ChatGPT-3.5 Responses Require Advanced Readability for the General Population and May Not Effectively Supplement Patient-Related Information Provided by the Treating Surgeon Regarding Common Questions About Rotator Cuff Repair.

PURPOSE: To investigate the accuracy of ChatGPT's responses to frequently asked questions prior to rotator cuff repair surgery. METHODS: The 10 most common frequently asked questions related to rotator cuff repair were compiled from 4 institution websites. Questions were then input into ChatGPT-3.5 in 1 session. The provided ChatGPT-3.5 responses were analyzed by 2 orthopaedic surgeons for reliability, quality, and readability using the Journal of the American Medical Association Benchmark criteria, the DISCERN score, and the Flesch-Kincaid Grade Level. RESULTS: The Journal of the American Medical Association Benchmark criteria score was 0, indicating the absence of reliable source material citations. The mean Flesch-Kincaid Grade Level was 13.4 (range, 11.2-15.0). The mean DISCERN score was 43.4 (range, 36-51), indicating that the quality of the responses overall was considered fair. All responses cited making final decision-making to be made with the treating physician. CONCLUSIONS: ChatGPT-3.5 provided substandard patient-related information in alignment with recommendations from the treating surgeon regarding common questions around rotator cuff repair surgery. Additionally, the responses lacked reliable source material citations, and the readability of the responses was relatively advanced with a complex language style. CLINICAL RELEVANCE: The findings of this study suggest that ChatGPT-3.5 may not effectively supplement patient-related information in the context of recommendations provided by the treating surgeon prior to rotator cuff repair surgery.

Ulnar Collateral Ligament Reconstruction Is Commonly Performed Using a Palmaris Graft and Provides Favorable Patient Outcomes With Variable Return-to-Play and Postoperative Complication Rates: A Systematic Review.

PURPOSE: To systematically review the literature to provide an updated evaluation of postoperative clinical outcomes, return to play (RTP), and postoperative complications after primary ulnar collateral ligament reconstruction (UCLR) in throwing and nonthrowing athletes at minimum 2-year follow-up. METHODS: A literature search was performed on November 25, 2023, by querying the Embase, PubMed, and Scopus online databases using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The inclusion criteria consisted of Level I to IV human clinical studies reporting postoperative outcomes and/or complications after primary UCLR with minimum 2-year follow-up. The exclusion criteria consisted of non-English-language studies; biomechanical, animal, and cadaveric studies; review articles; letters to the editor; and studies not reporting postoperative outcomes or complications. Study quality was evaluated using the Methodological Index for Non-Randomized Studies criteria. The incidence of reported complications among the included studies was extracted. Clinical outcome scores included the Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow (KJOC) score, Andrews-Timmerman (AT) score, and satisfaction score. RTP data were also extracted. RESULTS: A total of 21 studies published from 2006 to 2023, consisting of 2,452 patients (2,420 male patients) with a mean age of 21.7 years (mean range, 12-65 years) and mean follow-up period of 50.5 months (mean range, 24-151.2 months), were included. The mean Methodological Index for Non-Randomized Studies score was 16 (range, 13-20). A total of 46% of patients (1,138 of 2,452) underwent concomitant ulnar nerve transposition. Palmaris graft was the most frequently used method (66.6%; n = 1,799), followed by hamstring graft (26.0%, n = 703). At the final follow-up, mean postoperative KJOC scores ranged from 72.0 to 88.0; mean AT scores, from 83.6 to 98.3; and mean satisfaction scores, from 86.1 to 98.3. The overall RTP rate ranged from 62.5% to 100% at a mean range of 9.5 to 18.5 months. The total incidence of complications ranged from 0% to 31.8%, with 0% to 7.4% of patients undergoing revision surgery. CONCLUSIONS: UCLR was commonly performed using a palmaris graft, with concomitant ulnar nerve transposition reported in 46% of patients. At a mean follow-up of 50.5 months, mean postoperative KJOC scores ranged from 72 to 98.3, AT scores ranged from 83.6 to 98.3, and satisfaction scores ranged from 86.1 to 98.3, with variable RTP rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Arthroscopic Shoulder Simulation May Improve Short-Term Speed, Accuracy, and Efficiency of Surgical Movements in Orthopedic Residents and Fellows: A Systematic Review.

PURPOSE: To systematically review the effectiveness and validity of orthopedic surgery training using simulation technologies including augmented-reality, virtual-reality, and/or mixed-reality within arthroscopic shoulder surgery. METHODS: A literature search utilized EMBASE and PubMed databases from inception to January 2024 per the 2020 PRISMA guidelines. Included studies described arthroscopic shoulder surgery simulation training among orthopedic surgery trainees. Exclusion criteria included studies assessing non-arthroscopic and non-shoulder simulations, non-English language studies, case reports, animal studies, studies with overlapping cohorts, and review articles. Simulation characteristics, performance measurements, and validity assessed were extracted. The Cochrane risk-of-bias tool and Newcastle-Ottawa Scale assessed study quality. Simulation type, validation type, and simulation outcomes were assessed. RESULTS: A total of 15 included articles, published from 2011 to 2021, evaluated 421 residents or fellows and 17 medical students. Virtual reality (VR) was used in 40% of studies and mixed reality in 60%. The most common outcomes assessed were time to completion (80%), visualizing and probing task performance (60%), and the Arthroscopic Surgery Skill Evaluation Tool (ASSET) (33.3%). Construct validity was assessed in 46.7% of studies, transfer validity in 26.7%, face validity in 20%, and content validity in 6.7%. Three studies demonstrated improved performance in those undergoing simulation training compared to non-simulation groups. Two studies (13.3%) demonstrated improved time-to-task completion and decreased camera distance travelled when using simulation training. One study demonstrated that PGY-1 and PGY-5 residents derived the greatest benefit from simulation training. CONCLUSION: Arthroscopic shoulder simulation training may benefit the surgical skills of orthopedic residents of all levels of experience as measured by time-to-completion, accuracy, and efficiency of surgical movements. Simulation training exhibits differences in operative time between more and less experienced orthopedic surgeons and trainees. Virtual reality simulation training may result in more efficient orthopedic surgical techniques. LEVEL OF EVIDENCE: III, Systematic review of level I-III studies.

Massive Irreparable Rotator Cuff Tears Treated With a Tuberoplasty Yield Favorable Clinical Outcomes With Variable Rates of Complications: A Systematic Review.

PURPOSE: To systematically review the patient-reported outcomes and postoperative complications following tuberoplasty for the treatment of massive irreparable rotator cuff tears. METHODS: A literature search was conducted using PubMed and EMBASE computerized databases from database inception to June 2023 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Included studies evaluated clinical outcomes, postoperative complications, and reoperation rates following tuberoplasty for the treatment of massive irreparable rotator cuff tears. Exclusion criteria consisted of non-English language, cadaveric studies, case reports, animal studies, studies with overlapping cohorts, letters to editors, and review articles. Study quality was assessed using the Methodological Index for Non-Randomized Studies criteria. Clinical outcome scores included the visual analog scale for pain, University of California Los Angeles score, and Constant score. RESULTS: Seven studies from 2002 to 2023 consisting of 123 patients with a mean age of 66.5 years (mean range, 63-70.4 years) were included. The mean follow-up time ranged from 18 to 98 months. The mean Methodological Index for Non-Randomized Studies score was 13.5 (range, 13-15). At final follow-up, the mean postoperative visual analog scale pain scores ranged from 2.3 to 2.5, University of California-Los Angeles shoulder score from 27.2 to 27.7, and Constant scores from 59.2 to 90.6. Postoperative active forward flexion and abduction ranged from 131° to 165°, and 123° to 160°, respectively. The change in acromiohumeral distance postoperatively ranged from -1 mm to -0.6 mm. The rate of postoperative complications ranged from 0% to 19% of patients, while 0% to 19% of patients underwent revision surgery to reverse shoulder arthroplasty. CONCLUSIONS: Tuberoplasty for the treatment of massive irreparable rotator cuff tears results in good clinical outcomes with significant pain relief in select populations. However, the variable reoperation rates should be considered when counseling patients. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

The Sex or Race of Program Directors May Not Play a Significant Role in Impacting Diversity Among Orthopaedic Surgery Residents.

PURPOSE: To identify the influence of residency program characteristics, including the presence of under-represented minorities in medicine (URiM) and/or female program directors (PDs), on the race and sex distribution of orthopaedic surgery residency trainees. METHODS: All active and Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs from 2017-2021 that reported usable information in the Residency Explorer Tool were included. Data collected included program characteristics, as well as faculty and resident sex distribution, ethnicity, race, and demographic characteristics. The PDs' specific sex, ethnicity, race, and demographic characteristics were collected using residency program websites. The prevalence of factors in programs with the top quartile of female and URiM residents was compared with that in programs with the bottom 3 quartiles. RESULTS: Data were obtained from 148 of 200 Accreditation Council for Graduate Medical Education-accredited programs (3,694 residents). The 52 excluded programs had no usable information in the Residency Explorer Tool or on an identifiable program website. Overall, 15.9% of residents in orthopaedic surgery residency programs were women and 14% were under-represented minorities. The rates of female PDs and chairs were 12.4% and 6.9%, respectively, whereas those of URiM PDs and chairs were 8.3% and 4.6%, respectively. Programs with more female residents were not associated with female PDs (P = .79) or URiM PDs (P = .48). Programs with a greater percentage of URiM residents were not associated with URiM PDs (P = .16). Larger programs (P = .021) and university-based programs (P = .048) had a greater percentage of female residents. Orthopaedic residency programs with visa sponsorship had a greater percentage of URiM residents (P = .017). CONCLUSIONS: Programs with a higher percentage of female or URiM residents did not show a significant association with having female or URiM PDs. Larger programs and university-affiliated programs were more likely to have a larger percentage of female residents, whereas programs that offered visa sponsorship had a higher percentage of URiM residents. CLINICAL RELEVANCE: This study highlights factors influencing diversity among orthopaedic surgery residents. Although the presence of female or URiM PDs does not influence the percentage of female or URiM residents, other program characteristics such as size, affiliation, and visa sponsorship offer potentially actionable insights for promoting greater diversity in orthopaedic training. Doing so may increase under-represented groups within the field and could ultimately impact patient care and improve health care equity.

"Does an Additional Advanced Degree Influence Career Trajectory as a Shoulder and Elbow Surgeon?"

BACKGROUND: As orthopedic surgery becomes increasingly competitive, orthopedic surgeons are now pursuing advanced degrees more frequently to enhance their resumes or gain additional expertise. The specific impact of this additional training and education on a surgeon's career trajectory is not well defined. The purpose of this study was to understand the impact of an advanced degree on the academic career of orthopedic shoulder and elbow surgeons. METHODS: Orthopedic shoulder and elbow fellowship-trained surgeons were identified using the directory listed on the American Shoulder and Elbow Surgeons website. Demographics, education, and current professional roles were obtained. Research productivity was obtained using SCOPUS and Google Scholar. Advanced degrees were defined as those additional to the primary medical degree (Doctor of Medicine [MD] or Doctor of Osteopathic Medicine [DO]). Outcome measures collected included timing of advanced degree obtainment, current academic and leadership roles, leadership on journal editorial boards, and research productivity. Statistical analysis was performed using the chi-square test and Mann-Whitney U test to determine the association of advanced degrees on outcome measures. RESULTS: In total, 893 orthopedic shoulder and elbow surgeons were identified, of whom 129 had advanced degrees. Most common advanced degrees included Master of Science (MS/MSc; 43%), Master of Business Administration (MBA; 23%), and Doctor of Philosophy (PhD; 13%). The most common period of degree obtainment was before medical school (35%) with the least common times being after medical school/before residency (0.9%) and between residency and fellowship training (0.9%). Surgeons who held advanced degrees demonstrated greater research productivity, with a higher h-index (p < 0.001), a greater number of citations (p < 0.001), and more publications (p < 0.001). Of the 523 shoulder and elbow surgeons who worked at an academic institution, those holding advanced degrees were more likely to serve as orthopedic department chair (p < 0.001) and serve an editorial board position (< 0.001). CONCLUSION: This study found that having an advanced degree as an orthopedic shoulder and elbow surgeon was linked to higher research impact and productivity and an increased likelihood of becoming a department chair and holding an editorial position. These significant findings can help future trainees and department leadership in understanding the importance and impact of additional training on career trajectories for academic faculty.

Social media use and patient ratings in shoulder and elbow surgeons: how many "likes" for five stars?

BACKGROUND: Social media plays an important role in healthcare and physician selection by facilitating direct communication with patients and impacting physician ratings. A concern however is the increased online scrutiny and negative impact on patient satisfaction with these connections. This study aimed to investigate whether social media activity by fellowship-trained shoulder and elbow surgeons impacts patient's perceptions and ratings on physician review websites (PRWs). METHODS: The American Shoulder and Elbow Surgeons physician directory was used to identify currently practicing shoulder and elbow surgeons in the United States. Physician ratings were collected from Healthgrades, Google reviews, and Vitals. The surgeons were divided into two groups: social media users (SMU) and non- SMU (NSMU). The association of social media use with online physician ratings was evaluated using simple and multilinear regressions. RESULTS: A total of 385 American Shoulder and Elbow Surgeons surgeons were included and 21.3% were SMU. SMU were younger (mean age, 48 years) compared to NSMU (mean age, 51 years) (P = .01), all other demographics were comparable including sex (P = .797), medical degree (P = .114), and geographic location within the United States (P = .49). SMU had significantly higher ratings on Healthgrades (P < .001) and Vitals (P < .001). However, social media use did not impact the total number of ratings on PRWs. Additionally, surgeons who utilized Facebook had higher physician ratings and number of website reviews on Healthgrades (P = .028 and P = .014, respectively). In addition, surgeons who used Twitter had higher ratings on Healthgrades (P < .001) and Vitals (P = .001). Surgeons with a greater average number of likes per post on Twitter had significantly higher average ratings across all three sites (P = .004). Surgeons with a greater number of Twitter followers and greater average number of likes per post had significantly higher average ratings on Healthgrades (P = .052 and P = .005, respectively) while surgeons with a greater average number of likes per post had significantly higher average ratings on Vitals (P = .006). Finally, surgeons with a greater average posting frequency on Instagram had significantly higher average ratings across all websites (P = .029). CONCLUSION: Shoulder and elbow surgeons who use Twitter and Facebook had significantly higher online ratings. However, the increased use of these platforms in terms of postcontent, postfrequency, comments, and number of followers was not as influential on PRWs. This suggests that social media is an important marketing and outreach method for orthopedic surgeons to improve their ratings and patient reviews.

Outcomes following revision reverse shoulder arthroplasty for infection.

BACKGROUND: In comparison to primary reverse shoulder arthroplasty (RSA) procedures, revision arthroplasty can be a longer and more complex procedure leading to an increased risk of complications. The reported rates of infection in primary RSA range from 1% to 19% and the cost impact on patients and health care systems is significant, leading to multiple revision surgeries. The purpose of this study was to evaluate the postoperative outcomes, complications, and revision rates for revision reverse shoulder arthroplasty (rRSA) due to infection compared with rRSA for noninfectious causes. METHODS: Patients who underwent rRSA between 2009 and 2020 by a single fellowship-trained orthopedic surgeon at a single institution were retrospectively identified through a prospectively collected database. Patients were separated into 2 cohorts based on revision diagnosis: (1) rRSA due to infection (rRSAi) and (2) rRSA due to noninfectious causes (rRSAn). Patient-reported outcome scores (PROs), including the Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, University of California-Los Angeles shoulder score, Shoulder Arthroplasty Smart score, and active range of motion (ROM) were collected preoperatively and at a minimum 1-year follow-up. Postoperative complications and revision rates were also collected. RESULTS: A total of 93 patients (n = 19 rRSAi group, n = 74 rRSAn group) with a mean age of 68 years were included in this analysis. All baseline demographics were comparable between groups. No significant differences were found in preoperative or postoperative PROs and ROM between the 2 groups. Postoperative complication rates and revision rates were comparable between the groups. CONCLUSION: RSA due to infection results in similar patient-reported outcome scores, range of motion, and revision rates when compared to rRSA for noninfectious causes. Our results suggest that despite the unique challenges associated with rRSA for infection, patient outcomes do not differ from cases attributed to noninfectious causes. More efforts are warranted to further validate and contextualize these findings, considering the protentional influence of patient-specific and implant-specific factors.

American Shoulder and Elbow Surgeons perspectives on political advocacy.

BACKGROUND: Physician involvement in political advocacy has become increasingly important in recent years. This study aims to explore the types of involvement and barriers to involvement in political advocacy among American Shoulder and Elbow Surgeons (ASES) members, identify issues considered most important by ASES members, and assess demographic factors that might correlate with involvement in political advocacy efforts among ASES members. METHODS: This survey was conducted by the ASES Political Advocacy Committee over a 2-week period in June 2021. The survey collected demographic information including sex, ethnicity, years in practice, practice type, political affiliation, and level of current involvement in political advocacy. Additional questions consisted of thoughts regarding current health care policy issues and the role of the American Academy of Orthopaedic Surgeons/ASES regarding such policy issues. RESULTS: We received 297 responses for a total response rate of 27%. Of those who responded, 24.6% identified as Democrat, 33% identified as Republican, and 42.4% identified as Independent. There was no difference in political affiliation between membership groups. Physician Reimbursement (82%), Medical Liability Reform (50%), and Physician Ownership (50%) were the most important issues identified among respondents. Physician Ownership, Physician Reimbursement and Graduate Medical Education and Student Loan Reform were most important to those in early practice, while Quality and Research was most important to those with greater than 25 years of practice experience. CONCLUSION: There is strong agreement among surgeons regarding the most important political advocacy issues. The efforts of the American Academy of Orthopaedic Surgeons and ASES should focus on these areas. Additionally, the vast majority of respondents felt that advocacy efforts had a positive impact on patients and surgeons.

Telemedicine in orthopaedics during the COVID-19 pandemic: a comparative landscape.

PURPOSE: The purpose of this study was to provide a comprehensive analysis on observed trends regarding the impact of the COVID-19 pandemic on telemedicine application in orthopaedics compared to other procedural, non-emergent specialties. METHODS: This was a retrospective review of all telemedicine and in-person visits at a large single institution from January to December 2020. The number of patient visits, visit type, location, and provider specifics were collected. Comparisons were made between subspecialties (orthopaedic surgery, oncology, family medicine, rheumatology) for analyses. RESULTS: All specialties included were not conducting virtual visits at the beginning of 2020. By April 2020, orthopaedic virtual visits spiked to an all-time high of 33.5% of all patient visits as compared to oncology at 25.5%, rheumatology at 92.9%, and family medicine at 94%. By the end of the study period, orthopaedic virtual visits decreased back down to 6.5% of patient visits compared to oncology at 7.0%, and family medicine (17.4%) and rheumatology (26.2%). Orthopaedic providers practicing greater than 20 years had the highest average virtual visit rates. CONCLUSION: Although the COVID-19 pandemic has posed unique challenges for healthcare providers, there was a great advancement in the rollout and application of telemedicine. To mitigate the spread of infection from coronavirus and given the recent adjustments to reimbursement policies and HIPAA regulations, orthopaedics saw a dramatic expansion of telemedicine since April 2020. The pandemic may have served as a catalyst to adopt telehealth into clinical practice. However, telehealth saw a downtrend trend by December 2020, particularly in procedure-based fields like orthopaedics and oncology.

Do modifiable patient factors increase the risk of postoperative complications after total joint arthroplasty?

INTRODUCTION: Numerous studies demonstrate that modifiable lifestyle risk factors can influence patient outcomes including survivability, quality of life, and postoperative complications following orthopaedic surgery. The purpose of this study was to determine the impact of modifiable lifestyle risk factors on postoperative medical and surgical complications following a total joint arthroplasty (TJA) in a large national healthcare system. METHODS: A retrospective chart review of a large national health system database was performed to identify patients who underwent TJA between 2017 and 2021. TJA included total knee arthroplasty, total hip arthroplasty, and total shoulder arthroplasty. Modifiable lifestyle risk factors were defined as tobacco use, narcotic drug abuse, hypertension, and diabetes mellitus. Postoperative medical complications and postoperative surgical complications were collected. Logistic regression and odds ratio point estimate analysis were conducted to assess for associations between postoperative complications and modifiable lifestyle risk factors. RESULTS: Of the 16,940 patients identified, the mean age was 71 years, mean BMI was 29.7 kg/m2, and 62% were women. We found that 3.5% had used narcotics, 8.7% were past or current smokers, 24% had diabetes, and 61% had hypertension; in addition, 5.4% experienced postoperative medical complications and 6.4% experienced postoperative surgical complications. Patients who used narcotics were 90% more likely to have postoperative complications (p < 0.0001) and 105% more likely to experience prosthetic complications (p < 0.0001). Similarly, patients with tobacco use were 65% more likely to have postoperative complications (p < 0.0001) and 27% more likely to experience prosthetic complications. CONCLUSIONS: Our results demonstrate critical rates of increased postoperative medical and surgical complications after TJA for patients with narcotic abuse, tobacco use, or diabetes mellitus. Furthermore, adopting preoperative interventions and optimization programs informed by our findings on specific modifiable risk factors could aid orthopaedic surgeons in optimizing patient health. LEVEL OF EVIDENCE: III; Retrospective study.

The Impact of Hospital Size and Teaching Status on Outcomes Following Total Ankle Arthroplasty.

The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models.

What do positive and negative Cutibacterium culture results in periprosthetic shoulder infection mean? A multi-institutional control study.

BACKGROUND: Deep tissue culture specimens obtained at the time of revision shoulder arthroplasty are commonly positive for Cutibacterium. Clinical interpretation of positive cultures can be difficult. This was a multi-institutional study evaluating the accuracy of cultures for Cutibacterium using positive control (PC) and negative control (NC) samples. The relationship between time to culture positivity and strength of culture positivity was also studied. METHODS: Eleven different institutions were each sent 12 blinded samples (10 PC and 2 NC samples). The 10 PC samples included 2 sets of 5 different dilutions of a Cutibacterium isolate from a failed total shoulder arthroplasty with a probable periprosthetic infection. At each institution, the samples were handled as if they were received from the operating room. Specimen growth, time to culture positivity, and strength of culture positivity (based on semiquantitative assessment) were reported. RESULTS: A total of 110 PC samples and 22 NC samples were tested. One hundred percent of specimens at the 4 highest dilutions were positive for Cutibacterium. At the lowest dilution, 91% of samples showed positive findings. Cutibacterium grew in 14% of NC samples. Cutibacterium grew in PC samples at an average of 4.0 ± 1.3 days, and all of these samples showed growth within 7 days. The time to positivity was significantly shorter (P < .001) and the strength of positivity was significantly higher (P < .001) in true-positive cultures compared with false-positive cultures. CONCLUSIONS: This multi-institutional study suggests that different institutions may report highly consistent rates of culture positivity for revision shoulder arthroplasty samples with higher bacterial loads. In contrast, with lower bacterial loads, the results are somewhat less consistent. Clinicians should consider using a shorter time to positivity and a higher strength of positivity as adjuncts in determining whether a tissue culture sample is a true positive.

The role of greater tuberosity healing in reverse shoulder arthroplasty: a finite element analysis.

BACKGROUND: The lack of greater tuberosity (GT) healing in proximal humerus fractures has been negatively correlated with outcomes for hemiarthroplasty; however, there is still debate regarding the effects of GT healing in reverse shoulder arthroplasty (RSA). Our goal was to examine the effects of GT healing using a kinematic finite element analysis (FEA) model. MATERIAL AND METHODS: Computer-aided design models of a medialized glenoid with a lateralized humerus (MGLH) RSA design were uploaded into an FEA shoulder model in 2 different configurations: healed greater tuberosity (HGT) and nonunion greater tuberosity (NGT). Deltoid muscle forces and joint reaction forces (JRFs) on the shoulder were calculated during abduction (ABD), forward flexion (FF), and external rotation (ER). RESULTS: Force magnitude of the anterior, middle, and posterior deltoid muscle as well as JRFs modeled in both GT scenarios were similar for ABD (muscle forces P = .91, P = .75, P = .71, respectively; and JRF P = .93) and for FF (muscle forces P = .89, P = .83, P = .99, respectively; and JRF P = .90). For ER, the force magnitude between 2 GT settings showed statistically significant differences (HGT: 9.51 N vs. NGT: 6.13 N) (P < .001). Likewise, during ER, JRFs were different, and the NGT group showed a steep drop in JRF after 10° of ER (HGT: 28.4 N vs. NGT: 18.38 N) (P < .001). CONCLUSION: GT healing does not seem to impact RSA biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. Overall orthopedic surgeons can expect good results for patients after RSA even with poor GT healing.

Factors Affecting the Cost and Profitability of Arthroscopic Rotator Cuff Repair.

PURPOSE: To examine the cost metrics and profitability of rotator cuff repairs (RCRs) in a large health care system. METHODS: A retrospective study was performed using value analysis team data from 2 hospitals within a large metropolitan health system from 2010 to 2014. Cost and profit metrics were collected and compared against surgeon volume, surgeon subspecialty training, implant costs, Current Procedural Terminology (CPT) coding, length of stay, and hospital site. RESULTS: A total of 5,899 RCRs were identified with a mean contribution margin of $2,133. Surgical supplies were the largest contributor to direct costs. Hospital site also significantly affected contribution margin ($1,912 at hospital 1 vs $3,129 at hospital 2, P < .001). The number of billed CPT codes was not significantly correlated to contribution margin; however, significant differences were noted in contribution margin and direct cost associated with different CPT code combinations, with arthroscopic RCR with subacromial decompression and distal clavicle excision being the most profitable, at an average contribution margin of $2,147. There was no correlation between surgeon volume and contribution margin or direct cost. CONCLUSIONS: Our overall findings show that improvement in the profitability of arthroscopic RCR for hospital systems is possible, both by examining institutions' direct costs and by providing individual surgeons with cost breakdowns and contribution margin information to improve the profitability of their practice. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

Biomechanical comparison of 2 augmented glenoid designs: an integrated kinematic finite element analysis.

BACKGROUND: Augmented glenoid implants are available to help restore the biomechanics of the glenohumeral joint with excessive retroversion. It is imperative to understand their behavior to make a knowledgeable preoperative decision. Therefore, our goal was to identify an optimal augmented glenoid design based on finite element analysis (FEA) under maximum physiological loading. METHODS: FEA models of 2 augmented glenoid designs-wedge and step-were created per the manufacturers' specifications and virtually implanted in a scapula model to correct 20° of retroversion. Simulation of shoulder abduction was performed using the FEA shoulder model. The glenohumeral force ratio, relative micromotion, and stress levels on the cement mantle, glenoid vault, and backside of the implants were compared between the 2 designs. RESULTS: The force ratio was 0.56 for the wedge design and 0.87 for the step design. Micromotion (combination of distraction, translation, and compression) was greater for the step design than the wedge design. Distraction measured 0.05 mm for the wedge design and 0.14 mm for the step component. Both implants showed a similar pattern for translation; however, compression was almost 3 times greater for the step component. Both implants showed high stress levels on the cement mantle. At the glenoid vault and on the implants, the stress levels were 1.65 MPa and 6.62 MPa, respectively, for the wedge design and 3.78 MPa and 13.25 MPa, respectively, for the step design. CONCLUSION: Implant design slightly affects joint stability; however, it plays a major role regarding long-term survival. Overall, the augmented wedge design provides better implant fixation and stress profiles with less micromotion.

The effect of glenohumeral radial mismatch on different augmented total shoulder arthroplasty glenoid designs: a finite element analysis.

BACKGROUND: Augmented glenoid implants to correct bone loss can possibly reconcile current prosthetic failures and improve long-term performance for total shoulder arthroplasty. Biomechanical implant studies have suggested benefits from augmented glenoid components, but limited evidence exists on optimal design. METHODS: An integrated kinematic finite element analysis (FEA) model was used to evaluate optimal augmented glenoid design based on biomechanical performance in translation in the anteroposterior plane similar to clinical loading and failure mechanisms with osteoarthritis. Computer-aided design software models of 2 different commercially available augmented glenoid designs-wedge (Equinox; Exactech, Inc., Gainesville, FL, USA) and step (STEPTECH; DePuy Synthes, Warsaw, IN, USA) were created according to precise manufacturer's dimensions of the implants. Using FEA, they were virtually implanted to correct 20° of retroversion. Two glenohumeral radial mismatches, 3.5/4 mm and 10 mm, were evaluated for joint stability and implant fixation simulating high-risk conditions for failure. RESULTS: The wedged and step designs showed similar glenohumeral joint stability under both radial mismatches. Surrogate for micromotion was a combination of distraction, translation, and compression. With similar behavior and measurements for distraction and translation, compression dictated micromotion (wedge: 3.5 mm = 0.18 mm and 10 mm = 0.10 mm; step: 3.5 mm = 0.19 mm and 10 mm = 0.25 mm). Stress levels on the backside of the implant and on the cement mantle were higher using a step design. DISCUSSION: Greater radial mismatch has the advantage of providing higher glenohumeral stability with tradeoffs, such as higher implant and cement mantle stress levels, and micromotion worse when using a step design.

The impact of solid organ transplant history on inpatient complications, mortality, length of stay, and cost for primary total shoulder arthroplasty admissions in the United States.

BACKGROUND: There is a growing population of patients with history of solid organ transplant (SOT) surgery among total joint patients. Patients with history of SOT have been found to have longer lengths of stay and higher inpatient hospital costs and complications rates after hip and knee arthroplasty. The purpose of this study was to determine whether this is true for shoulder arthroplasty in SOT patients. METHODS: The Nationwide Inpatient Sample was queried to describe relative demographic, hospital, and clinical characteristics, perioperative complications, length of stay, and total costs for patients with a history of SOT (International Classification of Diseases-9th Edition-Clinical Modificiation V42.0, V42.1, V42.7, V42.83) undergoing shoulder arthroplasty (81.80, 81.88) from 2004 to 2014. RESULTS: A weighted total of 843 patients (unweighted frequency = 171) and 382,773 patients (unweighted frequency = 77,534) with and without history of SOT, respectively, underwent shoulder arthroplasty. SOT patients were more often younger and more likely to be male, have Medicare, and undergo surgery in a large teaching institution in the Midwest or Northeast (P < .001). SOT patients had higher or similar comorbid disease prevalence for 27 of 29 Elixhauser comorbidities. The risk of any complication was significantly higher among SOT patients (15.5% vs. 9.3%, P = .007). SOT patients experienced inpatient admissions an average 0.27 days longer (P < .001) and $1103 more costly (P = .06) than non-SOT patients. CONCLUSIONS: Patients with history of SOT undergoing shoulder arthroplasty appear to remain a unique population due to their specific vulnerability to minor complications and inherently increased inpatient resource utilization.

Comparison of Microbial Count on Various Surfaces in Operating Rooms at Different Times of the Day.

The purpose of this study was to determine the degree of microbial contamination of surfaces in the operating room (OR) and to understand the relationship between time and location of contamination. Five OR surfaces were sampled at two time points on three consecutive Mondays and Thursdays. Each sample was cultured on a blood agar plate and introduced to a liquid nutrient broth. The most sterile surface was the OR lights with only one positive growth sample at each time. At both times, the most commonly contaminated surface was the staff keyboard. Coagulase-negative staphylococcus was the most common isolated species. Contamination rate of OR surfaces was not affected by time of day or day of the week. Simple cleaning and daily decontamination of staff keyboards can significantly reduce bacterial burdens and should be of primary importance to optimize OR sterility. (Journal of Surgical Orthopaedic Advances 27(4):281-285, 2018).

National trends in proximal humerus fracture treatment patterns.

BACKGROUND: The treatment of proximal humerus fractures (PHF) is largely surgeon dependent with no clear guidelines for selecting the optimal method of treatment. AIMS: The aim of this study was to evaluate trends and variations in treatment methods of PHF in the United States from 2004 to 2012 and to determine the regional differences in treatment. METHODS: The National Inpatient Sample was used to identify all patient discharges with diagnosis codes for PHF and the data were classified based on ICD-9 procedure codes. Patient and hospital demographics were also analyzed. Simple linear regression analyses were performed for each treatment modality to evaluate current treatment trends and to extrapolate the future trends of PHF treatment over the next 20 years. RESULTS: A national estimate of 550,116 PHF discharges was identified over the time period. Significant correlations between change over time and treatment modality were found for reverse shoulder arthroplasty (RSA) (r = 0.903, p < 0.001), open reduction internal fixation (r = 0.876, p = 0.002), and closed reduction internal fixation (r = -0.922, p < 0.001). The RSA regression model showed that by the year 2032, PHF treated with RSA will increase 100% from 2012. DISCUSSION: There were significant changes in treatment modalities for PHF from 2004 to 2012; The projected number of RSA used to treat PHF will be about 9115 in 2032, compared to 340 in 2004. CONCLUSION: Overall, there was a growth in proximal humerus fractures treated in an inpatient setting in the United States. RSA had the greatest proportional increase over time, but only accounted for less than 2% of total interventions.