Anatomic or Reverse Total Shoulder Arthroplasty? How Fellowship Training Affects Selection of Arthroplasty Type.

BACKGROUND: While both anatomic (ATSA) and reverse total shoulder arthroplasty (RTSA) have been popularized as a means of treating individuals with degenerative shoulder conditions, the indications for each can vary widely amongst providers. While surgeons with differing fellowship training commonly perform these procedures, it is not understood how fellowship training influences choice of implant. METHODS: A national database was queried to identify surgeons performing anatomic and reverse total shoulder arthroplasty. For all surgeons who performed more than 10 cases between 2010-2022, fellowship data was individually collected via online search. For each fellowship group, rates of anatomic and reverse total shoulder arthroplasty were identified using International Classification of Diseases (ICD) procedural codes. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Primary outcome measures included the proportion of primary and revision ATSA and RTSA by fellowship in addition to the rate of RTSA performed for a primary diagnosis of glenohumeral osteoarthritis. RESULTS: A total of 131,974 patients met the inclusion criteria and were retained for this study. RTSA increased from 50.1% of all primary shoulder arthroplasty cases in 2011 to 72.0% in 2022. After adjusting for age and comorbidities, Sports Medicine fellowship-trained (Sports) surgeons opted for primary RTSA over ATSA at a significantly higher rate than Shoulder and Elbow fellowship-trained (Shoulder) surgeons and surgeons who completed another type of fellowship or no fellowship (Other). Sports surgeons also chose RTSA more frequently for the diagnosis of glenohumeral osteoarthritis compared to Shoulder surgeons. Surgeons in the Other cohort were more likely to perform primary ATSA rather than RTSA in comparison to surgeons in the Shoulder and Sports cohorts. Sports surgeons were responsible for the greatest increase in percentage of all shoulder arthroplasty procedures from 2010-2022 (28.4% to 40.4%) while the Other group decreased by a comparable amount (45.9% to 32.4%) over the same period. CONCLUSION: Surgeons who have completed a Sports Medicine fellowship choose RTSA over ATSA at a higher rate than Shoulder and Elbow surgeons, both for all indications and also for a primary diagnosis of glenohumeral osteoarthritis. Those who have no fellowship training or fellowship training outside of Sports Medicine and Shoulder and Elbow surgery have the highest percentage of ATSA in their arthroplasty practice. Revision anatomic and revision reverse total shoulder arthroplasty represents a larger percentage of overall case volume for Shoulder and Elbow surgeons.

The Effect of Surgeon Volume on Complications Following Total Shoulder Arthroplasty: A Nationwide Assessment.

BACKGROUND: Increased surgeon volume has been demonstrated to correlate with improved outcomes after orthopedic surgery. However, there is a lack of data demonstrating the effect of surgeon volume on outcomes after total shoulder arthroplasty. METHODS: The PearlDiver Mariner database was retrospectively queried from the years 2010-2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472 (Total Shoulder Arthroplasty). Patients under 40 years of age, those undergoing revision arthroplasty and cases of bilateral arthroplasty were excluded. Additionally, cases with a history of fracture, infection, or malignancy prior to surgery were excluded. Only surgeons who performed a minimum of 10 cases were selected and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90 day, 1-year, and 2-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at p≤0.00082 RESULTS: A total of 155,560 patients met inclusion criteria and were retained for analysis. The 90th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90th percentile (n=340) operated on 68,531 patients whereas surgeons below the 90th percentile (n=3,038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship (p<0.001) and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine (p<0.001). Low-volume surgeons operated on patients with higher baseline comorbidities (CCI: 2.01 vs 1.85, p<0.001). After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure (p<0.001), anemia (p<0.001), and UTI (p<0.001). All cause readmission (0.90, p<0.001), reoperation at 90 days (OR 0.75, p<0.001) and reoperation at 1 year (OR: 0.86, p<0.001) were significantly lower among high-volume surgeons. High-volume surgeons exhibited lower rates of various complications including prosthetic joint infection (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001), periprosthetic fracture (90d: p<0.001; 1yr: p<0.001; 2yr: p<0.001) and all complications (90d: p<0.001; 1yr: p<0.001). CONCLUSION: Surgeons who perform a high volume of total shoulder arthroplasty are more likely to operate on healthier patients than surgeons who perform a lower volume of cases. When compared to low-volume surgeons, and after adjusting for age, gender, and CCI, high-volume surgeons have a significantly lower overall complication rate. Despite this lower complication rate, high-volume surgeons are responsible for a decreasing portion of shoulder arthroplasty since 2016.

How fellowship training affects complication rate after shoulder arthroplasty: a nationwide assessment.

BACKGROUND: Total shoulder arthroplasty is performed by orthopedic surgeons with various fellowship training backgrounds. Whether surgeons performing shoulder arthroplasty with different types of fellowship training have differing rates of complications and reoperation remains unknown. METHODS: The PearlDiver Mariner database was retrospectively queried from the years 2010 to 2022. Patients undergoing shoulder arthroplasty were selected using the CPT code 23472. Those undergoing revision arthroplasty and those with a history of fracture, infection, or malignancy were excluded. Fellowship was determined and verified via online search. Only surgeons who performed a minimum of 10 cases were selected; and PearlDiver was queried using their provider ID codes. Primary outcome measures included 90-day, 1-year, and 5-year rates of complication and reoperation. A Bonferroni correction was utilized in which the significance threshold was set at P ≤ .00023. RESULTS: In total, 150,385 patients met the inclusion criteria and were included in the study. Analysis of surgical trends revealed that Sports Medicine and Shoulder and Elbow fellowship-trained surgeons are performing an increasing percentage of all shoulder arthroplasty over time, with each cohort exhibiting an 11.3% and 4.2% increase from 2010 to 2022, respectively. The geographic region with the highest proportion of cases performed by Sports Medicine surgeons was the West, while the Northeast has the highest proportion of cases performed by Shoulder and Elbow surgeons. Shoulder and Elbow surgeons operated on patients that were significantly younger and had fewer comorbidities. Both Shoulder and Elbow and Sports Medicine surgeons had lower rates of postoperative complications at 90 days, 1 year, and 5 years in comparison to surgeons who completed another type of fellowship or no fellowship. Across each time point, the rates of individual complications between Sports Medicine and Shoulder and Elbow were comparable, but the pooled complication rate was lowest in the Shoulder and Elbow cohort. CONCLUSION: Surgeons who have completed either a Sports Medicine or Shoulder and Elbow fellowship are performing an increasing proportion of shoulder arthroplasty over time. Sports Medicine and Shoulder and Elbow-trained surgeons have significantly lower complication rates at 90 days, 1 year, and 5 years postoperatively. The individual complication rates between Sports Medicine and Shoulder and Elbow are comparable, but Shoulder and Elbow have the lowest pooled complication rates overall.

Revision Hip Arthroplasty Performed by Fellowship-Trained Versus Non-Fellowship-Trained Surgeons: A Comparison of Perioperative Management and Complications.

BACKGROUND: Successful revision hip arthroplasty (rTHA) requires major resource allocation and a surgical team adept at managing these complex cases. The purpose of this study was to compare the results of rTHA performed by fellowship-trained and non-fellowship-trained surgeons. METHODS: A national administrative database was utilized to identify 5,880 patients who underwent aseptic rTHA and 1,622 patients who underwent head-liner exchange for infection by fellowship-trained and non-fellowship-trained surgeons from 2010 to 2020 with a 5-year follow-up. Postoperative opioid and anticoagulant prescriptions were compared among surgeons. Patients treated by fellowship-trained and non-fellowship-trained surgeons had propensity scores matched based on age, sex, comorbidity index, and diagnosis. The 5-year surgical complications were compared using descriptive statistics. Multivariable analysis was performed to determine the odds of failure following head-liner exchange when performed by a fellowship-trained versus non-fellowship-trained surgeon. RESULTS: Aseptic rTHA patients treated by fellowship-trained surgeons received fewer opioids (132 versus 165 milligram morphine equivalents per patient) and nonaspirin anticoagulants (21.4 versus 32.0%, P < .001). Fellowship-training was associated with lower dislocation rates (9.9 versus 14.2%, P = .011), fewer postoperative infections, and fewer periprosthetic fractures and re-revisions (15.2 versus 21.3%, P < .001). Head-liner exchange for infection performed by fellowship-trained surgeons was associated with lower odds of failure (31.2 versus 45.7%, odds ratio 0.76, 95% confidence interval 0.62 to 0.91, P < .001). CONCLUSIONS: rTHA performed by adult reconstruction fellowship-trained surgeons results in fewer re-revisions in aseptic cases and head-liner exchanges. Variations in resources, volumes, and perioperative protocols may account for some of the differences.

Antibiotic calcium sulphate beads lower the bacterial burden and prevent infection in a mouse model of periprosthetic joint infection.

Aims: Delayed postoperative inoculation of orthopaedic implants with persistent wound drainage or bacterial seeding of a haematoma can result in periprosthetic joint infection (PJI). The aim of this in vivo study was to compare the efficacy of vancomycin powder with vancomycin-eluting calcium sulphate beads in preventing PJI due to delayed inoculation. Methods: A mouse model of PJI of the knee was used. Mice were randomized into groups with intervention at the time of surgery (postoperative day (POD) 0): a sterile control (SC; n = 6); infected control (IC; n = 15); systemic vancomycin (SV; n = 9); vancomycin powder (VP; n = 21); and vancomycin bead (VB; n = 19) groups. Delayed inoculation was introduced during an arthrotomy on POD 7 with 1 × 105 colony-forming units (CFUs) of a bioluminescent strain of Staphylococcus aureus. The bacterial burden was monitored using bioluminescence in vivo. All mice were killed on POD 21. Implants and soft-tissue were harvested and sonicated for analysis of the CFUs. Results: The mean in vivo bioluminescence in the VB group was significantly lower on POD 8 and POD 10 compared with the other groups. There was a significant 1.3-log10 (95%) and 1.5-log10 (97%) reduction in mean soft-tissue CFUs in the VB group compared with the VP and IC groups (3.6 × 103 vs 7.0 × 104; p = 0.022; 3.6 × 103 vs 1.0 × 105; p = 0.007, respectively) at POD 21. There was a significant 1.6-log10 (98%) reduction in mean implant CFUs in the VB group compared with the IC group (1.3 × 100 vs 4.7 × 101, respectively; p = 0.038). Combined soft-tissue and implant infection was prevented in 10 of 19 mice (53%) in the VB group as opposed to 5 of 21 (24%) in the VP group, 3 of 15 (20%) in the IC group, and 0% in the SV group. Conclusion: In our in vivo mouse model, antibiotic-releasing calcium sulphate beads appeared to outperform vancomycin powder alone in lowering the bacterial burden and preventing soft-tissue and implant infections.

Monoclonal Antibody Disrupts Biofilm Structure and Restores Antibiotic Susceptibility in an Orthopedic Implant Infection Model.

Bacterial biofilms on orthopedic implants are resistant to the host immune response and to traditional systemic antibiotics. Novel therapies are needed to improve patient outcomes. TRL1068 is a human monoclonal antibody (mAb) against a biofilm anchoring protein. For assessment of this agent in an orthopedic implant infection model, efficacy was measured by reduction in bacterial burden of Staphylococcus aureus, the most common pathogen for prosthetic joint infections (PJI). Systemic treatment with the biofilm disrupting mAb TRL1068 in conjunction with vancomycin eradicated S. aureus from steel pins implanted in the spine for 26 of 27 mice, significantly more than for vancomycin alone. The mechanism of action was elucidated by two microscopy studies. First, TRL1068 was localized to biofilm using a fluorescent antibody tag. Second, a qualitative effect on biofilm structure was observed using scanning electron microscopy (SEM) to examine steel pins that had been treated in vivo. SEM images of implants retrieved from control mice showed abundant three-dimensional biofilms, whereas those from mice treated with TRL1068 did not. Clinical Significance: TRL1068 binds at high affinity to S. aureus biofilms, thereby disrupting the three-dimensional structure and significantly reducing implant CFUs in a well-characterized orthopedic model for which prior tested agents have shown only partial efficacy. TRL1068 represents a promising systemic treatment for orthopedic implant infection.

Active rheumatoid arthritis in a mouse model is not an independent risk factor for periprosthetic joint infection.

INTRODUCTION: Periprosthetic joint infection (PJI) represents a devastating complication of total joint arthroplasty associated with significant morbidity and mortality. Literature suggests a possible higher incidence of periprosthetic joint infection (PJI) in patients with rheumatoid arthritis (RA). There is, however, no consensus on this purported risk nor a well-defined mechanism. This study investigates how collagen-induced arthritis (CIA), a validated animal model of RA, impacts infectious burden in a well-established model of PJI. METHODS: Control mice were compared against CIA mice. Whole blood samples were collected to quantify systemic IgG levels via ELISA. Ex vivo respiratory burst function was measured via dihydrorhodamine assay. Ex vivo Staphylococcus aureus Xen36 burden was measured directly via colony forming unit (CFU) counts and crystal violet assay to assess biofilm formation. In vivo, surgical placement of a titanium implant through the knee joint and inoculation with S. aureus Xen36 was performed. Bacterial burden was then quantified by longitudinal bioluminescent imaging. RESULTS: Mice with CIA demonstrated significantly higher levels of systemic IgG compared with control mice (p = 0.003). Ex vivo, there was no significant difference in respiratory burst function (p = 0.89) or S. aureus bacterial burden as measured by CFU counts (p = 0.91) and crystal violet assay (p = 0.96). In vivo, no significant difference in bacterial bioluminescence between groups was found at all postoperative time points. CFU counts of both the implant and the peri-implant tissue were not significantly different between groups (p = 0.82 and 0.80, respectively). CONCLUSION: This study demonstrated no significant difference in S. aureus infectious burden between mice with CIA and control mice. These results suggest that untreated, active RA may not represent a significant intrinsic risk factor for PJI, however further mechanistic translational and clinical studies are warranted.