Patients Aged >50 Years With Anterior Shoulder Instability Have a Decreased Risk of Recurrent Dislocation After Operative Treatment Compared With Non-Operative Treatment.

Purpose: To compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first-time anterior shoulder dislocation after the age of 50 years. Methods: An established geographic medical record system was used to identify patients who experienced a first-time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi-square tests and survivorship curves were generated using Kaplan-Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment. Results: 179 patients were included with a mean follow-up of 11 years. 14% (n = 26) underwent early surgery within 3 months and 86% (n = 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full-thickness rotator cuff tears (82% vs 55%; P = .01), labral tears (24% vs 8.0%; P = .01), and humeral head fracture (23% vs 8.5%; P = .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate-severe pain (19% vs 17%; P = .78) and frozen shoulder (8 vs 9%, respectively; P = .87) at final follow-up. Although nerve palsy (19% vs 8%; P = .08) and progression to osteoarthritis (20% vs 14%; P = .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P = .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent (n = 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01). Conclusions: Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow-up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery. Level of Evidence: Level III, retrospective cohort study.

Can Selected Use of Cemented and Uncemented Femoral Components in a Broad Population Produce Comparable Results Following Primary Total Hip Arthroplasty for Osteoarthritis?

BACKGROUND: Registry data have demonstrated lower rates of revision and periprosthetic fracture in select cohorts with cemented femoral fixation at primary total hip arthroplasty. Whether this is true of all component designs is not known. We hypothesized that selected use of ream-and-broach triple-tapered uncemented stem designs may provide comparable results to cemented stems. METHODS: From 2000 to 2018, 5,809 primary total hip arthroplasties were performed with either a cemented (1,304) or ream-and-broach triple-tapered uncemented stem (4,505). Implant choice was at surgeon discretion. The cemented group was older, more often women, and had slightly lower body mass index. A subgroup analysis was performed on patients ≥75 years of age. Statistical weighting accounted for baseline cohort differences. RESULTS: At 10 years, there was a trend toward higher all-cause revision (hazards ratio (HR) 1.6, P = .053) and higher all-cause reoperation (HR 1.6, P = .02) in the cemented fixation cohort. The cemented fixation group had fewer intraoperative periprosthetic fractures (HR 0.21, P < .001) but no difference in postoperative fractures (HR 0.99, P = .96). The same was true in patients ≥75 years. In the ≥75-years subgroup, there was no difference in revision or reoperation at 10 years. CONCLUSION: Compared to cemented stems, the use of ream-and-broach triple-tapered uncemented stems in select patients, including those ≥75 years, was associated with more intraoperative fractures but no difference in 10-year implant survivorship. These findings are different than some registry data and suggest that specific uncemented components, implanted in selected patients by experienced surgeons, can perform as well as cemented implants in a broad patient population.

Preference-Signaling During the Orthopaedic Surgery Residency Application Process.

The orthopaedic surgery residency selection process has grown more competitive over recent years, with programs receiving an unprecedented number of applications. As an effort to target applications to programs of interest, the American Orthopaedic Association has announced the introduction of a formal preference-signaling program into the 2022 to 2023 orthopaedic surgery residency selection cycle. This system will allow applicants to assign "signals" to a total of 30 programs. The purpose of this article was to (1) discuss implications of the new preference-signaling program, (2) introduce the framework of the "strategic signaling spear" for applicants to conceptualize the power of all methods of preference-signaling to improve their odds of matching, and (3) describe the role of strong mentorship at all stages of the residency application process.

Natural History of First-Time Anterior Shoulder Dislocation in Patients Older Than 50 Years: A Study of 179 Patients With a Mean Follow-up of 11 Years.

Background: There is a dearth of knowledge on anterior shoulder instability in older patients. Purpose/Hypothesis: The purposes of this study were to describe the incidence and epidemiology, injury characteristics, and treatment and outcomes in patients ≥50 years old with first-time anterior shoulder instability. We also describe the historical trends in diagnosis and treatment. It was hypothesized that the rates of obtaining a magnetic resonance imaging (MRI) scan and surgical intervention have increased over the past 20 years. Study Design: Descriptive epidemiology study. Methods: An established geographic database was used to identify 179 patients older than 50 years who experienced new onset anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient characteristics, imaging characteristics, and surgical treatment and outcomes, including recurrent instability. Comparative analysis was performed to identify differences between age groups. Mean follow-up time was 11 years. Results: The incidence of first-time anterior shoulder dislocation in our study population was 28.8 per 100,000 person-years, which is higher than previously reported. Full-thickness rotator cuff tears were found in 62% of the 66 patients who underwent MRI scans. Of all patients, 26% progressed to surgery at a mean time of 1.6 years after injury; 57% of all surgical procedures involved a rotator cuff repair, and 17% included anterior labral repair. All patients who underwent a labral repair also underwent concomitant rotator cuff repair. The rate of recurrent instability for the cohort was 15% at a median of 176 days after the initial instability event. There were no instances of recurrent instability after operative intervention. At an average of 7.5 years after the initial instability event, 14% of patients developed radiographic progression of glenohumeral arthritis. The rate of surgical intervention within 1 year of initial dislocation increased from 5.1% in 1994 to 1999 to 52% in 2015 to 2016. Conclusion: The incidence of first-time anterior shoulder instability in patients aged ≥50 years was 28.8 per 100,000 person-years. Full-thickness rotator cuff tears (62%) were the most common condition associated with anterior shoulder instability, followed by Hill-Sachs lesions (56%). The rate of recurrent instability for the entire cohort was 15%, with no instances of recurrent instability after operative intervention.

Anteroinferior Glenoid Rim Fractures Are a Relatively Common Finding in Shoulder Instability Patients Aged 50 Years or Older but May Not Portend a Worse Prognosis.

Purpose: To investigate the incidence of anteroinferior glenoid rim fractures (AGRFs) after anterior shoulder instability (ASI) in patients aged 50 years or older, identify risk factors for surgical intervention for AGRFs, compare initial treatment strategies, and compare clinical outcomes of patients with and without associated AGRFs. Methods: An established geographic medical record system was used to identify patients aged 50 years or older with ASI between 1994 and 2016. Patients with radiographic evidence of AGRFs were identified and matched 1:1 to patients without AGRFs. Outcome measures included recurrent instability, recurrent pain events, conversion to arthroplasty, and osteoarthritis graded with the Samilson-Prieto classification for post-instability arthritis. Results: Overall, 177 patients were identified, with a mean follow-up period of 10.8 years. Of these patients, 41 (23.2%) had AGRFs and were matched to 41 control patients without AGRFs. The average age was 58.6 and 58.2 years for the AGRF and control groups, respectively. Rates of surgical intervention (27% vs 49%), recurrent instability (12% vs 20%), progression of osteoarthritis (34% vs 39%), and conversion to arthroplasty (2% vs 5%) were similar between AGRF patients and controls. For patients with AGRFs, increased bone fragment size (odds ratio, 1.1) and increased body mass index (odds ratio, 1.2) correlated with an increased risk of surgery. The cutoff value for an increased risk of surgery in patients with AGRFs was a fragment size 33% of the glenoid width or greater. Conclusions: Of patients aged 50 years or older at presentation of ASI, 23.2% presented with an associated AGRF. A fragment size 33% of the glenoid width or greater and a higher patient body mass index were significant factors for surgical intervention; however, most patients did not require surgery and still showed acceptable clinical outcomes, and the most common reason for surgical intervention was a rotator cuff tear. Overall, the presence of an AGRF did not portend a worse prognosis as treatment strategies and long-term outcomes including recurrent instability, progression of osteoarthritis, and conversion to arthroplasty were similar to those in patients without AGRFs. Level of Evidence: Level III, retrospective comparative study.

Collarless Taper Slip and Collared Composite Beam Stems Differ in Failure Modes and Reoperation Rates.

BACKGROUND: Cemented femoral components are used in older patients based on lower risk of periprosthetic fracture and implant loosening. This study reports the survivorship free of periprosthetic femoral fracture (PPFX), femoral loosening, all-cause revision, and reoperation between 2 philosophies of cemented stems. METHODS: In total, 1,306 primary hybrid total hip arthroplasties were performed for osteoarthritis between 2000 and 2018 in a retrospective single center study. Cemented stems included 798 EON composite beam (CB) and 508 Exeter collarless taper slip (CTS) stems. Mean age was 77 years. An inverse treated probability weighted model was utilized to control for risk factors including age, gender, body mass index, year, and surgeon. RESULTS: There was no difference in risk of PPFX at 10 years (CTS 9% vs CB 5%; hazard ratio [HR] 1.4, P = .47). There was an increased risk of intraoperative fractures requiring fixation in the CB cohort (7/798 [5 calcar, 2 greater trochanter] vs 0/508, P < .001), while there was an increased risk of Vancouver B2 PPFX in the CTS cohort (7/508 vs 0/798; P < 001). There was a higher risk of femoral loosening in the CB cohort (6/798 vs 0/508; P < .0001). Higher survivorship free of revision (98% vs 91%; HR 4, P = .001) and free of reoperation (96% vs 88%; HR 2.5, P = .002) was seen at 10 years in the CB cohort. CONCLUSION: The risk of PPFX requiring implant revision was increased in the CTS cohort, while there was an increased risk of femoral component loosening and intraoperative fractures seen in the CB cohort. Surgeons should be aware of the different failure modes when choosing implant design for their patient.

Is There an Association Between Insurance Status and Survival and Treatment of Primary Bone and Extremity Soft-tissue Sarcomas? A SEER Database Study.

BACKGROUND: Several recently published population-based studies have highlighted the association between insurance status and survival in patients with various cancers such as breast, head and neck, testicular, and lymphoma [22, 24, 38, 41]. Generally, these studies demonstrate that uninsured patients or those with Medicaid insurance had poorer survival than did those who had non-Medicaid insurance. However, this discrepancy has not been studied in patients with primary bone and extremity soft-tissue sarcomas, a unique oncological population that typically presents late in the disease course and often requires referral and complex treatment at tertiary care centers-issues that health insurance coverage disparities could aggravate. QUESTIONS/PURPOSES: (1) What is the relationship between insurance status and cause-specific mortality? (2) What is the relationship between insurance status and the prevalence of distant metastases? (3) What is the relationship between insurance status and the proportion of limb salvage surgery versus amputation? METHODS: The Surveillance, Epidemiology, and End Results database (SEER) was used to identify a total of 12,008 patients: 4257 patients with primary bone sarcomas and 7751 patients with extremity soft-tissue sarcomas, who were diagnosed and treated between 2007 and 2014. Patients were categorized into one of three insurance groups: insured with non-Medicaid insurance, insured with Medicaid, and uninsured. Patients without information available regarding insurance status were excluded (2.7% [113 patients] with primary bone sarcomas and 3.1% [243 patients] with extremity soft-tissue sarcomas.) The association between insurance status and survival was assessed using a Cox proportional hazards regression analysis adjusted for patient age, sex, race, ethnicity, extent of disease (lymph node and metastatic involvement), tumor grade, tumor size, histology, and primary tumor site. RESULTS: Patients with primary bone sarcomas with Medicaid insurance had reduced disease-specific survival than did patients with non-Medicaid insurance (hazard ratio 1.3 [95% confidence interval 1.1 to 1.6]; p = 0.003). Patients with extremity soft-tissue sarcomas with Medicaid insurance also had reduced disease-specific survival compared with those with non-Medicaid insurance (HR 1.2 [95% CI 1.0 to 1.5]; p = 0.019). Patients with primary bone sarcomas (relative risk 1.8 [95% CI 1.3 to 2.4]; p < 0.001) and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.1]; p < 0.001) who had Medicaid insurance were more likely to have distant metastases at the time of diagnosis than those with non-Medicaid insurance. Patients with primary bone sarcomas (RR 1.8 [95% CI 1.4 to 2.1]; p < 0.001), and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.0]; p < 0.001) that had Medicaid insurance were more likely to undergo amputation than patients with non-Medicaid insurance. Patients with primary bone and extremity soft-tissue sarcomas who were uninsured were not more likely to have distant metastases at the time of diagnosis and did not have a higher proportion of amputation surgery as compared with patients with non-Medicaid insurance. However, uninsured patients with extremity soft-tissue sarcomas still displayed reduction in disease-specific survival (HR 1.6 [95% CI 1.2 to 2.1]; p = 0.001). CONCLUSIONS: Disparities manifested by differences in insurance status were correlated with an increased risk of metastasis at the time of diagnosis, reduced likelihood of treatment with limb salvage procedures, and reduced disease-specific survival in patients with primary bone or extremity soft-tissue sarcomas. Although several potentially confounding variables were controlled for, unmeasured confounding played a role in these results. Future studies should seek to identify what factors drive the finding that substandard insurance status is associated with poorer survival after a cancer diagnosis. Candidate variables might include medical comorbidities, treatment delays, time to first presentation to medical care and time to diagnosis, type of treatment received, distance travelled to treatments and transportation barriers, out-of-pocket payment burden, as well as educational and literacy status. These variables are almost certainly associated with socioeconomic deprivation in a vulnerable patient population, and once identified, treatment can become targeted to address these systemic inequities. LEVEL OF EVIDENCE: Level III, therapeutic study.