The impact of fellowship type on trends and complications following total shoulder arthroplasty for osteoarthrosis by recently trained board-eligible orthopedic surgeons.

BACKGROUND: Total shoulder arthroplasty (TSA) with an anatomic or reverse prosthesis is a commonly used and successful treatment option for many degenerative shoulder conditions. There is an increasing trend toward fellowship training and subspecialization in newly trained orthopedic surgeons. The literature also suggests that subspecialization and high volume are associated with better clinical outcomes. The purpose of this study was to evaluate the effects of fellowship training on the trends and outcomes of TSA in board-eligible orthopedic surgeons. METHODS: The American Board of Orthopaedic Surgery database was used to identify primary TSA cases performed for osteoarthrosis submitted by American Board of Orthopaedic Surgery Part II Board Certification candidates. Candidates were grouped based on fellowship training and subspecialty examination being taken. Groups were analyzed with analysis of variance and Bonferroni post hoc analysis to evaluate significant differences between groups for a number of candidates, cases per candidate, and patient age/sex. Differences in complications, reoperations, and readmissions were statistically evaluated with χ2 tests and multivariate logistic regression analysis. RESULTS: From 2010 to 2017, 854 candidates performed at least 1 primary TSA (anatomic or reverse) after a diagnosis of osteoarthritis and 2720 submitted cases met inclusion criteria. Candidates completing a Shoulder fellowship performed significantly more TSAs per candidate compared with all other groups (Shoulder = 8.0 ± 6.2, Sports Medicine = 2.4 ± 2.1, Hand and Upper Extremity = 2.9 ± 2.9, General Orthopedics = 2.4 ± 2.3, P < .001). The Shoulder fellowship group had significantly lower complication rates (17.9%) as compared with the Sports Medicine fellowship (23.7%, P = .008) and Hand and Upper Extremity fellowship (25.0%, P = .008) groups. CONCLUSIONS: Shoulder fellowship-trained surgeons performed significantly more TSAs per year than other groups, with a lower complication rate when compared with other fellowship-trained candidates. Fellowship type had no effect on reoperation or readmission rates.

The effect of starting point placement technique on thoracic transverse process strength: an ex vivo biomechanical study.

BACKGROUND: The use of thoracic pedicle screws in spinal deformity, trauma, and tumor reconstruction is becoming more common. Unsuccessful screw placement may require salvage techniques utilizing transverse process hooks. The effect of different starting point placement techniques on the strength of the transverse process has not previously been reported. The purpose of this paper is to determine the biomechanical properties of the thoracic transverse process following various pedicle screw starting point placement techniques. METHODS: Forty-seven fresh-frozen human cadaveric thoracic vertebrae from T2 to T9 were disarticulated and matched by bone mineral density (BMD) and transverse process (TP) cross-sectional area. Specimens were randomized to one of four groups: A, control, and three others based on thoracic pedicle screw placement technique; B, straightforward; C, funnel; and D, in-out-in. Initial cortical bone removal for pedicle screw placement was made using a burr at the location on the transverse process or transverse process-laminar junction as published in the original description of each technique. The transverse process was tested measuring load-to-failure simulating a hook in compression mode. Analysis of covariance and Pearson correlation coefficients were used to examine the data. RESULTS: Technique was a significant predictor of load-to-failure (P = 0.0007). The least squares mean (LS mean) load-to-failure of group A (control) was 377 N, group B (straightforward) 355 N, group C (funnel) 229 N, and group D (in-out-in) 301 N. Significant differences were noted between groups A and C, A and D, B and C, and C and D. BMD (0.925 g/cm2 [range, 0.624-1.301 g/cm2]) was also a significant predictor of load-to-failure, for all specimens grouped together (P < 0.0001) and for each technique (P <0.05). Level and side tested were not found to significantly correlate with load-to-failure. CONCLUSIONS: The residual coronal plane compressive strength of the thoracic transverse process is dependent upon the screw starting point placement technique. The funnel technique significantly weakens transverse processes as compared to the straightforward technique, which does not significantly weaken the transverse process. It is also dependent upon bone mineral density, and low failure loads even in some control specimens suggest limited usefulness of the transverse process for axial compression loading in the osteoporotic thoracic spine.

Prospective analysis of arthroscopic rotator cuff repair: prognostic factors affecting clinical and ultrasound outcome.

The purpose of this study was to identify potential predictors of function and tendon healing after arthroscopic rotator cuff repair that will enable the orthopaedic surgeon to determine which patients can expect a successful outcome. Between 2003 and 2005, the Arthroscopic Rotator Cuff Registry was established to collect demographic, intraoperative, functional outcome, and ultrasound data prospectively on all patients who underwent primary arthroscopic rotator cuff repair. At total of 193 patients met the study criteria, and 127 (65.8%) completed the 2-year follow-up. The most significant independent factors affecting ultrasound outcome were age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.02-1.14; P = .006) and tear size (OR, 2.29; 95% CI, 1.55-3.38; P < .001). After adjustment for age and tear size, the intraoperative factors found to be significantly associated with a tendon defect were concomitant biceps procedures (OR, 11.39; 95% CI, 2.90-44.69; P < .001) and acromioclavicular joint procedures (OR, 3.85; 95% CI, 1.46-10.12; P = .006). In contrast to the ultrasound data, the functional outcome variables, such as satisfaction (OR, 3.92; 95% CI, 2.00-7.68; P < .001) and strength (OR, 10.05; 95% CI, 1.61-62.77; P = .01), had a greater role in predicting an American Shoulder and Elbow Surgeons score greater than 90. The progression from a single-tendon rotator cuff tear to a multiple-tendon tear with associated pathology increased the likelihood of tendon defect by at least 9 times, and therefore, earlier surgical intervention for isolated, single-tendon rotator cuff tears could optimize the likelihood of ultrasound healing and an excellent functional outcome.

Initial fixation and cyclic loading stability of knotless suture anchors for rotator cuff repair.

This study evaluated the resistance to gapping and the mode of failure for 2 knotless suture anchor systems used for rotator cuff repair compared with the performance of a conventional titanium anchor system. Eight matched pairs of fresh-frozen humeri were dissected free of all soft tissues and scanned to measure bone mineral density (BMD). The suture anchor systems tested were the TwinFix 5.0 Titanium (Smith & Nephew, Andover, MA), Bioknotless RC (DePuy Mitek, Norwood, MA), and Magnum (Opus Medical, San Juan Capistrano, CA), and each was inserted into each humerus. Cyclic, tensile loading was applied through the suture loop for 5000 cycles, or until failure, by using a servohydraulic testing machine. Gapping distances, defined as increasing elongation of the bone/anchor/suture system, were continuously measured. Total cycles to failure and mechanism of failure were documented. Mean initial (first cycle) and final (last cycle) gapping distances were 3.81 mm and 5.36 mm for the TwinFix 5.0, 4.02 mm and 5.34 mm for the Bioknotless RC, and 3.56 mm and 4.98 mm for the Magnum anchors. No significant difference was detected among mean gap openings (P > .05). However, the Bioknotless RC had more early failures (5) than the other 2 implants (1 each), approaching significance (P = .07). Trials of the Bioknotless RC that did not fail early were found to have significantly less gap opening than the other 2 systems for both initial (1.89 mm vs 3.82 mm for the TwinFix 5.0 and 3.56 mm for the Magnum) and final (2.00 mm vs 4.68 mm for the TwinFix 5.0 and 4.24 mm for the Magnum) gap opening. BMD was a significant predictor of initial (P = .029) and final (P = .008) gap opening, whereas the site of anchor insertion was a significant predictor of final displacement. The Opus Magnum was comparable with a conventional suture anchor, but the Mitek Bioknotless RC showed a trend toward early failure. Biomechanical analysis of knotless suture anchor systems can demonstrate trends among implants in an experimental setting. Knowledge of these trends could influence implant selection.