Pyrocarbon hemiarthroplasty of the shoulder: a systematic review and meta-analysis of clinical results.

BACKGROUND: Hemiarthroplasty is often considered in the setting of preserved glenoid cartilage given the high risk of revision associated with total shoulder arthroplasty. Pyrocarbon (PyC) has been used as an implant material that theoretically allows for formation of a neo-membrane that would act like cartilage to reduce glenoid wear. The purpose of this study was to evaluate the clinical outcomes, radiographic outcomes, revision rates, and complication rates in the existing literature on shoulder hemiarthroplasty using PyC. METHODS: The MEDLINE, Embase, and Scopus databases were searched for articles relating to shoulder hemiarthroplasty using the terms "pyrocarbon" or "pyrolytic carbon." Abstracts and articles were screened against predefined inclusion and exclusion criteria, with a minimum of 24 months' follow-up required. Data on patient demographic characteristics, clinical outcome scores, complications, revision rates, and radiographic findings were recorded. Where appropriate, meta-analysis was performed. RESULTS: Twelve studies were selected for final inclusion, with a total of 536 patients. Among the studies reporting preoperative and postoperative range of motion (ROM), an overall improvement in ROM was observed. The mean Constant score was 70.9 points postoperatively, with a mean improvement of 36.2 points (n = 359, 9 studies). Radiographically, 22.8% of patients (n = 536, 8 studies) had evidence of glenoid erosion, 10.4% had changes in implant positioning, and 9.9% had tuberosity thinning. In addition, 1.5% of patients had radiographic subacromial space reduction, whereas 0.7% had an increase in tuberosity thickness. Across all studies, there was an 8.6% complication rate, with the most common cause being glenoid erosion (2.6%, n = 14). There was an overall 7.7% revision rate (n = 41), with 63% of revisions (n = 26) undergoing conversion to reverse or total shoulder arthroplasty. CONCLUSION: PyC hemiarthroplasty shows overall improvements in ROM and patient-reported outcomes for patients. However, there remains concern for glenoid erosion on radiographic evaluation at minimum 2-year follow-up. Although preliminary studies have shown encouraging results, this systematic review emphasizes the need for longer-term follow-up studies with further radiographic evaluation of the severity of glenoid erosion and the association with functional outcomes and failure risk.

The characteristics of opioid use in patients with proximal humerus fractures.

BACKGROUND: Orthopaedic surgeons prescribe more opioid narcotics than any other surgical specialty. Proximal humerus fractures (PHF) often occur in the high-risk elderly population. The opioid epidemic has led to public policy aimed at reductions in opioid prescription. This study aimed to evaluate the impact that new legislation has had on opioid prescription patterns in patients who sustained proximal humerus fractures. METHODS: A retrospective review of all patients who sustained PHF at a single academic institution from 1/1/2015-12/31/2019 was performed. A total of 762 proximal humerus fractures were identified and final analysis included 383 patients. Collected data included basic demographics and opioid prescriptions obtained through review of the electronic medical record. The North Carolina Strengthen Opioid Misuse Prevention act legislation that went into effect on July 1, 2017. RESULTS: There was no difference in the number of pre- or postoperative opioid prescriptions provided with the new legislation. Our data showed a significant reduction in MeQs prescribed preoperatively pre-STOP act (188.1 MeQs) and post-STOP act (99.4 MeQs). There was also a significant difference in the amount of postoperative narcotics prescribed in the pre-STOP (972.6 MeQs) and post-STOP act (508.6 MeQs) groups (p < 0.01). CONCLUSIONS: With the enactment of the STOP act in North Carolina, we have seen a significant reduction in the amount of narcotic prescribed after sustaining a proximal humerus fracture preoperatively and postoperatively. This data demonstrates the impact that implementation of state-wide regulatory changes in opioid prescribing policy has had for a common orthopedic condition.

Impairment in neurocognitive function following experimental neonatal guinea pig cytomegalovirus infection.

BACKGROUND: Cytomegalovirus (CMV) is a leading infectious cause of neurologic deficits, both in the settings of congenital and perinatal infection, but few animal models exist to study neurodevelopmental outcomes. This study examined the impact of neonatal guinea pig CMV (GPCMV) infection on spatial learning and memory in a Morris water maze (MWM) model. METHODS: Newborn pups were challenged intraperitoneally (i.p.) with a pathogenic red fluorescent protein-tagged GPCMV, or sham inoculated. On days 15-19 post infection (p.i.), pups were tested in the MWM. Viral loads were measured in blood and tissue by quantitative PCR (qPCR), and brain samples collected at necropsy were examined by histology and immunohistochemistry. RESULTS: Viremia (DNAemia) was detected at day 3 p.i. in 7/8 challenged animals. End-organ dissemination was observed, by qPCR, in the lung, liver, and spleen. CD4-positive (CD4+) and CD8-positive (CD8+) T cell infiltrates were present in brains of challenged animals, particularly in periventricular and hippocampal regions. Reactive gliosis and microglial nodules were observed. Statistically significant spatial learning and memory deficits were observed by MWM, particularly for total maze distance traveled (p < 0.0001). CONCLUSION: Neonatal GPCMV infection in guinea pigs results in cognitive defects demonstrable by the MWM. This neonatal guinea pig challenge model can be exploited for studying antiviral interventions. IMPACT: CMV impairs neonatal neurocognition and memory in the setting of postnatal infection. The MWM can be used to examine memory and learning in a guinea pig model of neonatal CMV infection. CD4+ and CD8+ T cells infiltrate the brain following neonatal CMV challenge. This article demonstrates that the MWM can be used to evaluate memory and learning after neonatal GPCMV challenge. The guinea pig can be used to examine central nervous system pathology caused by neonatal CMV infection and this attribute may facilitate the study of vaccines and antivirals.

Epidemiology of Shoulder Instability Injuries in Collision Collegiate Sports From 2009 to 2014.

PURPOSE: To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate collision athletes during the 2009-2010 through 2013-2014 academic years using the National Collegiate Athletic Association Injury Surveillance Program; to compare the injury incidence between men's collision sports and their women's non-collision counterparts, when possible; and to compare injury outcomes between Divisions I, II, and III. METHODS: Data regarding men's football, wrestling, ice hockey, and lacrosse, as well as women's ice hockey and lacrosse, were obtained. Injuries requiring attention from a health care provider were reported. Incidence rates per 100,000 athlete-exposures (AEs) were calculated with 95% confidence intervals (CIs). Analysis of variance was used to compare time loss (TL), and χ2 analysis was used to compare surgery rates between divisions. RESULTS: A total of 445 shoulder instability injuries occurred in 1,421,561 AEs from 2009-2010 to 2013-2014 (incidence rate, 31.30 injuries/100,000 AEs; 95% CI, 28.4-34.21 injuries/100,000 AEs). Subluxation accounted for 59.1% of injuries, with anterior subluxation (35.3%) being the most common injury. Dislocation resulted in the most TL per injury (17.58 days). Mean TL for all injuries was 8.17 days (standard deviation, 7.21 days). When non-time-loss injuries were excluded from analysis, players experienced a mean TL of 18.34 days (standard deviation, 8.44 days). Divisions I (4.77 days), II (20.52 days), and III (11.23 days) differed significantly in mean TL (P = .01). Of the injuries, 29.3% required surgery. The surgery rates for Divisions I (32.9%), II (38.1%), and III (19.4%) also differed significantly (P = .04). Men's ice hockey and lacrosse players sustained a 2.17-fold (95% CI, 1.04-4.50) higher incidence of shoulder instability than their female counterparts. CONCLUSIONS: Anterior subluxation and dislocation accounted for 52.1% of all shoulder instability injuries. Injured athletes missed 8 days on average, and nearly 30% of injuries required surgery. Surgery rates and TL were significantly different between Divisions I, II, and III. Female athletes playing non-collision ice hockey and lacrosse experienced significantly lower shoulder instability rates than their male counterparts. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Association between sleep dysfunction and Patient-Reported Outcomes Measurement Information System scores in patients with rotator cuff tears.

OBJECTIVES: The purpose of this study was to utilize Patient-Reported Outcomes Measurement Information System (PROMIS) sleep scores to determine the prevalence of sleep dysfunction and its association with other PROMIS scores in patients with rotator cuff tears (RCT). METHODS: Patients were retrospectively identified using the International Classification of Diseases-10 codes for RCT pathology, and PROMIS outcomes were assessed at multiple visits between November 2017 and February 2020. Generalized linear mixed effects models were fitted with PROMIS sleep score as the predictor variable and other PROMIS scores as the response variable. Additionally, models were fit using a clinically significant dichotomization of PROMIS sleep scores to assess differences in average PROMIS scores. RESULTS: The study cohort included 481 patients, 201 (41.8 â€‹%) of whom had disrupted sleep at first visit. A higher percentage of those with disrupted sleep at first visit were female, nonwhite, and not married compared to those with normal sleep. PROMIS scores at first visit differed by sleep category. Higher PROMIS sleep scores were associated with higher anxiety, depression, fatigue, pain intensity, and pain interference scores and lower physical function, social participation, and upper extremity scores. Relationships were similar when dichotomous PROMIS sleep scores were considered. CONCLUSION: There was a high prevalence of sleep dysfunction in patients with RCT. Sleep disturbance is associated with increased anxiety, depression, fatigue, pain intensity, pain interference and decreased physical function, social participation, and upper extremity function in patients with RCTs. LEVEL OF EVIDENCE III: Retrospective Cohort Study.

Operative Versus Nonoperative Treatment of Acute Achilles Tendon Rupture: A Propensity Score-Matched Analysis of a Large National Dataset.

Background: No consensus exists regarding the superiority of operative versus nonoperative management for Achilles tendon ruptures, as multiple randomized controlled trials conducted since the advent of early mobilization protocols have found outcomes for these 2 interventions to be more similar than were previously held. Purpose: To use a large national database to (1) compare reoperation and complication rates between operative and nonoperative treatment of acute Achilles tendon ruptures and (2) evaluate trends in treatment and cost over time. Study Design: Cohort study; Level of evidence, 3. Methods: The MarketScan Commercial Claims and Encounters database was used to identify an unmatched cohort of 31,515 patients who sustained primary Achilles tendon ruptures between 2007 and 2015. Patients were stratified into operative and nonoperative treatment groups, and a propensity score-a matching algorithm-was used to establish a matched cohort of 17,996 patients (n = 8993 per treatment group). Reoperation rates, complications, and aggregate treatment costs were compared between groups with an alpha level of .05. A number needed to harm (NNH) was calculated from the absolute risk difference in complications between cohorts. Results: The operative cohort experienced a significantly larger total number of complications within 30 days of injury (1026 vs 917; P = .0088). The absolute increase in cumulative risk was 1.2% with operative treatment, which resulted in an NNH of 83. Neither 1-year (1.1% [operative] vs 1.3% [nonoperative]; P = .1201) nor 2-year reoperation rates (1.9% [operative] vs 2% [nonoperative]; P = .2810) were significantly different. Operative care was more expensive than nonoperative care at 9 months and 2 years after injury; however, there was no difference in cost between treatments at 5 years. Before matching, the rate of surgical repair for Achilles tendon rupture remained stable, from 69.7% to 71.7% between 2007 and 2015, indicating little change in practice in the United States. Conclusion: Results indicated no differences in reoperation rates between operative and nonoperative management of Achilles tendon ruptures. Operative management was associated with an increased risk of complications and higher initial costs, which dissipated over time. Between 2007 and 2015 the proportion of Achilles tendon ruptures managed operatively remained similar despite increasing evidence that nonoperative management of Achilles tendon rupture may provide equivalent outcomes.

Microdrilling Resulted in Less Subchondral Bone Destruction Than a Traditional Microfracture Awl for Articular Cartilage Defect Bone Marrow Stimulation.

Purpose: The purpose of this study was to compare bone marrow stimulation using micro-computed tomography (micro-CT) analysis of an abrasion arthroplasty technique, drilling k-wire technique, traditional microfacture awl, or a microdrill instrument for subchondral bone defects. Methods: Eleven cadaveric distal femoral specimens were obtained and divided into 3 common areas of osteochondral defect: trochlea and weightbearing portions of the medial and lateral femoral condyles. Each area of interest was then denuded of cartilage using a PoweRasp and divided into quadrants. Each quadrant was assigned either a 1.6 mm Kirschner wire (k-wire), 1.25 mm microfracture awl, 1.5 mm fluted microdrill, PowerPick, or a curette (abrasion arthroplasty) to create 4 channels into the subchondral bone sing the same instrument. Subchondral bone and adjacent tissue areas were then evaluated using micro-CT to analyze adjacent bone destruction and extension into the bone marrow. Results: Overall, there was a significantly decreased area of bone destruction or compression using the microdrill (0.030 mm) as compared to the microfracture awl (0.072 mm) and k-wire (0.062 mm) (P < .05). Within the trochlea and the medial femoral condyle, there was significantly decreased bony compression with the microdrill as compared to the awl and k-wire (P < .05); however, when stratified, this was not significant among the lateral femoral condylar samples (P = .08). Conclusion: Bone marrow stimulation causes bony compression that may negatively impact subchondral bone and trabecular alignment. It is important to understand which tools used for bone marrow stimulation cause the least amount of damage to the subchondral bone. Clinical Relevance: This study demonstrates the decreased subchondral bony defects seen with the microdrill versus the traditional microfracture awl indicating that when performing bone marrow stimulation, the microdrill may be a less harmful tool to the subchondral bone.

The Efficacy of Peroxide Solutions in Decreasing Cutibacterium acnes Burden Around the Shoulder.

BACKGROUND: Cutibacterium acnes is a common pathogen associated with surgical site infection after shoulder surgery; current standard of care products are largely ineffective at reducing C acnes bacterial burden before surgery. The purpose of this systematic meta-analysis was to assess the efficacy of peroxide-containing solutions (PCS) in decreasing the C acnes burden on the shoulder. METHODS: This was a systematic review of all level I and II studies investigating the effect of peroxidase-containing products for skin preparation. We extracted data regarding demographics, treatment details and timing, study methodology, and culture positivity. Forest plots were used to determine the pooled efficacy of peroxide solutions versus control. RESULTS: Seven studies with 412 patients were eligible for inclusion. Notable heterogeneity was observed in the manner and timing of peroxide application. Two studies applied PCS at the time of surgery; four studies applied PCS in the 24- to 72-hour period leading up to culture acquisition. Compared with the placebo, peroxide significantly diminished C acnes culture positivity (Hazard Ratio 0.174, P = 0.009). When considering using peroxide-containing products in the period leading up to surgery or at the time of surgery, in addition to standard preparation, the addition of peroxide significantly diminished C acnes culture positivity (HR 0.467, P = 0.004). Owing to study heterogeneity, we could not make notable comparisons based on the timing or duration of benzoyl peroxides application. CONCLUSIONS: Despite heterogeneity in study design, pooled results of high-quality data suggest that the addition of PCS can markedly reduce C acnes bioburden. This review was not able to identify the ideal regimen for the utilization of PCS for reduction of C acnes burden. LEVEL OF EVIDENCE: Level II.

Perioperative Management in Shoulder Arthroplasty: A Review of Current Practice.

Perioperative management for patients undergoing shoulder arthroplasty has evolved significantly over the years to reduce overt complications and improve patient outcomes. The groundwork for perioperative care encompasses initial patient selection and education strategies for achieving successful outcome. Multimodal pain management strategies have advanced patient care with the increased use of new regional/local anesthetics. In addition, complications resulting from blood loss and transfusions have been curtailed with the use of synthetic antifibrinolytic agents. It remains critical for shoulder arthroplasty surgeons to optimize patients during the perioperative period through various modalities to maximize functional progression, outcomes, and patient's satisfaction following shoulder arthroplasty.

Surgical Skills Course for Fourth Year Medical Students Entering an Orthopaedic Surgery Residency.

This article was migrated. The article was marked as recommended. Surgical skills training outside of the operating room is a critical component of surgical education. There has been little incorporation of these programs for medical students entering orthopaedic surgery residencies. As such, there is concern that incoming orthopaedic residents matriculate with skills below residency programs' expectations. This study aimed to assess the need for an orthopaedic surgical skills course during the 4 th year of medical school.An anonymous electronic survey was emailed to 1457orthopaedic surgery residents and 732 current orthopaedic residency applicants using application data from a single orthopaedic residency program during the 2015-2016 through 2017-2018 cycles. 200 resident and 31 applicant emails were returned undeliverable, resulting in distribution to 1257 residents and 701 applicants. 135 junior residents (11% response rate) and 181 applicants (26% response rate) completed portions of the survey. 76 of 117 (65%) residents and 170 of 181 (94%) applicants did not participate in a formal orthopaedic surgical skills course. 110 of 118 (93%) residents and 160 of 171 (94%) applicants indicated that implementing such a course before entering residency would be beneficial. Applicants rated basic fracture reduction (95%; 171/180), casting/splinting (94%; 170/180), and reading basic x-rays (90%; 162/180) as the most important potential course components.Most respondents were not exposed to an orthopaedic skills course prior to residency. Participants indicated that such a course would be beneficial to incoming orthopaedic residents. Pilot programs should be developed to optimize an orthopaedic preparatory skills course for 4 th year medical students pursuing careers in orthopaedic surgery.

Gender-related Differences in Research Productivity, Position, and Advancement Among Academic Orthopaedic Faculty Within the United States.

INTRODUCTION: The number of female residents in orthopaedic surgery is rising; however, orthopaedics currently has the lowest percentage of women among all medical specialties. The Hirsch index (h-index) is a metric used to determine research productivity, an important factor for academic promotion in the field of orthopaedics. The purpose of this study was to compare research productivity (using the h-index) among male and female orthopaedic surgeons at academic residency programs within the United States. METHODS: The websites for all Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs in the United States were evaluated and the following information was collected: geographic region of the institution, sex, specialty, academic rank, and institutional leadership positions of faculty members. The h-index for each faculty member was collected from the Web of Science Database. RESULTS: H-indices of 4,323 academic orthopaedic surgeons from 160 residency programs in the United States were collected. In total, 1,587 faculty members were assistant professors (220, 13.9% women), 839 were associate professors (91, 10.8% women), 902 were professors (50, 5.5% women), and academic rank was not specified for 991 (74, 7.5% women). One hundred forty-three faculty members held the position of department chair (2, 1.4% women) and 701 were division chiefs (58, 8.3% women). In geographic regions with a greater proportion of female orthopaedic faculty members, women had greater research productivity. Among Department Chairs, associate professors, and professors there was no difference in research productivity between male and female academic orthopaedic surgeons. By contrast, among assistant professors, there was a significant difference in research productivity. CONCLUSION: A higher proportion of female faculty in an orthopaedic department was positively associated with increased female research productivity. Female faculty at the highest ranks and leadership positions are as academically productive as their male counterparts. Despite similar research productivity, female orthopaedic surgeons are not nearly as well represented as their male counterparts in orthopaedics in general and in leadership positions within the field. In addition, a significantly smaller research productivity among female assistant professors disappears at the higher ranks in comparison to their male counterparts. This indicates a critical gap in factors that influence research productivity according to sex at the most junior faculty rank. LEVEL OF EVIDENCE: Level III.