Utility of Recovery Room vs Post-Operative Day 1 Radiographs Following Shoulder Arthroplasty.

Background: Postoperative radiographs may be performed on different timelines after shoulder arthroplasty. Radiographs obtained in the post-operative recovery unit (PACU) are often of poorer quality. The purpose of the current study was to explore and compare the quality of PACU radiographs and radiographs performed in the radiology suite on post-operative Day 1 (POD1), as well as determine their impact on changes in post-operative management. Methods: Our series included 50 consecutive anatomic total shoulder arthroplasties (TSA) for which post-operative radiographs were obtained in the PACU and 50 consecutive TSA for which post-operative radiographs were obtained in the radiology suite on POD 1. TSA radiographs were blinded and reviewed by 3 authors and graded on their quality using criteria described using previously published methods. The weighted kappa was used to describe the intra-rater agreement and inter-rater agreement between two raters. Results: There was no difference in age, sex, BMI, and comorbidities between cohorts. Intra-observer reliability was moderate to substantial with weighted kappa values of 0.65±0.07 (p<0.001), 0.58±0.09 (p<0.001), and 0.67±0.07 (p<0.001). Inter-observer reliability was moderate to substantial with weighted kappa values of 0.605±0.07 (p<0.001), 0.66±0.07 (p<0.001), and 0.65±0.08 (p<0.001). When assessing quality of radiographs, 30% of radiographs obtained in PACU were deemed quality while 57% of radiographs obtained in the radiology suite were deemed quality (p<0.001). Conclusion: Post-operative radiographs in the PACU do not alter patient management and are often inadequate to serve as baseline radiographs. Conversely, radiographs obtained in the radiology suite are of higher quality and can serve as a superior baseline radiograph. Level of Evidence: IV.

Periostin Is a Biomarker for Anterior Shoulder Instability: Proteomic Analysis of Synovial Fluid.

BACKGROUND: The incremental biological changes in the synovial microenvironment of the shoulder in acute and chronic instability that may contribute to joint degeneration are poorly understood. Proteomic analysis of synovial fluid in patients with shoulder instability may improve our understanding of proteins that are shed into shoulder synovial fluid after an injury. HYPOTHESIS: Injury-specific factors such as the direction of instability and the severity of glenoid and humeral bone loss are associated with the proteome of synovial fluid in patients with shoulder instability. STUDY DESIGN: Descriptive laboratory study. METHODS: Synovial fluid lavage samples were compared between patients with anterior (n = 12) and posterior (n = 8) instability and those without instability (n = 5). Synovial proteins were identified with liquid chromatography-tandem mass spectrometry. Orthogonal validation of protein targets found to be significant on tandem mass spectrometry was performed in a separate set of prospective patients with Western blotting. Data were processed and analyzed, and P values were adjusted with the Benjamini-Hochberg method for multiple comparisons. RESULTS: A total of 25 patients were included. Tandem mass spectrometry identified 720 protein groups in synovial fluid of patients with shoulder instability. There were 4 synovial proteins that were significantly expressed in patients with anterior instability relative to posterior instability: periostin (POSTN) (adjusted P value = .03; log fold change [logFc] = 4.7), transforming growth factor beta-induced protein ig-h3 (adjusted P value = .05; logFc = 1.7), collagen type VI alpha-3 chain (adjusted P value = .04; logFc = 2.6), and coagulation factor V (adjusted P value = .04; logFc = -3.3). Among these targets, POSTN showed a moderate correlation with the Hill-Sachs lesion size (r = 0.7). Prospective validation with Western blotting confirmed a significantly higher level of POSTN in synovial fluid of patients with anterior instability (P = .00025; logFc = 5.1). CONCLUSION: Proteomic analysis enriched our understanding of proteins that were secreted into shoulder synovial fluid of patients with shoulder instability. The identification of POSTN, a proinflammatory catabolic protein involved with tissue remodeling and repair, as a significant target in anterior shoulder instability is a novel finding. Therefore, further study is warranted to determine the role that POSTN may play in the progression of bone loss and posttraumatic osteoarthritis. CLINICAL RELEVANCE: Proteomic analysis of synovial fluid in patients with shoulder instability improved our understanding of this abnormality after an injury.

Musculoskeletal Biorepository: Establishment, Sustainment, and Tips for Success.

A biorepository, also referred to as a "biobank," is a collection of biologic samples that are stored for laboratory research. With the emergence of precision medicine, the importance of leveraging individual patient biomolecular signatures to improve diagnosis, prognosis, and treatment is becoming increasingly recognized. Successful development and sustainment of a biorepository provides the potential for transformative preclinical research. Establishing a biobank requires a team approach with involvement of the institutions' research laboratory team and regulatory body. Execution of research activities requires a coordinated team approach for case identification, consent process, data and specimen collection, specimen processing, and storage and archiving. The advancing fields of precision medicine and orthobiologics provide incredible opportunities for institutions to generate novel lines of inquiry in musculoskeletal diseases through a multiomics approach (genomic, transcriptomic, proteomic, microbiomic). In addition, a biobank is an important component of post-market surveillance for the rapidly emerging field of orthobiologics.

Rate of incidental findings on routine preoperative computed tomography for shoulder arthroplasty.

BACKGROUND: Incidental findings are commonly noted in advanced imaging studies. Few data exist regarding the rate of incidental findings on computed tomography (CT) for preoperative shoulder arthroplasty planning. This study aims to identify the incidence of these findings and the rate at which they warrant further work-up to help guide orthopedic surgeons in counseling patients. METHODS: A retrospective review was performed to identify patients with available preoperative shoulder CT who subsequently underwent shoulder arthroplasty procedures at a single institution between 2015 and 2021. Data including age, sex, and smoking status were obtained. Radiology reports for CTs were reviewed for incidental findings and categorized based on location, tissue type, and/or body system. The rate of incidental findings and the rate at which further follow-up was recommended by the radiologist were determined. RESULTS: A total of 617 patients was identified. There were 173 incidental findings noted in 146 of these patients (23.7%). Findings ranged from pulmonary (59%), skin/soft tissue (16%), thyroid (13%), vascular (9%), spinal (2%), and abdominal (1%) areas. Of the pulmonary findings, 50% were pulmonary nodules and 47% were granulomatous disease. Overall, the final radiology report recommended further follow-up for 50% of the patients with incidental findings. CONCLUSIONS: Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients. Most of these findings are pulmonary in nature. Overall, half of the patients with incidental findings were recommended for further follow-up. These results establish population data to guide orthopedic surgeons in patient counseling. Level of evidence: III.

Modifiable and Nonmodifiable Risk Factors Associated with the Development of Recurrent Rotator Cuff Tears.

Nonoperative and operative strategies exist to manage rotator cuff pathology. Although surgical repair is successful for most patients, others may experience retear or nonhealing of the rotator cuff. Several modifiable and nonmodifiable risk factors are associated with an increased retear rate. The literature shows consistency and agreement regarding many of these risk factors, most notably, patient age, tear size, and rotator cuff muscular atrophy, whereas others remain controversial. It is important that shoulder surgeons are familiar with modifiable and nonmodifiable risk factors associated with retear, to better advise patients and optimize their chances of success following rotator cuff repair surgery.

Outcomes of Geriatric Periprosthetic Distal Femur Fractures: Comparison of Fixation Versus Reconstruction.

OBJECTIVE: Comparing outcomes of periprosthetic distal femur fractures treated with open reduction and internal fixation (ORIF) versus distal femoral replacement (DFR). SETTING: Three major academic hospitals within one metropolitan area. DESIGN: Retrospective. PATIENTS/PARTICIPANTS: Three hundred seventy patients >64 years old with periprosthetic distal femur fractures were identified and 115 were included (65 ORIF vs. 50 DFR). INTERVENTION: ORIF with locked plating versus DFR. MAIN OUTCOME MEASUREMENT: One-year mortality, ambulatory status at 1 year, reoperations, and hospital readmissions. RESULTS: No differences were observed between ORIF and DFR cohorts regarding demographics or medical history, including Charleston Comorbidity Index. DFR was associated with longer hospital stay (6.09 days ORIF vs. 9.08 days DFR, P < 0.001) and more frequent blood transfusion (12.3% ORIF vs. 44.0% DFR, P < 0.001). Logistic regression analysis using propensity score matching (PSM) demonstrated no statistically significant difference in reoperation, hospital readmission, ambulatory status at 1 year, or 1-year mortality between the 2 cohorts. Finally, applying Bayesian model averaging using PSM to identify risk factors for 1-year mortality demonstrated that increasing age, length of index hospital stay, and 90-day hospital readmission were significantly associated with 1-year mortality, regardless of type of surgical treatment. CONCLUSION: Rehospitalization, reoperation, ambulatory status, and 1-year mortality are no different between ORIF and DFR in the treatment of geriatric periprosthetic distal femur fractures when PSM is applied to mitigate selection bias. Further study is warranted to elucidate functional outcomes, long-term sequelae, and costs of care related to these treatment options to better guide treatment planning. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Increasing Awareness of Complications of Nerve Injury Following Shoulder Surgery: Preventing Delays in Referral and Treatment.

BACKGROUND: Nerve injuries remain a challenging complication after shoulder surgery. While most resolve spontaneously, some require surgical intervention. This study describes the characteristics of patients sustaining nerve injuries following shoulder surgery, evaluates referral patterns to nerve surgeons, and characterizes nerve surgeries performed and their outcomes. Increased awareness of these injuries allows patients and providers to be better informed regarding the appropriate management when these complications occur. METHODS: A retrospective review of referrals with nerve injuries following shoulder surgery between 2007 and 2015 was performed. The final analysis included 65 patients. Data reviewed included demographics, procedure and anesthesia type, and diagnosis of nerve injury. Time to referral to nerve surgeon and proportional changes in the Disabilities of the Arm, Shoulder, and Hand (DASH) scores were determined. Outcomes were categorized as failed, partially successful, and successful based on final follow-up. RESULTS: Patients were referred following arthroscopic shoulder surgeries (35.4%), shoulder arthroplasties (24.6%), open shoulder procedures (21.5%), and combined open and arthroscopic procedures (18.5%). The mean time to referral was 7.6 months. Nerve injuries involved brachial plexus (33) and individual and multiple peripheral nerve branches (23 and 7, respectively). Twenty-five (38%) nerve injuries demonstrated spontaneous recovery. Thirty-five patients underwent surgical intervention, of which 27 were successful, 3 were partially successful, and 3 failed. CONCLUSIONS: This is the largest series of patients with iatrogenic nerve injury following shoulder surgeries to date. Our data demonstrate a lack of timely referral to nerve surgeons, especially after arthroscopy. There continues to be a variable injury pattern even among similar surgeries. Despite this, timely surgical intervention, when indicated, can lead to favorable outcomes.

Physician-Patient Communication in the Orthopedic Clinic: Surgeon-Identified Challenges.

Background: Effective communication between the physician and the patient is crucial to quality healthcare. The orthopedic surgery clinic setting provides an environment for cultivating the physician-patient relationship, eliciting diagnostic data, and developing treatment strategies. However, little is known about the orthopedic surgeon perspective on communicating with patients. The purpose of the study was to identify patient communication and care issues faced in the orthopedic surgery clinic setting that physicians categorize as challenging. Methods: All surgeons in the department of orthopedics in a large tertiary care center were invited to respond to an online survey on common communication challenges. Physicians were asked to rate 13 challenges identified by the literature and opinion leaders using a four-point Likert scale ranging from "Not at all challenging" to "Extremely challenging". In addition, the survey included open ended questions regarding common challenges in communicating with patients and types of encounters, and thematic analysis was applied. Mean scores were calculated. Results: Nineteen orthopedic surgeons completed the survey and were included in the analysis. Orthopedic surgeons identified misaligned expectations for surgical intervention for a nonsurgical diagnosis as the most challenging encounter in the clinic (16/19). Managing postoperative patient expectations (14/19) and communicating with patients who were dissatisfied with their surgical outcome (13/19) were also commonly rated as particularly challenging. Open ended responses echoed these ratings and additional difficulty facilitating patient understanding of complex information as common communication challenges. Conclusion: Common challenges in the orthopedic clinic often surround managing patient expectations and providing effective explanations, particularly where physicians perceive a surgical intervention as inappropriate for addressing the patient complaint. Identifying these issues can guide training efforts to help orthopedic physicians in managing these and improving communication. These findings can also provide basis for collecting information about communication challenges from orthopedic surgeons across institutions. Level of Evidence: IV.

Standardizing Screw Head Orthopaedic Trauma Implants. Is There an Interest? An OTA Member Survey.

OBJECTIVE: To determine the level of interest in standardization of design for fracture fixation implants within the orthopaedic trauma community. METHODS: A survey regarding implant removal concerns and implant design preferences was electronically distributed to members of Orthopaedic Trauma Association (OTA). RESULTS: Three hundred thirty respondents participated in the survey (response rate of 19%) Only 2.4% of respondents indicated a consistent ability to identify the implant vendor and/or manufacturer of retained implants in the preoperative planning phase of care; >75% of respondents reported investing a minimum of an additional 30 minutes to their operative times to remove screw(s) to successfully extract a plate. More than 80% of respondents reported multiple occurrences requiring modification of their surgical plans because of implants that could not be removed, preventing the completion of the planned procedure. The majority of respondents expressed interest in the adoption of standardized locking head screws for mini, small, and large screw sizes sets (63.5%); 84.8% of respondents desire standardization of screw head and driver sizes across the industry. Also, 83.6% of respondents expressed interest in the adoption of a standardized locking screw head for each cannulated screw, regardless of manufacturer. CONCLUSIONS: Members of the orthopaedic community, as represented in the membership of the OTA, are interested in the adoption of universal standards in implant design. Establishing standard screw heads and drivers will optimize the delivery of operative care.

Influence of subscapularis stiffness with glenosphere lateralization on physiological external rotation limits after reverse shoulder arthroplasty.

BACKGROUND: Repair of the subscapularis following reverse shoulder arthroplasty (RSA) remains a controversial topic among surgeons. Poor rotator cuff muscle quality is associated with increased musculotendinous stiffness, and the subsequent effect of compromised tissue repair on RSA functional outcomes remains unclear. The objective was to investigate the influence of subscapularis stiffness together with glenoid component lateralization on pre- and postimpingement joint mechanics during external rotation after RSA. METHODS: A validated finite element model incorporating the Zimmer Trabecular Metal reverse system was used. The deltoid and subscapularis tendon were tensioned and wrapped around the joint prior to controlled shoulder external rotation. Baseline subscapularis stiffness, determined from cadaveric testing, was varied to 80%, 120% and 140% of baseline, to simulate a range of pliability associated with fatty infiltration and fibrosis. We evaluated the effects of varying subscapularis stiffness and the corresponding variation in joint tension with varying glenosphere lateralization (2, 4, and 10 mm) on the torque required to externally rotate the shoulder and the impingement/subluxation risk. RESULTS: Prior to any impingement, the torques required to externally rotate the shoulder ranged from 22-47 Nm across the range of parameters studied, with the greatest torques required for the 10-mm glenosphere lateralization. The impact of increasing subscapularis stiffness on torque requirements was most pronounced at the 10-mm lateralization, as well. A 20% increase in subscapularis stiffness necessitated a 7%-14% increase in preimpingement torque, whereas a 40% stiffness increase was associated with a 12%-27% increase in torque. Torque was proportional to lateralization. When lateralization was increased from 2 to 4 mm, the preimpingement torque increased by 10%-13%, whereas a 10-mm lateralization necessitated a 35%-62% torque increase relative to 2 mm of lateralization. Increased subscapularis stiffness did not limit impingement-free range of motion or substantially decrease postimpingement subluxation in this model. DISCUSSION: Mechanical gains achieved through lateralization may be hindered by increased torque demands, especially when a stiffer subscapularis is repaired. As lateralization increases subscapularis tension, greater torque is required to externally rotate the shoulder. The torque required for external rotation has been reported between 15-50 Nm. Subscapularis repair with the simulated increases in stiffness requires relative increases in torque that the reconstructed shoulder may not be able to physically produce to rotate the glenohumeral joint, particularly at 10-mm lateralization. These results suggest that subscapularis repair may not be indicated in cases where a lateralized glenoid component is used and the subscapularis is compromised.

New versus old: 95 degree angled blade plate versus distal femoral locking plate. A randomized clinical trial.

INTRODUCTION: The purpose was to compare the locking condylar plate (LCP) with the 95° angled blade plate (ABP) for distal femoral fracture patterns amenable to either device. Our hypothesis was that LCP would outperform ABP with primary outcome of nonunion and secondary outcomes of reoperation and malunion. METHODS: 78 adult patients with 79 eligible fractures and mean age of 60 years were prospectively randomized to LCP (n = 45) or ABP (n = 34). Mean ISS was 16. 22% fractures were open. Patient-reported functional outcomes were assessed with the Musculoskeletal Function Assessment (MFA). RESULTS: All patients were followed to union, and mean follow-up was 25 months. There were no differences in age, sex, fracture pattern, co-morbidities or mechanism for the two groups. Three patients had infections, one superficial after LCP and one deep infection each after ABP and LCP. Three patients developed nonunion after LCP versus none after ABP (p = 0.06). Nine patients healed with minor deformity after LCP versus 5 following ABP. One fracture had major deformity after ABP versus two after LCP. Eight patients had a secondary procedure following LCP versus two after ABP (p = 0.05). CONCLUSIONS: The investigation failed to support newer technology being better. Evidence did not indicate the LCP was superior to the ABP. Trends for primary union and fewer secondary procedures suggest that ABP may have superior performance to LCP for fracture patterns which may be treated with either implant.

Artificial Intelligence to Identify Arthroplasty Implants From Radiographs of the Knee.

BACKGROUND: Revisions and reoperations for patients who have undergone total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and distal femoral replacement (DFR) necessitates accurate identification of implant manufacturer and model. Failure risks delays in care, increased morbidity, and further financial burden. Deep learning permits automated image processing to mitigate the challenges behind expeditious, cost-effective preoperative planning. Our aim was to investigate whether a deep-learning algorithm could accurately identify the manufacturer and model of arthroplasty implants about the knee from plain radiographs. METHODS: We trained, validated, and externally tested a deep-learning algorithm to classify knee arthroplasty implants from one of 9 different implant models from retrospectively collected anterior-posterior (AP) plain radiographs from four sites in one quaternary referral health system. The performance was evaluated by calculating the area under the receiver-operating characteristic curve (AUC), sensitivity, specificity, and accuracy when compared with a reference standard of implant model from operative reports. RESULTS: The training and validation data sets were comprised of 682 radiographs across 424 patients and included a wide range of TKAs from the four leading implant manufacturers. After 1000 training epochs by the deep-learning algorithm, the model discriminated nine implant models with an AUC of 0.99, accuracy 99%, sensitivity of 95%, and specificity of 99% in the external-testing data set of 74 radiographs. CONCLUSIONS: A deep learning algorithm using plain radiographs differentiated between 9 unique knee arthroplasty implants from four manufacturers with near-perfect accuracy. The iterative capability of the algorithm allows for scalable expansion of implant discriminations and represents an opportunity in delivering cost-effective care for revision arthroplasty.

Transformation from a traditional model to a virtual model of care in orthopaedic surgery: COVID-19 experience and beyond.

Virtual encounters have experienced an exponential rise amid the current COVID-19 crisis. This abrupt change, seen in response to unprecedented medical and environmental challenges, has been forced upon the orthopaedic community. However, such changes to adopting virtual care and technology were already in the evolution forecast, albeit in an unpredictable timetable impeded by regulatory and financial barriers. This adoption is not meant to replace, but rather augment established, traditional models of care while ensuring patient/provider safety, especially during the pandemic. While our department, like those of other institutions, has performed virtual care for several years, it represented a small fraction of daily care. The pandemic required an accelerated and comprehensive approach to the new reality. Contemporary literature has already shown equivalent safety and patient satisfaction, as well as superior efficiency and reduced expenses with musculoskeletal virtual care (MSKVC) versus traditional models. Nevertheless, current literature detailing operational models of MSKVC is scarce. The current review describes our pre-pandemic MSKVC model and the shift to a MSKVC pandemic workflow that enumerates the conceptual workflow organization (patient triage, from timely care provision based on symptom acuity/severity to a continuum that includes future follow-up). Furthermore, specific setup requirements (both resource/personnel requirements such as hardware, software, and network connectivity requirements, and patient/provider characteristics respectively), and professional expectations are outlined. MSKVC has already become a pivotal element of musculoskeletal care, due to COVID-19, and these changes are confidently here to stay. Readiness to adapt and evolve will be required of individual musculoskeletal clinical teams as well as organizations, as established paradigms evolve. Cite this article: Bone Joint Open 2020;1-6:272-280.

Correction to: Skin closure with 2-octyl cyanoacrylate and polyester mesh after primary total knee arthroplasty offers superior cosmetic outcomes and patient satisfaction compared to staples: a prospective trial.

The original version of this article unfortunately contained a mistake.

Are We Treating Similar Patients? Hospital Volume and the Difference in Patient Populations for Total Knee Arthroplasty.

BACKGROUND: Early findings of superior total knee arthroplasty (TKA) outcomes at high volume centers have been thought to have led to distinct referral patterns. However, the effect of these selective referral processes has not been well assessed. Therefore, this study compared the characteristics of primary TKA patients at high, intermediate, and low volume hospitals. METHODS: A total of 12,541 primary TKA patients were stratified into risk groups based on age (>65 years), body mass index (>40), and Charlson Comorbidity Index (≥4). Hospitals were classified as low, intermediate, or high volume based on mean annual TKA volumes (<250, 250-499, and >500). Multivariate logistic regression models evaluated the relationship between baseline patient characteristics and hospital volume. RESULTS: There was a greater percentage of high risk patients at high volume (19%, n = 853) compared to those at intermediate (16%, n = 899) or low volume (17%, n = 444) hospitals (P < .001). Patients with a body mass index >40 were more likely to be treated at high compared to intermediate (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.6, P < .001) and low volume centers (OR 1.4, 95% CI 1.2-1.7, P < .001). Patients with Charlson Comorbidity Index scores ≥4 were also more likely be treated at high compared to intermediate (OR 1.5, 95% CI 1.3-1.6, P < .001) or low (OR 1.2, 95% CI 1.0-1.4, P = .002) volume centers. CONCLUSION: This study found that TKA patients at high volume centers have significantly different baseline characteristics compared to those at lower volume centers. This study highlights the importance of considering hospital volume status and the associated disparity in the preoperative risk of patients when comparing primary TKA outcomes between centers.

Skin closure with 2-octyl cyanoacrylate and polyester mesh after primary total knee arthroplasty offers superior cosmetic outcomes and patient satisfaction compared to staples: a prospective trial.

INTRODUCTION: The goals of this study were to compare patient satisfaction and wound-related complications in patients receiving 2-octyl cyanoacrylate (glue) and polyester mesh for skin closure after primary total knee arthroplasty (TKA) versus staples. METHODS: A total of 60 knees in 54 patients undergoing TKA were enrolled in a prospective trial and randomized to receive either skin closure with glue and polyester mesh (n = 30) or a control group closed with staples (n = 30). Hollander wound cosmesis score (measured on a scale of 0-5, with 0 being the best) and visual analog scale (VAS) scores (range 0-100 mm) for patient satisfaction with wound cosmesis, as well as wound-related readmission, reoperation, and complications, including superficial surgical site infection, wound dehiscence, wound hematoma, stitch abscess, and wound discharge, were assessed at 6 weeks and 90 days after TKA. Baseline characteristics were not statistically significantly different between the groups (p > 0.05). RESULTS: At 6 weeks and 90 days, the Hollander wound cosmesis score was significantly lower (p < 0.01) in the glue and polyester mesh groups. Similarly, at 6 weeks and 90 days, the VAS for patient satisfaction with wound cosmesis was significantly higher (p < 0.01) in the glue and polyester mesh groups. The rate of superficial surgical site infection was 1/30 (3%) in glue and polyester mesh groups versus zero in the control group (p = 1.00). The rate of wound dehiscence was 1/30 (3%) in glue and polyester mesh groups versus zero in the control group (p = 1.00). CONCLUSION: These results suggest that glue and polyester mesh closure may offer superior cosmetic outcomes to staples for skin closure in TKA.