Opioid requirements in primary versus revision reverse shoulder arthroplasty.

PURPOSE: The purpose of this study is to evaluate the inpatient pain medication use of patients who had a revision shoulder arthroplasty procedure performed and compare them to a cohort of patients who had a primary reverse total shoulder arthroplasty (rTSA) performed to determine whether revision shoulder arthroplasty requires more pain medication.. METHODS: A retrospective review was performed on patients undergoing revision arthroplasty (n = 75) and primary rTSA (n = 340). Inpatient medication records were reviewed to tabulate the visual analog pain (VAS) all narcotic medication use, and total morphine equivalent units (MEUs) were calculated for the duration of the inpatient stay. RESULTS: There was no significant difference between groups regarding age, sex, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, preoperative narcotic pain medication use, tobacco use, postoperative VAS scores or hospital length of stay. There were no predictors of total postoperative MEUs identified. Overall, patients in the revision arthroplasty group received significantly less total MEUs than those in the primary rTSA group, 134.96 MEUs vs. 69.79 MEUs, respectively (p < .0005). CONCLUSION: The perceived notion that revision shoulder arthroplasty is more painful may cause providers to be more inclined to increase narcotic use, or use more invasive pain control techniques. Based on these data, we found that revision shoulder arthroplasty did not require an increased opioid requirement, longer length of stay or increase VAS, suggesting that these patients can often be managed similarly to primary rTSA.

Utility of Allograft Talus as a Source for Grafting of Concurrent Humeral and Glenoid Defects Associated With Anterior Glenohumeral Instability: An Anthropometric Analysis.

PURPOSE: To compare morphologic data of the talus using magnetic resonance images with previously reported values of the humeral head and the glenoid as a potential graft source for both the humeral head as well as glenoid reconstruction in the setting of concomitant glenoid and humeral head defects. METHODS: All magnetic resonance images of the ankle were reviewed for assessment of the morphology and variation of the talus among individuals. Patients with post-traumatic, osteoarthritic, or surgical changes to the distal tibia about the mid- or hind- foot, or patients with incomplete medical records were excluded. Radiographic parameters that were measured included the maximum vertical height (MVH), the height to the talar neck, the radius of curvature (ROC) of the talar dome, ROC of the subtalar joint, and the maximum medial-to-lateral width of the talar dome. Demographic data also were collected on each individual. Statistical analysis was performed via a linear regression model with backwards elimination to determine which demographic data correlated most strongly with talar anthropometric values. RESULTS: A total of 82 study patients met inclusion criteria (59 male, 23 female; mean age 40.91 ± 14.69 years). Sex was found have a positive correlation of the following talar dimensions: MVH (P = .039), talar dome ROC (P < .001), and subtalar joint ROC (p = 0.001). Height was the most positive correlation for medial-to-lateral width (P < .001), height to the talar neck (P = .004), and also correlate for MVH (P = .004). Body mass index was found to have multicollinearity and was therefore not used as a variable. CONCLUSIONS: Allograft talus appears to be a viable graft, as demonstrated in this anthropometric study for both reconstruction of the glenoid and humeral head when cases of bipolar glenohumeral bone loss are present. CLINICAL RELEVANCE: This study aims to further evaluate potential allograft donor sites for bipolar lesions.

Use of the Contralateral Glenoid for Calculation of Glenoid Bone Loss: A Cadaveric Anthropometric Study.

PURPOSE: The purpose of this study was to determine if there are significant side-to-side anthropometric differences between paired glenoids. METHODS: Forty-six matched-pair cadaver glenoids were harvested, and their glenoid heights (GHs) and glenoid widths (GWs) were measured with digital calipers. The glenoid surface area was calculated using the standard assumption that the inferior two-thirds of the glenoid is a perfect circle. RESULTS: There was a statistically significant difference between matched-pair GHs of 0.96 ± 3.07 mm (P = .020) and GWs of 0.46 ± 1.64 mm (P = .033). There was a significant difference of glenoid cavity area of 20.30 ± 81.53 mm2 (P = .044), or a difference of ∼3%. A total of 4 of 46 pairs of glenoids (8.6%) showed a difference in width >3 mm. CONCLUSIONS: This study demonstrates the fallacy of use of the contralateral glenoid in measuring glenoid bone loss. Although many paired samples exhibited similar side-to-side glenoid measurements, the number of cadaveric pairs that showed differences of >3 mm was substantial. Caution should be taken when using calculation methods that include this assumption for surgical decision making, as surface area, GW, and GH were all shown to have statistically significant side-to-side differences in their measurements. CLINICAL RELEVANCE: Many methods exist for measuring glenoid bone loss after anterior shoulder dislocation, but some of the current methods may be inaccurate and lead to unreliable estimations.

Routine postoperative laboratory tests are unnecessary after primary reverse shoulder arthroplasty.

BACKGROUND: Obtaining postoperative laboratory studies after primary reverse shoulder arthroplasty (RSA) is a common practice. However, justification of this practice remains unclear. This study assesses the utility of routine postoperative laboratory studies in RSA. METHODS: The electronic medical records of 369 patients who underwent RSA over 10 years were retrospectively reviewed. A total of 213 patients qualified for analysis. Primary outcomes were intervention related to abnormal laboratory values, length of stay, and 90-day emergency department visits/readmissions. Multivariate logistic regression analysis was performed to identify risk factors associated with abnormal laboratory values and postoperative visits/readmissions. RESULTS: Of 213 patients analyzed, 188 (88.7%) had abnormal postoperative laboratory values: 69% had an abnormal hemoglobin (Hgb) or hematocrit level, but only 12% underwent interventions. Lower preoperative Hgb was a significant predictor of receiving a transfusion. A significant association existed between abnormal postoperative electrolyte and creatinine levels with lower body mass index (BMI) and higher Charlson Comorbidity Index (CCI). Only 4 patients (1.8%) received non-transfusion related intervention. Emergency department visits were not statistically different between patients with positive or negative laboratory tests (P = .73). CONCLUSION: Because 87.3% of laboratory studies did not influence patient management, we recommend against routine testing for primary RSA. This study demonstrates that the practice of obtaining routine postoperative laboratory studies is not justified. We recommend selectively obtaining a postoperative basic metabolic profile in patients with increased American Society of Anesthesiologists classification and/or CCI with a lower BMI. We also recommend selectively ordering postoperative complete blood count in patients with a lower preoperative Hgb.

Occupational health and safety portrait of lobster fishers from a St. Lawrence Gulf community.

Lobstering industry workers are known to have poor overall health and low safety records, but there is still a gap in information concerning Canadian lobster fishers. This study aimed to report occupational health and safety characteristics of an Atlantic Canada community of lobster fishers and to assess differences between captains and deckhands. Twenty-eight participants (10 captains, 18 deckhands) were questioned and self-reported on lifestyle, general health status, work-related musculoskeletal disorders and traumatic injuries. The data collected reveal both groups' high prevalence of cardiometabolic and musculoskeletal health issues. Captains reported more occupational exposition and health issues, and showed poorer lifestyle habits than deckhands. Fishers reported potential solutions to reduce occupational risks, presented as three types: lifestyle, working behaviours and leadership. This study evaluated a community of Canadian lobster fishers regarding their occupational health and safety. Potential avenues for mitigating occupational risk specific to this community will nurture future implementation.

Is There Unconscious Bias in the Orthopaedic Residency Interview Selection Process?

OBJECTIVE: Orthopaedic surgery has historically been a white male-dominated field. Given the diverse patient population presenting to providers with musculoskeletal pathology, it is thought that it would be beneficial for the orthopaedic workforce to more closely mirror this patient population. This study aims to elucidate whether unconscious bias may have an effect on the scoring of applications for residency interview selection. DESIGN: Applications for the 2019-2020 residency match cycle were initially reviewed and scored by faculty members. Applications were then redacted of all information suggestive of race or gender and returned to evaluators for rescoring after at least 6 months. The pre and post-redaction data was compared using ANOVA and student's two-tailed t tests. SETTING: Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University. PARTICIPANTS: Thirteen attending surgeons scored 320 2019-2020 Electronic Residency Application System (ERAS) applications, unblinded and blinded of applicant identifying information. RESULTS: Interviewed applicants were similar to the non-interviewed group in all measured variables except for higher pre-redaction scores (8.73-7.81; p = 0.02) which was expected (Table 2). Minority applicants had significant differences in Step 1 scores (243 vs 247; p < 0.01), Step 2 scores (251 vs 254; p = 0.01), articles (5.9 vs 3.8; p < 0.01), posters (5.9 vs 3.5; p < 0.01), and pre-redaction scores (7.44 vs 8.07; p = 0.01) compared to white applicants (Table 4). There was no relationship noted between step score and number or type of research items (Table 5). Pre-redaction and post-redaction scores were significantly different in white applicants who experienced a negative change (8.07-7.88; p = 0.03 (Table 6)). Males had statistically significant differences compared to females in Step 1 score (246 vs 243; p = 0.01) (Table 7). CONCLUSIONS: This study was unable to prove unconscious bias based on a lack of statistically significant change of score when blinded, however the direction in change of scores was unlikely to be accounted for exclusively by objective differences between applicants, suggesting a trend toward unconscious bias. It remains unclear how influential subjective portions of the ERAS application such as personal statements, Letters of Recommendation, hobbies, and activities are on the overall assessment of an applicant and whether or not unconscious bias manifests in these subjective portions. Further investigation is needed in this area. Until then, residency programs should take immediate measures to mitigate potential implicit bias in the residency interview selection process. Actions can include implicit bias training for all faculty members involved in resident selection, standardization of application scoring and possibly redacting all or portions of the ERAS application so that only objective academic markers are presented to evaluators. Gaining a better understanding of these barriers is not only essential for their removal, but also allows for better preparation of applicants for success in the match with the ultimate goal being to correct the persistent disparity in the field of orthopaedic surgery.

Benzoyl Peroxide is Cost-Effective for Preventing Infection by Cutibacterium Acnes in Arthroscopic Rotator Cuff Repair.

PURPOSE: To evaluate the cost-effectiveness of benzoyl peroxide (BPO) in decreasing postoperative infections through a mathematical model in the setting of arthroscopic rotator cuff repair (RCR). METHODS: A break-even equation compared the costs associated with perioperative BPO use and postoperative infection following an arthroscopic RCR. The postoperative infection rate used for calculations was 0.28%, a value established in current literature. The break-even analysis produced a new infection rate, which defined how much BPO is needed to reduce the known infection rate in order for its prophylactic use to be cost-effective. The institution's business office assessed the minimum itemized costs associated with the standard-of-care treatment of postoperative RCR infection. Sensitivity analysis was conducted to demonstrate how variability in the costs of BPO, in infection rates and in the cost of infection treatment affected the absolute risk reduction (ARR) and number needed to treat (NNT). RESULTS: Financial review yielded a minimum institutional cost of treating a postoperative infection following arthroscopic RCR of $24,991.31. Using the break-even formula to calculate the ARR at which the overhead costs of BPO and the treatment of infection were equal, BPO was economically viable if it decreased infection rate by 0.000734% (NNT = 1,361.92). This value was low because of the order of magnitude of difference between the costs of infection prevention when compared to the costs of treating postoperative infections. CONCLUSIONS: This break-even analysis model suggests that the use of preoperative BPO in the setting of arthroscopic RCR is cost-effective for prevention of infection with Cutibacterium acnes, given the high cost of treating the infection versus the low cost of the solution. CLINICAL RELEVANCE: The economic feasibility of preoperative use of BPO in the setting of arthroscopic RCR could alter the standard of care.

Predicting adjacent infections in pediatric septic arthritis: Do predictive criteria extrapolate across geographic regions?: Predicting Periarticular Infection in the Southeast.

PURPOSE: This study aims to assess previously determined predictive criteria for presence of adjacent infection in septic arthritis within a Southeastern United States (US) pediatric population. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value of the Rosenfeld criteria were: 91.7%, 22.7%, 39.3%, and 83.3%, respectively. The patients with periarticular infection were more likely to have positive blood cultures than those with isolated septic arthritis. There was no difference in likelihood of secondary surgical intervention. CONCLUSIONS: Previously defined criteria to predict adjacent infection in pediatric septic arthritis did not demonstrate external validity in a Southeastern US pediatric population.

Anterior Glenoid Reconstruction With Distal Tibial Allograft: Biomechanical Impact of Fixation and Presence of a Retained Lateral Cortex.

BACKGROUND: Glenoid reconstruction with distal tibial allograft (DTA) is a known surgical option for treating recurrent glenohumeral instability with anterior glenoid bone loss; however, biomechanical analysis has yet to determine how graft variability and fixation options alter the torque of screw insertion and load to failure. HYPOTHESIS: It was hypothesized that retention of the lateral cortex of the DTA graft and the presence of a washer with the screw will significantly increase the maximum screw placement torque as well as the load to failure. STUDY DESIGN: Controlled laboratory study. METHODS: Whole, fresh distal tibias were used to harvest 28 DTA grafts, half of which had the lateral cortex removed and half of which had the lateral cortex intact. The grafts were secured to polyurethane solid foam blocks with a 2-mm epoxy laminate to simulate a glenoid with an intact posterior glenoid cortex. Grafts underwent fixation with 4.0-mm cannulated drills, and screws and washers were used for half of each group of grafts while screws alone were used for the other half, creating 4 equal groups of 7 samples each. A digital torque-measuring screwdriver recorded peak torque for screw insertion. Constructs were then tested in compression with a uniaxial materials testing system and loaded in displacement control at 100 mm/min until at least 3 mm of displacement occurred. Ultimate load was defined as the load sustained at clinical failure. RESULTS: The use of a washer significantly improved the ultimate torque that could be applied to the screws (+cortex and +washer = 12.42 N·m [SE, 0.82]; -cortex and +washer = 10.54 N·m [SE, 0.59]) (P < .0001), whereas the presence of the native bone cortex did not have a significant effect (+cortex and -washer = 7.83 N·m [SE, 0.40]; -cortex and -washer = 8.03 N·m [SE, 0.56]) (P = .181). CONCLUSION: In a hybrid construct of fresh cadaveric DTA grafts secured to a foam block glenoid model, the addition of washers was more effective than the retention of the lateral distal tibial cortex for both load to failure and peak torque during screw insertion. CLINICAL RELEVANCE: This biomechanical study is relevant to the surgeon when choosing a graft and selecting fixation options during glenoid reconstruction with a DTA graft.

Learning Integrated Health System to Mobilize Context-Adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From Hospitals and Emergency Departments to the Community (LEARNING WISDOM): Protocol for a Mixed-Methods Implementation Study.

BACKGROUND: Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a "Wiki-suite" (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders. OBJECTIVE: The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools. METHODS: Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools. RESULTS: Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit. CONCLUSIONS: This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada. TRIAL REGISTRATION: ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17363.

Engineering Controlled Peritumoral Inflammation to Constrain Brain Tumor Growth.

Brain tumors remain a great clinical challenge, in part due to their capacity to invade into eloquent, inoperable regions of the brain. In contrast, inflammation in the central nervous system (CNS) due to injuries activates microglia and astrocytes culminating in an astroglial scar that typically "walls-off" the injury site. Here, the hypothesis is tested that targeting peritumoral cells surrounding tumors to activate them via an inflammatory stimulus that recapitulates the sequelae of a traumatic CNS injury, could generate an environment that would wall-off and contain invasive tumors in the brain. Gold nanoparticles coated with inflammatory polypeptides to target stromal cells in close vicinity to glioblastoma (GBM) tumors, in order to activate these cells and stimulate stromal CNS inflammation, are engineered. It is reported that this approach significantly contains tumors in rodent models of GBM relative to control treatments (reduction in tumor volume by over 300% in comparison to controls), by the activation of the innate and adaptive immune response, and by triggering pathways related to cell clustering. Overall, this report outlines an approach to contain invasive tumors that can complement adjuvant interventions for invasive GBM such as radiation and chemotherapy.

Socioeconomic stakes in the development of telemedicine.

This brief article points out that more empirical knowledge is required about the diverse factors that influence the diffusion, implementation, outcomes and behaviours associated with the spread of information and communication technologies (ICT). This includes the domain of telemedicine and ICT-based outpatient care. A detailed understanding of these processes and the participants involved offers the potential to illuminate the multiplicity of inter-related issues with which medical practitioners and health-care policy makers must contend. More important, it is only through such a detailed, user-centred understanding--as opposed to abstract assessments of technological potential--that we can formulate effective strategies that do not lose sight of the clinical and therapeutic aspects of health care in the quest to improve its delivery.

The acceptability of humor between palliative care patients and health care providers.

BACKGROUND: Humor frequently occurs in palliative care environments; however, the acceptability of humor, particularly between patients and health care providers has not been previously examined. OBJECTIVES: To explore the importance and acceptability of humor to participants who are patients in a palliative care context, the study determines if demographics are correlated with the degree of acceptability, and examines the acceptance of humor by patients with advanced illness when interacting with nurses or physicians. METHODS: One hundred participants admitted to a palliative care unit or residential hospice were surveyed. Basic demographic data were collected, as well as responses on a five-point Likert scale to a variety of questions regarding the participants' attitudes about humor before and after their illness and the acceptability of humor in a palliative setting. Participants were also given the opportunity to comment freely on the topic of humor and the palliative experience. RESULTS: A large majority of participants valued humor highly both prior to (77%) and during (76%) their illness experience. Despite this valuation, the frequency of laughter in their daily lives diminished significantly as patients' illness progressed. Most participants remembered laughing with a nurse (87%) and a doctor (67%) in the week prior to the survey, and found humor with their doctors (75%) and nurses appropriate (88%). CONCLUSION: The vast majority of participants found humorous interactions with their health care providers acceptable and appropriate, and this may indicate a opportunity for enhanced and more effective end-of-life care in the future.