Radiographic and clinical outcomes of second generation Trabecular Metal™ glenoid components in total shoulder arthroplasty.

BACKGROUND: Total shoulder arthroplasty with second generation porous tantalum glenoid implants (Trabecular Metal™) has shown good short-term outcomes, but mid-term outcomes are unknown. This study describes the clinical, radiographic, and patient-rated mid-term outcomes of total shoulder arthroplasty utilizing cemented Trabecular Metal™ glenoid components. METHODS: Patients who underwent anatomic total shoulder arthroplasty with cemented Trabecular Metal™ glenoid components for primary osteoarthritis were identified for minimum five-year follow-up. The primary outcome measure was implant survival; secondary outcome measures included patient-rated outcome scores, shoulder range of motion findings, and radiographic analysis. RESULTS: Twenty-seven patients were enrolled in the study. Twenty-one patients had full radiographic follow-up. Mean follow-up was 6.6 years. There was 100% implant survival. Shoulder range of motion significantly improved and the mean American Shoulder and Elbow Society score was 89.8. There was presence of metal debris radiographically in 24% of patients. Twenty-nine percent of patients had evidence of radiolucency. Fourteen percent of patients had moderate superior subluxation. CONCLUSION: Total shoulder arthroplasty with second generation cemented Trabecular Metal™ glenoid components yielded good outcomes at mean 6.6-year follow-up. Metal debris incidence and clinical outcomes were similar to short-term findings. The presence of metal debris did not significantly affect clinical outcomes. Continued observation of these patients will elucidate longer-term implant survival.

Chondral Damage After Arthroscopic Repair Techniques for Acute Bony Bankart Lesions: A Biomechanical Study.

BACKGROUND: Bony Bankart lesions can be encountered during treatment of shoulder instability. Current arthroscopic bony Bankart repair techniques involve intra-articular suture placement, but the effect of these repair techniques on the integrity of the humeral head articular surface warrants further investigation. PURPOSE: To quantify the degree of humeral head articular cartilage damage secondary to current arthroscopic bony Bankart repair techniques in a cadaveric model. STUDY DESIGN: Controlled laboratory study. METHODS: Testing was performed in 13 matched pairs of cadaveric glenoids with simulated bony Bankart fractures, with a defect width of 25% of the glenoid diameter. Half of the fractures were repaired with a double-row technique, while the contralateral glenoids were repaired with a single-row technique. Samples were subjected to 20,000 cycles of internal-external rotation across a 90° arc at 2 Hz after a compressive load of 750 N, or 90% body weight (whichever was less) was applied to simulate wear. Cartilage defects on the humeral head were quantified through a custom MATLAB script. Mean cartilage cutout differences were analyzed by the Wilcoxon rank-sum test. RESULTS: Both single- and double-row repairs showed macroscopic damage. The histomorphometric analysis demonstrated that the double-row technique resulted in a significantly (P = .036) more chondral damage (mean, 57,489.1 µm2; SD, 61,262.2 µm2) than the single-row repair (mean, 28,763.5 µm2; SD, 24,4990.2 µm2). CONCLUSION: Both single-row and double-row arthroscopic bony Bankart fixation techniques resulted in damage to the humeral head articular cartilage in the concavity-compression model utilized in this study. The double-row fixation technique resulted in a significantly increased cutout to the humeral head cartilage after simulated wear in this cadaveric model. CLINICAL RELEVANCE: This study provides data demonstrating that placement of intra-articular suture during arthroscopic bony Bankart repair techniques may harm the humeral head cartilage. While the double-row repair of bony Bankart lesions is more stable, it results in increased cartilage damage. These findings suggest that alternative, cartilage-sparing arthroscopic techniques for bony Bankart repair should be investigated.

A Biomechanical, Cadaveric Evaluation of Single- Versus Double-Row Repair Techniques on Stability of Bony Bankart Lesions.

BACKGROUND: Previous studies comparing stability between single- and double-row arthroscopic bony Bankart repair techniques focused only on the measurements of tensile forces on the bony fragment without re-creating a more physiologic testing environment. PURPOSE: To compare dynamic stability and displacement between single- and double-row arthroscopic repair techniques for acute bony Bankart lesions in a concavity-compression cadaveric model simulating physiologic conditions. STUDY DESIGN: Controlled laboratory study. METHODS: Testing was performed on 13 matched pairs of cadaveric glenoids with simulated bony Bankart fractures with a defect width of 25% of the inferior glenoid diameter. Half of the fractures were repaired with a double-row technique, and the contralateral glenoids were repaired with a single-row technique. To determine dynamic biomechanical stability and ultimate step-off of the repairs, a 150-N load and 2000 cycles of internal-external rotation at 1 Hz were applied to specimens to simulate early rehabilitation. Toggle was quantified throughout cycling with a coordinate measuring machine. Three-dimensional spatial measurements were calculated. After cyclic loading, the fracture displacement was measured. RESULTS: The bony Bankart fragment-glenoid initial step-off was found to be significantly greater (P < .001) for the single-row technique (mean, 896 µm; SD, 282 µm) compared with the double-row technique (mean, 436 µm; SD, 313 µm). The motion toggle was found to be significantly greater (P = .017) for the single-row technique (mean, 994 µm; SD, 711 µm) compared with the double-row technique (mean, 408 µm; SD, 384 µm). The ultimate interface displacement was found to be significantly greater (P = .029) for the single-row technique (mean, 1265 µm; SD, 606 µm) compared with the double-row technique (mean, 795 µm; SD, 398 µm). CONCLUSION: Using a concavity-compression glenohumeral cadaveric model, we found that the double-row arthroscopic fixation technique for bony Bankart repair resulted in superior stability and decreased displacement during simulated rehabilitation when compared with the single-row repair technique. CLINICAL RELEVANCE: The findings from this study may help guide surgical decision-making by demonstrating superior biomechanical properties (improved initial step-off, motion toggle, and interface displacement) of the double-row bony Bankart repair technique when compared with single-row fixation. The double-row repair construct demonstrated increased stability of the bony Bankart fragment, which may improve bony Bankart healing.

Cemented versus uncemented fixation of second-generation Trabecular Metal glenoid components: minimum 5-year outcomes.

BACKGROUND: Total shoulder arthroplasty (TSA) with second-generation Trabecular Metal™ implants (Zimmer, Warsaw, IN, USA) has shown good short-term outcomes. Differences in outcomes between cemented and uncemented fixation are unknown. This study compared the clinical, radiographic, and patient-rated outcomes of TSA with cemented vs. uncemented TM glenoids at minimum 5-year follow-up. METHODS: Patients who underwent anatomic TSA with second-generation TM glenoid components for primary osteoarthritis were identified for minimum 5-year follow-up. The patients were divided into 2 groups: cemented and uncemented glenoid fixation. Outcome measures included implant survival, patient-rated outcome scores (Patient-Reported Outcomes Measurement Information System [PROMIS] and American Shoulder and Elbow Surgeons scores), shoulder range of motion, and radiographic analysis. Findings were compared between groups. RESULTS: The study included 55 shoulders: 27 in the cemented group (21 with full radiographic follow-up) and 28 in the uncemented group (22 with full radiographic follow-up). Both groups had similar follow-up times (6.6 years in cemented group vs. 6.7 years in uncemented group, P = .60). Moreover, the groups did not differ significantly in sex composition, age at the time of surgery, or preoperative Walch glenoid grade distribution. No patients required revision surgery. The 2 groups had similar preoperative range of motion, but patients in the uncemented group had greater follow-up forward flexion (P = .03), external rotation (P < .01), and lateral elevation (P = .03) than did patients in the cemented group. PROMIS scores were not significantly different between groups. American Shoulder and Elbow Surgeons scores were similar (89.8 in cemented group vs. 94.1 in uncemented group, P = .21). Mid-term radiographs showed a metal debris rate of 24% in the cemented group and 27% in the uncemented group. Although these values were not significantly different (P = .90), the frequency of mild metal debris (grade 1-2), when present, was greater in the uncemented group (grade 2 in 6 shoulders) than in the cemented group (grade 1 in 4 and grade 2 in 1, P = .02). There was a greater presence of mild (grade 1) radiolucent lines in the uncemented group (64%) than in the cemented group (29%, P < .01). No glenoid had evidence of loosening (defined by a change in position or radiolucent lines > 2 mm). The presence of metal debris and radiolucent lines did not have a significant effect on clinical outcomes. CONCLUSION: At minimum 5-year follow-up, TSA patients with TM glenoids demonstrated excellent clinical and patient-reported outcomes with a 100% implant survival rate, regardless of cemented vs. uncemented fixation. However, the uncemented group showed a significantly higher rate of radiolucent lines and a higher frequency of mild metal debris. These radiographic findings did not affect the clinical outcomes, and their implications for long-term outcomes and prosthesis survival is unknown.

An Electronic Medical Record-Based Discharge Disposition Tool Gets Bundle Busted: Decaying Relevance of Clinical Data Accuracy in Machine Learning.

BACKGROUND: Determining discharge disposition after total joint arthroplasty (TJA) has been a challenge. Advances in machine learning (ML) have produced computer models that learn by example to generate predictions on future events. We hypothesized a trained ML algorithm's diagnostic accuracy will be better than that of current predictive tools to predict discharge disposition after primary TJA. METHODS: This study was a retrospective cohort study from a single, tertiary referral center for primary TJA. We trained and validated an artificial neural network (ANN) based on 4368 distinct surgical encounters between 1/1/2013 and 6/28/2016. The ANN's ability to identify discharge disposition was then tested on 1452 distinct surgical encounters between 1/3/17 and 11/30/17. RESULTS: The area under the curve and accuracy achieved during model validation were 0.973 and 91.7%, respectively, with 25% of patients being discharged to skilled nursing facilities (SNFs). Within our testing data set, 6.7% of patients went to SNFs. The performance in the testing set included an area under the curve of 0.804, accuracy of 61.3%, sensitivity of 28.9%, and specificity of 93.8%. CONCLUSIONS: This is the first prediction tool using an electronic medical record-integrated ANN to predict discharge disposition after TJA based on locally generated data. Dramatically reduced numbers of patients discharged to SNFs due to implementation of a bundled payment model lead to poor recall in the testing model. This model serves as a proof of concept for developing an ML prediction tool using a relatively small data set and subsequent integration into the electronic medical record.

Direct Anterior Approach to Total Hip Arthroplasty for Femoral Neck Fractures.

Femoral neck fractures are a common injury pattern, especially within the elderly. Replacement with either hemiarthroplasty or total hip arthroplasty allows for immediate weight-bearing. This video demonstrates the direct anterior approach to total hip arthroplasty for management of displaced femoral neck fractures.

Do PROMIS Physical Function, Pain Interference, and Depression Correlate to the Oswestry Disability Index and Neck Disability Index in Spine Trauma Patients?

STUDY DESIGN: Correlational study. OBJECTIVE: In spine trauma patients, we aimed to assess the correlation of patient-reported outcome measurement information system (PROMIS) physical function (PF), pain interference (PI), and Depression scores with Oswestry Disability Index (ODI) and Neck Disability Index (NDI) ODI/NDI scores. SUMMARY OF BACKGROUND DATA: The ODI and NDI were intended as patient-reported outcome measures (PROMs) to evaluate clinical outcomes in patients seeking spine care. To date, the PROMIS has not been studied in the spine trauma population. METHODS: Between January 1, 2015 and December 13, 2017, patients presenting to a single, level 1 trauma center spine clinic with known spine trauma were identified. A total of 56 patients (52 operative, 4 nonoperative) representing 181 encounters were identified. PROMIS PF, PI, and Depression, as well as the ODI or NDI, were administered to patients. Spearman rho (ρ) were calculated between PROMs. RESULTS: A strong correlation exists between PROMIS PI and the ODI (ρ = 0.79, P < 0.001), while a strong-moderate correlation exists between PROMIS PF and the ODI (ρ = -0.61, P < 0.001). A moderate correlation exists between PROMIS Depression and the ODI (ρ = 0.54, P < 0.001). Strong correlations exist between PROMIS PI and the NDI (ρ = 0.71, P < 0.001) and PROMIS Depression and the NDI (ρ = 0.73, P < 0.001). A poor correlation exists between PROMIS PF and the NDI (ρ = -0.28, P = 0.005). CONCLUSION: PROMIS PF, PI, and Depression domains significantly correlate with the ODI and NDI; however, only PROMIS PI strongly correlates with both the NDI and ODI. This suggests that PROMIS PI can be used to capture similar information to that of the ODI or NDI but that PROMIS PF and Depression may offer additional clinical information. LEVEL OF EVIDENCE: 2.

Postdischarge Opiate-Prescribing Habits for Primary THA and TKA: A Survey of American Association of Hip and Knee Surgeons Members.

Abuse of opiate medications has reached epidemic proportions, and elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) typically require outpatient use of narcotic medications. This survey sought to determine opiate-prescribing habits of members of the American Association of Hip and Knee Surgeons (AAHKS) for patients undergoing primary THA and TKA. An 11-question online survey was developed to evaluate current prescribing habits for opiate and nonopiate medications prescribed after primary THA and TKA. An invitation to complete the survey was e-mailed to 2698 orthopedic surgeons using an AAHKS listserv. Surgeons' demographic information and their prescribing habits of opiate and nonopiate medications postdischarge were recorded. Data were examined using descriptive statistics, chi-square, and multivariate logistic regression. Responses were received from 325 of 2698 (12.1%) AAHKS members. Significant variation in the type of opiate prescribed and the number of pills dispensed was observed. Higher surgical volume and less years in surgical practice were associated with a higher number of opiate pills prescribed after THA and TKA. There were no statistically significant associations between opiates prescribed and use of an ambulatory surgery center or presence of departmental guidelines. Although THA and TKA are relatively standardized procedures performed nationwide, significant variability exists among surgeons regarding postdischarge opiate- and nonopiate-prescribing habits. There is a need for greater standardization to create a unified, evidence-based, and safe regimen for the postoperative period while reducing the opiate burden in the surrounding community. [Orthopedics. 2019; 42(6):361-367.].

Orthopedic Surgery and the Geriatric Patient.

As more patients live longer, it is probable that an increasing number of geriatric patients will require surgery. An organized, systematic, coordinated, multidisciplinary approach to the perioperative management of these patients will result in fewer complications, improved outcomes, and reduced cost of care. Details are herein provided on the preoperative diagnostic evaluation and assessment as well as perioperative care provided to optimize outcomes. The diagnosis, workup, and treatment of osteoporosis and fragility fractures are presented. The article concludes with a review of the care of the geriatric orthopedic patient in the posthospital time period.