Revision of failed reverse total shoulder arthroplasty with reverse: short-term clinical outcomes.

BACKGROUND: The prevalence of failed reverse total shoulder arthroplasty (rTSA) is increasing. This can often present a challenging clinical situation with substantial bone loss and limited reconstruction options. This study reports a single tertiary referral center's experience with revision of failed rTSA managed with revision rTSA of bone-interfacing components. METHODS: After institutional review board approval, all revision shoulder arthroplasty cases performed at a single institution between 2012 and 2020 were reviewed. Cases in which rTSA was revised to a new rTSA construct with revision of at least 1 bone-interfacing implant (humeral stem and/or baseplate) with a minimum 2-year follow-up were identified. Characteristics of revision cases-including indications, bony stock, revised components, and use of bone graft-were collected. All patients were contacted for patient-reported outcome measures at a minimum of 2 years after surgery. In addition, the incidence and indication for any reoperation after revision were determined. RESULTS: Thirty-three patients with an average age of 66 years (range: 46-82 years), with 19 (58%) being female, met the inclusion criteria and had a mean follow-up of 4.2 years (range: 2-8 years). The most common indication for revision rTSA included humeral component loosening (33%; 11/33), baseplate loosening (27%; 9/33), and instability (21%; 7/33). Prerevision infectious workup demonstrated no cases of periprosthetic shoulder infection. Thirteen cases had massive bone loss-5 treated with humeral allograft prosthetic composite, 5 with glenoid bone grafting, and 3 with custom glenoid implant. In total, 10 of 33 cases (30%) required reoperation at a mean of 13 months (range: 1-44 months) for instability (4), humeral loosening (2), infection (1), baseplate loosening (1), or periprosthetic fracture (1). The reoperation rate for patients with revised baseplates only, humerus only, or combined was 23% (3/13), 28% (5/18), and 27% (3/11), respectively. Overall, the visual analog scale pain score improved from 6.5 preoperatively to 2.0 (P < .001), and the American Shoulder and Elbow Surgeons score improved from 30.7 to 67.5 (P < .001). However, the postoperative Single Assessment Numeric Evaluation score averaged only 51.2% (range: 2-100%). CONCLUSION: This study demonstrates that failed rTSA can be salvaged with a revision rTSA. However, patient expectations for functional improvements should be tempered, and a high reoperation rate should be expected.

Program Directors' Perception of the Role of Personal Statements in the Orthopaedic Surgery Residency Selection Process.

The purpose of this study was (1) to determine how much emphasis is placed on the Personal Statement (PS) by program directors (PDs) and (2) to gain a better understanding of what factors within the PS are considered most important to PDs. An anonymous survey was distributed to PDs at allopathic orthopaedic residency programs in the United States using Survey Monkey (San Mateo, CA). Survey responses were received from 51 of 152 (34%) PDs. Forty-five (88.2%) identified as male, five (9.8%) identified as female, and one (1.9%) chose not to disclose. PDs reported the PS was of average importance, with an average score of 2.82 (range,1-4). Although the PS is still given consideration as part of the overall orthopaedic surgery residency application process, it does not play a major role in determining which applicants will be invited for an interview or how they will be ranked. (Journal of Surgical Orthopaedic Advances 31(2):090-095, 2022).

Analyzing the Orthopaedic Surgery Personal Statement: Do Residency Applicants See Value in Its Use?

Orthopaedic surgery is one of the most competitive specialties in the residency match. The personal statement (PS) is one component of the application. The significance of the PS to orthopaedic surgery residency applicants is unknown. This study evaluates applicant perceptions of the PS. Applicants to two separate United States orthopaedic residency programs for the 2019-2020 cycle were invited to participate. Survey was distributed via email. Twenty-one percent (204/978) of applicants completed the survey. Most were men (157/204, 77%), and most (125/204, 61%) spent up to 15 hours writing their PS. Many [79.4% (162/204)] believed the PS should continue to be included in the application. Women always edited their PS, while 7.0% (11/ 157) of men did not use any editors. Applicants believe the PS is valuable. The PS is time consuming but allows applicants to communicate details that otherwise may not be included in their application. (Journal of Surgical Orthopaedic Advances 31(1):034-041, 2022).

Achilles Injury and Access to Care in South Florida.

Introduction. Despite the amount of orthopaedic research evaluating access to care based on insurance status, no study quantifies the effects of insurance status on the care of acute Achilles tendon ruptures. Methods. Using Current Procedural Terminology codes, we identified all patients who underwent surgical management of Achilles tendon rupture between December 31, 2013, and December 31, 2018, and followed-up at either a county hospital-based orthopaedic surgery clinic and/or private university-based clinic. Inclusion criteria included patients who (1) underwent surgical management of an Achilles tendon rupture during this time period and (2) were at least 18 years of age at the time of surgery. A univariate 2-tailed t test was used to compare various groups. Statistical significance was set at P < 0.05. Results. When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of injury to first clinic visit (14.5 days vs 5.2 days, P < .001), first clinic visit to surgery (34.6 days vs 4.8 days, P < .002), injury to surgery date (48.9 days vs 9.8 days, P < .001), initial presentation to when magnetic resonance imaging was obtained (48.1 days vs 1.9 days, P < .002). Conclusions. Disparities in access to care for Achilles tendon ruptures are intimately related to insurance status. Uninsured and Medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance.Levels of Evidence: Level III: Prognostic, retrospective.

Optimizing the Virtual Interview Experience for Hand Surgery Fellowships.

Similar to many other medical training programs, fellowship interviews for hand surgery will be conducted virtually for a second consecutive year. We provide strategies for applicants to ideally portray themselves and to learn about fellowship programs. We include approaches for fellowship programs to identify candidates that match their values as a program, as well as ways to provide useful information to applicants about the program's culture. Given that components of virtual interviewing and recruitment will likely be an ongoing part of fellowship applications, we hope this article provides a framework to guide both applicants and program faculty for the 2021 to 2022 cycle and beyond.

Liquid Nitrogen Applied at Point of Sale: A New Presentation of Gastric Perforation in Children.

ABSTRACT: The August 30, 2018, US Food and Drug Administration advisory warned consumers to avoid eating, drinking, or handling food products prepared with liquid nitrogen (LN) (US FDA. Safety Alerts & Advisories: FDA Advises Consumers to Avoid Eating, Drinking, or Handling Food Products Prepared with Liquid Nitrogen at the Point of Sale. US Food and Drug Administration). We report on the case of a pediatric patient sustaining gastric perforation after ingestion of LN applied to food at the point of sale in the United States. "Dragon's Breath" is a popular snack of cereal puffs coated in LN giving the allusion of breathing smoke on ingestion. Instructions provided by vendors include avoidance of touching or drinking the liquid in the bottom of the cup. We report on a case of a 9-year-old girl presenting with peritonitis and gross pneumoperitoneum after consumption of Dragon's Breath with injury conferred secondary to LN ingestion. Intraoperative finding of a large perforation along the lesser curvature of the stomach was repaired primarily with an omental overlay. Her postoperative course was complicated by pneumonia and a surgical site infection. She was discharged 13 days after admission. A review of the literature of previous case reports of LN ingestion by intentional or accidental means is provided. This case report and review of the literature bring awareness of the dangers posed to pediatric patients exposed to LN applied at the point of sale.

The limited role of ultrasound in the surgical assessment of solid pediatric breast lesions.

INTRODUCTION: Ultrasound (US) is an adjunct to history and clinical exam (CE) in the assessment of pediatric breast lesions. We sought to investigate the reliability of US and CE to predict final pathologic diameter (P). METHODS: A single institutional retrospective analysis of patients aged ≤18 years who underwent breast mass resection was performed. Data was collected and analyzed using SPSS. RESULTS: 88 patients met inclusion criteria with an average age at surgery of 16 ± 1.5 years. No malignancies were encountered. The largest mean diameter measured by final pathology (MPØ) for all lesions was 4.1 ± 2.6 cm. Pathology encountered were fibroadenoma (83%, MPØ 3.7 ± 1.7 cm), juvenile fibroadenoma (10%, MPØ 7.0 ± 5.4 cm), and low-grade phyllodes tumor (3%, MPØ 6.2 ± 3.8 cm). 67 patients had documented CE measurement with a mean diameter of 3.4 ± 1.8 cm. 62 patients underwent US with a mean diameter of 3.3 ± 1.6 cm. US and CE were accurate in determining P by Cronbach Alpha reliability testing. CONCLUSION: US and CE are reliable measurements of P. The surgical utility of US when considering pediatric breast lesions is limited and should be individualized following pediatric surgical evaluation and CE.

Availability and Variability of Consumer Prices for Lumbar Discectomy Across US Hospitals in 2018.

OBJECTIVE: To determine the availability and variability of consumer pricing data for an elective lumbar discectomy in the USA. METHODS: Hospital representatives were contacted via telephone, hospital websites, and state price-transparency websites. A total of 153 hospitals were contacted via telephone calls under the guise of a patient requesting a self-pay price for elective lumbar discectomy. The same hospitals were then researched for price comparison between those requested by phone and those listed on hospital websites after installment of the price transparency law by the Centers of Medicare and Medicaid Services (CMS) on 1 January 2019. Complete and partial prices were recorded for both datasets when available. Hospitals were grouped based on profit status, teaching status, and geographical region. Statistical analysis compared rates of price availability and mean prices between hospital groups and between datasets. RESULTS: Thirty-four (23.0%) of 148 hospitals included in the final analysis were able to provide complete price information via telephone. An additional 70 (47.3%) were able to provide a partial price. A total of four (2.7%) institutions provided a complete price and an additional 65 (43.9%) provided a partial price via website. The mean complete price for microdiscectomy when provided was $27,342.36 (n = 34). When compared to government and non-profit hospitals combined, private hospitals had significantly lower partial-prices. CONCLUSION: A patient seeking to undergo a common surgical procedure in the USA will likely be met with difficulty and few options if motivated by price. A high degree of variability exists among US hospitals in 2018 with regards to availability and comprehensiveness of pricing information.

Restructuring of an Orthopaedic Surgery Residency Research Rotation Correlates with Increased Academic Productivity in Teaching Faculty.

INTRODUCTION: Contribution toward clinical research is paramount to the education of physician trainees and is required by the Accreditation Council for Graduate Medical Education. From 1987 through 2015, our single institution orthopaedic surgery residency research experience included 2 dedicated research rotations. Because few resident projects were pursued to completion, feedback was used to restructure the curriculum, including the appointment of 2 clinical orthopaedic faculty to serve as codirectors, development of a revised curriculum, use of research teams, and a centralized research database. Our group previously displayed increased resident productivity within 2 years after the 2015 implementation. The aim of this study was to investigate the impact of orthopaedic residency curricular changes on scholarly activity of orthopaedic teaching faculty. METHODS: The curriculum vitae (CVs) of a single institution's orthopaedic teaching faculty were collected and retrospectively reviewed from 2014 through 2018 to determine academic productivity of clinical faculty. Indicators of academic productivity included peer-reviewed publications (including journal impact factors) and podium or poster presentations. RESULTS: Twenty-three of 27 faculty members responded to our request for CVs. One hundred three CVs were reviewed on 23 faculty. All academic indicators increased over 5 years. Multivariate analysis of variance (MANOVA) using a multivariate repeated measures analysis was completed. A sphericity χ2 test was violated for all measures, precluding us from using unadjusted univariate analysis. Univariate MANOVA with repeated measures displays significance regarding impact factor (f < 0.02, p < 0.05) and journal publications (f < 0.004, p < 0.05). Subsequent multivariate analysis shows similar results regarding impact factor (f < 0.0008), journal publications (0.0005), and poster presentations (f < 0.016). CONCLUSIONS: Improved structure of an established resident research rotation combined with enhanced faculty mentorship resulted in a significant increase in academic productivity for clinical teaching faculty of the department of orthopaedic surgery. This increase parallels that seen in orthopaedic resident research productivity; indicating a positive impact on teaching faculty scholarly activity. LEVEL OF EVIDENCE: III.

Cancer stem cells as a therapeutic target in 3D tumor models of human chondrosarcoma: An encouraging future for proline rich polypeptide­1.

Chondrosarcoma is a malignant bone neoplasm that is refractory to chemotherapy and radiation. With no current biological treatments, mutilating surgical resection is the only effective treatment. Proline rich polypeptide 1 (PRP­1), which is a 15­amino acid inhibitor of mammalian target of rapamycin complex­1 (mTORC1), has been indicated to exert cytostatic and immunomodulatory properties in human chondrosarcoma cells in a monolayer. The aim of the present study was to evaluate the effects of PRP­1 on an in vitro 3D chondrosarcoma tumor model, known as spheroids, and on the cancer stem cells (CSCs) which form spheroids. JJ012 cells were cultured and treated with PRP­1. An ALDEFLUOR™ assay was conducted (with N,N­diethylaminobenzaldehyde as the negative control) to assess aldehyde dehydrogenase (ALDH) activity (a recognized CSC marker), and bulk JJ012, ALDHhigh and PRP­1 treated ALDHlow cells were sorted using flow cytometry. Colony formation and spheroid formation assays of cell fractions, including CSCs, were used to compare the PRP­1­treated groups with the control. CSCs were assessed for early apoptosis and cell death with a modified Annexin V/propidium iodide assay. Western blotting was used to identify mesenchymal stem cell markers (STRO1, CD44 and STAT3), and spheroid self­renewal assays were also conducted. A clonogenic dose­response assay demonstrated that 20 µg/ml PRP­1 was the most effective dose for reducing colony formation capacity. Furthermore, CSC spheroid growth was significantly reduced with increasing doses of PRP­1. Annexin V analysis demonstrated that PRP­1 induced CSC cell death, and that this was not attributed to apoptosis or necrosis. Western blot analysis confirmed the expression of mesenchymal markers, and the spheroid self­renewal assay confirmed the presence of self­renewing CSCs. The results of the present study demonstrate that PRP­1 eliminates anchorage independent CSC growth and spheroid formation, indicating that PRP­1 likely inhibits tumor formation in a murine model. Additionally, a decrease in non­CSC bulk tumor cells indicates an advantageous decline in tumor stromal cells. These findings confirm that PRP­1 inhibits CSC proliferation in a 3D tumor model which mimics the behavior of chondrosarcoma in vivo.

The Impact of COVID-19 on the Orthopaedic Surgery Residency Application Process.

Over recent months, coronavirus disease 2019 (COVID-19) has swept the world as a global pandemic, largely changing the practice of medicine as it was previously known. Physician trainees have not been immune to these changes-uncertainty during this time is undeniable for medical students at all levels of training. Of particular importance is the potential impact of COVID-19 on the upcoming residency application process for rising fourth-year students; a further source of added complexity in light of the newly integrated allopathic and osteopathic match in the 2020 to 2021 cycle. Owing to the impact COVID-19 could have on the residency match, insight regarding inevitable alterations to the application process and how medical students can adapt is in high demand. Furthermore, it is very possible that programs will inquire about how applicants spent their time while not in the hospital because of COVID-19, and applicants should be prepared to provide a meaningful answer. Although competitive at a basal level, the complexity of COVID-19 now presents an unforeseen, superimposed development in the quest to match. In this article, we aim to discuss and provide potential strategies for navigating the impact of COVID-19 on the residency application process for orthopaedic surgery.