.

Patient Outcomes as a Function of Shoulder Surgeon Volume: A Systematic Review.

PURPOSE: To examine surgical complications, length of stay, surgical time, cost, revision rates, clinical outcomes, current surgical trends. and minimum number of cases in relationship to surgeon volume for shoulder arthroplasty and rotator cuff repair. METHODS: We performed a systematic review of studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that met inclusion criteria from January 1990 to January 2016 were included. Inclusion criteria included Level IV evidence or greater, contained specific surgeon volume, and were written in or translated into English. Exclusion criteria included non-English manuscripts, abstracts, and review papers. A written protocol was used to extract relevant data and evaluate study results. Data extracted included volume-specific data pertaining to length of stay, operating time, complications, and cost. RESULTS: A total of 10 studies were included. Seven studies evaluated arthroplasty with 88,740 shoulders, and 3 studies evaluated rotator cuff repair with 63,535 shoulders. Variation was seen in how studies defined low- versus high-volume surgeon. For arthroplasty, <5 cases per year met the criteria for a low-volume surgeon and were associated with increased length of stay, longer operating room time, increased in-hospital complications, and increased cost. Mortality was not significantly increased. In rotator cuff surgery, <12 surgeries per year met the criteria for low volume and were associated with increased length of stay, increased operating room time, and increase in reoperation rate. CONCLUSIONS: Our systematic review demonstrates increased surgical complications, length of stay, surgical time, and surgical cost in shoulder arthroplasty and rotator cuff repair when performed by a low-volume shoulder surgeon, which is defined by those performing <5 arthroplasties and/or <12 rotator cuff repairs per year. LEVEL OF EVIDENCE: Level III, systematic review of Level II and III studies.

The Patient Experience: An Analysis of Orthopedic Surgeon Quality on Physician-Rating Sites.

BACKGROUND: With the advent of the Consensus Core of Orthopedic Measures, arthroplasty surgeons are increasingly subjected to public performance reviews on physician-rating sites. Therefore, we evaluated (1) web site details of physician-rating sites, (2) differences between sites and the Consensus Core, (3) published patient experiences, (4) search rank among sites, and (5) differences between academic vs nonacademic and arthroplasty vs nonarthroplasty surgeons. METHODS: The 5 busiest physician-rating sites were analyzed. To compare physician-rating sites to the Consensus Core, 3 reviewers analyzed the web site details. To evaluate patient ratings and reviews, orthopedists from the top 5 academic and nonacademic hospitals (2016 US News & World Report) were analyzed. Institution-produced rating sites were also analyzed. Findings were stratified between academic vs nonacademic and arthroplasty vs nonarthroplasty surgeons. Five hundred and six staff surgeons across 10 academic and nonacademic affiliated hospitals yielded 27,792 patient-generated ratings and reviews for 1404 accounts. RESULTS: Features on all sites were practice location, languages spoken, and patient experience. Two sites autogenerated profiles of surgeons without consent. No physician-rating site contained all Consensus Core domains. The composite orthopedic surgeon rating was 4.1 of 5. No significant differences were found between academic and nonacademic affiliated surgeons. Arthroplasty surgeons had a greater number of reviews and ratings on 2 sites. CONCLUSION: Reliability of physician-rating sites is questionable, as none contained all Consensus Core domains. Autogeneration of surgeon profiles is occurring, and no differences between academic vs nonacademic or arthroplasty vs nonarthroplasty surgeons were found. Institution-produced sites may serve to better promote and market surgeons.

Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015: Association of Anaesthetists of Great Britain and Ireland British Orthopaedic Association British Geriatric Society.

Concise guidelines are presented for the preparation and conduct of anaesthesia and surgery in patients undergoing cemented hemiarthroplasty for hip fracture. The Working Party specifically considered recent publications highlighting complications occurring during the peri-operative period. The advice presented is based on previously published advice and clinical studies.

Metric Development for an Arthroscopic Bankart Procedure: Assessment of Face and Content Validity.

PURPOSE: To establish the metrics (operational definitions) necessary to characterize a reference arthroscopic Bankart procedure, and to seek consensus from experienced shoulder arthroscopists on the appropriateness of the steps, as well as errors identified. METHODS: Three experienced arthroscopic shoulder surgeons and an experimental psychologist (comprising the Metrics Group) deconstructed an arthroscopic Bankart procedure. Fourteen full-length videos were analyzed to identify the essential steps and potential errors. Sentinel (i.e., more serious) errors were defined as either (1) potentially jeopardizing the procedure outcome or (2) creating iatrogenic damage to the shoulder. The metrics were stress tested for clarity and the ability to be scored in binary fashion during a video review as either occurring or not occurring. The metrics were subjected to analysis by a panel of 27 experienced arthroscopic shoulder surgeons to obtain face and content validity using a modified Delphi Panel methodology (consensus opinion of experienced surgeons rendered by cyclical deliberations). RESULTS: Forty-five steps and 13 phases characterizing an arthroscopic Bankart procedure were identified. Seventy-seven procedural errors were specified, with 20 designated as sentinel errors. The modified Delphi Panel deliberation created the following changes: 2 metrics were deleted, 1 was added, and 5 were modified. Consensus on the resulting Bankart metrics was obtained and face and content validity verified. CONCLUSIONS: This study confirms that a core group of experienced arthroscopic surgeons is able to perform task deconstruction of an arthroscopic Bankart repair and create unambiguous step and error definitions (metrics) that accurately characterize the essential components of the procedure. Analysis and revision by a larger panel of experienced arthroscopists were able to validate the Bankart metrics. CLINICAL RELEVANCE: The ability to perform task deconstruction and validate the resulting metrics will play a key role in improving surgical skills training and assessing trainee progression toward proficiency.

Evaluation of Quality of Lower Limb Arthroplasty Observational Studies Using the Assessment of Quality in Lower Limb Arthroplasty (AQUILA) Checklist.

UNLABELLED: This study used the assessment of quality in lower limb arthroplasty (AQUILA) checklist to assess the quality of lower limb arthroplasty observational studies. Among 132 studies the mean reporting quality score was 5.4 (SD=1.2) out of 8 possible points. Most studies adequately reported reasons for revisions (98%) and prosthesis brand and fixation (95%) in sufficient detail. Only 3% of studies adequately reported the number of patients unwilling to participate, 15% stated a clear primary research question or hypothesis, 11% reported a worst-case analysis or competing risk analysis for endpoints, and 42% reported more than 5% of patients were lost to follow-up. There is significant room for improvement in the reporting and methodology of lower limb arthroplasty observational studies. LEVEL OF EVIDENCE: Level III.

Mid- to long-term outcomes after cervical disc arthroplasty compared with anterior discectomy and fusion: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: To evaluate the mid- to long-term clinical outcomes after cervical disc arthroplasty (CDA) as compared with anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical disc disease. METHODS: A systematic review and a meta-analysis were performed for articles published up to March 2013. Randomized controlled trials that reported mid- to long-term outcomes (≥48 months) after CDA as compared with ACDF were included. Two authors independently extracted the articles and the predefined data. RESULTS: Five US Food and Drug Administration randomized controlled trials that reported 4-6 years of follow-up data were retrieved. Patients who underwent CDA had a lower mid- to long-term rate of reoperation and had greater mid- to long-term improvements in the Neck Disability Index, neck and arm pain scores, and Short Form 36 Health Survey physical component score than did those who underwent ACDF. Segmental motion was maintained in patients who underwent CDA. The mid- to long-term rates of adjacent segment disease and neurological success were not significantly different between the two groups. CONCLUSIONS: CDA may result in better mid- to long-term functional recovery and a lower rate of subsequent surgical procedures than ACDF would. A review of the literature showed that only an insufficient number of studies had investigated adjacent segment disease; therefore, it is mandatory that adequate future research should focus in this direction.

[Implementation of the EndoCert system for certification of arthroplasty centers. Experiences from the pilot phase]. / Die Einführung des EndoCert-Systems zur Zertifizierung von Endoprothesenzentren. Erfahrungen aus der Pilotphase.

BACKGROUND: EndoCert is an initiative of the Deutschen Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC, German Society for Orthopedics and Orthopedic Surgery) which has been available since October 2012 and is the first system worldwide for certification of specialized arthroplasty centers. Before implementation of this certification concept two sequential pilot phases were carried out with representative treatment institutions. The results from these pilot clinics are presented with respect to quality improvement effects. NONCONFORMITIES: Early effects on the quality of treatment have been achieved by rectification of nonconformities determined in the audit with respect to structural and process quality. A total of 172 nonconformities found in the 23 participating pilot clinics could be rectified. Long-term effects on the quality of results will in future be analyzed in cooperation with the German endoprosthesis register (EPRD) and by accompanying evaluations. FEEDBACK: A close feedback of the collated experiences and results to the certification committee, which is responsible for the procedure together with the DGOOC, allows continuous further development of the system CONCLUSION: EndoCert represents a substantial step towards a nationwide safety and improvement of the quality in arthroplasty treatment within the preoperative, perioperative and postoperative framework and can in future represent a decisive tool together with the EPRD in quality management.

Mechanical endurance and in vivo radiographic analysis of a flexible, mono-unit cervical disc implant in intermediate follow-up period.

AIM: The flexible artificial disc may create a system with a biomimetic structure that has the potential to tolerate dynamic motion in a way similar to a normal intervertebral disc over a long period. The objective was to evaluate the mechanical feasibility and clinical and radiological findings with a mono-unit and flexible artificial disc at intermediate-term follow-up. METHODS: Fifty-six patients with degenerative disc disease were selected to participate in the study. They underwent discectomy with a flexible artificial disc with a mean follow-up period of 24.8 months. Outcomes were evaluated with the visual analogue scale (VAS) and Oswestry Disability Index (ODI). Mechanical endurance was evaluated by a dynamic testing. RESULTS: Fifty one-levels and six bi-levels were included in the study (average age 41.8 years). VAS improved from 6.8 ± 2.2 to 1.5 ± 1.7 (P<0.05) and ODI improved from 43.1 ± 10.4 to 18.2 ± 10.2 (P<0.05). Disc height before mechanical testing was 8.9 mm, and decreased to 8.4 mm after six million cycles with no mechanical failure. CONCLUSION: Our results indicate that flexible and mono-unit cervical disc provides favorable mechanical performance and clinical outcomes for at least a relatively intermediate-term follow up period. It is indicated that the flexible cervical disc maintains mobility at the level of the prosthesis that is comparable with preoperative ranges of motion. Further evaluation will be completed once long-term results have been obtained.

Expert's comment concerning Grand Rounds case entitled "L5-S1 disc replacement after two previous fusion surgeries for scoliosis" (by S. Jehan, S. Elsayed, J. Webb and B. Boszczyk).

The attempt to preserve motion below a long fusion is certainly praiseworthy even if it is clearly understood with the patient that the result might be only temporary, buying some good years in the most active part of life. The analysis of the case presented here suggests that such an approach could be recommended in the right patient, with the right team. More experience and reports are necessary to evolve from an anecdotal report to a new path in the treatment of adult scoliosis.

L5-S1 disc replacement after two previous fusion surgeries for scoliosis.

Following scoliosis surgery, lumbar motion segment degeneration below the level of fusion is not uncommon. Especially long fusions extending to the mid and lower lumbar spine increase the likelihood of degeneration of the remaining motion segments. The management for these patients is controversial and depends on the clinical presentation and level of degeneration. The increasing confidence in motion-preserving technology leads to a dilemma on whether to fuse the remaining lumbar levels or risk utilising disc arthroplasty to preserve the remaining motion segments and facilitate coronal balance in patients with previous long fusion for scoliosis. We present an interesting case of a 44-year-old lady, who underwent two-stage corrective surgery for progressive idiopathic scoliosis at the age of 22 years. In the first stage, she had T11-L3 anterior fusion, whilst in the second stage posterior fusion was done from T5 to L3. At 22 years after the initial surgery, she presented with worsening low back pain and bilateral L4 radicular symptoms. MRI scan confirmed severe disc degeneration at L3-4 and L5-S1 levels with preserved L4-5 disc. She initially underwent L3-L4 decompression and posterolateral fusion at that level, which relieved her radicular symptoms. However, she had persistent pain at the lumbosacral junction with Modic I changes. The options of an anterior L5-S1 fusion or disc replacement were considered and discussed with the patient. The disc replacement option was decided upon with the patient, as anterior fusion was judged to increase the risk of coronal imbalance. At the 1-year follow-up, she reported significant improvement in the back pain. The radiographs at 1 year showed satisfactory position and function of the artificial disc replacement. The disc was flexed laterally, accommodating the coronal balance of the spine. We conclude that L5-S1 motion segment can be preserved with artificial disc replacement in patients with previous long fusion for scoliosis surgery. The real difficulty arises when choosing between disc replacement and extension of fusion. In our patient, the disc replacement has worked well so far. However, the disc is clearly at a mechanical disadvantage, and loss of function in the mid- or long term would not be surprising.

Sagittal balance parameters influence indications for lumbar disc arthroplasty or ALIF.

UNLABELLED: Chronic lower back pain is a potentially incapacitating condition associated with disc degeneration. Although therapy is primarily pharmaceutical, surgery comprising arthrodesis constitutes an alternative. Anterior intersomatic lumbar arthrodesis (ALIF, anterior interbody lumbar fusion) is the reference approach, although total disc arthroplasty may also be undertaken. Analysis of pelvic and spinal parameters provides the best indication of sagittal balance. MATERIALS AND METHODS: This was a prospective study in a continuous series of 99 patients presenting chronic lower back pain due to disc disease. Pelvic incidence, sacral slope, pelvic tilt, spino-sacral angle (SSA) and the four back types in the Roussouly classification were studied in radiographs of the whole spine under load using an EOS imaging system. RESULTS: The pre-operative SSA value for the study population was 126.09° ± 8.45° and the mean spine tilt angle was 90° compared with 95° in healthy subjects. Following surgery, the SSA was considerably increased in the discal arthroplasty, resulting in a significantly more balanced spinal position. In the group of patients undergoing arthrodesis using the ALIF technique, no such significant improvement was found despite the use of a lordosis cage. We showed that in cases of low pelvic incidence, it was necessary to maintain a Roussouly type 1 or 2 back without increasing lordosis. The results demonstrated the value of L4-L5 disc prostheses in these subjects. L5-S1 arthrodesis seemed a more suitable approach for treating patients with elevated sacral slope (back type 3 or 4). This new type of analysis of sagittal parameters should be performed prior to all surgical procedures involving lumbar prostheses.

Effect of arthroplasty design on cervical spine kinematics: analysis of the Bryan Disc, ProDisc-C, and Synergy disc.

OBJECT: Cervical total disc replacement has emerged as a surgical option to preserve motion and potentially avoid adjacent-segment disease after anterior cervical discectomy and fusion. Recently, much attention has been directed at the ability of a given device to maintain and/or restore normal segmental alignment. Nonphysiological disc and segmental angulation could result in increased stresses transmitted to the facet joints and posterior elements, conflicting with the essence of arthroplasty and potentially leading to adjacent-segment disease. The goal of this study was to contrast device alignment and segmental kinematics provided by 3 different cervical disc prostheses. METHODS: Sixty patients were retrospectively analyzed and divided into 3 groups receiving the Bryan, ProDisc-C, or Synergy disc. Only single-level arthroplasty cases were included in the study. Lateral dynamic radiographs of the cervical spine were analyzed using quantitative motion analysis software (Medical Metrics, Inc.) to analyze the kinematics at the index level both preoperatively and postoperatively. Several parameters were noted, including range of motion, disc angles, shell angles, anterior and posterior disc heights, translation, and center of rotation. Preoperative and postoperative data were compared using the Student t-test with a significance level of p < 0.05. RESULTS: Postoperatively, all 3 disc groups maintained adequate range of motion at the implanted level. With respect to the shell angles, the Synergy disc demonstrated the least variability, maintaining 6 degrees lordotic configuration between the device endplates. In the Bryan disc group, significant shell kyphosis developed postoperatively (p < 0.0001). Both ProDisc-C and Synergy discs significantly increased anterior and posterior disc heights (p < 0.0001). The Bryan and Synergy discs maintained the natural center of rotation, whereas significant anterior shift occurred with ProDisc-C. CONCLUSIONS: The goal for motion preservation at the implanted level was achieved using all 3 devices. The Synergy disc was unique in its ability to alter device angulation by 6 degrees. The Bryan disc demonstrated device endplate kyphosis. Both the Synergy disc and ProDisc-C increased disc space height.

Mitigating Biases in a Cohort Study: A Critical Examination of the Silicone Arthroplasty in Rheumatoid Arthritis Study.

Research bias, or the systematic errors of a study, can arise before, during, or after a trial ends. These biases hinder the internal validity of the study, which is the accuracy of a study's conclusions regarding the effects of an intervention on a given group of subjects. With the growing use of evidence-based medicine, there is a demand for high-quality evidence from the research community. Systematic reviews and meta-analyses of randomized controlled trials are considered the highest level of evidence, followed by individual randomized controlled trials. However, most surgical trials cannot be conducted as randomized controlled trials because of factors such as patient preferences and lack of equipoise among surgeons. Therefore, surgical trials may lack features that are held as important standards for high-quality evidence, such as randomization and blinding. To demonstrate the biases that surgical trials may encounter, the authors examined a prospective cohort study, the Silicone Arthroplasty in Rheumatoid Arthritis study. The authors focus on the challenges that arise during a surgical trial, including the design, implementation, and methods used to report the clinical evidence. By recognizing and addressing obstacles that exist in research, investigators will provide health care providers with high-quality evidence needed to make well-informed, evidence-based clinical decisions.

Pathology Assessment of Femoral Head Resection Specimens: An Important Quality Assurance Procedure.

CONTEXT.­: Decisions to perform hip arthroplasty rely on both radiographic and clinical findings. Radiologists estimate degree of osteoarthritis (OA) and document other findings. Arthroplasty specimens are sometimes evaluated by pathology. OBJECTIVE.­: To determine the frequency of pathologic changes not recognized clinically. DESIGN.­: Nine hundred fifty-three consecutive femoral head resections performed between January 2015 and June 2018, with recent radiologic and histologic study, were reviewed. We compared severity of OA reported by radiology and pathology. Findings unrecognized radiographically but recorded pathologically, and discrepancies between clinical diagnosis and pathology diagnosis, were tabulated. RESULTS.­: Twenty-one cases of osteomyelitis were diagnosed radiographically or pathologically. Eight discrepancies were present. Fourteen osteomyelitis cases were recognized clinically. Pathology recognized 2 neoplasms missed radiographically. Avascular necrosis was diagnosed on pathology but not radiology in 25 cases, and 35 cases of avascular necrosis were seen radiographically but not pathologically. Osteoarthritis was graded both radiographically and pathologically from 0 to 3. Five hundred ninety-one of 953 cases (62%) were grade 3. Pathologists and radiologists had perfect agreement in 696 of 953 cases (73%). When grade of OA seen at pathology was correlated with surgeon, 2 groups of surgeons were detected: one with a low threshold for performance of hip arthroplasty (23%-28% low-severity OA) and the second with a high threshold (2%-5% low-severity OA). CONCLUSIONS.­: Correlation between radiology and pathology diagnoses is high. Degree of OA present varies significantly between surgeons. Pathology discloses findings not recognized clinically.

Healthcare quality measurement in orthopaedic surgery: current state of the art.

Improving quality of care in arthroplasty is of increasing importance to payors, hospitals, surgeons, and patients. Efforts to compel improvement have traditionally focused measurement and reporting of data describing structural factors, care processes (or 'quality measures'), and clinical outcomes. Reporting structural measures (eg, surgical case volume) has been used with varying degrees of success. Care process measures, exemplified by initiatives such as the Surgical Care Improvement Project measures, are chosen based on the strength of randomized trial evidence linking the process to improved outcomes. However, evidence linking improved performance on Surgical Care Improvement Project measures with improved outcomes is limited. Outcome measures in surgery are of increasing importance as an approach to compel care improvement with prominent examples represented by the National Surgical Quality Improvement Project. Although outcomes-focused approaches are often costly, when linked to active benchmarking and collaborative activities, they may improve care broadly. Moreover, implementation of computerized data systems collecting information formerly collected on paper only will facilitate benchmarking. In the end, care will only be improved if these data are used to define methods for innovating care systems that deliver better outcomes at lower or equivalent costs.