Variability in Surgical Case Volume Performed During ACGME-Accredited Orthopaedic Foot and Ankle Fellowship Training.

INTRODUCTION: Previous studies have demonstrated a positive correlation between case volume and outcomes in foot and ankle surgery. This study elucidates surgical case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic foot and ankle fellowship training in the United States. METHODS: The ACGME provided case logs for orthopaedic residents and foot and ankle fellows (2018-2021). Variabilities in reported fellowship case volumes were defined as the fold-difference between 90th and 10th percentiles. Reported case volumes were compared between training cohorts with parametric tests. RESULTS: Case logs from 65 orthopaedic foot and ankle fellows and 3146 orthopaedic residents were included. Fellows reported 1.3- to 1.5-fold more foot and ankle cases during fellowship training than during residency training (P < .001). On average, orthopaedic foot and ankle fellows reported 405.4 cases and most were arthrodesis (17%), forefoot reconstruction (17%), mid/hindfoot reconstruction (13%), tendon repair/transfer (12%), and trauma ankle hindfoot (11%). Case categories with the highest variabilities were amputation (14.8-fold difference), infection/tumor (11.6-fold difference), arthroscopy (9.2-fold difference), and calcaneus (8.7-fold difference). DISCUSSION: Case volume benchmarks can assist trainees and faculty during orthopaedic foot and ankle training. More research is needed to determine case minimum requirements needed for autonomous practice in foot and ankle surgery. LEVEL OF EVIDENCE: Level III.

Irreparable Subscapularis Tears: Current Tendon Transfer Options.

PURPOSE OF REVIEW: Irreparable subscapularis tears, especially in younger patients with higher functional demands, present a challenging entity. Pectoralis major and latissimus dorsi tendon transfers are commonly considered for surgical management of this pathology, yet no consensus exists regarding the superior option. The purpose of this article is to review the most current tendon transfer techniques for irreparable subscapularis tears. RECENT FINDINGS: For decades, transfer of the pectoralis major has been considered the gold standard technique for irreparable subscapularis tears. This transfer was found to reduce pain and improve functional outcome scores, yet range of motion and force of internal rotation were not maintained in long-term follow-up studies. The latissimus dorsi tendon transfer for the same indications has demonstrated biomechanical superiority in recent cadaveric studies with promising short-term results clinically. Both pectoralis major and latissimus dorsi tendon transfers improve outcomes of patients with irreparable subscapularis tears. Future comparative studies are still needed to determine superiority amongst techniques.

Impact of COVID-19 on clinical outcomes following total shoulder arthroplasty.

Background: The coronavirus (COVID-19) pandemic has introduced patient stressors and changes to perioperative protocols in total shoulder arthroplasty (TSA). The purpose of this study is to evaluate the short-term effects of the COVID-19 pandemic on various patient outcomes and satisfaction following elective TSA. Methods: A retrospective review was performed on 147 patients who underwent primary TSA at a single institution between June 2019 and December 2020. Patients were divided into 2 cohorts: pre-COVID (June 2019-March 2020; n = 74) and post-COVID (April 2020-December 2020; n = 73). No elective TSA were performed between 10 March 2020 and 23 April 2020 at our institution. Data were collected prospectively both pre- and postoperatively. Range of motion (ROM) testing included active abduction, internal rotation, and external rotation. Patient reported outcome measures (PROMs) included global shoulder function, Simple Shoulder Test, American Shoulder and Elbow Surgeons, Visual Analog Scale pain scoring systems, and patient satisfaction. ROM and PROMs were compared at preoperative, 3-month follow-up, and 12-month follow-up intervals. Operative time, length of stay (LOS), 90-day readmission, and 90-day reoperation were also compared. Results: There were no differences in baseline patient characteristics. The operative time, LOS, home discharge rate, readmission, and reoperation did not differ between groups. For both cohorts, the PROMs and ROM improved at each follow-up visit postoperatively. While preoperative abduction, internal rotation, and external rotation were significantly greater in the post-COVID group, all ROM measures were similar at 3-month and 12-month follow-up visits. There was no difference in pain, global function, Simple Shoulder Test, American Shoulder and Elbow Surgeons, or patient satisfaction between groups at all time intervals. Conclusions: Patients undergoing elective TSA amidst the COVID-19 pandemic demonstrate excellent PROMs, ROM, and high satisfaction up to 12-months postoperatively that are comparable to pre-pandemic standards. Operative time, LOS, discharge destination, as well as 90-day readmission and reoperation rates were not impacted by the pandemic. Patients can expect similar outcomes for TSA when comparing pre-COVID to post-COVID as the pandemic continues.

Surgical Construct Type Is Associated With Time to Fusion and Reoperation Rate in Double and Isolated Talonavicular Arthrodeses.

BACKGROUND: This study evaluates the effect of surgical construct on postoperative outcomes in patients undergoing isolated talonavicular (TN) or double (TN and subtalar ST) arthrodesis. TN constructs included plate and screw, screw and staple, and isolated staple constructs. Subtalar constructs included 1- and 2-screw constructs. METHODS: Retrospective chart review identified 52 patients who underwent double or isolated TN arthrodesis between 2016 and 2021 by a single fellowship-trained foot and ankle surgeon with minimum 6 months of follow-up (mean = 1.62 years, range = 0.50-4.39 years). Data collected included demographics, medical history, surgical indication, surgical constructs used, complications, reoperations, patient-reported outcome measures, and radiographic measures. RESULTS: Overall complication and reoperation rates were 26.3% and 12.3%, respectively. Among TN constructs, time to ST (P = .026) and TN (P = .018) fusion was significantly slower among patients receiving a plate and screw construct. Complication rate did not differ, but reoperation rate was significantly higher for plate and screw TN constructs (P = .039). Postoperative Foot and Ankle Outcome Score (FAOS) Quality of Life (P = .028) and Total (P = .016) scores were significantly better among plate and screw TN constructs. CONCLUSION: Utilization of screw and staple or isolated staple construct have significantly quicker time to fusion and lower reoperation rates than plate and screw constructs for the TN joint. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

Does glenohumeral offset affect clinical outcomes in a lateralized reverse total shoulder arthroplasty?

BACKGROUND: Reverse total shoulder arthroplasty (rTSA) exhibits high rates of success and low complication rates. rTSA has undergone numerous design adaptations over recent years, and lateralization of implant components provides theoretical and biomechanical benefits in stability and range of motion (ROM) as well as decreased rates of notching. However, the magnitude of implant lateralization and its effect on these outcomes is less well understood. The purpose of this study was to evaluate how increasing glenohumeral offset affects outcomes after rTSA, specifically in a lateralized humerus + medialized glenoid implant model. METHODS: Primary rTSA using a lateralized humeral + medialized glenoid implant model performed at a single academic institution between 2012 and 2018 were retrospectively reviewed. Patient-reported outcome (PRO) parameters and clinical outcomes including ROM were evaluated both pre- and postoperatively. Pre- and postoperative radiographs were analyzed for measurement of glenohumeral offset, defined as the acromial-tuberosity offset (ATO) distance on the anteroposterior radiograph. RESULTS: A total of 130 rTSAs were included in the analysis, with a mean follow-up of 35 mo. The mean postoperative absolute ATO was 16 mm, and the mean delta ATO (difference from pre- to postoperatively) was 4.6 mm further lateralized. Among all study patients, improvements in all ROM parameters and all PROs were observed from pre- to postoperative assessments. When assessing for the effects of lateralization on these outcomes, multivariate analysis failed to reveal a significant effect from the absolute postoperative ATO or the delta ATO on any outcome parameter. CONCLUSIONS: rTSA using a lateralized humeral + medialized glenoid implant model exhibits excellent clinical outcomes in ROM and PROs. However, the magnitude of lateralization as measured radiographically by the ATO did not significantly affect these outcomes; patients exhibited universally good outcomes irrespective of the degree of offset restoration.

Pain Catastrophizing Scale Associated With Other Patient-Reported Outcome Measures in Plantar Fasciitis and Chronic Ankle Instability Patients.

BACKGROUND: The Pain Catastrophizing Scale (PCS) is a measure of how patients emotionally respond to pain. It is composed of 3 subscales-rumination, magnification, and helplessness-which address intrusive thoughts of pain, expectations of negative outcomes, and inability to cope with pain. Our purpose is to compare baseline PCS scores with other baseline patient-reported outcome measures (PROMs) in patients with plantar fasciitis (PF) or chronic ankle instability (CAI). METHODS: We retrospectively reviewed 201 patients who reported at least 1 pretreatment PCS subscore and were diagnosed with PF or CAI between 2015 and 2020 in a single fellowship-trained foot and ankle surgeon's clinic. Demographics, comorbidities, treatments, other baseline PROMs (i.e., visual analog scale [VAS], Pain Disability Index [PDI], 12-Item Short Form Survey [SF-12], 8-Item Somatic Symptom Scale [SSS-8]), and postoperative outcomes were recorded. RESULTS: The PCS total score and its subscores significantly correlated with the total score and/or subscores of each PROM. Higher PCS total score significantly correlated with worse VAS (P<.001), SF-12 mental (P=.007), PDI total (P<.001), and SSS-8 (P<.001) scores. Only the PCS magnification subscore was significantly greater among patients who did (n=41) undergo surgery (P=.043). Those who had previously undergone foot and/or ankle surgery had significantly higher PCS rumination (P=.012), magnification (P=.006), helplessness (P=.008), and total (P=.003) scores. Likewise, those with a history of substance abuse also had significantly higher PCS scores (P=.005; P=.003; P=.006; P=.003). CONCLUSION: The correlations between PCS scores and other baseline PROMs indicate that strong pain catastrophizers with PF or CAI may be at risk for poor treatment outcomes. PCS scores could be used to help with treatment for such high-risk patients.

Variability and reliability of 2-dimensional vs. 3-dimensional glenoid version measurements with 3-dimensional preoperative planning software.

BACKGROUND: Preoperative planning for total shoulder arthroplasty (TSA) may change according to the measured degree of glenoid version. Both 2-dimensional (2D) and 3-dimensional (3D) computed tomographic (CT) scans are used to measure glenoid version, with no consensus on which method is more accurate. However, it is generally accepted that 3D measurements are more reliable, yet most 3D reconstruction software currently in clinical use have never been directly compared to 2D. The purpose of this study is to directly compare 2D and 3D glenoid version measurements and determine the differences between the two. METHODS: CT scans were performed preoperatively on 315 shoulders undergoing either anatomic or reverse TSA. 2D measurements of glenoid version were obtained manually using the Friedman method, whereas 3D measurements were obtained using the Equinoxe Planning Application (Exactech Inc.) 3D-reconstruction software. Negative version values indicate retroversion, whereas positive values indicate anteversion. Two observers collected the 2D measurements 2 separate times, and intra- and interobserver measurements were calculated. Groups were compared for variability using intraclass correlation coefficients (ICCs), and for differences in sample means using Student t tests. Additionally, samples were stratified by version value in order to better understand the potential sources of error between measurement techniques. RESULTS: For the 2D measurements, intraobserver variability indicated excellent reproducibility for both observer 1 (ICC = 0.928, 95% confidence interval [CI] 0.911-0.942) and observer 2 (ICC = 0.964, 95% CI 0.955-0.971). Interobserver variability measurements also indicated excellent reproducibility (ICC = 0.915, 95% CI 0.778-0.956). The overall 2D version measurement average (-4.9° ± 10.3°) was significantly less retroverted than the 3D measurement average (-8.4° ± 9.1°) (P < .001), with 3D measurements yielding a more retroverted value 73% of the time. When stratified on the basis of version value with outliers excluded, there was no significant difference in the distribution of high-error samples within the data. DISCUSSION: There was excellent reproducibility between the 2 observers in terms of both intra- and interobserver variability. The 3D measurement techniques were significantly more likely to return a more retroverted measurement, and high-error samples were evenly distributed throughout the data, indicating that there were no discernable trends in the degree of error observed. Shoulder surgeons should be aware that different glenoid version measurement strategies can yield different version measurements, as these can affect preoperative planning and surgeon decision making.

Effects of obesity on clinical and functional outcomes following anatomic and reverse total shoulder arthroplasty.

BACKGROUND: Limited data exist regarding the clinical and functional outcomes following primary total shoulder arthroplasty in obese patients. The purpose of this study is to determine the effects of obesity on the clinical and functional outcomes following primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) in a large patient population with mid-term follow-up. METHODS: Patients in a multi-institutional shoulder registry receiving either primary aTSA (n = 1520) or rTSA (n = 2054) from 2004 to 2018 with a minimum follow-up period of 2 years were studied. All patients received the same single-platform shoulder prosthesis. Study groups were assigned based on implant type (anatomic or reverse), and further stratification was based on patient body mass index (BMI), with obese patients having a BMI ≥ 30 and non-obese patients having a BMI < 30. Patients were evaluated and scored preoperatively and at latest follow-up by use of 5 scoring metrics and range of motion (ROM). RESULTS: The mean follow-up period was 5 years (range, 2-14 years). Obese patients comprised 41% of the aTSA group and 35% of the rTSA group. Significant postoperative improvements in visual analog scale pain scores, ROM, and all 5 scoring metrics occurred in both obese and non-obese patients (P < .05). Obese patients in both groups reported higher preoperative and postoperative visual analog scale pain scores and less preoperative and postoperative ROM compared with non-obese patients. Compared with non-obese patients, obese patients receiving aTSA reported significantly worse postoperative Simple Shoulder Test, Constant-Murley, American Shoulder and Elbow Surgeons, University of California, Los Angeles, and Shoulder Pain and Disability Index scores compared with non-obese patients, and those receiving rTSA reported significantly worse American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index scores (all P < .05). However, these differences did not exceed the minimal clinically important difference or substantial clinical benefit criteria. Radiographic analysis showed that in the rTSA group, obese patients had significantly less postoperative scapular notching and a lower scapular notching grade compared with non-obese patients (P < .05). DISCUSSION: Both non-obese and obese patients can expect clinically significant improvements in pain, motion, and functional outcome scores following both aTSA and rTSA. Obese patients reported significantly more postoperative pain, lower outcome scores, and less ROM compared with non-obese patients after both aTSA and rTSA at a mean follow-up of 5 years. However, statistically significant differences were not found to be clinically significant with respect to established minimal clinically important difference and substantial clinical benefit criteria. Therefore, obese and non-obese patients experience similar clinical outcomes following total shoulder arthroplasty, regardless of BMI. However, obese patients have more comorbidities, greater intraoperative blood loss, and less scapular notching compared with non-obese patients.

Clinical and radiographic outcomes after reverse total shoulder arthroplasty in patients 80 years of age and older.

BACKGROUND: Previous studies have found less favorable outcomes for patients aged 80 years and older after primary reverse total shoulder arthroplasty (rTSA). However, they are based on small sample sizes with no control group for comparison. The purpose of this study is to compare the clinical, functional, and radiographic outcomes after primary rTSA in patients aged 80 years and older with a younger cohort of patients aged 60-79 years. METHODS: Patients undergoing primary rTSA between 2004 and 2018 were identified within a multi-institutional database with a minimum of 2 years of follow-up. All patients received the same platform prosthesis. Patients were divided into 2 groups based on age: 80 years and older (n = 369) and 60-79 years (n = 1764). Statistical analyses were performed to compare the 2 age cohorts based on pre- and postoperative function and range of motion (ROM) scores, adverse event rates, pain scores, and patient satisfaction. RESULTS: Patients aged 80 years and older had lower preoperative functional and ROM scores relative to patients aged 60-79 years. The differences observed in active abduction, active forward elevation, and Constant scores exceed the minimal clinically important difference (MCID). The evaluation of function and ROM at latest follow-up showed that patients in both age cohorts had significant improvements that exceeded both the MCID and substantial clinical benefit, but older patients still scored lower relative to younger patients, with the differences in active abduction and Constant scores exceeding the MCID. Despite the lower scores observed in older patients, both groups report similar satisfaction (93% in older patients vs. 92% in younger patients, P = .379). There were no differences between the 2 age cohorts with regard to humeral radiolucent lines (9.2% vs. 8.7%, P = .765), scapular notching (11.0% vs. 10.3%, P = .727), adverse events (3.5% vs. 3.3%, P = .863), and revisions (0.8% vs. 1.8%, P = .188). CONCLUSIONS: Patients aged 80 years and older can expect significant improvements in function and ROM after primary rTSA, with satisfaction similar to that of patients aged 60-79 years. Patients in both age cohorts have similar rates of adverse events and revisions, and the rates observed in patients 80 years and older are much lower than what has previously been reported in the literature. rTSA in patients age 80 years and older is a beneficial surgery with outcomes similar to those found in younger patients, and age should not be a limiting factor when considering rTSA.

Increased perioperative complication rates in patients with solid organ transplants following rotator cuff repair.

BACKGROUND: Rotator cuff repair is the second most common soft tissue procedure performed in orthopedics. Additionally, an increasing percentage of the population has received a solid organ transplant (SOT). The chronic use of immunosuppressants as well as a high prevalence of medical comorbidities in this population are both important risk factors when considering surgical intervention. The purpose of this study is to determine the demographic profile, comorbidity profile, and perioperative complication rate of SOT patients undergoing inpatient rotator cuff repair surgery compared to nontransplanted patients. METHODS: The Nationwide Inpatient Sample (NIS) database was queried from years 2002-2017 to identify all patients who underwent inpatient rotator cuff repair (n = 144,528 weighted). This group was further divided into SOT (n = 286 weighted) and nontransplant (n = 144,242 weighted) cohorts. Demographic and comorbidity analyses were performed between these groups. Additionally, a matched cohort of nontransplanted patients controlled for the year of procedure, age, sex, race, income, and hospital region was created in a 1:1 ratio to the SOT group (n = 286 each) for perioperative complication rate analysis. RESULTS: Compared to nontransplanted patients, SOT patients were more likely to have at least 1 significant medical comorbidity (98% vs. 69%, P < .001), had a higher number of total comorbidities (3.1 vs. 1.4, P < .001), and had a higher Charlson-Deyo Comorbidity Index (2.6 vs. 0.54, P < .001). Compared to the matched cohort, SOT patients experienced longer hospital stays (2.9 vs. 1.8 days, P < .001), higher surgery costs ($12,031 vs. $8476, P < .001), and were more likely to experience a perioperative complication (24% vs. 3%, P < .001) with an odds ratio of 7.7 (95% confidence interval: 3.9-15.1). CONCLUSION: Compared with nontransplanted patients, SOT patients undergoing rotator cuff repair had a significantly higher comorbidity index, longer hospital stays, costlier surgeries, and were >7 times more likely to experience a perioperative complication. With nearly a quarter of all SOT patients experiencing a perioperative complication following rotator cuff repair, careful consideration for surgery as well as increased postoperative surveillance should be considered in this unique population.

Increased Risk of Perioperative Complications in Dialysis Patients Following Rotator Cuff Repairs and Knee Arthroscopy.

PURPOSE: To determine the effects of dialysis on postoperative and perioperative complications following rotator cuff repair (RCR) and knee arthroscopy (KA). METHODS: The National Surgical Quality Improvement Program (NSQIP) was queried from 2006 to 2018. Groups were matched for age, sex, body mass index, smoking status, preoperative functional status, and the American Society of Anesthesiologists (ASA) status. Chi-squared tests and Fisher's exact tests were used to analyze the comorbidities. Differences in occurrences of postoperative adverse events (AE), mortality within 30 days, reoperations with 30 days, extended hospital stay (≥2 days), and readmissions within 30 days were analyzed using the Mantel-Haenszel test. Sign tests were used to evaluate differences in operative time, as well as length of hospital stay. RESULTS: Dialysis patients in both the RCR and KA groups had greater odds of experiencing any AE (OR: 6.33 and 7.46, P value: .031 and <.001, respectively) and readmission within 30 days (OR: 10.5 and 4.1, P value: .015 and .014, respectively). They also had significantly greater operating times (P = .049 for both). Dialysis patients undergoing KA had greater odds of staying in the hospital ≥2 days (OR: 10, P = <.001) and being reoperated on within 30 days (OR: 3.78, P = .033). The total hospital stay was significantly greater for dialysis patients in the KA group (P < .001) but not in the RCR group (P = .088). None of the individual AE's significantly differed between the dialysis and non-dialysis patients in the RCR cohort; however, dialysis patients in the KA cohort had greater incidences of three AE's. CONCLUSIONS: This study identified significantly worse short-term complication rates in dialysis patients undergoing RCR and KA. Careful preoperative evaluation and postoperative surveillance are warranted in this high-risk patient group. Patients should be counseled appropriately on the increased complication risks associated with RCR and KA surgeries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Longitudinal Stretching for Maturation of Vascular Tissues Using Magnetic Forces.

Cellular spheroids were studied to determine their use as "bioinks" in the biofabrication of tissue engineered constructs. Specifically, magnetic forces were used to mediate the cyclic longitudinal stretching of tissues composed of Janus magnetic cellular spheroids (JMCSs), as part of a post-processing method for enhancing the deposition and mechanical properties of an extracellular matrix (ECM). The purpose was to accelerate the conventional tissue maturation process via novel post-processing techniques that accelerate the functional, structural, and mechanical mimicking of native tissues. The results of a forty-day study of JMCSs indicated an expression of collagen I, collagen IV, elastin, and fibronectin, which are important vascular ECM proteins. Most notably, the subsequent exposure of fused tissue sheets composed of JMCSs to magnetic forces did not hinder the production of these key proteins. Quantitative results demonstrate that cyclic longitudinal stretching of the tissue sheets mediated by these magnetic forces increased the Young's modulus and induced collagen fiber alignment over a seven day period, when compared to statically conditioned controls. Specifically, the elastin and collagen content of these dynamically-conditioned sheets were 35- and three-fold greater, respectively, at seven days compared to the statically-conditioned controls at three days. These findings indicate the potential of using magnetic forces in tissue maturation, specifically through the cyclic longitudinal stretching of tissues.